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Variations in Right Colic Vascular Anatomy Observed During Wu et al. World Journal of Surgical Oncology (2019) 17:16 https://doi.org/10.1186/s12957-019-1561-4 RESEARCH Open Access Variations in right colic vascular anatomy observed during laparoscopic right colectomy Chuying Wu†, Kai Ye*†, Yiyang Wu, Qiwei Chen, Jianhua Xu, Jianan Lin and Wengui Kang Abstract Background: This study aimed to analyze right colonic vascular variability. Methods: The study included 60 consecutive patients who underwent laparoscopic radical right colectomy and D3 lymph node dissection for malignant colonic cancer on the ileocecal valve, ascending colon or hepatic flexure (March 2013 to October 2016). The videos of the 60 surgical procedures were collected. Variations of right colonic vascular anatomy were retrospectively analyzed based on 60 high-resolution surgical videos of laparoscopic surgery. Results: The superior mesenteric artery and vein were present in all cases; 95.0% (57/60) had the superior mesenteric artery on the left side of the superior mesenteric vein. The ileocolic artery and vein occurred in 96.7% (58/60) and 100% (60/60) of cases, respectively; 50.0% (29/58) had the ileocolic artery passing the superior mesenteric vein anteriorly. Thirty-three (55.0%) cases had a right colic artery, and 2 (3.33%) had a double right colic artery; 90.9% (30/36) had the right colic vein passing anterior to the superior mesenteric artery. Fifty-six (93.3%) cases had a right colic vein; 7 (12.5%) had a right colic vein accompanied by a right colic artery, 66.1% (37/56) had the right colic vein draining into the gastrocolic trunk of Henle, 23.2% (13/56) had the right colic vein directly draining into superior mesenteric vein, and 10.7% (6/56) had one right colic vein draining into the superior mesenteric vein and the other into the gastrocolic trunk of Henle. Fifty-three (88.3%) cases had a gastrocolic trunk of Henle: a gastrocolic trunk in 35.8% (19/53), a gastropancreatic trunk in 9.4% (5/53), and a gastropancreaticocolic trunk in 54.7% (29/53). The frequencies of middle colic artery and vein were respectively 100% (60/60) and 93.3% (56/60). Conclusions: Right colonic vascular variations were classified in Chinese patients. Notable findings included a superior mesenteric artery positioned to the right of the superior mesenteric vein and variation in middle colic artery length. This knowledge may be helpful to colorectal surgeons and could potentially help to improve safety by reducing vascular complications during minimally invasive procedures. Keywords: Laparoscope, Right colon radical resection, Vascular anatomic variation, Operative management of vessels Background the right colon vasculature are complex [8], and im- Laparoscopic surgery for colon cancer [1] has been ex- proper management of vessels during laparoscopic sur- tensively validated [2], and long-term survival outcomes gery can cause vascular complications [9]. Studies of are comparable between laparoscopic and open surgery right colon vascular variations could potentially mini- [3]. Laparoscopic right colectomy based on complete mize the risk of complications. Most previous autopsy mesocolic excision [4, 5] increases the number of dis- and imaging studies of the right colon have focused on sected lymph nodes, improves prognosis, and lowers arteries [10–13] rather than veins, although venous local relapse [6, 7]. Nevertheless, anatomic variations of tributaries of the right colon were recently described in a Japanese cohort using three-dimensional (3D) com- puted tomography (CT) [14]. Nonetheless, variations of * Correspondence: [email protected] †Chuying Wu and Kai Ye contributed equally to this work. Department of Tumor Surgery, Second Affiliated Hospital of Fujian Medical University, Quanzhou, People’s Republic of China © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wu et al. World Journal of Surgical Oncology (2019) 17:16 Page 2 of 13 right colon vascularity in Chinese people remain unchar- field. The superior mesenteric vein was used as a land- acterized. Preoperative 3D-CT vascular reconstruction is mark for the medial border of the LRRC. The not performed routinely due to radiation risks and other mesocolon-mesoileum junction was cut at the inferior considerations [15, 16]. ileocolic margin. Via this window, Toldt’sgapwasex- We consider that a detailed knowledge of right colon tended to expose the horizontal/descending part of the vascular variations is important to improve safety and duodenum. The superior mesenteric