Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study

Abstract

Right colonic lymphovascular bundles are volumes of mesenteric tissue that surround the superior mesenteric vessels anteriorly and posteriorly. Long lymphatic vessels traverse the superior mesenteric vein anteriorly/posteriorly approaching the superior mesenteric artery between arterial bundles and placing the medial clearance on the left side of the artery. These do not correlate to arterial crossing patterns. Cranial-caudal clearances determine the tissue to be removed superior/inferior to arterial origins together with long lymphatic vessels transversing independently between the lymphovascular bundles placing the weight of lymphatic resection on the mesenteric tissue and not on the level of vessel division (High tie).

Routine CT scan one year after surgery can be used to estimate the level of central ligation in colon cancer surgery

“…The concept of CME introduced standardized colon cancer surgery with resection in the mesocolic plane and central ligation of the tumor feeding vessel [1]. In recent years, there has been significant debate about the clinical benefit of CME surgery and specifically mandatory division of the tumor feeding artery remains controversial [5,6].…”

Bowel Motility After Injury to the Superior Mesenteric Plexus During D3 Extended Mesenterectomy

“…The medial border follows a line running along the left border of the SMA. 8 Because this is the pathway for the SMP, one must assume that most of the nerves belonging to the plexus at this level are transected. The procedure is significantly more radical than the traditional lymphadenectomy, including the so-called complete mesocolic excision (Fig.…”

“…To improve the oncological outcomes of colon cancer, the focus has turned toward more radical lymphadenectomy. 8 In the case of the right colon, this leads us directly into the common neurovascular stem of the midgut containing the extrinsic nerve plexus 2 . Based on theoretical considerations and constraints, surgeons were hesitant to enter this area.…”

Regional Lymph Nodes Distribution Pattern in Central Area of Right-sided Colon Cancer: In-Vivo Detection and the Update on the Clinical Exploration.

“…Until now the internal border of the central area has remained fuzzy, and the data on regional LNs around superior mesenteric vessels are scanty [8,9]. Currently, most surgeons de ne SMV as the destination of RCC surgery, but this opinion is controversial.…”

“…In 2013, Milan Spasojevic et al reported an anatomical postmortem study and established the presence of LNs posterior to SMV, which was associated with the cross-modal relationship between an ileocolic artery (ICA) and SMV [10]. Recent postmortem research developed the understanding that the long right colonic lymphovascular bundles were across the SMV and described the midline of SMA as the watershed between the small bowel and right colon lymphatics [8]. This research had shown the potential necessity to de ne the internal border of RCC resection to the midline of SMA.…”