Subileal approach for laparoscopic right colectomy with D3 lymph node dissection.mp4

Recent studies have shown worse outcomes on stage II and III right colon cancer compared to left-sided colon cancer. Some authors believe that it is due to the lack of a standardized oncological right hemicolectomy with an extended lymph node dissection. The aim of this video is to describe the steps of the subileal approach for the CME technique with D3 lymphadenectomy.

The patient is a 65 years old woman diagnosed with locally advanced colon cancer (cT3N2M0). 

For the subileal approach, dissection starts caudal to the ileal mesentery (Fig 1). This maneuver allows the surgeon to identify the duodenum and to mobilize upwards the right colon and the ileocolic vessels, with a great exposure of the superior mesenteric vein (SMV). An independent tie of both ileocolic vessels should be done at the root of the SMV and SMA (Fig 2). Following the dissection along the SMV, the right colic artery (Fig 3) and the right branch of middle colic vessels are identified and clipped (Fig 4).

Lastly, the gastrocolic trunk should be exposed, allowing the surgeon to perform a selective tie of the colic vein/s. Once the vascular dissection is completed, a mechanical side-to-side intracorporeal anastomosis is done.

The patient was discharged after 4 days with no complications. Pathology report revealed a moderately-well differentiated adenocarcinoma with perineural invasion. 0/35 lymph nodes were infiltrated (pTNM: T4aN0).

 CME with D3 lymph node dissection is a technically challenging procedure, but it can be safely performed following a standardized technique.