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Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
SAE Yeo
Surgical intervention
1 year ago
12293 views
1080 likes
0 comments
13:33
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
JL Ng, SAE Yeo
Surgical intervention
1 year ago
13962 views
1175 likes
0 comments
05:37
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)
Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.
S Puntambekar, V Sharma, H Parikh, G Joshi, S Mitkare, A Dokrimare
Surgical intervention
3 years ago
15903 views
596 likes
0 comments
11:00
Laparoscopic right hemicolectomy (mesocolic excision) in advanced right colonic tumor with parietal fixation (T4)
Similar to TME in rectal cancer, a comparable approach for the surgical resection of colonic cancers is described as complete mesocolic excision (CME), which includes central vascular ligation and dissection in the mesocolic space. According to a recently published Danish study, a 4-year disease-free survival (DFS) in the CME group was 85.8% whereas it was 75.9 % in the conventional group. Here, we present a video demonstration of laparoscopic right radical hemicolectomy in which complete mesocolic excision was performed. The mesocolic layer was identified as a shiny avascular film, which was preserved during the procedure in order to limit tumor dissemination. In this medial to lateral approach, the first duodenum is identified by incising the peritoneum and using a gauze piece for dissection purposes in an avascular plane, making sure to preserve the mesocolon. The right colic vessel is identified and clipped. The right branch of the middle colic artery and the ileocolic vessel are ligated. All fibrotic and adipose tissues are swept along with the specimen, and the ureter and gonadal vessels are dissected away. Lateral mobilization is achieved, and the specimen is then removed through small transverse incision to prepare for an extracorporeal ileo-transverse anastomosis.
Four different intracorporeal ileocolic anastomoses during suprapubic single incision laparoscopic right hemicolectomy
Background: Single incision laparoscopic right hemicolectomy is a feasible procedure. Suprapubic access allows to offer satisfactory cosmetic results in case of extended scar due to a large tumor. Intracorporeal anastomosis is mandatory through a suprapubic access, because it prevents traction on the mesentery and on the transverse mesocolon.
Video: This video shows four different types of intracorporeal ileocolic anastomoses.
1) Linear mechanical side-to-side
2) Completely manual side-to-side
3) Completely manual end-to-side
4) Completely manual end-to-end
At the end of each type of anastomosis, mesenteric defect closure is mandatory, to prevent intestinal obstruction caused by internal hernia.
Results: After an appropriate learning curve, time to perform linear mechanical anastomosis is 25 minutes and manual anastomosis takes 40 minutes.
Conclusions: Different ileocolic anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire right hemicolectomy, please click here.
G Dapri
Surgical intervention
4 years ago
3823 views
178 likes
0 comments
07:58
Four different intracorporeal ileocolic anastomoses during suprapubic single incision laparoscopic right hemicolectomy
Background: Single incision laparoscopic right hemicolectomy is a feasible procedure. Suprapubic access allows to offer satisfactory cosmetic results in case of extended scar due to a large tumor. Intracorporeal anastomosis is mandatory through a suprapubic access, because it prevents traction on the mesentery and on the transverse mesocolon.
Video: This video shows four different types of intracorporeal ileocolic anastomoses.
1) Linear mechanical side-to-side
2) Completely manual side-to-side
3) Completely manual end-to-side
4) Completely manual end-to-end
At the end of each type of anastomosis, mesenteric defect closure is mandatory, to prevent intestinal obstruction caused by internal hernia.
Results: After an appropriate learning curve, time to perform linear mechanical anastomosis is 25 minutes and manual anastomosis takes 40 minutes.
Conclusions: Different ileocolic anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire right hemicolectomy, please click here.
Laparoscopic right colectomy for caecal cancer using Sonicision™ cordless ultrasonic dissection device
The interest of this video is to demonstrate a fully laparoscopic oncologic right colectomy technique performed by means of novel dissection instruments such as the Sonicision™ cordless ultrasonic dissection device (Valleylab, Covidien) as well as stapling devices designed for anastomosis (Endo-GIA™ Tri-staple™ technology, Covidien). Regarding the Sonicision™ cordless ultrasonic dissection device, one may appreciate its efficacy, notably to achieve hemostasis of ileocolic and right colic vessels.
Its simplicity of use and safety in controlling the action to coagulate and divide tissues have been strongly appreciated from the operator’s side who is a regular user of the Ligasure™ technology. The great freedom of movement related to the absence of cable and to the lightness of the instrument accounts mostly for the almost immediate adoption of this novel laparoscopic instrument.
J Leroy, J Marescaux
Surgical intervention
7 years ago
6000 views
134 likes
0 comments
12:28
Laparoscopic right colectomy for caecal cancer using Sonicision™ cordless ultrasonic dissection device
The interest of this video is to demonstrate a fully laparoscopic oncologic right colectomy technique performed by means of novel dissection instruments such as the Sonicision™ cordless ultrasonic dissection device (Valleylab, Covidien) as well as stapling devices designed for anastomosis (Endo-GIA™ Tri-staple™ technology, Covidien). Regarding the Sonicision™ cordless ultrasonic dissection device, one may appreciate its efficacy, notably to achieve hemostasis of ileocolic and right colic vessels.
