Simplified and reproducible laparoscopic complete mesocolic excision with D3 right hemicolectomy.

Aim: Laparoscopic complete mesocolic excision (CME) with D3 lymphadenectomy for right colon cancer is gaining acceptance. However, this procedure has not yet been standardized like total mesorectal excision. Ergonomics is very important in this surgery (e.g. patient positioning, port placement) and identification of vascular anatomy is a critical step. The aim of this work is to present ten procedural steps that are simple and reproducible.

Method: The French position is adopted. The surgeon stands between the patient's legs. Four ports are placed: a camera port 2.5 cm to the left of the umbilicus; two working ports-a 12 mm right-hand port 5-7 cm below the umbilicus in the midline and a 5 mm left-hand port 2.5 cm medial and at the level of anterior superior iliac spine-and an assistant port at the level of the umbilicus at the pararectal line. This is most comfortable position in the 'caudal to cranial approach' for CME dissection. The right-hand instrument always dissects parallel to the superior mesenteric artery (SMA) axis so there is less chance of injury to major vascular structures. When clipping the ileocolic, right colic and gastrocolic trunk (GCT) branches, the instrument is always perpendicular to these structures, giving ease of clipping and division. An intentional attempt is made to dissect all tributaries of the GCT. This avoids inadvertent injury and bleeding. Identifying the SMA/superior mesenteric vein (SMV) axis and ileocolic pedicle is the most crucial step. We use surface landmarks for this-the ligamentum teres and SMA/SMV are both midline structures. Giving traction on the transverse mesocolon just below the ligamentum makes the pulsatile SMA visible irrespective of the patient's body mass index. Giving traction at the ileocaecal junction mesentery makes the ileocolic pedicle prominent. These two landmarks for identification of the vascular anatomy make this technique unique and reproducible. CME dissection is done caudal to cranial and lateral to medial. Supracolic and lateral mobilization of the colon is simple. While starting dissection in the right paracolic gutter the already dissected CME plane make this step easier. Anastomosis can be made intracorporeal or extracorporeal.

Conclusion: Ergonomics and landmarks for identification of the vascular anatomy make this technique simple and reproducible.