尾侧入路腹腔镜辅助右半结肠切除术

(1)暴露右髂窝小肠系膜根部与后腹膜粘连形成的黄白线,由此进入Told’s间隙,拓展间隙至头侧肝结肠韧带、肠系膜上血管及属支后方以及胰前间隙。(2)暴露结肠系膜腹侧,充分显露肠系膜上静脉走形,自静脉前纵行切开结肠系膜、解剖肠系膜上静脉,并与右侧融合间隙贯通;其后依次分离中间系膜及血管根部,并沿静脉右侧缘向头侧分离,结扎各结肠血管后切断;处理胃结肠干并离断副右结肠静脉。(3)切开胃结肠韧带进入小网膜囊,分离胃系膜和结肠系膜,扩展系膜间的融合间隙和胰前间隙,在胰腺前方与尾侧间隙相通。(4)完整游离后体外行回肠、横结肠的端侧吻合。     

腹腔镜辅助中央入路根治性右半结肠切除术

患者全身麻醉后,5孔法建立气腹,术者左侧站位。探查腹腔未见转移,行腹腔镜辅助中央入路根治性右半结肠切除术。手术步骤：充分显露右半结肠系膜,辨认回结肠血管,沿肠系膜上静脉投影切开右半结肠系膜根部,进入Toldt’s间隙。分离显露回结肠血管并清扫淋巴结,进而显露肠系膜上静脉。向头侧拓展显露肠系膜上静脉并清扫血管根部淋巴结。显露右结肠、中结肠血管,清扫其根部淋巴结。结扎离断回结肠血管、右结肠血管及中结肠血管右支。向头侧及外侧拓展Toldt’s间隙,分离回肠系膜根部,最后从外侧游离升结肠与内侧贯通,完成右半结肠游离。修整回肠,距回盲部10 cm离断血管弓。采用5 cm上腹正中辅助切口,完成回肠-横结肠端侧吻合并移除标本。     

尾侧入路腹腔镜右半结肠癌CME术

主要步骤包括:(1)腹腔探查;(2)右结肠后间隙(RRCS)拓展:进入Told筋膜与结肠系膜间的天然外科平面。至结肠肝曲水平,同时向内侧暴露十二指肠,此为进入横结肠后间隙(TRCS)的标志。(3)中间入路结扎肠系膜血管:以回结肠血管(ICV,ICA)在肠系膜表面投影为解剖标志打开结肠系膜,可轻易与其后方已打开的RRCS间隙相汇合。以肠系膜上静脉(SMV)为主线,清扫外科干,进一步解剖Henle’s干及其分支。(4)幽门下淋巴结清扫;(5)消化道重建。本文对由外周入路和中间入路发展而来的尾侧联合中间入路进行了简要介绍,该术式技术上可行,术者操作相对简便,手术安全性高,可供结直肠外科医生参考。     

腹腔镜辅助右半结肠癌根治切除术

采用中间入路五孔法。沿肠系膜上静脉(SMV)表面用超声刀切开后腹膜,暴露SMV。紧贴SMV主干离断回结肠动静脉,在右结肠动脉根部将其结扎切断。游离出结肠中动静脉脉主干、Henle’干、副右结肠静脉(SRCV)和胃网膜右静脉(RGEV)。结扎切断结肠中动静脉右支,解剖出胃网膜右动脉(RGEA),胰头前切开横结肠系膜前叶进入小网膜囊。依次在根部结扎切断SRCV、RGEV及RGEA。沿Todlt’间隙将右半结肠系膜掀向右侧腹,切断部分回肠系膜,沿右结肠旁沟切开侧腹膜。切断胃结肠韧带,清除第6组淋巴结。切断肝结肠韧带,完全游离右半结肠,在右中腹做小切口行标本切除及吻合。     

