Laparoscopic Colorectal Surgery for Cancer: What Is the Role of Complete Mesocolic Excision and Splenic Flexure Mobilization?

Laparoscopic colorectal surgery for cancer is nowadays routinely performed worldwide. After the introduction by Heald of total mesorectal excision for rectal cancer, also a complete mesocolic excision has been advocated as an essential surgical step to improve oncologic results in patients with colon cancer. The complete removal of mesocolon with high ligation of the main mesenteric arteries and veins and the mobilization of splenic flexure are well-known but still debated in western surgical society. The authors reviewed the literature and outlined the rationale and the results of splenic flexure mobilization and complete mesocolic excision in laparoscopic surgery for colorectal cancer.     

结肠癌完整结肠系膜切除——规范化质量控制手术的趋势

全直肠系膜切除已成为直肠癌手术中应用最广泛的全球化规范治疗手段,但结肠癌手术目前尚缺乏规范化手术方式。完整结肠系膜切除作为结肠癌规范化手术的新理念由德国Hohenberger首次提出,该术式以胚胎解剖学为基础,更符合肿瘤学特点,后续研究发现该术式可改善预后,降低局部复发率,并不增加术后并发症发生率。完整结肠系膜切除的手术要点主要包括：锐性分离脏层、壁层筋膜;中央血管根部结扎;确保合理淋巴结清扫范围。结肠系膜完整切除术的提出是结肠癌外科治疗观念的更新,在经多中心前瞻性研究证实后,有可能成为大肠癌手术又一新的手术典范。     

腹腔镜右半结肠癌CME手术技巧

当腹腔镜结直肠手术普及的同时,完整全结肠系膜切除(CME)理念也逐渐成为右半结肠癌根治手术的标准。腔镜下完成CME手术涉及较为复杂的解剖结构,中央淋巴结的清扫可能带来潜在的风险,规范手术步骤、熟悉血管解剖,可以缩短学习曲线,减少并发症的发生。从解剖位置恒定的回结肠血管开始,完成肠系膜上静脉的裸化,直至完整游离右半结肠系膜,是目前国内外广泛采用的手术步骤。精细解剖可以减少出血,防止手术野的模糊,清晰分辨解剖层次,可以顺利完成手术过程。     

结肠癌完整结肠系膜切除术的实践与技术

全直肠系膜切除术(TME)已被公认为是直肠癌的标准化手术技术,但结肠癌手术尚缺乏标准化手术技术.2009年,德国外科医生Hohenberger提出了完整结肠系膜切除术(CME)的概念,认为结肠与直肠周围存在的解剖平面相似,也存在脏壁层筋膜及两者间的疏松无血管间隙,沿该间隙锐性分离,可获得被脏层筋膜完整包被的整个结肠系膜.掌握结肠胚胎发育和解剖是开展CME的前提和基础.CME技术以确保结肠系膜完整、中央血管高位结扎为操作要点.目前多数循证医学证据认为该技术有更好的肿瘤学优势,为CME技术的推广提供了科学依据.北京大学人民医院胃肠外科在国内积极实践推广CME技术,并对CME手术切除范围、淋巴结清扫范围、手术适应证选择、应用解剖等进行了探讨和系列的临床科学研究.     

胃癌D2根治术与全胃系膜切除术的解析

全系膜切除作为肿瘤外科的一种手术理念,目前已得到外科同道的广泛接受。而对于不同的器官,所谓全系膜的范围或标准是什么,除结直肠以外尚未完全明确。针对胃而言,其系膜构造复杂,且胚胎期系膜与成体后的解剖学系膜差异也较大,即使按照其解剖学系膜的范围来施行切除术，与目前推广的标准D2根治术相比，范围也相对过大。为此,我们提出外科系膜这一概念,即全系膜切除的实质应为全外科系膜切除。在临床实践中我们发现,胃与结直肠存在许多的对称相似性，通过对胃的延展、折叠等变形，即可在某种程度上实现其向结直肠的转变。转变后的胃不仅在形态、而且在血管分布、淋巴回流和系膜构成等方面均与结直肠存在惊人的吻合。在此基础上，我们提出胃的外科系膜范围，即肝胃韧带、肝十二指肠韧带、肝胰皱襞、脾胰皱襞、胃膈韧带、脾胃韧带、胃结肠韧带及大网膜等。这个范围与目前推广的D2根治术的范围也相吻合。本文还进一步探讨了胃癌的N分期。我们通过胃与结直肠的对照研究，将胃所属淋巴结重新归纳,即胃周、中间和根部3群，从而弥合了东西方学者长期存在的歧义。另外，我们也认同外科系膜以外淋巴转移的存在,即所谓的侧方转移。我们认为，关于胃肠癌的N分期,首先要界定系膜内、外淋巴结转移,如果存在系膜外淋巴结转移（侧方转移），应直接归入M1期，除非有证据显示侧方转移存在，否则不提倡进行扩大的侧方清扫。对于系膜内淋巴结转移,可依照目前NCCN规定的按淋巴结转移数量来划分（N1-3）。     

