Clinical application of the caudal-to-dorsal priority combined with cephalic approach in laparoscopic radical resection of right colon cancer

Clinical application of the caudal-to-dorsal priority combined with cephalic approach in laparoscopic radical resection of right colon cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical application of the caudal-to-dorsal priority combined with cephalic approach in laparoscopic radical resection of right colon cancer Li TengTeng, Sun Xu, Fu HaiXiao, Wang Kai, Fu Wei, Xuan Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4064639/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective The objective of this study is to examine the safety and feasibility of laparoscopic total colonic mesenteric resection for radical right hemicolectomy, utilizing a caudal-to-dorsal priority access approach in combination with a cephalic approach. Methods This study aims to conduct a retrospective analysis of the clinical data of 56 patients diagnosed with right hemi-colon cancer, who underwent radical right hemi-colon resection through laparoscopic total colonic mesenteric resection with caudal-to-dorsal priority, combined with cephalic approach, between January 2021 and June 2022. Results All 56 cases were completed without any instances of open surgery. The average operative time was (153.8 ± 42.5) minutes, with an average intraoperative bleeding of (53.3 ± 21.3) mL. The average time to first gas after surgery was (58.3 ± 13.6) hours, while the average time to return to a liquid diet was (68.5 ± 19.6) hours. The average postoperative hospital stay was (6.1 ± 3.0) days. Following surgery, two cases of lymphatic fistula and one case of anastomotic bleeding were reported. Following conservative treatment, all cases were cured, and no perioperative deaths were reported. Post-operative pathological results indicated that all cases were diagnosed with adenocarcinoma, with an average of 20.1 ± 5.9 lymph nodes cleared. Tumor staging revealed 8 cases in stage I, 19 cases in stage IIA, 11 cases in stage IIB, 12 cases in stage IIIA, and 6 cases in stage IIIB. During the 12-month postoperative follow-up, no instances of recurrence, metastasis, or death were observed. Conclusions The utilization of a caudal-to-dorsal priority in conjunction with a cephalic approach during laparoscopic radical resection of right hemicolectomy is a secure and viable method that aligns with the fundamental principles of radical oncology. This technique can aid in reducing the learning curve for surgeons performing laparoscopic right hemicolectomy and in guaranteeing surgical safety. Right hemi-colon neoplasms Laparoscopy surgery caudal-to-dorsal access caudal-to-dorsal access Figures Figure 1 Figure 2 Figure 3 Introduction The optimal surgical approach for resectable right colon cancer remains uncertain. Currently, the primary methods for laparoscopic radical resection of right-sided nodules are the lateral and middle approaches [1] . During the initial stages of laparoscopy, a laparoscopic right hemicolectomy was executed by the surgeon through the open approach, utilizing the lateral peritoneal flexure as the entry point to locate the natural space, resulting in a straightforward and secure operation. However, as laparoscopic techniques advanced and the principle of radical tumor resection gained prominence, the intermediate approach emerged as the prevailing method for laparoscopic right colon surgery. In 2001, Fujita and colleagues from Japan were the first to document the laparoscopic radical resection of right colon cancer utilizing the caudal median approach (ventral) [2] . In 2013, Mitsutomo from Japan presented a report on the implementation of laparoscopic right hemicolectomy through a dorsal median approach to the caudal ileocecum [3] . In 2015, Zou et al provided a summary of the operational procedure for right colon cancer, which bears resemblance to the dorsal middle approach of caudal ileocecum of Mitsutomo, and yielded favorable outcomes [4] . The present state of laparoscopic radical right hemicolectomy involves two distinct approaches: a cephalic (ventral, i.e., anterior) approach and a caudal (ventral and dorsal, i.e., anterior or posterior) intermediate approach. The contentious issue at hand pertains to determining which of these approaches is more conducive to mastering the technique of performing a complete mesocolectomy (CME). Zheng Bobo et al and Fei Li et al have determined that the caudal approach surgery time is shorter, with less bleeding and greater ease of operation when performed on the head side [5–6] . However, the prevailing view among scholars is that the identification of the appropriate retroperitoneal space is more readily achieved through a caudal approach as opposed to a cephalic approach. It should be noted, however, that the ventral or dorsal approach via the caudal approach remains a topic of debate. Mitsutomo [3] and Zou Shaonan [4] considered that the right retroperitoneal space could be found more easily by the caudal medial approach with the ileocecal region turned upside down than by the caudal medial approach under the ileocolic vessels (ventral), the ileocecal region was then reduced, and ventral dissection and high ligation were performed more easily. In contemporary times, numerous academics have embraced the intermediate approach, which employs the superior mesenteric vein (SMV/SMA) as a guide to address the right hemi-vessel, subsequently revealing and widening the Toldt's Gap, from the center to the lateral, to achieve complete liberation and excision of the right colon. Currently, the intermediate approach is deemed the most appropriate for a thorough tumor resection, albeit it is intricate, perilous, and prone to intraoperative hemorrhage, necessitating a high level of proficiency from the operator. Hence, our objective is to identify a straightforward, readily comprehensible, secure, viable, and consistent with the tenets of radical tumor management technique, with the aim of facilitating novice proficiency, curtailing the learning period, mitigating surgical complexity, and accomplishing the procedure with enhanced safety and expediency. Drawing upon our extensive clinical experience in laparoscopic colon cancer surgery and our comprehensive knowledge of surgical anatomy, we have discovered that the mesentery and the right hemicolon form a continuous, rotating entity that is centered around the superior mesenteric vein (SMV/SMA). Specifically, we have observed that the mesenteric root is attached to the posterior abdominal wall in an upper left to lower right orientation, and that the posterior mesentery represents a naturally occurring, vascular-free Toldt's fusion fascia. Furthermore, we have found that the SMV/SMA can be readily exposed within the posterior mesentery of the colon. The dissection of the superior mesenteric vessels was performed in the fusion fascia space, commencing from the caudal side and proceeding towards the head side, followed by a reversal of direction from the head side to the caudal side, ultimately freeing and treating the right hemicolon tumor. The utilization of a combined approach involving head-tail-side, ventral-dorsal, and medial-lateral directions facilitates a structured and simplified right hemicolon operation, thereby reducing complexity and enhancing pedagogical efficacy. This method is characterized by its safety and minimal bleeding. This study retrospectively examined the clinical data of 56 consecutive patients who underwent laparoscopic radical resection of right colon cancer utilizing a caudal-to-dorsal priority combined with cephalic approach between January 2021 and June 2022 in our department. The objective was to investigate the safety, feasibility, and clinical application value of this surgical approach. Materials and Methods General information Among the cohort of 56 patients, 35 were identified as male and 21 as female, with a mean age of (59.2 ± 11.5) years and a mean BMI of (23.0 ± 3.1) kg/m². Specifically, 13 patients were diagnosed with cancer of the cecum, 25 with cancer of the ascending colon, and 18 with cancer of the hepatic flexure of the colon, all of whom were confirmed to have adenocarcinoma of the colon through preoperative colonoscopic biopsy pathology. Additionally, three patients presented with comorbid diabetes mellitus, while seven patients had hypertension. Five patients had a history of abdominal surgery, including two cases of biliary surgery and three cases of caesarean section. The preoperative ASA score ranged from I to III, and no distant metastases were detected in any of the preoperative ancillary examinations. The Ethics Committee of the Affiliated Hospital of Xuzhou Medical University approved the surgical method employed in this study, and informed consent was obtained from all participating patients. Preoperative preparation: Three days prior to the surgical procedure, a liquid diet was initiated and oral laxatives were administered on the morning of the surgery to empty the bowel. Intravenous antibiotics were administered to patients 30 minutes prior to the induction of anesthesia and the commencement of the surgical procedure. Surgical procedure The patient assumes a lithotomy position, while the operator stands on the left side, the assistant on the right side, and the scope holder between the legs(Fig. 1A,B). The pneumoperitoneum pressure is maintained at 12-15mmHg. A standard exploration of the abdominal cavity is conducted, with particular attention paid to the peritoneum, omentum, and visceral surface for the presence of metastatic lesions. Upon detection of the primary lesion, the tumor's location and size were identified, and the operative range was established. Following exploration of the abdominal cavity, the greater omentum was positioned above the transverse colon and below the liver, while the small intestine was placed in the left upper abdomen, thereby exposing the root of the ileum mesentery. The assistant successfully grasped the appendix and the ileum mesentery 15 cm away from the ileocecal region without any harm. Our surgical procedure is comprised of seven distinct modules. 