A modified combined approach in laparoscopic right hemicolectomy for right-sided colon based on surgical trunk orientation: a case of a new surgical technique

Abstract

Colorectal cancer remains a significant threat to human life and health, with Laparoscopic technology represents a pivotal advancement in its treatment. Laparoscopic right hemicolectomy has emerged as the preferred surgical modality for managing right-sided colon cancer, offering minimally invasive benefits and expedited recovery. However, the right colon anatomy, characterized by complex vascular branching patterns and frequent variations, presents significant surgical challenges. Various surgical access methods have been proposed to address these challenges, each with distinct advantages and limitations. To optimize surgical outcomes, our research team has meticulously analyzed these approaches and developed a modified combined approach for laparoscopic right hemicolectomy in the treatment of right-sided colon cancer. This innovative approach integrates the strengths of different methods to enhance surgical efficacy while minimizing intraoperative bleeding, facilitating rapid recovery, and ensuring favorable prognosis. We report a case of a 76-year-old male with hypertension who presented with rectal bleeding. Preoperative evaluation revealed moderately differentiated adenocarcinoma in the ascending colon (clinical stage T3N1bM0). The patient underwent the modified combined approach of laparoscopic right hemicolectomy. The surgery was successful, with few intraoperative complications. Postoperatively, the patient had an uneventful recovery, was discharged after 8 days, and showed no signs of recurrence at 6-month follow-up. We anticipate that this novel surgical approach will provide more precise and efficient treatment options, ultimately improving the overall quality of life for patients with right-sided colon cancer.

Highlight box.

Surgical highlights

• This article shows a new procedure for right hemicolectomy that promises to provide surgeons with new perspectives.

What is conventional and what is novel/modified?

• Laparoscopic surgery is known for its advantages of reduced trauma and faster recovery, but right hemicolectomy poses significant challenges due to the complexity of the involved anatomy.

• We found that the combined approach may have advantages over the traditional approach in simplifying and standardizing the surgical process.

What is the implication, and what should change now?

• The combined approach may be a better strategy for right hemicolectomy.

Introduction

As reported by the International Agency for Research on Cancer (IARC) of the World Health Organization (WHO), colorectal cancer is the third most common malignancy worldwide. Its incidence and mortality rates have been on a steady rise, particularly among the younger population below 50 years of age (1). This upward trend poses a significant threat to human life and health (2,3). Among colonic malignancies, right-sided colon cancer exhibits a higher degree of malignancy and a propensity for invasion and metastasis due to its anatomical location and physiological characteristics. These characteristics, coupled with the subtle clinical manifestations, further complicate the treatment of right-sided colon cancer. Surgical resection remains the cornerstone of treatment for this condition, with chemotherapy and radiotherapy providing limited efficacy (4).

The application of laparoscopic techniques in colorectal cancer surgery dates back to the early 1990s. In 1991, Dr. Jacobs pioneered laparoscopic right hemicolectomy, marking a paradigm shift in the surgical management of right-sided colon cancer (5). Compared to traditional open surgery, laparoscopic surgery offers several advantages, including reduced surgical trauma, shorter postoperative recovery time, and improved aesthetic outcomes (6-8).

The laparoscopic approach for resection of right-sided colon cancer, despite its advantages, involves several challenges. Anatomically, the right colon’s proximity to vital organs including the liver, duodenum, and pancreas limits the surgical workspace, thereby elevating the risk of iatrogenic organ injury. Additionally, the lymphatic drainage pattern of the right colon, centered around the superior mesenteric vein (SMV) and artery (SMA), necessitates thorough lymphadenectomy to minimize the risk of tumor recurrence (9-11). This lymphadenectomy, however, is technically demanding, requiring surgical expertise and precision.

Furthermore, vascular variations pose another significant consideration in laparoscopic surgery for right-sided colon cancer (12-14). The SMA and the SMV, being the primary blood suppliers to the right colon, can exhibit anatomical variations such as increased branching or aberrant vessel positioning (15-17). Mitigating these challenges requires preoperative vascular assessment, individualized surgical planning, and intraoperative adaptations.

