Laparoscopic right colectomy with complete mesocolic excision. a three-trocar technique – a video vignette

Since Hohenberger, the principle of complete mesocolic excision (CME) has been accepted and increasingly performed by colorectal surgeons [1]. However, compared with D2 dissection, laparoscopic CME or D3 dissection has a longer learning curve and a higher surgery-related risk due to the complicated surgical anatomy and the laparoscopic approach [2] (Video S1). The aim of this video is to demonstrate the benefits of our three-trocar technique with the use of a vessel sealing device that may reduce surgery-related risk, the learning curve and operative time. The video underlines the key vascular steps needed safely to perform a complete lymphadenectomy. The first step of our technique is the identification and sealing of the ileocolic pedicle, using the energy device LigasureTM (Covidien, Walpole, Massachusetts, USA), which combines monopolar tip dissection and a vessel sealer which decreases blood loss and operative time [3]; then we continue the dissection from the duodenum and the pancreas with sealing of the right branch of the middle colic vessels as high as possible. We then demonstrate a medial to lateral dissection of the right retrocolic space along Toldt’s fascia. According to ‘no touch’ technique principles, the right colon is mobilized laterally only after the vascular supply has been divided, which also facilitates retraction during the medial dissection. Surgeons choose either a medial-to-lateral or a lateral-to-medial approach, according to their experience [4]. Although there is no consensus about the correct dissection plane in laparoscopic colectomy, we are convinced that the better outcomes from our approach are due to decreased manipulation of the cancer, early detection of retroperitoneal structures and consequently reduced bleeding. After right colonic resection we perform a completely intracorporeal side-to-side stapled isoperistaltic primary anastomosis between the distal ileum and the transverse colon and then a laparoscopic hand-sewn double layer closure of the enterotomy. The use of laparoscopic surgery in an ascending colon cancer, with CME, remains a challenge for surgeons, especially with a three-trocar technique. In the era of laparoscopic CME, the importance of finding the origin of the ileocolic pedicle should be emphasized. According to our experience, the three-trocar technique, using only a major vessel sealing device, is safe, fast and effective