1.Tail-side approach The surgeon utilized a triangular traction technique by grasping the distal ileum mesentery root at a distance of 1 cm from the caudal aspect. To gain access to the loose layer between Toldts' fascia and the retroperitoneal subfascia (Gerota's fascia), the peritoneum is incised 1 cm cephalad to the right iliac artery using an ultrasound knife. The two fascia's exhibit a slight difference in color, and the vascularity direction within Toldts' fascia is predominantly perpendicular to the long axis of the body, while the direction of capillary vascularity within the retroperitoneal subfascia is mostly parallel to the long axis of the body, which can aid in identifying the correct layer. To prevent harm to the genital vessels and ureter, it is recommended to maintain the seamless integrity of the retroperitoneal subfascia while continuing to widen the gap cephalad. The assistant should utilize grasping forceps on both the left and right sides to lift the ascending colonic mesentery, thereby exposing the junction of the descending and horizontal duodenum medially. Further expansion of the anterior pancreaticoduodenal space along the anterior duodenum is advised. The medial termination point of the separation lies adjacent to the projection of the inferior mesenteric vein, while the lateral boundary extends towards the lateral border of the right kidney and the superior limit is positioned at the junction of the duodenal bulb and descending portion. To demarcate the entire cleared area, gauze strips are positioned anteriorly to both the pancreas and duodenum, serving as the right-hand border(Fig. 2A). 2.Superior mesenteric vein dorsal free The assistant proceeds to lift the left and right mesentery of the superior mesenteric vein, turning caudally medially. This action results in the unfolding of the dorsal aspect of the superior mesenteric vein and the release of the peritoneum dorsal to the superior mesenteric vein. The area of focus is distal to the confluence of the ileocolic veins and proximal to the level of the gastrocolic trunk (Henle trunk). Subsequently, the assistant prepares the right side of the superior mesenteric vein for clearance by placing gauze in position(Fig. 2B). 3. Localization of the mesenteric root of the transverse colon The small intestine is situated in the inferior abdominal region. During the surgical procedure, the assistant elevates both the left and middle portions of the transverse mesocolon, while the primary scalpel secures the right side of the ligamentous flexure mesentery. The triangular transverse mesocolon is then extended and unfurled, and the ultrasonic scalpel is employed to incise the mesentery from the base of the left side of the middle colonic artery depression, releasing it in a cephalad direction along the superior border of the pancreas and converging with the posterior wall of the stomach. A gauze strip is filled in as the left border of the entire clearing area(Fig. 2C). 4.Lateral cephalic approach The caudal traction of the greater omentum and transverse colon is accompanied by the assistant's upward traction of the lateral arterial arches of the greater curvature of the stomach, specifically the right and left sides, while the surgeon simultaneously pulls the omentum caudally to establish a triangular retraction. Starting from the center of the triangle, the greater omentum is incised to access the omental sac. Subsequently, the greater omentum is dissected towards the left and extended towards the right by freeing it along the gastrocolic mesenteric gap. This dissection exposes the gastric mesentery on the cranial side and the colonic mesentery on the caudal side, extending towards the right until the anterior wall of the duodenum and the head of the pancreas are visible. Finally, the posterior gap of the ascending colon is connected to reveal the positioning gauze for the caudal approach. The dissection of the deep gastrocolic mesentery exposes the branches of the Henle trunk, including the right gastroretinal vein on the cephalic side, the superior anterior pancreaticoduodenal vein, and the paramedian right colic vein on the caudal side. The paramedian right colic vein is subjected to free ligation at the root. The main trunk of the superior mesenteric vein is exposed by freeing along the inferior margin of the pancreas towards the deep side. The peritoneal layer covering the root of the transverse colonic mesentery is incised on the left side of the root of the middle colonic artery, thereby exposing the gauze located at the root of the transverse colon. The gauze is then extracted and spread out over the superior mesenteric vein's main trunk, extending towards the gastrocolic mesenteric space, which demarcates the cephalolateral boundary of the entire sweeping region. This procedure concludes the comprehensive demarcation of the gauze strip's wrapping area(Fig. 2D). 