Splenic flexure mobilization during laparoscopic colorectal surgery, which is used for elongation of the remaining colon after resecting the left colon or rectum, is sometimes essential for making a secure anastomosis without tension. However, laparoscopic splenic flexure mobilization is often time consuming and technically demanding, particularly in obese patients with severe adhesion. Therefore, three surgical approaches are introduced to make the procedure easier according to the method of entering the lesser sac: anterior approach, inferio-medial approach, and lateral approach.
Colon ; Colon, Transverse ; Colorectal Surgery ; Humans ; Laparoscopy ; Methods ; Peritoneal Cavity ; Rectum

Delayed gastric emptying is a syndrome of gastric motility disorder with slow gastric emptying as the main sign, provided that mechanical factors such as intestinal obstruction and anastomotic stricture are excluded. The incidence of delayed gastric emptying after colon cancer surgery is 1.4%, mainly after transverse colon cancer surgery. Most of the studies on delayed gastric emptying are case reports, lacking systematic studies. The diagnoses and treatments can be draw on the experience of delayed gastric emptying after pancreatic surgery. Our retrospective study indicated that the incidence of delayed gastric emptying after surgery for transverse colon cancer was 4.0%, higher than that for other colon cancer. Patients who underwent gastrocolic ligament lymph node dissection were at higher risk than those who did not (3.6% vs. 0.8%). Gastrocolic ligament lymph node dissection and stress are causative factors for delayed gastric emptying after surgery for transverse colon cancer. We add the gastrografin test upon the diagnostic criteria of the International Study Group for Pancreatic Surgery, which is simple and practical. Nasogastric tube decompression, enteral nutrition combined with parenteral nutrition, glucocorticoids, and prokinetic agents can cure most patients with postoperative delayed gastric emptying. All the patients with postoperative delayed gastric emptying were cured in our studies. Strict indications for gastrocolic ligament lymph node dissection (patients with cT3-4 and cN+) may decrease the occurrence of delayed gastric emptying after surgery for transverse colon cancer.
Colon, Transverse/surgery* ; Colonic Neoplasms/surgery* ; Gastric Emptying ; Gastroparesis/surgery* ; Humans ; Lymph Node Excision ; Retrospective Studies

Objective: To investigate the anatomic characteristics of the left parietal peritoneum and its surgical implementation while dissecting in left retro-mesocolic space. Methods: A descriptive case series research methods was used. (1) surgical videos of 35 patients who underwent laparoscopic radical resection (complete mobilization of splenic flexure) of colorectal cancer in Union Hospital of Fujian Medical University between January 2018 and December 2018 were reviewed; (2) four specimens after radical resection of rectal cancer performing in June 2020 were prospectively enrolled and reviewed; (3) five specimens of left parietal peritoneum from 5 cadaveric abdomen (3 males and 2 females) were enrolled and reviewed as well; Tissues of 3 unseparated regions, namely the root of the inferior mesenteric artery (IMA), the medial region and the lateral region (including kidney tissue), from above the 5 cadaveric abdominal specimens were selected to perform Masson staining and histopathological examination. Results: (1) Surgical video observation: "Staggered layer phenomenon" and typical left parietal peritoneum was found in 77.1% (27/35) of patients when the left retro-mesocolic space was separated from the lateral and central approaches. The left parietal peritoneum presented as a rigid fascia barrier between the lateral and central approaches, which was a translucent dense connective tissue fascia. After the splenic flexure were completely mobilized, the left parietal peritoneum stump continued to the cephalic side. (2) Observation of 4 surgical specimens: The dorsal side of the left mesocolon specimen was studied, and the left parietal peritoneum stump edge was identified. The outside of the stump edge was the left hemicolon dorsal layer, which was continuously downward to the rectal fascia propria. (3) Cadaveric abdominal specimens: The left retro-mesocolic space was separated through lateral and central approaches, and the rigid fascia barrier, essentially the left parietal peritoneum and Gerota fascia, was encountered. Cross-section view showed that the left parietal peritoneum could be further detached from the dorsal layer of the left mesocolon from the outside, but could not be further detached from the inside out. (4) Histological examination: There was no obvious fascia structure in the IMA root region, while outside the IMA root region, the left bundle of inferior mesenteric plexus penetrating Gerota fascia was observed. There were 4 layers of fascias in the medial region, including the ventral layer of the left mesocolon, the dorsal layer of the left mesocolon, left parietal peritoneum and Gerota fascia. Small vessels were observed between the dorsal layer of the left mesocolon and the left parietal peritoneum. In lateral region, renal tissue and renal fascia were observed. Three layers of fascia structures were observed clearly under high power field, including the dorsal layer of the left mesocolon, left parietal peritoneum, and Gerota fascia. Conclusions: The left parietal peritoneum is the anatomical basis of the "staggered layer phenomenon" from the lateral or central approaches during the separation of left retro-mesocolic space. The small vessels in the dissection plane are the anatomical basis of intraoperative microbleeding, which need pre-coagulation. The central part of Gerota fascia is penetrated by the branches of the inferior mesenteric plexus, which results in a relatively dense surgical plane. Thus, during the dissection through the central approach, it is easy to involve in wrong surgical plane by deeper dissection.
Colon, Transverse ; Colonic Neoplasms/surgery* ; Dissection ; Female ; Humans ; Laparoscopy ; Male ; Mesocolon ; Peritoneum ; Rectal Neoplasms/surgery*

