A laparoscopic complete mesocolic excision for the surgical treatment of right hemicolon cancer

Safety and Short-term Efficacy of a Laparoscopic Complete Mesoco-
lic Excision for the Surgical Treatment of Right Hemicolon Cancer
Original article
Ting Li et al 29
Clin Surg Res Commun 2018; 2(2): 29- 33
Ting Li*, Xiang-Ling Meng, Wei Chen
Abstract
Objective: This study was designed to evaluate the safety and short-term efficacy of a laparoscopic complete
mesocolic excision (CME) in patients with right hemicolon cancer.
Methods: A total of 88 patients with right hemicolon cancer were retrospectively reviewed. Forty patients
underwent laparoscopic CMEs, and 48 patients underwent open CMEs. The clinical data were analyzed and
the outcomes were compared between the two groups.
Result: There was no significant difference between the laparoscopic CME group and open CME group with
regard to the harvested lymph node number (16.60±3.20 vs. 15.33±3.10, respectively, P=0.060), hospital stay
length (18.15±5.17 days vs. 17.21±4.47 days, respectively, P=0.360), and postoperative complications (10.0%
vs. 10.4%, respectively, P=0.950). The operation time in the laparoscopic CME group (3.02±0.55 hours) was
significantly longer than that in the open CME group (2.58±0.50 hours, P=0.004). The time to first flatus
(3.28±0.75 days vs 3.92±0.71 days, respectively, P=0.001) and getting out of bed time (1.95±0.75 days vs
3.54±0.71 days, respectively, P=0.001) were both earlier in the laparoscopic CME group than in the open CME
group.
Conclusion: A laparoscopic CME is a safe and effective minimally invasive surgery for the treatment of right
hemicolon cancer.
Keywords: colon cancer; complete mesocolic excision; laparoscope
Corresponding author: Ting Li
Mailing address: Department of Gastrointestinal Surgery,
the First Affiated Hospital of Anhui Medical University, Hefei
230022, China
Address: Jixi Road No.218, Hefei, Anhui, 230022, China
E-mail: tingli_022@163.com
lon cancer have improved over the last decade [5,6]
. In-
creasing evidence has reported that CMEs contribute
to a decreased recurrence rate and increased five-year
survival [4,7,8]
. At present, a CME is considered to be the
standard surgical method for treating colon cancer.
Laparoscopy is a minimally invasive technique that
can allow one to visualize the inside of the abdominal
cavity with a special camera, and the application of lap-
aroscopic surgery was a significant revolution in clin-
ical practice [9]
. When compared with traditional open
surgery, a laparoscopic surgery has the advantages of a
smaller incision, less pain, and a more rapid recovery.
Moreover, laparoscopy has been widely used in gas-
trointestinal malignancy surgeries. A CME can also be
guided via a laparoscope, and this procedure is called
a laparoscopic CME. It has been reported that a laparo-
scopic CME provides a better prognosis for colon can-
cer treatment [10,11]
. Feng et al. first introduced the lap-
aroscopic CME procedure for right hemicolon cancer
[12]
; however, the literature regarding this technology
for the surgical treatment of right hemicolon cancer is
relatively sparse.
In this study, the clinical data of patients with right
hemicolon cancer who underwent laparoscopic CMEs
was retrospectively reviewed, and the safety and short-
term efficacy were evaluated.
INTRODUCTION
Colon cancer is a common gastrointestinal malignan-
cy, and it is becoming more common among younger
age groups [1]
. There are several therapeutic options for
the treatment of colon cancer. However, surgery is the
most frequently used and efficient method for all stages
of colon cancer [2]
. The concept of a total mesorectal ex-
cision (TME) was first introduced in 1986 by Heald and
Ryall, and it was considered to be the standard surgical
treatment for rectal cancer [3]
. In 2009, Hohenberger et
al. first proposed that a TME could be translated into a
surgical treatment for colon cancer, and this was called
a complete mesocolic excision (CME) [4]
. This technique
is performed in order to obtain a complete separation
of the mesocolon from the parietal plane, while the sup-
plying arteries and draining veins are ligated at their
roots. This technique has been proven to achieve lower
local recurrence rates and better overall survival. With
the development of the CME, radical resections for co-
Department of Gastrointestinal Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
DOI: 10.31491/CSRC.2018.6.016
Creative Commons 4.0