5. Central mesenteric region clearance(Fig. 2E) The small intestine is situated in the lower left quadrant of the abdomen. The assistant grasps the mesenteric opening located at the base of the transverse colonic mesentery and elevates the vascular projection of the ileocolon, thereby facilitating the unfolding of the right hemicolectomy. The ileocecal mesentery is incised at the inferior margin of the depression beneath the ileocolon and extends into the posterior interval of the ascending colon. Upon exposing the primary trunk of the superior mesenteric vein, the grasping forceps should be adjusted to a distance of 3 cm from the root of the ileocolic vessels. Subsequently, a pulling force in the direction of 11 points should be applied, while collaborating with an assistant to rectify the central mesenteric region. This maneuver will result in the complete liberation of the dorsal aspect of the superior mesenteric vein and the entire region will be secured (with priority given to the superior mesenteric vein). This marks the point at which the dorsal aspect of the superior mesenteric vein is released. The dissection of the superior mesenteric vein involves a cephalad approach along the left side of the main trunk, with blunt separation occurring 5 mm anterior to the vein and subsequent cutting of the vein surface using an ultrasound knife. This dissection method is deemed relatively safe for anterior dissection of the superior mesenteric vein due to the absence of apparent adhesions to surrounding tissues and the majority of its branches being located on either side of the main trunk. The cephalad removal and dissection of the ileocolic vein and artery at their root, along with the clearance of the 203rd group of lymph nodes, is performed. In cases where the ileocolic artery is situated dorsal to the superior mesenteric vein, dissection of the artery is carried out at the left margin of the superior mesenteric vein. In instances where the right colonic artery or vein is absent, the former is removed at the left margin of the superior mesenteric vein if it is located dorsal to it. Following this, group 213 lymph nodes are cleared. The Henle trunk is then freed cephalad, and the paramedian right colonic vein is dissected and connected to the cephalad free plane. The procedure involves the continued dissection of the middle colonic vein in a cephalad direction towards the superior mesenteric vein and to the left of the Henle trunk. The vein is then ligated at its root to facilitate disconnection and enlargement for connection with the cephalad free plane. Additionally, the middle colonic artery is dissected in a cephalad direction and ligated at its root to enable disconnection. In cases of ascending colon tumours, the bifurcation of the middle colonic artery is further dissected, with the right branch being disconnected while preserving the left branch. Finally, the 223 groups of lymph nodes are cleared. The lymph nodes located in group 223 have been effectively cleared. Subsequently, the cephalic free plane is utilized to completely clear the area, and the gauze is subsequently extracted. 6. Lateral free(Fig. 2F) The assistant executes a lateral maneuver to extract the transverse colon 10 cm from the colonic hepatic flexure towards the 4 o'clock position, simultaneously drawing the ascending colon 10 cm from the colonic hepatic flexure towards the 6 o'clock position. The hepatic colonic ligament is then carefully opened in proximity to the liver to release the colonic hepatic flexure in an undamaged state. The assistant manipulates the colonic hepatic flexure towards the 3 o'clock position while simultaneously manipulating the appendix towards the 5 o'clock position, thereby separating and spreading the lateral peritoneum of the ascending colon and achieving complete liberation of the right hemicolon. In order to prevent torsion during specimen retrieval, the right hemicocele and omentum are repositioned. 