Its simplicity of use and safety in controlling the action to coagulate and divide tissues have been strongly appreciated from the operator’s side who is a regular user of the Ligasure™ technology. The great freedom of movement related to the absence of cable and to the lightness of the instrument accounts mostly for the almost immediate adoption of this novel laparoscopic instrument.
A laparoscopic right hemicolectomy with a primary vascular approach
Introduction:
We present the case of a 54-year-old male with a 5cm villous adenoma at the ileocaecal valve with a focus of invasive carcinoma. Previous attempts at endoscopic mucosal resection were unsuccessful.

Methods:
The set-up consisted of two 10/12mm ports (sub-umbilical and left iliac fossa) and three 5mm ports (right iliac fossa, supra-umbilical and epigastric). The primary vascular approach initially consists of identification, ligation and division of the vessels (ileocolic, right colic and right branch of the middle colic) at their origin, retroperitoneal mobilization of the mesocolon, taking down of the hepatic flexure and completion of the mobilization of the caecum and lateral attachments.

Conclusion:
The primary vascular approach to laparoscopic right hemi-colectomy is achievable.
M Walz, J Marescaux
Surgical intervention
7 years ago
11267 views
258 likes
0 comments
35:19
A laparoscopic right hemicolectomy with a primary vascular approach
Introduction:
We present the case of a 54-year-old male with a 5cm villous adenoma at the ileocaecal valve with a focus of invasive carcinoma. Previous attempts at endoscopic mucosal resection were unsuccessful.

Methods:
The set-up consisted of two 10/12mm ports (sub-umbilical and left iliac fossa) and three 5mm ports (right iliac fossa, supra-umbilical and epigastric). The primary vascular approach initially consists of identification, ligation and division of the vessels (ileocolic, right colic and right branch of the middle colic) at their origin, retroperitoneal mobilization of the mesocolon, taking down of the hepatic flexure and completion of the mobilization of the caecum and lateral attachments.

Conclusion:
The primary vascular approach to laparoscopic right hemi-colectomy is achievable.
En bloc laparoscopic right hemicolectomy associated to atypical hepatectomy for advanced cancer of the hepatic flexure
Background: An adenocarcinoma of the hepatic colic flexure associated to liver invasion was diagnosed in a 55 year-old woman, who consulted for weight loss and anemia. The patient was submitted to neoadjuvant chemotherapy and, after 4 cycles, an en bloc laparoscopic right hemicolectomy and atypical hepatectomy of segment VI was proposed.
Video: The surgeon stood between the patient’s legs, and the cameraman to the patient’s left. Four trocars were placed in the abdomen. The right mesocolon was opened at the root of the ileocaecal vessels, which were meticulously dissected and clipped. The arterial and venous branch of the middle colic vessels were sectioned as well. The right mesocolon was freed from the duodenum respecting Toldt’s fascia. The proximal transverse colon and the distal ileum were divided by firing of a linear stapler (purple and white loads). Peroperative ultrasonography permitted exclusion of other hepatic lesions and the delimitation of the en bloc resection of segment VI. The hepatic parenchyma was transected using the coagulating hook. A laparoscopic manual side-to-side ileocolic anastomosis by 2 runnings sutures was performed. The mesocolic defect was closed, and the specimen was retrieved through a protected suprapubic incision.
Results: Operative time was 180 minutes and estimated blood loss 150 mL. The patient was discharged on the 5th postoperative day. Pathology evidenced a pT4N1 colic adenocarcinoma. She underwent additional adjuvant chemotherapy, and was doing well at the time of the last office visit.
Conclusion: Advanced colic cancer associated to hepatic invasion can be safely treated by laparoscopy.
G Dapri, J Himpens, GB Cadière
Surgical intervention
7 years ago
7091 views
41 likes
0 comments
10:17
En bloc laparoscopic right hemicolectomy associated to atypical hepatectomy for advanced cancer of the hepatic flexure
Background: An adenocarcinoma of the hepatic colic flexure associated to liver invasion was diagnosed in a 55 year-old woman, who consulted for weight loss and anemia. The patient was submitted to neoadjuvant chemotherapy and, after 4 cycles, an en bloc laparoscopic right hemicolectomy and atypical hepatectomy of segment VI was proposed.
