Caudal-to-cranial Approach in Laparoscopic Right Hemicolectomy with Complete Mesocolon Excision and D3 Lymph Node Dissection

My research is for minimally invasive surgery for colorectal tumors, focusing on laparoscopic right hemicolectomy using a caudal-to-cranial approach. To begin, dissect and develop the right retro-colic space and the pre-pancreatoduodenal space using a caudal approach. Apply traction to the ileocecal region and the root of the small bowel mesentery, reflecting them cranially to expose the membranous bridge between the right mesocolon and the retroperitoneum.

Incise the membranous bridge along the avascular line of Toldt, approximately 1 centimeter above the right common iliac artery to enter the right retro-colic space. Expand the space cranially until the horizontal part of the duodenum is visible medially. Use the vessels on the medial side of the duodenum as landmarks.

Perform a deliberate crawling up maneuver to identify the pancreas. Dissect the pre-pancreatoduodenal space to expose the pancreas. Perform medial dissection to reveal the superior mesenteric vein.

Incise Toldt's fusion fascia lateral to the duodenum to connect the right retro-colic space and the pre-pancreatoduodenal space. Dissect cranially near the colonic hepatic flexure. Incise the parietal peritoneum of the right colon to complete the plane dissection for the caudal approach.

Have the assistant's left forceps pull the middle colic vessels cranially and the right forceps lift the ileocolic vascular pedicle. Incise the mesentery at the oblique fold below the ileocolic vascular pedicle connecting with the previously dissected right retro-colic space. Continue incising medially to expose the superior mesenteric vein.

Use the line from the root of the ileocolic vein to the medial edge of the middle colic artery as the cutting line and incise the right mesocolon. Open the superior mesenteric vein vascular sheath and dissect within the sheath to expose the ileocolic vein and artery, right colic artery, and middle colic artery. Perform mesenteric resection and D3 lymph node dissection along the medial border of the superior mesenteric vein.

Ligate the vessels stepwise using disposable ligation clips. Dissect Henle's trunk and its branches. Clearly expose the trunk before ligating the right colic vein to avoid injury to adjacent veins.

Complete all medial approach steps. Transition to the cranial approach by opening the gastrocolic ligament outside the gastroepiploic vascular arch. Separate the transverse colonic mesentery from the mesogastrium to connect with the medial dissection plane.

Dissect rightwards toward the hepatic flexure to complete excision of the right mesocolon. Trim the mesocolon and ileal mesentery along the planned transection lines. Perform transection using a 60-millimeter endoscopic linear stapler.

To perform intracorporeal digestive tract reconstruction, place the specimen in an endoscopic retrieval bag. Create an opening in the taenia coli 6 centimeters from the transverse colon stump, and another opening 2 centimeters from the ileal stump. Perform a side-to-side isoperistaltic anastomosis using a 60-millimeter endoscopic linear stapler.

Close the common opening with continuous 3-0 barbed suturing, followed by seromuscular imbrication. Then extend the infra-umbilical observation port incision 3 to 5 centimeters for specimen extraction. Irrigate the abdominal cavity with 500 to 1, 000 milliliters of normal saline.

Place one drain near the anastomosis and another in the pelvis. The mean patient age was 64.42 years, and the mean body mass index was 22.80 kilograms per square meter. Seven patients had a history of abdominal surgery and one patient presented with preoperative intestinal obstruction.

The mean operative time was 181.25 minutes, and the mean estimated blood loss was 76.67 milliliters. Total intracorporeal anastomosis was performed in six cases. The mean time to first flatus was 3.39 days.

To initiating a liquid diet was 4.57 days. And the mean postoperative hospital stay was 10.36 days. According to the American Joint Committee on Cancer Staging System, nine patients were stage I, 11 patients were stage II, and 13 patients were stage III.

Three patients received neoadjuvant therapy. The mean number of harvested lymph nodes was 26.85, and the mean number of positive lymph nodes was 1.30. The overall postoperative complication rate was 12.12%Postoperative complications included wound infection in two patients, chylous fistula in one patient, and anastomotic leakage in one patient.

My protocol is focused on the caudal approach, which prioritizes the utilization layer and may help reduce the difficulty of the surgery, improving surgical safety. Future research will evaluate the long-term prognostic impact of the caudal approach through extended follow-up studies.