7. Anastomosis(Fig. 3) An incision was created in the upper abdomen, measuring approximately 5 cm in length, to access the right hemicolectomy and greater omentum. The resection of the ileum, including the tumor and right hemicolectomy, was performed, followed by an anastomosis of the lateral ileo-transverse colon outside the body. The pneumoperitoneum was reconstructed, and the mesenteric fissure was sutured. A drainage tube was placed in the right upper abdomen, and the intestinal tube was inserted before closing the abdomen. Observation index During the perioperative period, patients were monitored for various factors such as operation duration, intraoperative hemorrhage, duration of postoperative fatigue, resumption of liquid diet, incidence of postoperative complications, length of hospital stay, and postoperative pathology, which encompassed the tumor's characteristics, number of cleared lymph nodes, and stage of the tumor. Postoperative follow up The study employed outpatient and telephone follow-up methods to document the recurrence of tumors and the quality of life of the patients. Statistical processing Data were analysed using SPSS 22.0 software. Normally distributed measures are expressed as (_x ±s) and skewed measures are expressed as M (range). Results Perioperative results All 56 cases were successfully completed without any surgical interventions. The mean operative time was (153.8 ± 42.5) minutes, the average intraoperative bleeding was (53.3 ± 21.3) milliliters, the average time to first gas after surgery was (58.3 ± 13.6) hours, the average time to resume liquid diet was (68.5 ± 19.6) hours, and the average postoperative hospital stay was (6.1 ± 3.0) days. Following surgery, two cases of lymphatic fistula and one case of anastomotic bleeding occurred, all of which were resolved through conservative treatment. No perioperative deaths were reported. Postoperative pathological findings All of the tumors observed were identified as adenocarcinomas, with an average of 20.1 ± 5.9 lymph nodes cleared. The distribution of tumor stages was as follows: 8 cases were classified as stage I, 19 cases as stage II A , 11 cases as stage II B , 12 cases as stage III A , and 6 cases as stage III B . Results of follow-up visits Chemotherapy was standardized based on post-operative pathological staging, and patients were subsequently monitored for 12 months post-operatively. No instances of recurrence, metastasis, or mortality were observed during this follow-up period. Discussion In 2009, a group of German scholars led by Hohenberger introduced the concept of CME, which involves the complete resection of the mesentery surrounding the rectum [7] . Throughout the course of human embryonic development, the posterior wall of the ascending colon and the posterior lobe of the ascending mesentery undergo fusion with the peritoneum of the posterior abdominal wall, ultimately resulting in the formation of the right Toldt fusion fascia. This fascia, in conjunction with the anterior lobe of the right hemicolectum (posterior peritoneum), envelops the nerves, blood vessels, and lymphatic adipose tissue contained within, thereby creating the ascending colonic mesentery. The ascending colonic mesentery, in combination with the transverse colonic mesentery, ultimately culminates in the formation of the right hemicolectum. The right Toldt fusion fascia is incised within the surgical plane for right hemicolectomy, known as the right Toldt space. This space is contiguous with the left Toldt space laterally, and is further partitioned into the pre-pancreatic and post-pancreatic spaces at the hepatic flexure of the colon. The space extends caudally to the posterior aspect of the rectum [8] . This approach aligns more closely with the principle of aggressive tumor management, enhances the prognosis of individuals with colon cancer, markedly diminishes the 5-year incidence of local recurrence of colon cancer, and elevates the 5-year survival rate associated with the tumor [7] . Performing a right hemicolectomy presents challenges due to the prevalence of vascular anatomical variation, the complexity of complete mesocolic excision (CME) surgery, and the absence of palpation, particularly in laparoscopic procedures. However, the safety and efficacy of laparoscopic radical surgery for right hemicolectomy have been preliminarily validated in terms of tumor radicality [9–11] . The complexity of laparoscopic complete mesocolic excision (CME) of right hemicolectomy is attributed to the stringent demands on the mastery of free space, release of blood vessels, and clearance of root lymph nodes. The selection of the surgical approach for this procedure has been a topic of debate, and a consensus has yet to be reached. The available surgical approaches comprise central, caudal, cephalic, and mixed approaches, with the complete central approach centered on the superior mesenteric vein being the most frequently employed [12–16] . The prevalent surgical techniques encompass central, caudal, cephalic, and mixed approaches, among which the completely central approach targeting the superior mesenteric vein is the most frequently employed. Nevertheless, the central approach poses challenges in terms of visualizing the superior mesenteric artery, discerning crucial anatomical structures, and reaching anatomical planes, particularly in patients with obesity or severe abdominal adhesions, or for inexperienced surgeons [17,18] . The caudal ventral approach is divided into a caudal ventral lateral approach and a dorsal lateral approach [19] . The caudal ventral lateral approach, also known as the caudal median approach, involves making an incision into the right retroperitoneal space at a natural fold located below the ventral ileocolic vessels in the ventral part of the ileocecum. On the other hand, the caudal dorsolateral approach entails turning the ileocecal region cephalad and making an incision into the right retroperitoneal space at the yellow-white junction line, which is located 1.0–2.0 cm above the right common iliac artery and corresponds to the dorsal projection of the root of the small bowel mesentery. The ventral approach presents a higher likelihood of traversing an incorrect gap compared to the dorsal approach, particularly among novice practitioners. In the event of accessing the retroperitoneal space beneath the ileocolic vessels, thin patients may be susceptible to inadvertent penetration of the colonic mesentery, whereas obese patients may encounter challenges in identifying anatomical landmarks, as well as hypertrophy of the mesentery and inconspicuous vascular elevation, which may impede entry into the appropriate surgical plane. Given this predicament, our center has developed a comprehensive approach to ensure consistency in surgical quality by implementing process-based quality control measures at every stage of the operation. This approach involves combining the expertise gained from performing laparoscopic right hemicolectomy CME surgery with the da Vinci robot-assisted hybrid access right hemicolectomy CME surgery, resulting in a level-first caudal-dorsal-first combined cephalad approach. Drawing upon a comprehensive analysis of laparoscopic radical treatment of right hemicolectomy across multiple healthcare facilities [20–22] , the surgical team practically summarized the advantages and disadvantages of different approaches and gradually carried out laparoscopic CME of right hemicolectomy with caudal-dorsal priority combined with cephalic approach. The findings of the present investigation indicate that the perioperative complication rate was 5.3% (3/56), which was comparable to that of the caudal-medial approach, thereby establishing the safety and feasibility of the procedure. With regard to radical tumour treatment, the mean number of lymph nodes excised in this study was (20.1 ± 5.9), satisfying the criteria for radical tumour treatment. Our observations suggest that the caudodorsal preferential combined with the cephalolateral approach confers several benefits: ⑴The radicality of the tumor is established through decreased surgical complexity, particularly in patients with higher levels of obesity or adhesion, thereby facilitating the acquisition of the complete mesocolic excision technique for the junior attending surgeon performing a right hemicolectomy. The determination of the right border of the sweep involves the retention of a gauze strip, thereby facilitating access to the superior pancreatic space from the root of the transverse colonic mesentery, leading to the omental sac. Similarly, the determination of the left border of the sweep entails the retention of a gauze strip. Ultimately, the omental sac can be reached through the lateral aspect of the vascular arch of the greater curvature of the stomach, specifically on the left side. This approach allows for the separation of the gastrocolic mesenteric space towards the right. These three spaces are readily identifiable, particularly in patients with obesity or significant abdominal adhesions. ⑵ Minimize intraoperative vascular injury resulting from indeterminate anatomical planes. The surgical trunk vessels present a challenging aspect of the right hemicolectomy procedure. Employing a mixed approach, the surgical trunk's left, right, and cephalic sides are isolated from the surrounding tissues using gauze strips. This is particularly crucial after the dorsal release of the superior mesenteric vein (SMV), which tethers the entire central clearance area and reflects the fundamental principles of complete mesocolic excision (CME) surgery. Subsequently, the vessels of the surgical trunk are cleared and disconnected sequentially, leading to a notable decrease in intraoperative vascular injury and bleeding. ⑶ The number of intraoperative position changes was minimized, necessitating only a single adjustment of the patient's position throughout the entirety of the procedure. ⑷Facilitating the sequential execution of surgical procedures facilitates the implementation of standardized training programs for novice surgeons, expediting their comprehension and proficiency in performing right hemicolectomy CME surgery, and consequently reducing the duration of the learning process for right hemicolectomy. ⑸The planned intraoperative strategy incorporates three cephalocaudal combinations to mitigate complexity and enhance safety. The internal and external combination circumvents spatial constraints and tension in