Laparoscopic radical colectomies have been more widely used gradually, among which laparoscopic extended right hemicolectomy is considered as the most difficult procedure. The difficulty of extended right hemicolectomy lies in the need to dissect lymph nodes along the superior mesenteric vein (SMV) and disconnect numerous and possible aberrant vessels. To address this problem, we emphasize two points in key vessel assessment: getting familiar with the anatomy along the medial-to-lateral approach and having a good understanding about the preoperative imaging presentations. An accurately preoperative imaging assessment by abdominal enhanced CT can help the surgeon understand the relative position of the key vessels to be dealt with during operation and the situation of the possible aberrant vessels so as to guide the procedure more effectively and facilitate the prevention and management of the intraoperative complications. During operation, the operator should pay special attention to the management of the vessels in the ileocolic vessel region, Henle's trunk and middle colon vessels. The operation highlights of the key vessels are as follows: (1) The ileocolic vessels: identifying the Toldt's gap correctly and opening the vascular sheath of the SMV securely; making sure that the duodenum is well protected. (2) Henle's trunk: dissecting along the surface of the Henle's trunk; preserving the anterior superior pancreaticoduodenal vein (ASPDV) and main trunk of the Henle's trunk; disconnecting the roots of the right colic vein (RCV) and right gastroepiploic vein (RGEV), and then dissecting lymph nodes along the surface of the pancreas. (3) The middle colon vessels: identifying the root of the middle colon vessel along the lower edge of the pancreas; avoiding entering behind the pancreas; mobilizing the transverse mesocolon sufficiently along the surface of the pancreas. Finally, we discuss and analyze the disputes currently existing in laparoscopic extended right hemicolectomy, including dissection of No.6 lymph nodes, naking the SMA and dissecting lymph nodes around the roots of the branches of SMA. This article shares our experience about laparoscopic extended right hemicolectomy, hoping that it could help beginners master the technique more safely and skillfully.
Colectomy ; methods ; Colon, Transverse ; Colonic Neoplasms ; surgery ; Humans ; Laparoscopy ; Mesocolon ; surgery

Splenic flexure colon cancer occurs at a relatively lower rate than colon cancer of other sites. It is also associated with more advanced disease and higher rate of acute obstruction. The splenic flexure receives blood supply from both superior and inferior mesenteric arteries (SMA and IMA), and therefore has lymphatic drainage to both areas. The blood supply is also highly variable, causing difficulties in determining the main feeding vessels and the main direction of lymph drainage. Few studies with limited cases focused on this specific tumor site with respect to the patterns of lymph node spread, especially the main lymph node status and the value of its dissection. The lack of information limits the development of a consensus on the extent of surgical resection and lymphadenectomy. Adequate mobilization of the colon facilitates a sufficient length of bowel resection and the high ligation of feeding arteries from both SMA and IMA. Further evidence on the chnoice of procedures and the extent of lymph node dissection need multicenter collaboration, with the use of modern techniques, including CT 3D reconstruction of the colon and angiography, as well as intraoperative fluorescent real-time imaging of lymph nodes.
Colon, Transverse/surgery* ; Colonic Neoplasms/surgery* ; Humans ; Laparoscopy ; Lymph Node Excision/methods* ; Lymph Nodes/pathology* ; Mesenteric Artery, Inferior/surgery*