To address these difficulties, surgeons have diligently researched and developed innovative surgical techniques (16,18-20). Initially, the lateral approach dominated laparoscopic right hemicolectomy, involving an initiation of the surgical procedure from the right side of the abdomen and progressing medially. However, with the growth of expertise and refinement of techniques, surgeons have introduced novel surgical methods such as the medial and intermediate approaches in laparoscopic right hemicolectomy (16,21). These modern approaches ensure complete resection of the right colon and comprehensive lymphadenectomy through distinct anatomical paths and surgical sequences (22-24).

To address the limitations of different surgical approaches and harness their collective strengths, our team has introduced a modified combined laparoscopic right hemicolectomy for the treatment of right-sided colon cancer. This method is a modification of the traditional laparoscopic right hemicolectomy for right-sided colon cancer and does not involve additional equipment or materials; rather, it only involves a change in surgical approach into a radical operation. It offers enhanced safety and efficacy, providing superior visualization of the vascularization of the right colon and more thorough lymphadenectomy in zone D3 (25). Additionally, it provides improved access to the anatomical level of the right mesocolon, mitigating intraoperative bleeding, reducing operative time, and facilitating postoperative recovery.

In this case, we aim to demonstrate the benefits of our novel laparoscopic right hemicolectomy procedure for right-sided colon cancer. We present this article in accordance with the SUPER reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-277/rc).

Preoperative preparations and requirements

Details about this new approach are provided below. This surgery was performed at Zhujiang Hospital of Southern Medical University, a tertiary hospital via a Karl Storz laparoscope (Tuttlingen, Germany). During the operation, Z.Z. was the chief surgeon, and Huang Renli was the first assistant, with camera-holder assistants, instrument nurses, the circulating nurse, and the anesthesiologists cooperating to complete this operation. The indications for this procedure included (I) pathological diagnosis of colonic malignancy via colonoscopy; (II) malignant tumors of the ileocecum, ascending colon, and hepatic flexure of the colon; (III) absence of metastases on preoperative imaging; and (IV) absence of contiguous tumors from other sites. Meanwhile, the contraindications included (I) tumors at sites other than the ileocecum, ascending colon, and hepatic flexure of the colon; (II) distant metastasis on preoperative imaging; and (III) presence of synchronous tumors at other sites.

A 76-year-old male patient, with a past medical history of hypertension (150/85 mmHg) and no history of blood transfusion, other comorbidities, or family history of hereditary disease, presented with rectal bleeding as the sole significant clinical symptom. The physical examination before admission revealed no abnormalities. Diagnostic colonoscopy and biopsy confirmed an intestinal mass as a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) scanning demonstrated irregular circumferential thickening and enhancement of the ascending colon’s middle and upper segments, accompanied by luminal narrowing and roughness of the plasma membrane surface, strongly suggestive of right-sided colon cancer, clinical stage T3N1bM0 (Figure 1). Laboratory tests, including a complete blood count, indicated a decreased red blood cell count; hemoglobin, platelet count, and mean platelet volume, and platelet-specific volume. These were attributed to the observed rectal bleeding. Preoperatively, he was assessed as having good cardiopulmonary function and was able to tolerate the surgery. Considering the tumor location, stage, and physical condition of the patient, the multidisciplinary team decided to perform laparoscopic surgery for right hemicolectomy with the modified combined surgical technique in order to achieve better therapeutic effect and reduce postoperative complications. Preoperative preparation did not differ from conventional right hemicolectomy.

Figure 1.

Preoperative biopsy pathology results and imaging findings. (A) Colonoscopy biopsy specimen. (B) Pathologic image of the colonoscopy biopsy specimen (hematoxylin and eosin staining). (C) Preoperative CT cross-section of the lesion. (D) Coronal view of the preoperative CT lesion. CT, computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian for the publication of this case and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