腹腔镜右半结肠切除术

术中纤维结肠镜业甲蓝染色定位,肿瘤位于结肠肝区,将大网膜和横结肠推向头侧,小肠推向左侧腹腔,暴露肠系膜根部,提起回盲部,沿肠系膜上静脉方向超声刀剪开后腹膜,分别于根部结扎回结肠动静脉和右结肠动静脉,同时清扫血管根部淋巴结.于结扎血管处进入Toldt间隙,暴露并切断胃网膜右血管,清扫幽门下方淋巴结.沿结肠外侧自髂窝至结肠肝曲,切开后腹膜,将升结肠从腹后壁游离,右下腹取7 cm切口,保护切口.体外切除右半结肠包括肿瘤、结肠系膜和足够的肠段（回肠末段、盲肠、升结肠和右半横结肠）.回肠横结肠端侧吻合.缝合横结肠系膜与回肠系膜的系膜裂口 放置引流,查无出血后,关腹.     

腹腔镜辅助全结肠系膜切除的右半结肠根治术

手术路径采用由内向外、自下而上的中间入路。右侧全结肠系膜切除(CME)手术强调间隙的分离和淋巴结的清扫。首先以回结肠血管解剖投影为起点切开腹膜,游离回结肠血管,显露肠系膜上静脉(SMV)远端并进入血管鞘,沿SMV向头侧解剖至胰腺颈部下缘,可逐个定位回结肠血管、右结肠血管和中结肠血管。在SMV前部行整体淋巴结清扫,再进入并由内向外拓展右侧Toldt间隙,显露十二指肠、胰腺头部、SMV的右侧及胃结肠干,最后由外侧分离将右半结肠完全游离,注意保护腹膜后结构。研究表明,CME理论指导下的右半结肠癌根治术可以彻底完成D3淋巴结清扫,并且降低局部复发和远处转移风险,延长总生存期。     

腹腔镜直肠癌低位前切除术

腹腔镜直肠癌低位前切除术。术中首先经中间入路打开乙状结肠系膜内侧浆膜,循Toldt’s间隙向头侧游离至肠系膜下动脉根部,夹闭离断肠系膜下动脉,并清扫253组淋巴结;继续向外侧、尾侧游离左侧Toldt’s间隙,并向下延续至直肠后间隙,分离过程中注意保护左侧输尿管、左侧生殖血管。沿左结肠旁沟打开结肠系膜与侧腹壁的融合筋膜,向上游离左侧结肠至脾曲。向下继续沿直肠后间隙分离,并向两侧拓展;前方在腹膜返折略上水平打开腹膜,在邓氏筋膜前间隙向下游离,从前、后及两侧交替游离并完整切除直肠系膜;双吻合器法切除直肠肿瘤及重建肠道。     

腹腔镜横结肠癌根治术

Trocar分布采用五孔法,助手向上牵拉横结肠,沿回结肠血管上方横行切开肠系膜血管表面腹膜,分别显露肠系膜上静脉和肠系膜上动脉,分离结肠中动脉,清扫NO.223淋巴结后于结肠中动脉根部结扎切断,向上分离至胰颈水平,根部结扎切断结肠中静脉,分离显露Henle干及其属支,切断右结肠静脉和网膜右静脉,拓展横结肠后胰十二指肠前间隙,三路包抄游离脾曲,注意保留肠系膜下静脉,肿瘤两端各10 cm确定肠管及胃网膜弓切除范围,清扫NO.204和NO.206淋巴结,游离肝曲。绕脐纵切口取出标本,两断端以直线切割闭合器完成侧侧吻合。     

全腹腔镜根治性右半结肠切除术

术中切开回结肠血管蒂下缘系膜进入正确层面,处理回结肠血管并清扫203组淋巴结;继续扩展右结肠后间隙,处理右结肠血管并清扫213组淋巴结,处理中结肠血管并清扫223组淋巴结;裁剪右侧半大网膜及横结肠系膜,游离结肠肝曲,向下游离整个右半结肠;全腔镜下行回肠横结肠侧侧吻合,标本装袋后取出。     