Ting Li et al 30
Published online: 26 June 2018
ANT PUBLISHING CORPORATION
METHODS
General patient information
A total of 88 patients with right hemicolon cancer were
enrolled from January 2012 through December 2015.
Forty patients underwent laparoscopic CMEs and 48
patients underwent open CMEs. Those cases with no
history of chemotherapy and/or radiotherapy under-
went enteroscopies, and they were diagnosed with co-
lon cancer via a pathological diagnosis. Those patients
with distant metastases and unresectable tumors were
excluded via the examination of chest x-ray films, chest
computed tomography (CT) scans, abdominal and pel-
vic brightness (B) scan ultrasonography, CT scans, and/
or magnetic resonance imaging (MRI). The surgery was
chosen after full communication with the patients and
their dependents. The general information of the pa-
tients in both groups is shown in Table 1.
Surgical procedure
Laparoscopic CME
After administering general anesthesia, the patient was
placed in the supine position with their legs apart. A
10-mm trocar was inserted into the umbilical region
for the camera port, and a 12-mm trocar was inserted
into the left midclavicular line 5 cm bellow the costal
margin for the main operating port. The 5-mm trocars
were inserted into the anterior superior iliac spine on
both sides and the midpoint of the umbilical cord, as
well as the right costal arch midclavicular line 5 cm be-
low the costal margin for the assistant operating ports.
The pneumoperitoneum pressure was maintained at
13 to 14 mmHg.
Aroutineabdominalexplorationwasperformedtocon-
firm the tumor location. After determining the locations
of the superior mesenteric vein and ileocolic vessel, the
right mesocolon was incised up to Toldt’s space, and
the duodenum was exposed using an ultrasound knife
2 cm below the ileocolic vessel. An incision was made
in the posterior peritoneum along the front left side of
the superior mesenteric vein, and the pericolic mesen-
teric lymph nodes and adipose tissue were dissected.
The ileocolic and right colic artery and vein were fully
exposed and skeletonized, and the vessel roots were li-
gated using a Hem-o-lock vascular clamp. The ascend-
ing mesorectum was raised, and the fusion fascial space
between the posterior mesorectum (Toldt’s fascia) and
the prerenal fascia (Gerota’s fascia) was entered. An in-
cision was made along the fusion fascial space up to the
junction of the ascending colon and the lateral abdomi-
nal wall, being careful not to damage to the ureters and
reproductive blood vessels. After dissociating upward
to expose the head of the pancreas and the descend-
ing and horizontal parts of the duodenum, the lymph
nodes in front of the pancreas and the surrounding
lymph nodes in the right gastroepiploic vessels were
removed. The surgical trunk was exposed at the roots
of the mesentery, and its surrounding lymph nodes and
adipose tissue were removed. The right branches of the
blood vessels in the colon were located and cut. If the
tumor was located next to the middle of the transverse
colon, the roots of the blood vessels in the colon were
interrupted using a clip. An ultrasonic blade was used
to cut the right omentum majus to the right of the gas-
tric retinal vascular arch, continuing on to incise the he-
patocolic ligament and the right ligamentum phrenico-
colicum towards the right. An incision was then made
downward on the right side of the peritoneum of the
ascending colon along the right paracolic sulcus. This
incision met the medial separating surface, completing
the dissociation of the right colon and its entire mes-
entery. The specimens from the excision underwent an
ilecolostomy, the abdominal cavity was rinsed with dis-
tilled water, and a drainage tube was placed under the
right side of the liver.
Open CME
The cecum, ascending colon, flexura hepatica coli, right
transverse colon, and mesangial vessels and lymph
nodes were removed. Five centimeters of the distal il-
eum and omentum majus were also removed. The sur-
gical procedure was consistent with the main points of
a CME, and it was performed via the sharp incision of
the fascia and high ligation of the central vessels. The
lymph nodes in the roots of the mesenteric vessels were
carefully removed.
Data collection
The data from all the patients undergoing the CMEs
was recorded and compared between the two groups,
including the operation time, getting out of bed time,
dissected lymph node number, time to first flatus, and
postoperative complications. Each patient received a
follow-up in order to determine any tumor recurrenc-
Laparosc
opicCME
Open CME Pvalue
Cases 40 48
Age (years) 59.52 60.81 0.611
±12.42 ±11.63
Gender 0.508
Female 18 25
Male 22 23
TNM stage 0.872
I 4 4
II 27 34
III 9 10
Table 1 . General information of patients

