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Title

Reply to: Right hemicolectomy with central vascular ligation in colon cancer

Authors
Spasojevic, M
Kiil, S
Ignjatovic, D
Published in Surgical Endoscopy. 2012, vol. 26, no. 2, p. 588-9
Abstract We thank Doctors Weber and Hohenberger for their kind comments [1]; however, we would like to stress some points of interest. The variance of colon arterial anatomy is an established fact and has been well pointed out that it can be due to definitions used, population examined, or methodology [2]. The numbers are not crucial; it is more important that the surgeon be aware of the individual variants, especially those that can complicate surgical procedures. We also have had the impression that the right colic artery is not found at surgery as often as with radiology. On occasion, a right colic artery seen at preoperative MDCT angiography was of such a small caliber that it could be successfully cauterized at surgery. However, this does not imply that there are no lymph nodes or vessels in its vicinity. Moreover, there are data in the literature about metastasis in cecal and ascending colon cancer to the central ileocolic, right colic, and middle colic nodes at rates of 11.1, 5.0, and 6.1%, respectively [3]. This becomes even more important in light of recent data suggesting that patients with micrometastasis and isolated cancer cells within harvested lymph nodes (found in 5–26% of negative nodes) have lower survival rates [4]. This is why we have started a randomized controlled trial (ClinicalTrials.gov) to study safe D3 resection in right-sided colon cancer through the help of preoperative MDCT angiography. Our operative technique for D3 resection (or CME) differs somewhat from that of Hohenberger et al. [5]. A medial approach is generally preferred in Norway. Dissection begins by dividing the visceral peritoneum over the terminal ileal vein and opening the vascular sheath of the superior mesenteric vein (SMV). The dissection continues toward the left-hand side of the superior mesenteric artery, and then cranially, following it to the level of the gastrocolic trunk. This is simultaneously followed (in the operating room) by a 3D reconstruction of the vessels using the Osirix software mentioned in our article (Fig. 1). The fatty tissue is dissected from the SMV toward the patient’s right side; the ileocolic and right colic arteries are found (when present) and divided at their origin. The middle colic artery is not divided, but the fatty tissue around the origin of the middle colic artery is removed, dissecting it toward the right side of the patient and keeping the specimen intact and en bloc. The right branch of the middle colic artery is divided. The arteries are drawn toward the right-hand side of the SMV anterior or posterior depending on their position, and the right colic vein is divided at its confluence with the gastrocolic trunk. We have a vascular surgeon present in this segment of the procedure (SK). Lateral mobilization of the devascularized specimen is then performed. If the dissection is done in this manner, one will notice a gutter toward the vena cava that is lifted together with the mesocolon. The resection of the vascular sheath posterior to the SMV is performed last. Finally, we would like to say that postoperative diarrhea was not an issue in patients who underwent a D3 resection at our institution, possibly because of the much lower extent of dissection than what Hohenberger et al. [5] describe. Furthermore, we are very glad that we agree that the right mesocolon is not clearly defined at its medial aspect, since this should lead to a resolution.
Keywords Colon/blood supplyFemaleHumansMaleMesenteric Veins/anatomy & histologyTomographyX-Ray Computed/methods
Identifiers
PMID: 21909856
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Research group Anatomie clinique (134)
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SPASOJEVIC, M et al. Reply to: Right hemicolectomy with central vascular ligation in colon cancer. In: Surgical Endoscopy, 2012, vol. 26, n° 2, p. 588-9. https://archive-ouverte.unige.ch/unige:26230

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Deposited on : 2013-02-06

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