Colon cancer by incidence is considered to be the second most common gastrointestinal malignancy in the world and is associated with a high mortality rate [1]. It is estimated that, on average, 900,000 people on average die from colon cancer annually, representing 10% of cancer-related deaths [2]. Over the last decades, changes in the surgical approach to the treatment of rectal cancer proposed by Heald in 1982 have subsequently modified the views of colorectal surgeons on the surgical treatment of colon cancer as well [3]. The beneficial aspect of this approach is based on dissection along embryological planes which enables to delivery of the complete package of lymph nodes enhancing the quality of surgery and therefore improving survival rates. Historically, patients with colon cancer have had better survival rates than those with rectal cancer. The advent of total mesorectal excision has reversed this surgical dogma. The complete mesocolic excision technique (CME) created by Hohenberger et al. [4] utilizes the theory of Heald in colon cancer which has proved to improve lymph node yield and improve survival [4].

CME has been practiced by Japanese surgeons for many decades, in the form of D3 lymphadenectomy and has largely been introduced to Europe after the seminal paper by West et al. [5] demonstrating that good-quality specimens offer long-term survival.

As it has been demonstrated that the number of lymph nodes resected en bloc with specimen significantly influences oncological outcomes, one of the topics of interest for all colorectal communities has become the extent of lymph node dissection. This issue is actively debated because of the lack of consensus the optimal level of dissection, whether a “D2” or “D3.”

We consider that one of the most clear and reproducible techniques on CME with D3 lymphadenectomy was described by Benz et al. [6], both open and minimally invasive approaches. The current article aimed to present the technical views on the application of the open book approach described by Benz et al. [6] in our unit as per our experience (CME with D3, n = 44).

A 45-year-old female patients with an Eastern Cooperative Oncology Group performance status of 0 and a body mass index of 21 kg/m2 presented with a change in bowel habits towards diarrhea and a positive fecal immunochemical test. A colonoscopy revealed a stricturing ascending colon tumor with the biopsies confirming moderately differentiated adenocarcinoma. The bi-phasic computer tomography scan of the abdomen pelvis was suggestive of thickening of the distal ascending colon with multiple suspicious enlarged lymph nodes. The detected lesion was reported as cT3N1M0. At the multidisciplinary team meeting, a decision was made to perform a right hemicolectomy with CME with D3 lymphadenectomy. The patient underwent a laparoscopic procedure (Supplementary Video 1). The patient was positioned in the Lloyd Davies position, with the surgeon operating between the patient’s legs and the assistant standing on the left side. A screen was positioned over the right shoulder. A 10-mm blunt infraumbilical port was created using the Hassan technique to establish pneumoperitoneum. A 5-mm port was placed at the McBurney point, a 12-mm AirSeal port (ConMed) was placed in the suprapubic region, and a fourth 5-mm assistant port was placed in line with the umbilicus on the left flank. Medial to lateral dissection was performed underneath the ileocolic pedicle, and a complete duodenal tunnel was made in a classic manner up to the hepatic flexure. A superior mesenteric vein (SMV) first approach or open book approach is used in order to perform D3 lymphadenectomy. This is a standard approach for CME and is especially helpful for surgeons at the initial phase or the beginning of the learning curve with CME. Special attention needs to be addressed to the vascular abnormal anatomy of the venous colonic system especially at vascular variations of Henle’s trunk. Care must be taken in dissection to identify and safeguard against injury to pancreatic branches, as such injury can lead to postoperative pancreatitis. Preoperative evaluation of computed tomography is essential for extended lymphadenectomy surgery in order to decrease vascular injury. After full mobilization and control of vessels using the Hem-o-Lok clips (Weck Closure Systems) and advanced devices, the specimen was extracted through the extension of the infra-umbilical incision. A wound protector was placed, and an extracorporeal antiperistaltic side-to-side ileotransverse stapled anastomosis was performed using the modified Barcelona technique [7].

The total operative time was 150 minutes, and the estimated blood loss was less than 50 mL without any transfusion pre- or postoperatively. The patient showed an uneventful postoperative course and was discharged on the 5th postoperative day in good condition. The final pathology report confirmed moderately differentiated adenocarcinoma with a maximum tumor size of 55 mm and 0/60 lymph nodes. The mesocolic fascia was intact, and R0 was achieved. The final staging was pT3pN0pM0. No perineural or lymphovascular infiltration was identified. The patient was followed with routine surveillance without adjuvant chemotherapy. There was no evidence of recurrence at 6 months after operation.

This multimedia article aimed to demonstrate the technique of laparoscopic right hemicolectomy with CME and D3 lymphadenectomy for right colonic adenocarcinoma. The video vignette shows a detailed description of the technique, anatomical landmarks, and important steps in successful procedure using the open book approach.

Numerous publications in the English literature have emphasized the benefits of CME and the safety. On the other hand, many colorectal surgeons are convinced that lymphadenectomy in SMV and artery territory can lead to higher morbidity, such as erratic bowel habit, gastroparesis, and intraoperative bleeding or vascular injury [8].

On the other hand, other techniques appeared as fluorescence-guided lymph node mapping (FLNM) which shows promising results with a similar increased number of harvested lymph nodes as CME surgery. The lymph node dissection using FLNM increases the accuracy of dissection of the lymph nodes, especially around the main surgical trunk decreasing the morbidity related to vascular injury. This method is a safe surgical tool that ensures the harvesting of more than 12 lymph nodes which represents an adequate oncological number for proper pathological staging [9].

Sentinel lymph node (SLN) mapping, an atypical form of lymphadenectomy, is an established technique in breast cancer and malignant melanoma. It has proven to reduce postoperative complications as a staged procedure. However, in colon cancer, lymphatic flow can be spread through various routes through the complex lymphatic network rather than through a linear connection, SLN mapping has many limitations in assessing the overall condition of lymph node metastasis [10]. Nowadays, there are many debates on the apical node dissection margin for colonic cancer, and further studies are needed.

Even though there is good evidence to support that implementation of CME surgery leads to improved outcomes in patients with colon cancer, in the United Kingdom, there is still skepticism for the adoption of the technique across secondary care hospitals. We believe that with adequate training and supervision, an open book approach for laparoscopic right hemicolectomy with CME and D3 lymphadenectomy is feasible at all hospitals.

However, further studies are required to investigate the real benefits of extended lymphadenectomy in the treatment of right colonic cancer.

Ethical statements

The article does not contain experimental studies with the patient. The surgery was documented, with an appropriate consent form for the procedure and video recording with prior authorization of the patient, it was edited for publication. This study is in accordance with the ethical standards of institutional research and the Declaration of Helsinki. A procedure-specific informed consent was obtained from the patient including the video recording and video publication.

Authors’ contributions

Conceptualization, Data curation, Formal analysis: All authors

Writing–original draf: All authors

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Acknowledgments

All authors are grateful for the input and guidance provided by all members of the Department of General Surgery in the Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.1.47.