Could the top-down right hemicolectomy be an easier alternative to the classic medial-to-lateral approach in obese patients? A case report with video example

Introduction and importance: Right colon cancer represents 30 % of colonic malignancies worldwide, and a laparoscopic approach is recommended. Recent surveys show that only 25 % of surgeons perform right hemicolectomies by laparoscopy. Contemporary obesity is rising, and besides being a risk factor for colon cancer, it represents an objective difficulty in performing surgery. These two factors imply a constant and progressive issue facing surgeons.

Case presentation: We describe the case of a 61Y/o woman with 32BMI, a previous left nephrectomy, and neoformation of the right colonic. She underwent laparoscopic right hemicolectomy, using a hybrid top-to-down approach to overcome intraoperative difficulty, consequent to visceral obesity. The postoperative course was uneventful, and she was discharged after five days.

Clinical discussion: The medial-to-lateral approach is the main technique used in laparoscopic right hemicolectomy. Some other techniques are used to perform this intervention, and the top-to-down strategy is adopted only in 4 % of cases. In obese patients, difficulties could be found in vascular and plan dissection. The top-to-down strategy allowed us to deal with some objective difficulties during the procedure, efficiently bypassing them.

Conclusion: Laparoscopy for right colon cancer would be the standard procedure as recommended. Some objective difficulty could be found during interventions, especially in obese patients. The top-to-down dissection is not so frequent and could be considered to deal with intraoperative difficulty. The knowledge of all different strategies and their application might be a possible interchangeably way to solve difficult dissection and increase the spreading of laparoscopy.