完整结肠系膜切除术的发展和评价

长期以来,结肠癌手术预后明显好于直肠癌.然而这一局面近20年来出现了逆转,究其原因直肠癌全直肠系膜切除术对于降低直肠癌局部复发,改善患者生存率的意义重大,而长期以来结肠癌缺少类似的质量控制性标准手术.尽管全球的外科医师知道结肠癌根治手术原则,然而通过何种方法能够保证达到良好的根治效果,目前尚存在争议.完整结肠系膜切除术的提出填补了这一空白,某种程度上讲它不是一种新的手术技术,然而它却对于如何实施高质量根治手术指明了方向.它基于解剖学和胚胎学理论,合理的提出了手术操作的层面,进一步诠释了结肠脏层筋膜的解剖结构,有利于外科医师学习和开展.     

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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。     

Giant cystic lymphangioma of right mesocolon: A case report

IntroductionCystic lymphangiomas are rare benign tumors of the lymph vessels and are usually found in children. However, abdominal cystic lymphangioma in mesocolon is extremely rare in adult patients.Presentation of caseWe reported a 15-year-old female with giant cystic lymphangioma of the right mesocolon. On examination, only abdominal pain was confirmed. Abdominal computed tomography (CT) showed a large multiseptated cystic mass. The patient underwent a total right mesocolic excision with the lesion. The patient recovered well on postoperative follow-up and was discharged on the fifth day. No evidence of recurrence had also been found in three months follow-up period.DiscussionThe diagnosis of intra-abdominal cystic lymphoma is often dismissed because the clinical symptoms are nonspecific. It is easy confusion because the ultrasound and CT scan images are relatively similar to the mesenteric and omental cysts. Sclerosing therapies may cause long-term consequences such as local recurrences with a very high proportion. Complete resection, including resection of the involved organs, is necessary. With tumors surrounding the colon, surgeons should consider performing removal block colon-lesion.ConclusionComplete tumor removal is the optimal choice for the management of intra-abdominal cystic lymphangioma. However, incomplete resection may lead to local recurrence.     

腹腔镜右半结肠癌切除淋巴结清扫范围及意义

腹腔镜右半结肠癌淋巴结清扫范围目前东西方的指南仍然存在较大的差异。近年来,随着全结肠系膜切除(CME)理念的提出和完善,以及腹腔镜技术在结肠癌手术中的广泛应用,许多结直肠专科医生认为腹腔镜CME手术应该成为右半结肠的"标准"术式。CME原则在右半结肠外科手术入路和标本质量控制方面作用巨大,沿胚胎学解剖层面的腹腔镜外科手术逐步成为规范,在理论上完整切除了可能存在转移、播散的病变肠管系膜,最大限度地清扫了区域淋巴结。这样的切除和淋巴清扫范围并未明显增加手术相关并发症,且能提高生存时间。但是,按照CME原则的根治术在手术风险以及肿瘤学获益方面的优势主要来源于回顾性研究的结果。因此,需要更高级别循证医学证据的研究结果来进一步证实目前的观点或共识。     

Laparoscopic colectomy for persistent descending mesocolon in sigmoid colon cancer: A case report

A 55-year-old-man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Preoperative barium enema showed a slightly medial displacement of the descending colon, and the sigmoid colon was quite long. The operative findings showed that the descending colon was not fused with the retroperitoneum and shifted to the midline and the left colon adhered to the small mesentery and right pelvic wall. Thus, a diagnosis of persistent descending mesocolon (PDM) was made. The left colon, sigmoid colon, and superior rectal arteries often branch radially from the inferior mesenteric artery. The sigmoid mesentery shortens, and the inferior mesenteric vein is often close to the marginal vessels. By understanding the anatomical feature of PDM and devising surgical techniques, laparoscopic sigmoidectomy for sigmoid colon cancer with PDM could be performed without compromising its curative effect and safety.     