Video: The surgeon stood between the patient’s legs, and the cameraman to the patient’s left. Four trocars were placed in the abdomen. The right mesocolon was opened at the root of the ileocaecal vessels, which were meticulously dissected and clipped. The arterial and venous branch of the middle colic vessels were sectioned as well. The right mesocolon was freed from the duodenum respecting Toldt’s fascia. The proximal transverse colon and the distal ileum were divided by firing of a linear stapler (purple and white loads). Peroperative ultrasonography permitted exclusion of other hepatic lesions and the delimitation of the en bloc resection of segment VI. The hepatic parenchyma was transected using the coagulating hook. A laparoscopic manual side-to-side ileocolic anastomosis by 2 runnings sutures was performed. The mesocolic defect was closed, and the specimen was retrieved through a protected suprapubic incision.
Results: Operative time was 180 minutes and estimated blood loss 150 mL. The patient was discharged on the 5th postoperative day. Pathology evidenced a pT4N1 colic adenocarcinoma. She underwent additional adjuvant chemotherapy, and was doing well at the time of the last office visit.
Conclusion: Advanced colic cancer associated to hepatic invasion can be safely treated by laparoscopy.
Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient
Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk of perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided upon.
J Leroy, J Marescaux
Surgical intervention
10 years ago
7843 views
175 likes
0 comments
17:41
Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient
Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk of perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided upon.
Totally laparoscopic right hemicolectomy with transvaginal specimen extraction
We present our technique for totally laparoscopic right colectomy for locally advanced colon cancer with transvaginal specimen extraction. The patient was a 73-year-old female who presented with a biopsy proven cecal adenocarcinoma. We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position. Medial to lateral mobilization and early high ligation of the ileocolic pedicle were performed. The resected specimen was placed in a large retrieval bag.
With the patient positioned in modified lithotomy, a posterior culpotomy was made and the specimen removed intact through the vagina. The culpotomy was closed from the vaginal approach. A 60mm stapled side-to-side anastomosis was created intracorporeally to complete the procedure. The specimen was 52cm in length and contained a 3.2cm tumor and 13 lymph nodes. The patient's pathologic stage was T3N1.
S McKenzie, JH Baek, A Pigazzi
Surgical intervention
10 years ago
4505 views
103 likes
0 comments
08:30
Totally laparoscopic right hemicolectomy with transvaginal specimen extraction
We present our technique for totally laparoscopic right colectomy for locally advanced colon cancer with transvaginal specimen extraction. The patient was a 73-year-old female who presented with a biopsy proven cecal adenocarcinoma. We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position. Medial to lateral mobilization and early high ligation of the ileocolic pedicle were performed. The resected specimen was placed in a large retrieval bag.
With the patient positioned in modified lithotomy, a posterior culpotomy was made and the specimen removed intact through the vagina. The culpotomy was closed from the vaginal approach. A 60mm stapled side-to-side anastomosis was created intracorporeally to complete the procedure. The specimen was 52cm in length and contained a 3.2cm tumor and 13 lymph nodes. The patient's pathologic stage was T3N1.
Laparoscopic right colectomy for cancer
Laparoscopic colorectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colorectal procedures has been demonstrated. Surgeons performing right hemicolectomy using the laparo-assisted technique consider it more difficult than open colectomy. It is possible to perform a completely laparoscopic right hemicolectomy in advanced laparoscopic centers with many benefits: less postoperative pain, short-term postoperative ileus, earlier return to daily activity. This chapter describes surgical anatomy, indications and techniques of laparoscopic right colon resection for cancer.
J Leroy, J Marescaux
Operative technique
10 years ago
86596 views
776 likes
1 comment
Laparoscopic right colectomy for cancer
Laparoscopic colorectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colorectal procedures has been demonstrated. Surgeons performing right hemicolectomy using the laparo-assisted technique consider it more difficult than open colectomy. It is possible to perform a completely laparoscopic right hemicolectomy in advanced laparoscopic centers with many benefits: less postoperative pain, short-term postoperative ileus, earlier return to daily activity. This chapter describes surgical anatomy, indications and techniques of laparoscopic right colon resection for cancer.
Laparoscopic treatment for right colon cancer
This video demonstrates an uncomplicated laparoscopic right hemicolectomy in an obese lady with cecal cancer. The surgeon uses 4 trocars to achieve medial mobilization of the mesentery, divide the ileocolic at the root and then mobilize the right colon up to proximal transverse colon. The terminal ileum is divided intracorporeally and the specimen is retrieved through a right lateral skin crease muscle splitting incision. An extracorporeal stapled anastamosis is made and the mesenteric window is not closed.
This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy for cancer using the medial approach.
T Rockall
Surgical intervention
13 years ago
5775 views
173 likes
0 comments
10:11
Laparoscopic treatment for right colon cancer
This video demonstrates an uncomplicated laparoscopic right hemicolectomy in an obese lady with cecal cancer. The surgeon uses 4 trocars to achieve medial mobilization of the mesentery, divide the ileocolic at the root and then mobilize the right colon up to proximal transverse colon. The terminal ileum is divided intracorporeally and the specimen is retrieved through a right lateral skin crease muscle splitting incision. An extracorporeal stapled anastamosis is made and the mesenteric window is not closed.
This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy for cancer using the medial approach.