Article Type : Research Article
Authors : Viola Malet M, Laurini M, Rodriguez P and Muniz N
Keywords : Oncologists; Radiotherapists; Endoscopists; Imaging specialists; Pathologists
Colorectal
cancer continues to be a very important health problem today, representing 10%
of all cancers worldwide, and responsible for 9.4% of cancer mortality around
the world. Laparoscopic surgery has shown to offer benefits compared to open
surgery, which are already widely known. As shown by various publications
(COLOR, COLOR II, and CLASSIC among others). Right colectomy has historically
been considered an intermediate complexity procedure, not standardized, and
generally performed by residents and less experienced general surgeons. This
has led to the fact that the morbidity and mortality related to it and the
oncological results over the years have not been ideal. In the last 30 years,
the development of laparoscopic colon surgery has been exponential, despite the
initial reluctance of many surgeons to use it in oncological pathology, due to
publications from the early 1990s that reported worse oncological results using
this approach. Since Hogenberger's publication in 2009 on the standardization
of colon cancer surgery, central vascular ligation, and complete excision of
the mesocolon, the surgical community's view of this technique has changed
substantially. Today these concepts are the cornerstone of colon cancer
surgery.
Objective:
We present our way of performing standardized step by step laparoscopic right
colectomy with central vascular ligation and complete excision of the
mesocolon, and revision of the literature. Secondarily, we present the
short-term and oncological outcomes of our series of 238 laparoscopic right
colectomies, of which 206 were for malignant pathology.
We have created a multidisciplinary team within our
hospital that is almost exclusively dedicated to colorectal surgery, with a
significant focus on oncological surgery. This is a colo-rectal surgery ERAS
TEAM, which includes five anaesthesiologists, three surgeons, a nurse who
specializes in nutrition, a nurse who specializes in the handling of ostomies,
and a chief nurse, who is our true star, and is in charge of educating the
patients and their families, as well as ensuring continuity of the healthcare
process. They also participate in the care of our patients and in the tumor
committee, where we make individualized therapeutic decisions for each patient.
The team includes oncologists, radiotherapists, endoscopists, imaging
specialists, and pathologists. In the year two thousand and seventeen we
launched our ERAS program for colorectal surgery. It entails a step-by-step
standardized procedure that includes intracorporeal sutures. As I mentioned
before, we have been teaching and performing colorectal laparoscopic surgery in
a standardized and repetitive way for a number of years. This allows us to
cross the river by stepping steadily on each Stone, which prevents us from
falling into the water. We have achieved optimal operative times, reduced
surgical morbidity and mortality, and have had a positive impact on oncologic
outcomes. Al these measures involve not only the surgeon, but all of the
healthcare team. Always keeping the patient and their family at the center of
our attention, we provide horizontal care over time and across spaces, with
communication among different specialists to ensure the highest quality and
excellence of care based on the best scientific evidence. Referring specifically
to right colectomy, it all changed in two thousand and nine, following
Hohemberg´s publishing of two key concepts in colonic surgery: complete
mesocolonic excision and central vascular ligation. These follow the precepts
that Heald described for rectal surgery in nineteen eightytwo, giving special
emphasis to the mesocolic dissection following embryologic planes, ensuring an
en-bloc resection of the mesocolon, with no disruption of its folds. There is
an historic confrontation between Eastern and western concepts of oncologic
surgery. On one side they state that oncological radicality lies in extended
lymphadenectomies (D3), while on the other the focus is set on the indemnity of
the mesocolic folds (CME). However, these are not actually opposite standpoints
but complementary approaches that allow a safer procedure from an oncological
point of view. When talking about CME we refer to respecting embryological
vascular planes that will guide our dissection, without violating the
peritoneal folds of the mesocolon. To this concept, we add CVL (Central
Vascular Ligation), which tries to ensure a complete lymphnode harvest by
performing the vascular transection close to the superior mesenteric vessels.
Finally, we must ensure the lateral oncologic margins within the colon wall (at
least 10cm from the tumor´s macroscopic margin on each side) and the pericolic
lymph node harvest. The embryologic planes that must guide our oncologic
dissection during the right colectomy procedure are: right Toldt´s fascia, Fredet´s
fascia and the fascia of Treitz. The pathologist´s audit of the surgical
specimen gives us information about the quality of the surgery. Garcia Granero
and collaborators propose that the right colectomy specimen must be shaped as a
sail, the boom being the ileocolic vessels, the mast being the surgical trunk
of Guillot, and the cloth of the sail represented by the right mesocolon
including the duodenal window. When aiming for oncologic radicality in right
colectomy we therefore must include CME and D3 lymphadenectomy. This includes
dissection following embryological planes, and ligation of the superior right
colic vessels, as well as the right branch of the middle colic vessels, at
their origin. To make it clear what we mean when we talk about the different
levels of lymphadenectomy in right colectomy, we present the different
definitions: D1 lymphadenectomy includes pericolic lymph nodes located at least
ten cm proximally and distally from the tumour. D2 lymphadenectomy adds
intermediate lymph nodes, in relation to the duodenal window of the right
mesocolon. D3 lymphadenectomy adds central lymph nodes, in relation to Guillot
Trunk, along the superior mesenteric vessels. When we are discussing an
extended lymphadenectomy, we must remember it has precise indications, needing
a thorough preoperative diagnosis, and a trained surgical team, with an
acceptable rate of surgical morbidity and mortality.
