Abstract
Introduction:
Total laparoscopic left hemicolectomy (D3 + complete mesocolic excision (CME)) based on membrane anatomy is an advanced minimally invasive technique in gastrointestinal oncology. 1 This procedure is performed through D3 lymphadenectomy 2 and dissection along the avascular plane between the mesocolon and mesenteric bed. It eliminates potential “fifth metastases.”3–4 It offers faster recovery, minimal scarring (vs. open surgery), and less bleeding. Herein, we present a video of this procedure for a 50-year-old female with splenic flexure colon cancer.
Methods:
The patient was placed in the lithotomy position with a Trendelenburg tilt. The small intestine was positioned cranially to expose the mesenteric root. Adhesiolysis between the sigmoid colon and left iliac fossa was performed, and the left Toldt’s space was expanded by dissecting along the sigmoid colon-Gerota fascia plane under assistance traction. The sigmoid mesocolon was fanned out, and the peritoneal membrane bridge at the right rectal fossa was incised with an electric knife. Utilizing the “hollowing effect,” fibrous connections between the sigmoid mesenteric dorsal leaf and Gerota fascia were transected to expand and lateralize the left Toldt’s space. The sigmoid mesenteric root was incised to expose the inferior mesenteric plexus, with station 253 lymph node dissection. Skeletonize the inferior mesenteric artery to the root of the left colic artery (LCA), then ligate and transect the LCA and superior rectal vein with concurrent dissection of station 232 lymph nodes. After repositioning to reverse Trendelenburg tilt, mesenteric mobilization extended cranially to the pancreatic body-tail inferior border, with gauze placement. The transverse mesocolic root was incised to expose the middle colic artery root; its left branch and middle colic vein (MCV) were transected, with station 223 and partial station 222 lymph node dissection. The greater omentum was incised to enter the omental bursa, and the splenic flexure was mobilized to communicate with the left Toldt’s space. The inferior mesenteric vein was ligated and transected. The bowel was transected 10 cm proximally and distally to the tumor, and a laparoscopic transverse-descending colon overlap side-to-side anastomosis was performed.
Results:
The operation lasted 3 h with intraoperative blood loss of 5 mL. The patient ambulated and started a liquid diet on post-operative day (POD) 1, passed flatus on POD 3, and was discharged on POD 8 (POD 5 hemoglobin: 94 g/L). Pathology confirmed pT4aN2a(4/21)M0 (stage IIIC) with perineural/vascular invasion. Adjuvant XELOX chemotherapy (6 cycles) was initiated 2 weeks postoperatively. At the 5-month follow-up, hemoglobin was 115 g/L, tumor markers were normal, and abdominal contrast-enhanced CT showed no recurrence.
Conclusion:
Total laparoscopic left hemicolectomy (D3 + CME) based on membrane anatomy reduces intraoperative bleeding/trauma, achieves complete D3 lymphadenectomy, eliminates “the fifth metastasis,” and improves prognosis.
The authors are deeply indebted to Professor Leya He for his invaluable guidance in study design, the refinement of surgical techniques, and article development.
L.H. had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: L.H. and J.G. Acquisition, analysis, or interpretation of data: All authors. Drafting of the article: All authors. Critical revision of the article for important intellectual content: All authors. Supervision: L.H.
This study was approved by the Ethics Committee of Tongji Hospital Affiliated to Tongji Medical College. Patients provided written informed consent pre-enrollment, and all clinical data were used with their full permission.
This study and article preparation received no funding from any public, commercial, or non-profit entity. The authors declare no relevant financial support or sponsorship.
No competing financial interests exist.
Runtime of video:
9 mins 55 secs.