with Dr. Beatriz Martín Pérez, Dr. Matthew Albert
We present the case of a 58-year-old female, who was found to have cecal cancer on a screening colonoscopy. The patient described no associated symptoms, and had a BMI of 34.
A medial mobilization was performed with central lymph node dissection, which included ligating the ileocolic, right colic, middle colic, and right gastroepiploic vessels successively at their origins.
The ileocolic and superior mesenteric vessel pedicles are located. The small bowel and the omentum are displaced and the transverse colon and the ileocecal junction are towed cranially and laterally respectively. These tractions tent up the root of the mesentery and the right mesocolon, displaying the ileocolic and superior mesenteric vessels clearly, even in very obese patients. The superior mesenteric vein is first exposed and the origin of the ileocolic vessels are identified and then ligated from the superior mesenteric vessels.
A medial-to-lateral approach creates a mesenteric window, just inferior to the ileocolic vascular pedicle. The right retrocolic space between the mesocolon and the right pre-renal fascia is the natural surgical plane, which is extended laterally and cranially. The inferior part of the duodenum is the first exposed structure, followed by the uncinate process of pancreas.
The superior mesenteric vein is skeletonized cranially, seeking the inferior part of the pancreatic neck, where the middle colic vessels branch out from the superior mesenteric vessels. The gastrocolic venous trunk is then located and skeletonized when dissecting the ventral part of the superior mesenteric vein caudally to cranially. The gastrocolic venous trunk is composed of the confluence of the right colic vein and the right gastroepiploic vein draining into the superior mesenteric vein at an average distance of 2 cm from the inferior pancreatic border.
The gastroepiploic artery was located at the anterior of the superior edge of the pancreatic neck, immediate to the right gastroepiploic vein. A hypopyloric lymphadenectomy could be performed along with the ligation of the gastroepiploic vessels.
The transverse colon was mobilized up to the hepatic flexure along the prior plane of dissection as well as the ascending colon, joining the right retrocolic plane. Then, the gastrocolic ligament was divided near the greater gastric curvature. The right colon was completely mobilized once the distal ileum had also been dissected.
Then, indocyanine green was injected to assess the vascularization of the transverse colon, at the level of the anastomosis. Vessels lit up under the camera, marking the site for the anastomosis, showing a correct vascularization. The same process was followed for the distal ileum. The transverse colon was sectioned using an endoGIA, as was the distal ileum.
A functional side-to-side intracorporeal anastomosis between the ileum and the transverse colon was performed. A single stitch was placed to fixate the bowels and facilitate the anastomosis. Two enterotomies were made on each side and an endoscopic stapler was introduced to create the anastomosis. The enterotomies were closed with a V-lock suture. The anastomosis was checked once more with indocyanine green, revealing a perfectly irrigated anastomosis.
For advanced tumors of the right colon, a right colectomy with D3 lymphadenectomy using a medial-to-lateral approach seems to be safe and feasible when the superior mesenteric vein serves as the main anatomical landmark and the right retrocolic space serves as the surgical plane.r advanced tumors of the right colon, a right colectomy with D3 lymphadenectomy using a medial-to-lateral approach seems to be safe and feasible when the superior mesenteric vein serves as the main anatomical landmark and the right retrocolic space serves as the surgical plane.
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