In this procedure, the patient is placed in the supine position while under general anesthesia. The surgeon is on the patient’s left side, and the assistant surgeon is on the right side. The surgeon’s station is similar to that described in Matsuda et al.’s article (26). The surgery is typically performed using a 10–12 mm camera port placed 5 cm below the umbilicus to establish a pneumoperitoneum. Three 5-mm ports and one 12-mm main port are placed. The abdominal cavity is then fully explored via laparoscopy to clarify the tumor location, size, depth of infiltration, and relationship with the surrounding tissues. The gastrocolic ligament is elevated, allowing the surgeon to incise the greater omentum with an ultrasonic scalpel, exterior to the gastroepiploic vessels of the greater curvature, thus providing access to the omental sac. After this, the dissection of the fused fascia between the duodenum and transverse colon continues laterally toward the abdominal wall. The fusion fascia connecting the transverse colon to the pancreas is then separated inferiorly, exposing the anterior pancreatic hiatus and allowing clear visualization of the anterior pancreatic vessels. The cephalad veins are prioritized for ligation, with temporary management of the arteries. Once the cephalad veins are fully ligated, a gauze marker is placed to indicate the given side. The assistant surgeon elevates the proximal colon, maintaining appropriate tension to facilitate caudal dissection. The Toldt’s fascia, being less vascular, can be easily dissected with an ultrasonic scalpel with simple push-pull maneuvers, even by novice surgeons. Once the pancreas is detached, the preplaced cephalad gauze marker becomes visible, and an additional gauze marker is placed caudally.

In the final stages, the central vessels are ligated and dissected. The faintly visible SMV is traced upward through the mesentery, carefully exposing and dissecting its branching vessels. Initially, the middle colic vein (MCV) is ligated, and then dissection continues up the SMV until the predissected anterior pancreatic vessels are visualized. Finally, ligation of the ileocolic vein (ICV) and ileocolic artery (ICA) is completed.

Finally, reconstruction of the digestive tract is then performed with staplers. A subsequent laparoscopic exploration of the entire abdomen is conducted to confirm the absence of active bleeding. The abdominal cavity is irrigated, a drain is inserted, and the operation is thus completed. Patient’s surgical procedure is detailed in Video 1.

Video 1.

Download video file ^{(127.1MB, mp4)}

A modified combined approach in laparoscopic right hemicolectomy for right-sided colon based on surgical trunk orientation.

Postoperative considerations and tasks

For the case described in this report, intraoperative blood loss was limited to 100 mL, and the total operation time was 130 minutes. Pathological examination of the resected specimen revealed moderately differentiated adenocarcinoma of the ascending colon, staged as T3N1bM0 (3/12 lymph nodes positive), corresponding to stage III B (Figure 2). A closed suction drain was placed. Postoperatively, the patient exhibited a rapid recovery, with an exhaust time of 4 days and a hospital stay of 8 days. Follow-up at 6 months postoperatively revealed no evidence of recurrence, suggesting a favorable short-term outcome, though longer-term monitoring is necessary to assess the prognosis fully.

Figure 2.

Postoperative gross specimens and pathologic findings. (A) Postoperative tumor specimen and (B) pathological image of the postoperative tumor specimen (hematoxylin and eosin staining).

Tips and pearls

During the procedure, we place a piece of gauze on the cephalic side and another on the caudal side to protect the vital tissues and to mark them. This allows for a more streamlined surgical procedure and facilitates the identification of vital structures by less-experienced surgeons. In the postoperative recovery period, a quality control team consisting of senior physicians is established to monitor the quality of the surgical process and assess the postoperative outcome; in addition, we organize multidisciplinary consultations during the perioperative period, including oncology, radiology, pathology, and other multidisciplinary consultations, to formulate individualized diagnostic and therapeutic protocols, so as to ensure the quality of the surgery. For the case reported here, during this period, the patient recovered well, with a hospital stay of 8 days, with no complications related to the incision, respiratory system, urinary system, or bowel obstruction.

Discussion

The prognosis and survival rates of patients with right-sided colon cancer are particularly poor, primarily due to the disease’s high propensity for metastasis (27). Lymph node metastasis, being the primary mode of dissemination, originates in the lymph nodes adjacent to the intestinal wall and progressively disseminates to the mesenteric vessel–associated lymph nodes and beyond (28,29). Recognizing this metastasis pattern is crucial for clinical diagnosis and treatment planning, as it underpins the assessment of disease severity and the selection of an appropriate therapeutic approach. Additionally, right-sided colon cancer can metastasize via hematogenous routes, involving the dissemination of tumor cells through the bloodstream to distant organs such as the liver, lungs, and bones (30-32). This extensive metastasis generally portends a more unfavorable prognosis.

The radical surgical treatment of right-sided colon cancer necessitates meticulous lymph node dissection and careful vascular management to minimize the risk of postoperative tumor recurrence and metastasis (33,34). This approach aims to enhance patient quality of life and prolong lifespan. Radical laparoscopic surgery for right hemicolectomy is an advanced surgical technique that emphasizes clearance of mesenteric root lymph nodes and high ligation of the central vessels (35,36).