The patient is set in a 30-degree Trendelemburg
position and sided to the left, making the small bowel fall into the upper left
quadrant of the abdomen, and allowing for a great exposition of the right side
of the abdominal cavity.
The surgeon stands at the patient´s left side, at his
left flank. We use four laparoscopic ports: a 12mm umbilical port for the
camera, a 12mm port on the left flank for the surgeon´s right hand, a five mm
suprapubic port for the surgeon´s left hand and another five mm port at the
right hypochondrium for the assistant.
We create a pneumoperitoneum of ten to twelve mm of
mercury, therefore avoiding the side effects of the CO2-related lowering of the
patient´s body temperature, and abdominal hypertension (Picture 1). We begin
the procedure by dividing the falciform ligament, maneuver that will allow us to
position the transverse colon and greater omentum above the liver, gaining
space in the inframescolic space (Picture 2). Here we can see the medial
approach for the blunt dissection of Todt´s fascia, below and posterior to the
ileocolic vessels (Picture 3). Once the ileocolic vessels are completely
dissected, we clip and section the ileocolic vein at its origin (Picture 4). Then
we proceed to clip and section the ileocolic artery at its origin, and continue
the dissection of the Fascia of Fredet before the duodenum and the pancreatic
head (Picture 5). Next step is the clipping and sectioning of the superior
right colic artery at its origin, and completing the dissection of Fredet´s
Fascia (Picture 6). We now complete Henle´s Trunk´s dissection and clip the
superior right colic vein at its origin (Picture 7). We identify and divide the
right Branch of the middle colic vessels (Picture 8). Afterwards, we continued
with the section of the greater omentum (Picture 9) and then divided the
gastrocolic ligament and the right gastroepiploic vessels are identified (Picture
10). Next step is the division of the parietocolic ligament, completing the
mobilization of the distal ileum and right colon (Picture 11). Once the
mobilization is completed, we perform the section of the distal ileum and
transverse colon (Picture 12). In Picture 13, we show the final view of the
dissection once we finish with the mobilization and resection of the specimen.
The clips on the central vascular ligation can be seen on the superior mesenteric
vessels. We once again perform an Indocyanine green angiography to evaluate
ileum and colonic perfusion (Picture 14). And then make an intracorporeal,
side-to-side, isoperistaltic, anastomosis. We then finish by closing the enterotomy
manually in two planes (Picture 15). (You can watch the entire video on the
websurg website, https://websurg.com/es/doi/vd01en6305/).
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A total of 238 medical records of patients who
underwent surgery over a period of 14 years (2008-2022) were analyzed. Of
these, the last 146 were included in an ERAS multimodal rehabilitation
protocol. The IBM SPSS Statistics version 25 program was used for analyzing the
variables.
Our case series includes two-hundred and thirty-eight patients, one hundred and thirty-four women, and one-hundred and four men, with an average age of 65 years. Hospital stay was in average 4 days. Anastomotic leak rate is 7,5%, and we have achieved a lower rate of 4,7% by applying the ERAS multimodal rehabilitation protocols and performing intracorporeal anastomoses. Over 85% or our patients are intervened due to malignant tumors. Operative mortality in our series is 1,9% (Table 1).
Table 1: Operative mortality in our series.
A 72% of the patient presented with locally advanced tumors, and nearly 40% had lymph node metastasis. Two-thirds of the patients presented at Stages II and III (Table 2).
Table 2: Two-thirds of the patients presented at Stages II and III.
Kaplan Meier survival curves show an overall five-year survival rate of 77,3% in our series (Graph 1).
Graph
1:
Kaplan-Meier Global Survaival curves and 5y GS.
Disease free survival rates for patients who had recurrences were 27, 5 months, and 86, 5% of patients were disease free five years after surgery (Graph 2).
Graph 2: Kaplan-Meier Disease Free Survival curves and 5y DFS
The survival rate of patients in stage cero is one 100%, 91, 4% for stage I, 88, 9% for stage II, 79, 2% for stage III and 53, 8% percent for stage IV. The global survival rate is 88, 7% (Graph 3) [1-19].
Graph
3: Kaplan-Meier
Stage Survival curves and 5y Sv.
Without a doubt, if we want to consider the
laparoscopic right colectomy as the gold standard for this procedure, we must
work together as a team and in a standardized manner. This will allow us to
navigate through still water, and if the waters are turbulent, we will always
have a tutor who can get us through. This way this scenario won´t happen, we
won´t end up in the water, and most importantly: the patient won´t drown.
Lastly, to perform a secure laparoscopic right colectomy it is of the utmost
importance to have a standardized step-by-step technique and a program that
involves the whole healthcare process. We must have a highly trained team and
the possibility of intraoperative tutoring by experienced surgeons (at least at
the beginning). Training and simulation are two non-negotiable tools for the
surgeon and his team. Recording of data and a permanent audit are also
essential to allow continuous improvement, and to offer the highest quality of
healthcare.