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Surg Endosc. 2018 Dec;32(12):5021-5030. doi: 10.1007/s00464-018-6267-0. Epub 2018 Oct 15.

Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept.

Author information

1
Clinic for General-, Visceral- and Vascular Surgery, Diakovere Hospital Friederikenstift, Humboldtstrasse 5, 30169, Hannover, Germany. strey@gmx.de.
2
Department of Visceral and Minimal Invasive Surgery, Helios Hospital Krefeld, Lutherplatz 40, 47805, Krefeld, Germany.
3
Department Chirurgie, Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401, Winterthur, Switzerland.
4
Klinik für Allgemein-, Viszeral-, Endokrine und Minimal-invasive Chirurgie, Klinikum Bogenhausen, Englschalkinger Straße 77, 81925, Munich, Germany.
5
General and Visceral Surgery, DRK-Krankenhaus Clementinenhaus, Lützerodestr. 1, 30161, Hannover, Germany.
6
Klinik für Allgemeine, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Straße 3, 24105, Kiel, Germany.
7
Department of Surgery, University Hospital of Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany.
8
Department of General, Visceral and Transplant Surgery, University Medical Center, University of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
9
Klinik für Viszeralchirurgie, Augusta Klinikum Bochum, Bergstrasse 26, 44791, Bochum, Germany.
10
Department of General-, Visceral- and Minimalinvasive Surgery, KRH Klinikum Hannover GmbH, Klinikum Siloah, Stadionbrücke 4, 30459, Hannover, Germany.
11
Sana Klinikum, Starkenburgring 66, 63069, Offenbach, Germany.
12
Department of General Surgery and Thoracic Surgery, University Hospital Schleswig-Holstein, 24105, Kiel, Germany.
13
Department of Visceral Surgery, Johanniter Hospital Bonn, Johanniterstr. 3, 53113, Bonn, Germany.
14
Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Otto-Hahn-Platz 8, 24118, Kiel, Germany.
15
Department for Abdominal and Pediatric Surgery, Klinkverbund-Suedwest, Klinken Boeblingen, Bunsenstrasse 120, 71032, Boeblingen, Germany.

Abstract

BACKGROUND:

Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable.

METHODS:

An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus.

RESULTS:

In order to provide a clear picture of the surgical anatomy, the "open book" model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure.

CONCLUSION:

Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME.

KEYWORDS:

Colon cancer; Complete mesocolic excision; Critical view; Laparoscopy; Right hemicolectomy; Standardization

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