完全机器人下右半结肠根治性切除术

患者女,66岁,升结肠癌。右高左低平卧位。机器人置于右肩旁。3号臂牵拉回结肠皱襞,切开并拓展Toldt间隙。沿肠系膜上静脉分离,切断回结肠血管。显露结肠中动脉并在根部结扎其右支。本例Henle干由胃网膜右静脉、右结肠静脉(RCV)及副右结肠静脉(ARCV)汇合而成。结扎切断RCV与ARCV。在Gerota筋膜与Toldt筋膜间继续拓展平面完成游离。在回肠末段与横结肠中段用腔镜切割器横断。机器人下完成回肠横结肠侧侧吻合。     

Laparoskopische Chirurgie des Kolonkarzinoms

The current S3 guidelines on the surgical treatment of colorectal cancer note that with a suitable patient selection and expertise of the surgeon the same oncological results can be achieved laparoscopically as with the open procedure. This requires that the same quality requirements have to be provided for both methods. The most important quality parameters of right sided (extended) hemicolectomy are central ligation of the supplying arteries (ileocolic artery, right branch of the middle colic artery and middle colic artery) flush to the central origin of the vessel (superior mesenteric artery or middle colic artery) and the sharp dissection of the mesocolon without any preparation tears. The photographic documentation of the fresh surgical specimens for categorizing the preparation quality as well as to determine the pedicle of the vessel can capture this quality well and is also currently the best surrogate parameter to evaluate the oncological quality of the operation. At present, there are still considerable widespread deficits not only with the laparoscopic approach but also in open surgery which must be urgently fixed.     

Laparoscopic complete mesocolic excision (CME) with medial access for right-hemi colon cancer: feasibility and technical strategies

Objective

This study was designed to investigate the feasibility and technical strategies of laparoscopic complete mesocolic excision (CME) for right-hemi colon cancer.

Methods

The clinical and pathological findings of 64 patients with right-hemi colon cancer who underwent laparoscopic CME between March 2010 and September 2011 were collected retrospectively. Among them, 35 cases were eligible for the final analysis through various screening factors. The quality of surgery also was assessed by reviewing the recorded video obtained through the operations in terms of specimen anatomic planes and completeness of the excised mesocolon.

Results

Laparoscopic CME is focused on applying the concept of enveloped visceral and parietal planes during the operations. Laparoscopic approach proceeds with medial access where the dissection starts at ileocolic vessel before proceeds along with the superior mesenteric vessel. The access also emphasized en bloc resection of mesocolon without defections to the planes. Besides, lymph node resections at the root of ileocolic; right colic and middle colic vessels are necessary for ileocecum cancer. Cancers at the hepatic flexure requires further dissection of subpyloric lymph nodes and of greater omentum that is within 15?cm of the tumor and along the greater curvature. Thirty-five cases were evaluated as good plane. The median total number of central lymph nodes retrieved was 19 (range, 15?C25) and central lymph node metastasis was found in 5 of all stage III cases. The median operation time was 2.6?h and the blood loss was 80?mL. The median time for passage of flatus and hospitalization were 2 and 12?days respectively. Complications were observed in three cases.

Conclusions

CME is a novel concept for colon cancer surgery and might be a standard for the procedure. Laparoscopic CME with medial access is technically feasible and randomized trials are needed to evaluate its long-term outcomes.     

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??Surgical anatomy of superior mesenteric vessels and its distributaries XIAO Yi??LU Jun-yang??XU Lai. Department of General Surgery??Peking Union Medical College Hospital??Peking Union Medical College??Chinese Academy of Medical Sciences??Beijing 100730??China
Corresponding author: XIAO Yi??E-mail: xiaoy@pumch.cn
Abstract Objective To study the surgical anatomy of superior mesenteric vessels and its distributaries in the pancreaticoduodenal area. Methods The prospective observational trial included 27 patients performed laparoscopic complete mesocolic excision (CME) procedure in order to study the anatomical artery-vein relationships of the ileocolic vessels??right colic vessels??middle colic vessels??and the configurationally relationship of the distributaries to Henle’s trunk. Results Ileocolic vessels were found in each patient. The probability of right colic artery and vein were 33.3% and 11.1% respectively. The middle colic artery and vein were found at a rate of 88.9% and 92.6% respectively. The length of middle colic artery was 1.9??0 to 7.2??cm. The probability of Henle’s trunk was 92.6%??with the length of 0.8 ??0.2 to 2.4??cm. There were 2 to 5 branches drained into Henle’s trunk. Conclusion Laparoscopic CME procedure should start at dissecting ileocolic vessles??because of its constant location. Getting familiar with the complicated anatomic configuration of pancreaticoduodenal area would be helpful to precisional surgery.     