the caudal approach while upholding the no-touch principle. The ventral-dorsal combination optimizes the degree of curettage and alleviates the challenges associated with the primary operative axis for dorsal management of SMA/V. The utilization of a mixed approach consisting of cephalocaudal echo, ventral-dorsal echo, and medial-external echo liberation facilitates a procedural method for performing right hemicolectomy, which enhances the attainment of complete mesocolic excision (CME) surgery, diminishes the complexity of the procedure, minimizes intraoperative bleeding and non-operative time, optimizes the training of novice surgeons, and is replicable irrespective of the patient's condition or the clinical proficiency of the responsible surgeon. This study is subject to certain limitations, namely its single-centre clinical design and the absence of comparative data between laparoscopic right hemicolectomy and conventional methods, as well as a lack of long-term follow-up on oncological outcomes. Efforts are currently underway to gather data in this regard. Preliminary results indicate that the caudodorsal preferential combined cephalic surgical approach to laparoscopic right hemicolectomy is a safe and feasible option with clinical utility and adherence to surgical oncology principles. Moreover, this approach can aid in reducing the learning curve for surgeons performing laparoscopic right hemicolectomy and ensuring surgical safety. Declarations Disclosures Zhang Xuan, Wang Kai, Fu HaiXiao, Li TengTeng, Sun Xu, Fu Wei have no conflicts of interest or financial ties to disclose. Author contributions FW and ZX performed the operation and drafted the manuscript. LTT and SX analyzed the data and designed the research. FHX and WK contributed to manuscript revision. LTT and ZX Conceived the idea, designed the research, and finalized the manuscript. All authors read and approved the final manuscript. 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Laparoscopic modified mesocolic excision with central vascular ligation in right-sided colon cancer shows better short- and long-term outcomes compared with the open approach in propensity score analysis. Surg Endosc. 2018;32(6):2721–2731. doi:10.1007/s00464-017-5970-6. Petz W, Ribero D, Bertani E, et al. Suprapubic approach for robotic complete mesocolic excision in right colectomy: Oncologic safety and short-term outcomes of an original technique. Eur J Surg Oncol. 2017;43(11):2060–2066. doi:10.1016/j.ejso.2017.07.020. Matsuda T, Sumi Y, Yamashita K, et al. Anatomy of the Transverse Mesocolon Based on Embryology for Laparoscopic Complete Mesocolic Excision of Right-Sided Colon Cancer. Ann Surg Oncol. 2017;24(12):3673. doi:10.1245/s10434-017-6070-5. Zurleni T, Cassiano A, Gjoni E, et al. 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Surg Endosc. 2018;32(5):2567–2574. doi:10.1007/s00464-017-5982-2. Enomoto M, Katsumata K, Tago T, et al. Laparoscopic modified complete mesocolic excision for right-sided colon cancer. Tech Coloproctol. 2022;26(1):71–73. doi:10.1007/s10151-021-02495-8. Feng H, Zhao XW, Zhang Z, et al. Laparoscopic Complete Mesocolic Excision for Stage II/III Left-Sided Colon Cancers: A Prospective Study and Comparison with D3 Lymph Node Dissection. J Laparoendosc Adv Surg Tech A. 2016;26(8):606–613. doi:10.1089/lap.2016.0120. Sato S, Sugano N, Shiozawa M, et al. Application and outcomes of a standardized lymphadenectomy in laparoscopic right hemicolectomy requiring ligation of the middle colic artery. Tech Coloproctol. 2021;25(2):223–227. doi:10.1007/s10151-020-02388-2. Widmar M, Keskin M, Strombom P, et al. Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches. Colorectal Dis. 2017;19(10):888–894. doi:10.1111/codi.13786. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 02 Aug, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers invited by journal 28 May, 2024 Editor assigned by journal 02 Apr, 2024 Submission checks completed at journal 02 Apr, 2024 First submitted to journal 10 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4064639","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286593052,"identity":"b0853f51-cd85-488b-b3b1-76174a880642","order_by":0,"name":"Li TengTeng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIie3PMYvCMBTA8UggLqlZryje4Bd40kEE0a+SItx0w41uBgQnca7fwaHTzS90LXYt3OLhLFhukbsOl3bomDoeXP5DSOD9SEKIy/UH69FmSxElzLgQyk4YrQ1U2xDPq5eBH2ELIQ3hI31Okxko2UK6Ql/evsvhRBwJhtuMA8HOrXi1PowGhz0E0+iKhnzwCVXUP7xbCet7Owjj/CRrMlXIqGcn3R9D1nGegiEnDihbCaP8DhKynRlO8SES9D0VjOOcSZSrJfcjvbH+RQj9+cXL4TNkSVLcYb4QYqNvhYXUdbZmeZLNUbXMV5XVffjAoMvlcv3LfgGGR1QTB3M0fgAAAABJRU5ErkJggg==","orcid":"","institution":"The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Li","middleName":"","lastName":"TengTeng","suffix":""},{"id":286593055,"identity":"defff7fd-c50f-44b6-864b-6d4c41b2975a","order_by":1,"name":"Sun