Given the intricate anatomical relationships and variable vascular patterns in the right-sided colon cancer, safe and effective vessel isolation and ligation during surgery are paramount. Throughout the surgery, the surgeons consistently maintain a clear visualization of the surgical field and ensure full exposure of the operative area. Meanwhile, in the dissection of the SMV and its branches, a combination of blunt separation and sharp separation is employed to gradually reveal and clamp the root of the blood vessel to avoid damage to the vessel wall. In scenarios where the surgical anatomy in the surgical field is unclear, the operation is difficult, or where there is multipart infiltration of the tumor, extensive adhesions, or a large amount of intraoperative bleeding that is difficult to stop, prompt consideration should be given to the possibility of timely conversion to an open laparotomy. By meticulously isolating and exposing vessels from various levels, surgeons can optimize procedure success rates and minimize complications.

A modified combined approach for laparoscopic surgery for right-sided colon cancer has been optimized to address the complexities of anatomical features and vascular variants unique to the right-sided colon cancer. This procedure follows a sequential approach, beginning with a cephalad dissection to access the avascular plane between the transverse colonic mesentery and the right mesentery of the gastric omentum, duodenum, and pancreas. This step exposes and manages the cephalad vein, facilitating subsequent vessel manipulation at the pancreatic head, Henle’s trunk, and the D3 lymph nodes. Subsequently, a caudal dissection is performed to separate the posterior colonic space and allow access to the avascular plane between the mesocolon and retroperitoneal fascia. This maneuver ensures minimal interference with vital structures, including the ureter and genitourinary vessels. Finally, a median incision is made through the mesentery to meticulously expose and facilitate ligation of the venous vascular sheaths. The overarching goal of this combined approach is to achieve complete lymph node clearance while minimizing collateral tissue damage.

It is noteworthy that dissection around the pancreatic head (exposing Henle’s trunk and pancreaticoduodenal vessels) constitutes a high-risk zone for surgical bleeding and collateral damage (to the pancreas, duodenum, and biliary tract), given the intricate anatomy and frequent vascular variations in this region. Although technical refinements have been implemented, this area remains significantly challenging for novice surgeons. The integration of fluorescence imaging or 3D reconstruction techniques may further mitigate surgical risks. Moreover, continuously enhanced surgical robotic systems with improved precision will consequently reduce intraoperative accidental injuries to some extent. Regarding methodology validation, this surgical approach primarily relies on data originating from our center. Therefore, multicenter studies, larger-scale trials, or expanded datasets incorporating diverse data types are imperative to validate the reliability of this novel procedure.

The modified combined approach in laparoscopic radical surgery for right-sided colon cancer seamlessly integrates the strengths of diverse surgical modalities while mitigating their respective limitations, ultimately enhancing surgical outcomes. The case reported here illustrates the efficacy of this approach. With ongoing procedural refinement and the accumulation of clinical experience, we anticipate that this surgical approach will yield superior treatment outcomes and enhance the quality of life for a growing number of patients with malignancies of the right colon. Furthermore, by sharing our innovative surgical technique, we hope to stimulate further thought and inspire our colleagues to collaborate and advance laparoscopic right hemicolectomy for right-sided colon cancer.

Conclusions

In conclusion, surgical optimization holds the key to enhancing therapeutic outcomes and improving patient quality of life in the treatment of right-sided colon cancer. Laparoscopic right hemicolectomy under a modified combined approach represents a promising and innovative surgical technique. Its potential to revolutionize the management of right-sided colon cancer stems from its capacity to address the limitations of traditional surgical methods.

By presenting this illustrative case, we aim to introduce surgeons to this innovative therapeutic concept, thereby fostering technological advancements and the optimization of clinical practice in the field. The modified combined approach represents a superior alternative, not only by virtue of its shortened operative times and reduced blood loss but also by its ability to minimize postoperative complications and accelerating recovery. In summary, the laparoscopic right hemicolectomy under a modified combined approach holds significant promise for the treatment of right-sided colon cancer. Its widespread adoption and accelerated refinement could lead to significant improvements in patient outcomes and overall survival rates.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian for the publication of this case and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.