腹腔镜右半结肠切除术外科间隙的解剖学观察

目的探讨腹腔镜右半结肠切除术（LRC）相关筋膜和间隙的局部解剖学特点。方法对7具尸体和49例接受LRC的患者进行解剖学观察：比较腹部健康者和结肠癌患者的CT影像资料。结果在升结肠系膜和肾前筋膜之间存在各向交通的右结肠后间隙：其前、后、中线侧、外侧、头侧和尾侧边界分别为升结肠系膜、各向延续的肾前筋膜、肠系膜上静脉、右结肠旁沟腹膜反折、十二指肠水平部下缘和肠系膜根下缘。在横结肠系膜和胰十二指肠之间．存在横结肠后间隙．其头侧以横结肠系膜根为界。在横结肠系膜和大网膜之间,存在胃结肠系膜间间隙。在CT影像上。正常肾前筋膜是与腹横筋膜相延续的等密度细线,右结肠后间隙无法辨认;但对于右侧结肠癌患者,肾前筋膜和右结肠后间隙可能受侵犯而较易辨认。结论右结肠后间隙和横结肠后间隙对于LRC是天然外科间隙．‘肾前筋膜是天然外科平面。     

Retrocolic spaces: anatomy of the surgical planes in laparoscopic right hemicolectomy for cancer

To explore the regional anatomy of the fasciae and spaces around the right-side colon from laparoscopic perspective, we observed the location, extension, and boundaries of the spaces around the right-side colon in seven cadavers and in 49 patients undergoing laparoscopic right hemicolectomy for cancer, and reviewed computed tomography images from patients and healthy individuals. Between the ascending mesocolon and prerenal fascia (PRF), there was a right retrocolic space (RRCS), which extended in all directions. The anterior, posterior, medial, lateral, cranial, and caudal boundaries of the RRCS were the ascending mesocolon, PRF, superior mesenteric vein, right paracolic sulcus, inferior margin of the duodenum, and inferior margin of the mesentery radix, respectively. Between the transverse mesocolon and the pancreas and duodenum, there was a transverse retrocolic space, which was enclosed cranially by the radix of the transverse mesocolon. In CT images, healthy PRF was noted as slender line of middle density, continuing to the transverse fascia. The retrocolic spaces was unidentifiable, unless they were filled with retroperitoneal lesions. The RRCS and transverse retrocolic space are natural surgical planes for laparoscopic right hemicolectomy for cancer. The boundaries of these fusion fascial spaces are the best access, and the PRF is the best guide.     

Laparoscopic complete mesocolic excision for right colon cancer

Laparoscopic colectomy for colon cancer has become a standard of care, with a number of publications highlighting its safety, improved postoperative recovery, and excellent oncologic outcomes. Complete mesocolic excision, recently reemphasized, is associated with superior oncologic outcomes, although this has not been discussed for laparoscopic surgery. A laparoscopic approach was performed for right colon cancer using a four-trocar technique. The key steps demonstrated are identification and high division of the ileocolic pedicle, medial-to-lateral mobilization of the ascending colon preserving the posterior mesocolic fascia, identification and high division of the right branch of the middle colic artery, mobilization of the greater omentum and hepatic flexure, completion of lateral mobilization of the ascending colon from the retroperitoneum, and mobilization of the small bowel mesentery up to the duodenum. A prospective series of 52 consecutive patients with right colon cancer underwent laparoscopic complete mesocolic excision with high-vessel ligation. Four of the patients required laparoscopic en bloc extended resections for local invasion. The median operative time was 136 min (interquartile range [IQR], 105–167 min), and the median blood loss was 20 ml (IQR, 10–45 ml). The median hospital stay was 3 days (IQR, 3–5 days). All the patients had an R0 oncologic resection with median margins of 12 cm, and a median of 22 lymph nodes (IQR, 18–29 lymph nodes) was retrieved. The median follow-up period was 38 months (IQR, 23–54 months). Of 14 patients with tumor-positive lymph nodes, 2 experienced distant recurrence. There were no local recurrences, but four patients experienced metastatic disease at a median of 37 months (IQR, 22–46 months). The median overall survival time was 38 months (IQR, 23–54 months). The embedded didactic video demonstrates a straight laparoscopic complete mesocolic excision with high-vessel ligation for a patient who had a right colon cancer. Laparoscopic right complete mesocolic excision is a safe and effective procedure associated with excellent 3-year oncologic outcomes and accelerated postoperative recovery.     

