Surgical Trunk Oriented Laparoscopic Right Hemicolectomy (ST-LRH) for Right-Sided Colon Cancer

This study introduces the STEM-oriented surgical approach aimed at optimizing the radical resection of right-sided colon cancer. During a laparoscopic right hemicolectomy the adjacent tissues are complex and frequent vascular variations can obscure the anatomical layers leading to increased bleeding and incomplete lymph node dissection. This technique can more clearly reveal the vascular anatomy of the surgical trunk and Henle's trunk, reducing the risk of bleeding.

Begin by inserting a five millimeter trocar two centimeters below the left costal margin at the midclavicular line under laparoscopic guidance. Place a 12 millimeter trocar midway between the observation port and the first trocar. Then insert symmetrical five millimeter and 10 millimeter trocars on the opposite side.

To begin exposure of the omental bursa, locate the vascular arch at the midpoint of the greater gastric curvature, and start the dissection lateral to it. Incise the gastrocolic ligament to expose the omental bursa. Continue dissecting along the greater omentum on the greater curvature towards the right, separating it up to the right margin of the omental bursa.

Continue the dissection by incising the anterior leaf of the transverse mesocolon. Separate the fused mesentery between the duodenum and the transverse colon towards the right, extending up to the lateral abdominal wall. Then incise the anterior leaf of the transverse mesocolon to access the retroperitoneale space located anterior to the pancreas and duodenum.

Dissect within this space by moving inferiorly towards the neck of the pancreas and laterally towards the ligament of Treitz. At this level, visualize Henle's trunk and its tributary veins as they course anterior to the pancreas. Complete the mobilization of the entire superior aspect of the transverse mesocolon.

To begin the dissection of the tolt space, incise the peritoneum along the mesentery bridge to gain access to the area. Adjust the surrounding tissue as necessary to allow separation. Using small gauze pads, carefully dissect the tolt space from the bottom up.

After completing the dissection, place a gauze strip within the to;t space to mark the area and protect the underlying structures. Incise the fusion fascia towards the left to enter the anterior retroperitoneale space of the pancreas and duodenum. After completing the dissection, insert another gauze strip into the anterior retroperitoneale space of the duodenum and position it at the posterior projection of the superior mesenteric vein to guide further dissection and protect posterior structures.

Ask the assistant to elevate the mesentery of the middle colic artery and in inferior mesenteric artery or vein to flatten the surgical trunk. Direct visual attention to the gauze strip positioned at the ligament of Treitz on the cephalic side, which acts as the medial reference point for peritoneal incision and dissection. Identify the area below the elevated ileocolic vessels as the lateral reference point.

Begin the peritoneal incision at the midpoint of the marked preliminary line typically located at the projection where the ileocolic vessels join the superior mesenteric vein. First incise laterally through to the posterior region where the gauze strip becomes visible. Continue the dissection along the preliminary incision line, moving medially toward the reference point.

Now, enter the sheath of the superior mesenteric vein through the incision at the midpoint, and carefully perform intra sheath separation. Dissect laterally until reaching the left boundary of the superior mesenteric vein. Identify the venous types forming the surgical trunk in this region.

Once identified, legate and transect the ileocolic vein, ileocolic artery, middle colic artery, and Henle's trunk at their bases. After vessel transection, dissect the ascending colon from the lateral abdominal wall by following the lateral plane. Proceed to perform ileo-transverse ostomy and then complete abdominal closure.

The average operative time and blood loss for single trunk laparoscopic right hemicolectomy were significantly lower than that of the conventional approach. The number of lymph nodes retrieved did not differ significantly between the single trunk laparoscopic and conventional approaches. The rate of postoperative complications was lower in the single-trunk laparoscopic group, though this difference was not statistically significant.

The average duration of hospital stay after surgery was significantly shorter in the single-trunk laparoscopic group compared to the conventional group.