Objective: At present, surgeons do not know enough about the mesenteric morphology of the colonic splenic flexure, resulting in many problems in the complete mesenteric resection of cancer around the splenic flexure. In this study, the morphology of the mesentery during the mobilization of the colonic splenic flexure was continuously observed in vivo, and from the embryological point of view, the unique mesenteric morphology of the colonic splenic flexure was reconstructed in three dimensions to help surgeons further understand the mesangial structure of the region. Methods: A total of 9 patients with left colon cancer who underwent laparoscopic radical resection with splenic flexure mobilization by the same group of surgeons in Union Hospital of Fujian Medical University from January 2018 to June 2019 were enrolled. The splenic flexure was mobilized using a "three-way approach" strategy based on a middle-lateral approach. During the process of splenic flexure mobilization, the morphology of the transverse mesocolon and descending mesocolon were observed and reconstructed from the embryological point of view. The lower margin of the pancreas was set as the axis, and 4 pictures for each patient (section 1-section 4) were taken during middle-lateral mobilization. Results: The median operation time of the splenic flexure mobilization procedure was 31 (12-55) minutes, and the median bleeding volume was 5 (2-30) ml. One patient suffered from lower splenic vessel injury during the operation and the bleeding was stopped successfully after hemostasis with an ultrasound scalpel. The transverse mesocolon root was observed in all 9 (100%) patients, locating under pancreas, whose inner side was more obvious and tough, and the structure gradually disappeared in the tail of the pancreatic body, replaced by smooth inter-transitional mesocolon and dorsal lobes of the descending colon. The mesenteric morphology of the splenic flexure was reconstructed by intraoperative observation. The transverse mesocolon was continuous with a fan-shaped descending mesocolon. During the embryonic stage, the medial part (section 1-section 2) of the transverse mesocolon and the descending mesocolon were pulled and folded by the superior mesenteric artery (SMA). Then, the transverse mesocolon root was formed by compression of the pancreas on the folding area of the transverse mesocolon and the descending mesocolon. The lateral side of the transverse mesocolon root (section 3-section 4) was distant from the mechanical traction of the SMA, and the corresponding folding area was not compressed by the tail of the pancreas. The posterior mesangial lobe of the transverse mesocolon and the descending mesocolon were continuous with each other, forming a smooth lobe. This smooth lobe laid flat on the corresponding membrane bed composed of the tail of pancreas, Gerota's fascia and inferior pole of the spleen. Conclusions: From an embryological point of view, this study reconstructs the mesenteric morphology of the splenic flexure and proposes a transverse mesocolon root structure that can be observed consistently intraopertively. Cutting the transverse mesocolon root at the level of Gerota's fascia can ensure the complete resection of the mesentery of the transverse colon.
Colectomy/methods* ; Colon, Transverse/surgery* ; Colonic Neoplasms/surgery* ; Dissection ; Fascia/anatomy & histology* ; Humans ; Laparoscopy ; Mesentery/surgery* ; Mesocolon/surgery* ; Pancreas/surgery* ; Photography ; Spleen/surgery*

OBJECTIVETo evaluate metastatic patterns of colorectal cancer following curative surgery based on primary tumor location in order to provide evidence for the decision of individualized adjuvant therapy and postoperative follow-up.

METHODSClinical and follow-up data of 904 patients who underwent curative colorectal cancer in The Affiliated Tumor Hospital of Zhengzhou University from October 2004 to October 2012 with complete follow-up data were analyzed retrospectively. A total 274 patients belonged to right-sided colon cancer group (cecum, ascending, hepatic flexure, and transverse colon), 243 belonged to left-sided colon cancer group(splenic flexure, descending, and sigmoid colon), and 387 belonged to rectal cancer group. The overall rate of distal metastasis and site-specific metastasis rates (liver, lung, and peritoneum) were compared among these 3 groups.

RESULTSThe cohort patients had a median follow-up of 37(4-122) months, and the median follow-up duration was similar in right-sided, left-sided, and rectal cancer groups with 39(5-119), 39(6-122) and 36(5-121) months(P=0.513). During the follow-up period, 44 patients (4.9%) had local recurrence alone, 137 (15.2%) distal metastasis alone, and 30(3.3%) local recurrence combined with distal metastasis. Compared to right-sided colon cancer group, rectal and left-sided cancer groups had significantly higher overall metastasis rates [23.5% (91/387), 17.3% (42/243) vs. 12.0% (33/274), P=0.000). With respect to specific regions, lung metastasis rate in rectal cancer group was 9.3%, which was significantly higher than that in left-sided(4.5%) and right-sided colon cancer group(2.6%)(P=0.001). Other sites of metastasis did not yield significant differences, including liver(P=0.130) and peritoneum(P=0.858).

CONCLUSIONSCancer location may be used as a reference of personalized adjuvant therapy and postoperative follow-up surveillance programs. Lower threshold for adjuvant therapy in rectal and left-sided colon cancers, and more aggressive surveillance for lung metastasis by chest X-ray or CT should be considered.