Laparoscopic right hemicolectomy with complete mesocolic excision

Background

Complete mesocolic excision (CME) has recently been reemphasized as a technical approach for anatomical dissection during colon cancer surgery. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. In our practice, the patient lies in a modified lithotomy position. The first step is ileocolic area mobilization, followed by adequate retraction of the cecum laterally. This procedure enables discrimination of the ileocolic vessels and superior mesenteric vessels. Importantly, this method facilitates identification of the superior mesenteric vein (SMV), followed by the identification of the root of ileocolic pedicles. After that, sharp dissection along the SMV in an upward direction helps to safely identify the middle colic artery (MCA). Dissection then continues to the level of the origin of MCA, after which the right branch of MCA can be divided.

Methods

A total of 128 consecutive patients (63 males) who underwent laparoscopic CME for right colon cancer by a single surgeon were analyzed in this study.

Results

There was no conversion to open surgery. The median operation time was 192 min (interquartile range [IQR] 118–363 min). The median proximal and distal resection margins were 11 and 10 cm, respectively. The median number of harvested lymph nodes was 28 (IQR 3–88). There were six postoperative complications (4.6 %). The median hospital stay was 5 days (IQR 4–37 days). The video demonstrates a laparoscopic CME for a patient who had advanced distal ascending colon cancer.

Conclusion

In conclusion, identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure for containing all potential routes of metastatic tumors. Initial ileocecal mobilization with adequate counter traction of the cecum may be useful for novice surgeons attempting to identify the location of SMV during laparoscopic CME for right colon cancer.     

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目的探讨腹腔镜下完整结肠系膜切除(complete mesocolic excision,CME)根治右半结肠癌的技术可行性。方法回顾性分析2010年3月至2011年9月上海交通大学医学院附属瑞金医院行腹腔镜CME术35例的临床病理数据及视频资料,分析其安全性与技术可行性;采用West分级系统评价手术质量;通过解剖学绘图描述腹腔镜CME的手术入路,解剖层次及技术要点。结果 (1)脏层筋膜呈"信封样"包绕整个结肠系膜,需超声刀锐性分离脏壁层筋膜,达到血管根部结扎与完整系膜切除。(2)中间入路以回结肠血管解剖投影为起步点,沿肠系膜上静脉为主线解剖血管,进入Told与肾前筋膜间的天然外科平面。(3)盲肠及升结肠癌,需清扫回结肠、右结肠及结肠中血管根部淋巴结;结肠肝曲癌,还需清扫No.6淋巴结及切除距肿瘤以远10～15cm胃大弯侧胃网膜。(4)35例均成功完成腹腔镜下CME;手术质量等级判定C级33例;中位清扫淋巴结数19(15～25)枚,Ⅲ期病人系膜根部淋巴结阳性25%;中位手术时间2.6(2～4)h,术中出血80(50～300)mL,术后排气时间2(1～4)d,住院时间12(6～20)d;术后发生肺部感染1例,出血1例,乳糜漏1例。结论 CME为基于胚胎解剖学与肿瘤外科学的新理念,有望成为规范化手术方式;中间入路腹腔镜下CME技术上可行,是否改善远期疗效有待对照研究证实。