基于膜解剖的腹腔镜脾曲结肠癌根治术33例临床分析

目的探讨基于膜解剖理论,腹腔镜下左半结肠完整系膜切除治疗脾区结肠癌的安全性、可行性及临床疗效。方法自2016年1月至2019年6月,我中心33例脾曲结肠癌患者接受了腹腔镜下左半结肠切除术,所有患者均于术前经结肠镜下行活检病理确诊,同时给予纳米碳和(或)钛夹标记,腹部增强CT/立位腹平片确认病变位于脾曲,术前TNM分期为Ⅰ期5例、Ⅱ期19例、Ⅲ期9例。根据膜解剖理论,术中采取头侧-中间-外侧入路相结合的方式进行,注意保持层面优先及结肠系膜的完整性,于根部结扎、切断左结肠动脉、结肠中动脉左支和肠系膜下静脉,清扫223和253淋巴结。计量资料包括患者一般资料、手术参数、术后康复数据以(±s)表示,术后并发症发生率以%表示,采用SPSS 20.0统计软件进行数据分析。结果33例手术均在腹腔镜下完成,无中转开腹。手术时间为(160.0±25.4)min,术中出血量为(70.6±46.4)ml,清扫淋巴结数目为(19.3±3.2)枚,标本肠管长度(23.0±2.8)cm,术后排气时间(4.5±1.2)d,术后进食时间(5.5±1.3)d,术后住院时间为(7.8±1.1)d。术后TNM分期为Ⅰ期4例、Ⅱ期21例、Ⅲ期8例。33例患者均未发生脾脏损伤,其中3例有不同程度的脾下极缺血,术后2例患者出现炎症性肠梗阻,保守治疗后康复出院。无术后腹腔出血、无吻合口漏、狭窄、出血等并发症发生。随访8~49个月(中位随访时间26个月),目前患者均健康存活,未见肿瘤复发、转移。结论对于脾曲结肠癌,在遵循膜解剖理论、层面优先原则的前提下,采用头侧-中间-外侧入路进行腹腔镜下左半结肠切除术,可以将操作化繁为简,具有安全、微创、可靠等优点,值得在临床推广应用。     

Standardized surgery for colonic cancer: complete mesocolic excision and central ligation – technical notes and outcome

Objective  Total mesorectal excision (TME) as proposed by R.J. Heald more than 20 years ago, is nowadays accepted worldwide for optimal rectal cancer surgery. This technique is focused on an intact package of the tumour and its main lymphatic drainage.
This concept can be translated into colon cancer surgery, as the mesorectum is only part of the mesenteric planes which cover the colon and its lymphatic drainage like envelopes. According to the concept of TME for rectal cancer, we perform a concept of complete mesocolic excision (CME) for colonic cancer. This technique aims at the separation of the mesocolic from the parietal plane and true central ligation of the supplying arteries and draining veins right at their roots.
Method  Prospectively obtained data from 1329 consecutive patients of our department with RO-resection of colon cancer between 1978 and 2002 were analysed. Patient data of three subdivided time periods were compared.
Results  By consequent application of the procedure of CME, we were able to reduce local 5-year recurrence rates in colon cancer from 6.5% in the period from 1978 to 1984 to 3.6% in 1995 to 2002. In the same period, the cancer related 5-year survival rates in patients resected for cure increased from 82.1% to 89.1%.
Conclusion  The technique of CME in colon cancer surgery aims at a specimen with intact layers and a maximum of lymphnode harvest. This is translated into lower local recurrence rates and better overall survival.     

完全腹腔镜下低位直肠前切除术+预防性回肠造口术

（1）暴露乙状结肠系膜根部与后腹膜粘连形成的黄白线,由此进入Toldt's间隙,拓展间隙至肠系膜下动脉根部,完成D3淋巴结清扫;（2）在直肠固有筋膜和腹下神经前筋膜之间分离,可以完好地保留盆腔自主神经系统从而完成全直肠系膜切除术;（3）完全腹腔镜下乙状结肠-直肠端端吻合;（4）预防性回肠袢式造口,皮内浆肌层连续缝合术在完全腹腔镜下直肠癌根治术中的应用。     

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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??Complete mesocolic excision for colon cancer YE Ying-jiang, GAO Zhi-dong, WANG Shan, et al. Department of Gastrointestinal Surgery, Beijing University People’s Hospital, Beijing 100044, China
Corresponding author: WANG Shan, E-mail: shwang60@sina.com
Abstract Objective To investigate the therapeutic effect of complete mesocolic excision (CME) for colon cancer. Methods The data of 31 cases of colon cancer without metastasis and intestinal obstruction performed elective CME by the same group of surgeons between November 1, 2009 and January 31, 2011 at Beijing University People’s Hospital were analyzed retrospectively. Results Among the 31 cases with CME, the median number of total lymph nodes retrieved was 19. Four (26.67%) cases of stage ?? had the positive lymph nodes in or over mesenteric root. The median operation time of all cases was 2.75 hours. The volume of intraoperative blood loss was 100 mL. The overall postoperative morbidity rate was 12.9% (4/31). The median time of exhaust and defecation was 4 days and 6 days respectively. The median hospital stay was 19.5 days. The median 30-day hospital readmission and postoperative mortality was none. Conclusion By complete mesocolic excision, the integrated radical resection for colon cancer could be completed successfully. The mesentery and lymphoid tissue could be eliminated maximally without more surgical risk. The intraoperative blood loss of CME is less than that of traditional resection. CME could achieve good short-term outcomes and does not affect the rehabilitation. But the effect of long term should be followed up.     