Ting Li et al 31
es or metastases. The duration of the follow-up ranged
from 1 to 46 months.
Statistical analysis
The statistical analysis was performed using SASS 12.0
software. The categorical data were compared using a
χ2 test, and the measurement data were compared with
an independent samples t test. A P value of less than
0.05 was considered to be statistically significant.
RESULTS
Surgical procedure
The general information from Table 1 shows that there
were no statistical differences in the age, gender, and
Tumor, Node, Metastasis (TNM) stage between the
laparoscopic CME and open CME groups (P>0.05). All
of the laparoscopic and open CME operations were fin-
ished smoothly, and no surgery-related or perioperative
deaths occurred in any of the cases. As shown in Table
2, the operation time in the open CME group was statis-
tically shorter than that in the laparoscopic CME group
(3.02±0.55 vs. 2.58±0.50 hours, P=0.004). The patholo-
gy reports showed no statistical difference in the har-
vested lymph node number between the two groups
(16.60±3.20 vs. 15.33±3.10, respectively, P=0.060).
Table 2 Postoperative recovery
Postoperative recovery
The length of the hospital stay for the patients in the
laparoscopic CME group was similar to that in the
open CME group (18.15±5.17 vs. 17.21±4.47 days, re-
spectively, P=0.360). However, the laparoscopic CME
group had a significantly shorter getting out of bed time
(1.95±0.75 vs. 3.54±0.71 days, respectively, P<0.001)
and a significantly shorter time to first flatus (3.28±0.75
vs. 3.92±0.71 days, respectively, P<0.001).
Postoperative complications
The postoperative complication rate in the laparoscop-
ic CME group was 10.0% (4/40), and the complications
included incision infections (n=3) and an intestinal ob-
struction (n=1). The complication rate in the open CME
group was 10.4% (5/48), including incision infections
(n=3), a pulmonary infection (n=1), and postoperative
anastomotic bleeding (n=1). There were no anastomotic
fistulas in either group. Moreover, there was no statis-
tical difference in the postoperative complication rate
between the two groups. During the follow-up (range
from 1 to 46 months), there were two tumor recur-
rence cases in the laparoscopic CME group and three
tumor recurrence cases in the open CME group. In ad-
dition, one patient in the laparoscopic CME group died,
and two patients in the open CME group died during
the follow-up. There were no statistical differences in
the recurrence rates (χ2=0.06, P=0.80) and death rates
(χ2=0.18, P=0.67) between the two groups.
DISCUSSION
The postoperative rectal cancer recurrence rate has
been significantly reduced, and the postoperative sur-
vival rate has been significantly improved since Heald
and Ryall presented the concept of a TME [3,13]
. In 2009,
Hohenberger et al. proposed the standardized applica-
tion of the CME in the radical resection of colon cancer.
They also analyzed a total of 1,329 patients with colon
cancer that had undergone CMEs, and they concluded
that a CME could significantly reduce the recurrence
rate and improve the survival rate [4]
. Based on the ex-
perience of Hohenberger et al., a CME should be per-
formed in the radical resection of colon cancer in or-
der to remove all of the tumors, based on the excision
of the complete mesocolon, and achieve a maximum
lymph node harvest. The CME has brought the new
concept of fine anatomy throughout the entire colon
cancer surgery process. We conducted CMEs based on
laparoscopic right hemicolon cancer resections, and we
observed their short-term efficacy and safety.
After reviewing the clinical data, we discovered that
the incision pain was slighter, and the time to get out of
bed and time to first flatus was earlier in those patients
who underwent laparoscopic CMEs than in those who
underwent open CMEs. This may have been due to the
minimally invasive laparoscopic surgery, with its small
abdominal incision and a slight traumatic reaction,
which are beneficial for the rapid recovery of postoper-
ative intestinal function. Its minimally invasive feature
is also good for preventing pulmonary complications.
In this study, the postoperative complications includ-
ed incision infections in three cases and an intestinal
obstruction in one case, but there were no pulmonary
Laparoscopic CME Open CME P value
Operation time (h) 3.02±0.55 2.58±0.50 0.004
Harvested lymph node number 16.60±3.20 15.33±3.10 0.060
Length of hospital stay (d) 18.15±5.17 17.21±4.47 0.360
Getting out-of-bed time(d) 1.95±0.75 3.54±0.71 <0.001
Time to first flatus(d) 3.28±0.75 3.92±0.71 <0.001
Table 2. Postoperative recovery
DOI: 10.31491/CSRC.2018.6.016

Ting Li et al 32
Published online: 26 June 2018
ANT PUBLISHING CORPORATION
correct anatomical level and improving the operation.
CME operations in laparoscopic hemicolectomies for
right colon carcinoma cases have been carried out in
the clinic [19,20]
. They not only elevate the survival rate,
but they also improve the quality of life of the patients
[10]
. This procedure has the advantage of being minimal-
ly invasive, and the patients can achieve rapid recovery
after the surgery. A laparoscopic CME for the treatment
of radical right colon cancer has been proven to be safe
and feasible, and its short-term curative effect is satis-
factory. It is a minimally invasive surgical method with
application prospects; however, the long-term efficacy
requires further study.
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of fine anatomy. A sharp dissection was made along the
fusion fascial space between Toldt’s fascia and Gero-
ta’s fascia, along the pancreaticoduodenal fascia. The
gastrocolic ligament was removed under or above the
vessel arches of greater curvature, and the right hemi-
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emphasizes the complete resection of the lymph nodes
and mesentery [4]
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superior mesenteric vein and arterial surface were
opened, and the blood vessels were ligated and cut off
in the central area for the most thorough removal of
the lymph nodes. It is also beneficial to block the he-
matogenous spreading pathway of the tumor. The op-
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sistent with the tumor-free principle in tumor surgery.
Third, the local magnification of the surgical field under
laparoscopy is fully utilized, making it more accurate
in the surgical approach and at the anatomical level.
The enlargement of the laparoscope enables the small-
er lymph nodes to be easily identified and removed.
Fourth, the use of an ultrasound knife can significant-
ly reduce blood loss, facilitating the dissection at the

Ting Li et al 33
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DOI: 10.31491/CSRC.2018.6.016

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