vein was divided reduce the risks of vascular complications during up to the inferior pancreatic margin. The ileocolic ar- minimally invasive surgery. This study aimed to retro- tery and right colic artery anterior to the superior mes- spectively review high-resolution videos of laparo- enteric vein were identified and clamped/transected. scopic radical right colectomy (LRRC) and explore The right posterior colon space was extended super- right colon vascular variations in order to summarize iorly, and the superior pancreaticoduodenal vein, right the patterns of the variations and identify methods of colic vein, and gastrocolic trunk of Henle were identi- coping with these variations during surgery. It was fied. The superior mesenteric vein was clamped/trans- anticipated that our findings would provide a useful ected. The middle colic artery was identified at the reference for surgeons. pancreatic neck. For extended LRRC, the middle colic artery was clamped/transected at the root, and Methods complete lymph node dissection was performed. For Study design standard LRRC, the left branch of the middle colic ar- This retrospective study enrolled patients who under- tery was preserved. The middle colic vein, identified went LRRC at the Department of Tumor Surgery, Sec- after opening the superior mesenteric vein sheath, was ond Affiliated Hospital of Fujian Medical University clamped/transected. The gastrocolic trunk of Henle (March 2013 to October 2016). The local ethics commit- and tributaries were identified, and every branch was tee approved the study. All procedures were in accord- divided. For standard LRRC, the anterior superior pan- ance with ethical standards of the relevant committee on creaticoduodenal vein was preserved while the right human experimentation and Helsinki Declaration. In- gastro-omental vein, right colic (and accessory right formed consent was waived because the study was colic) vein, and middle colic vein were transected. For retrospective. extended LRRC, the gastrocolic trunk of Henle was Consecutive patients were initially enrolled based on clamped/transected at its root. the following inclusion criteria: (1) malignant colonic The transverse colon was repositioned after division neoplasm clinically or pathologically diagnosed before of the lower colon. For standard LRRC, the gastro- surgery; (2) tumor on the ileocecal valve, ascending colic ligament was divided outside the gastro-omental colon or hepatic flexure (distal end < 10 cm from the arch, Toldt’s gap was opened between the mesogas- transverse colon); (3) LRRC performed between March trium and transverse mesocolon, and the transverse 2013 and October 2016; (4) standard D3 lymph node mesocolon anterior lobe was opened from the inferior dissection undertaken according to the complete pancreatic margin to the inferior region of the colon. For mesocolic excision principle. The following exclusion extended LRRC, group IV lymph nodes and lymphoid adi- criteria were then applied: (1) artery-vein classifica- pose tissue within 10 cm of the pyloric arch were re- tions or compositions unrecognized due to ineligible moved. The right gastro-omental artery was identified and standards for D3 lymph node dissection (one case); (2) transected. videos unclear, incomplete, or damaged (five cases); (3) The patient was adjusted to the Trendelenburg pos- impossible to distinguish artery-vein classifications/ ition and left-tilted 15 °. The ileocecus, ascending colon, compositions due to excessive hemorrhage/blurred op- and hepatic flexure were divided, starting from the “yel- erative fields (three cases); (4) palliative rather than low-white boundary” of the ileocecus, mesostenium root, radical resection performed (five cases). Based on the and paracolic sulci up to the interior right posterior colic inclusion and exclusion criteria, the final analysis in- space. The right colon and accessory fixation tissues cluded 60 patients. were then completely divided. The pneumoperitoneum was closed, and the right Surgical approach colon (including tumor, mesocolon, and sufficient in- The videos of all 60 surgical procedures featured LRRC testinal segment) was removed via a 5-cm median in- (or extended LRRC) using a standard five-port medial cision in the upper abdomen. End-to-side (or side- approach [17, 18]. The central-to-medial approach was to-side) anastomosis of the ileum and transverse used with the patient in a dorsal elevated, left-tilted colonwasperformed.Thefreemarginsofthemesoi- position. The small intestine
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