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??Enhance the standardization practice of colon cancer surgery WANG Shan, YE Ying-jiang. Department of Gastroenterological Surgery, Peking University People’s Hospital, Beijing 100044,China
Corresponding author: WANG Shan, E-mail: shwang60@sina.com
Abstract Total mesorectal excision has contributed greatly to standardization of rectal cancer operation, which improves the prognosis of rectal cancer patients. However, although regiment of chemotherapy updated rapidly, the technique of colon cancer surgery proceed so slowly that the prognosis of colon cancer has less progress. Complete mesocolic excision (CME) is a new concept of colon cancer surgery, which might improve the outcomes of patients with colon cancer. Moreover, whatever procedure of colon cancer operation must obey the principles as below: operating precisely based on the anatomy and embryology; performing during operation according to the oncological principle to decrease the recurrence of the tumor; paying more attention to the multi-disciplinary collaboration to promote the standardization of the colon cancer operation. The standardization of the colon cancer operation warrants the radical resection of the colon cancer, which is essential to make patients benefit from the surgery.     

腹腔镜右半结肠癌扩大切除原则与评价

完整结肠系膜切除原则(CME)在结肠癌手术中的应用已有十年,该原则强调了解剖平面下的结肠完整系膜切除,中央组淋巴结的清扫,饲养血管的中央部位结扎和离断。但在随后的临床应用和推广中,人们发现该原则在诸多方面并未有准确定义,比如右半结肠癌的手术中中央组淋巴结清扫的界限、肠管切除长度等。以该原则实施手术的质量控制标准等问题也是在不断的实践过程中得以明确。本文拟对腹腔镜右半结肠癌扩大切除的定义、CME手术的原则进行梳理,论述腹腔镜右半结肠癌扩大切除手术的评价标准。     

Offene Rektumchirurgie

This article describes the individual techniques and strategies of conventional surgery of the rectum, including photographic documentation of the important steps. Our own figures of postoperative complications and long-term oncological results obtained by this approach are added. In our experience, operations for radical surgery of rectal cancer have been the most frequent procedures. In the pelvis, the important planes between which dissection occurs are (1) the mesorectal fascia up to the origin of the inferior mesenteric artery and continuing laterally to the mesosigmoid fascia and (2) on the opposite side the autonomous nerves forming the plexus and web-like layers. Apart from rectal excision, complete mobilisation of the descending colon and the splenic flecture is a prerequisite for tension-free anastomoses and low leakage rates. Again this dissection follows the plane between the mesocolon and the parietal fascia covering the retroperitoneal organs. The greater omentum has to be taken down from the transverse colon with exposure of the entire lesser sac, followed by the division of the transverse mesocolon along the inferior aspect of the pancreas, including central tying of the inferior mesenteric vein.     

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??Laparoscopic complete mesocolic excision (CME) for left-sided colon cancer: analysis of feasibility and technical tips ZONG Ya-ping , HAN Ding-Pei , LU Ai-Guo , et al.Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai 200025, China
Correspondence author: ZHENG Min-Hua ,E-mail: zmh_tiger@yeah.net ; LU Ai-Guo ,E-mail:adams_lu66@aliyun.com
Abstract Objective To investigate the feasibility and technical tips of laparoscopic complete mesocolic excision (CME) for left-sided colon cancer. Methods The clinicopathological data of 31 cases with left-sided colon cancer underwent laparoscopic CME between September 2010 and December 2012 in our center was analyzed retrospectively. The quality of surgery was staged by the system reported by West, anatomic planes and technical tips were also elucidated by pictures and videos. Results All the 31 cases were successfully performed laparoscopic CME. Sharp dissection of the visceral plane from somatic one was performed to keep the integrity of mesocolon. Central ligation of the supplying vessels was needed to obtain an increased lymph node removal. The mean operative time was 106±15 min and the blood loss was 105±74 m1. The mean time for hospitalization were 11.1±2.8 days. Complications were observed in 4 cases (12.9%). 28 cases were evaluated pathologically as Grade A and 3 were Grade B. The total number of lymph nodes removed was 13.9±5.0. In the cases of stage III, the positive rate of principle lymph nodes was 15.8% (3 /19cases). Conclusions Laparoscopic CME for left-side colon cancer with medial access is technically feasible and randomized trials are needed to evaluate its long-term outcomes.