Aged ; Colon, Ascending ; Colon, Sigmoid ; Colon, Transverse ; Colorectal Neoplasms ; surgery ; Female ; Humans ; Lung Neoplasms ; Male ; Middle Aged ; Neoplasm Metastasis ; Neoplasm Recurrence, Local ; Retrospective Studies

OBJECTIVESTo investigate the surgical approach, feasibility and surgical outcomes of laparascopic distal gastrectomy D2(LDGD2).

METHODSFifty-four patients who underwent LDGD2 were examined in terms of pathologic findings, operative outcomes, and complications. A simple and effective surgical procedure was as follows: gastrocolic ligament--transverse mesocolon anterior lobe--pancreatic capsule--4sb--4d--6--14v, 8a--12a--9--7--11p, 1--3--5--lesser omental bursa. Efficacy and feasibility of this procedure was analyzed.

RESULTSThe mean operative time was (236±51) minutes, the mean number of lymph nodes was(18±5), the mean positive lymph nodes were 0-14, the mean blood loss was(217±65) ml, and postoperative mean hospital stay was(15±4) days.

CONCLUSIONSLDGD2 for lower and lower-middle gastric cancer is feasible and safe, and can meet the oncological demand.

Colon, Transverse ; Gastrectomy ; Humans ; Laparoscopy ; Length of Stay ; Lymph Node Excision ; Lymph Nodes ; Mesocolon ; Pancreas ; Stomach Neoplasms ; surgery

OBJECTIVETo study the validity of transplanting transverse colon to replace esophagus in treating cicatricial stricture resulting from severe esophageal chemical burns in children.

METHODSA retrospective study was carried out on the clinical data of 46 patients with severe chemical esophageal burns who were treated from November 1972 to September 2008. The transverse colon with the ascending branch of the left colic artery was brought through a retrosternal tunnel to replace strictured esophagus. Thirty-two patients underwent colon-esophageal anastomosis and 14 patients underwent colon-pharyngeal anastomosis.

RESULTSAll patients survived after surgery, but complications occurred in 7 cases, including leakage of anastomosis in cervical region in 4 cases, stenosis of anastomosis in 2 cases, and dyspnea in 1 case, and they were cured after due treatment. Follow-up study (1 - 26 years) in 39 patients revealed that there was no difference in growth, development and diet between the patients and the normal children of the same age.

CONCLUSIONSEsophageal reconstruction with transverse colon together with the ascending branch of the left colic artery through a retrosternal tunnel is a valuable method for treating cicatricial stricture of the esophagus secondary to severe chemical burns of the esophagus in children.

Burns, Chemical ; complications ; surgery ; Child ; Child, Preschool ; Cicatrix ; complications ; etiology ; Colon, Transverse ; transplantation ; Esophageal Stenosis ; etiology ; surgery ; Esophagus ; surgery ; Female ; Humans ; Infant ; Male ; Postoperative Complications ; surgery ; Retrospective Studies

OBJECTIVETo investigate the clinical significance of resection of the pancreatic capsule and anterior layer of transverse mesocolon in radical gastrectomy.

METHODSBetween January 2007 and July 2008, a total of 213 gastric cancer patients enrolled in the study. These patients were randomly assigned into two groups: 105 in group R and 108 in group N. Only in group R were the pancreatic capsule and anterior layer of transverse mesocolon resected during radical gastrectomy. The pancreatic capsule and anterior layer of transverse mesocolon were histologically analyzed for metastasis. The data including blood loss during operations, number of dissected lymph nodes and postoperative complications were analyzed in both groups.

RESULTSThere were no significant differences between the two groups in blood loss during operation and postoperative complications, but the differences in operation time and number of dissected lymph nodes between the two groups were significant. Metastases to the pancreatic capsule and/or anterior layer of transverse mesocolon were diagnosed in nine (8.6%) patients of group R. The metastases to the pancreatic capsule and/or anterior layer of transverse mesocolon were found to be associated with tumor invasion depth, anterior or posterior gastric wall, clinical staging and perigastric lymph node metastasis extent (P<0.05), but not with age, gender, tumor location, size, Borrmann type and pathological classification (P>0.05).

CONCLUSIONSResection of pancreatic capsule and anterior layer of transverse mesocolon in group R does not increase postoperative complications in comparison with group N. The resection is beneficial to the patients with advanced gastric cancer staging relatively late because of potential metastasis to pancreatic capsule and anterior layer of transverse mesocolon.

Adult ; Aged ; Aged, 80 and over ; Colon, Transverse ; Female ; Gastrectomy ; methods ; Humans ; Male ; Mesocolon ; surgery ; Middle Aged ; Pancreas ; surgery ; Stomach Neoplasms ; surgery