Xu","email":"","orcid":"","institution":"The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Sun","middleName":"","lastName":"Xu","suffix":""},{"id":286593058,"identity":"a10300ec-0690-440c-b898-aae1d05b2120","order_by":2,"name":"Fu HaiXiao","email":"","orcid":"","institution":"The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fu","middleName":"","lastName":"HaiXiao","suffix":""},{"id":286593060,"identity":"788283b4-c536-4cae-9ba2-a5c82b550051","order_by":3,"name":"Wang Kai","email":"","orcid":"","institution":"The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Kai","suffix":""},{"id":286593062,"identity":"281432d8-4838-4ed8-8e94-cf77cf079d22","order_by":4,"name":"Fu Wei","email":"","orcid":"","institution":"The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fu","middleName":"","lastName":"Wei","suffix":""},{"id":286593064,"identity":"87dc458d-8de7-4cd0-8aeb-e1b4aacc5916","order_by":5,"name":"Xuan Zhang","email":"","orcid":"","institution":"The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xuan","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-03-10 11:46:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4064639/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4064639/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54192219,"identity":"5b57d6ce-ead3-4354-a3f8-59713f55b460","added_by":"auto","created_at":"2024-04-05 21:02:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":97232,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"OnlineFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4064639/v1/094580dee357fc307e2d95dd.png"},{"id":54192221,"identity":"cd487d20-69ea-4b54-bc05-d841b8e71375","added_by":"auto","created_at":"2024-04-05 21:02:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":16816603,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig21.png","url":"https://assets-eu.researchsquare.com/files/rs-4064639/v1/c1e9b49d30e30f7591291f56.png"},{"id":54192477,"identity":"dfd7d0c9-996a-45a2-8f66-6025ca969c46","added_by":"auto","created_at":"2024-04-05 21:10:52","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1028667,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4064639/v1/d1bdc4b8fd1e8f3d7822e187.jpg"},{"id":54192984,"identity":"9c2c7ce0-f47c-4756-94e9-bd08240b636f","added_by":"auto","created_at":"2024-04-05 21:18:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1988763,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4064639/v1/f71927f6-22f8-4ff2-afe7-93efd8d9c14e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical application of the caudal-to-dorsal priority combined with cephalic approach in laparoscopic radical resection of right colon cancer","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe optimal surgical approach for resectable right colon cancer remains uncertain. Currently, the primary methods for laparoscopic radical resection of right-sided nodules are the lateral and middle approaches\u003csup\u003e[1]\u003c/sup\u003e. During the initial stages of laparoscopy, a laparoscopic right hemicolectomy was executed by the surgeon through the open approach, utilizing the lateral peritoneal flexure as the entry point to locate the natural space, resulting in a straightforward and secure operation. However, as laparoscopic techniques advanced and the principle of radical tumor resection gained prominence, the intermediate approach emerged as the prevailing method for laparoscopic right colon surgery. In 2001, Fujita and colleagues from Japan were the first to document the laparoscopic radical resection of right colon cancer utilizing the caudal median approach (ventral)\u003csup\u003e[2]\u003c/sup\u003e. In 2013, Mitsutomo from Japan presented a report on the implementation of laparoscopic right hemicolectomy through a dorsal median approach to the caudal ileocecum\u003csup\u003e[3]\u003c/sup\u003e. In 2015, Zou et al provided a summary of the operational procedure for right colon cancer, which bears resemblance to the dorsal middle approach of caudal ileocecum of Mitsutomo, and yielded favorable outcomes\u003csup\u003e[4]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe present state of laparoscopic radical right hemicolectomy involves two distinct approaches: a cephalic (ventral, i.e., anterior) approach and a caudal (ventral and dorsal, i.e., anterior or posterior) intermediate approach. The contentious issue at hand pertains to determining which of these approaches is more conducive to mastering the technique of performing a complete mesocolectomy (CME). Zheng Bobo et al and Fei Li et al have determined that the caudal approach surgery time is shorter, with less bleeding and greater ease of operation when performed on the head side\u003csup\u003e[5\u0026ndash;6]\u003c/sup\u003e. However, the prevailing view among scholars is that the identification of the appropriate retroperitoneal space is more readily achieved through a caudal approach as opposed to a cephalic approach. It should be noted, however, that the ventral or dorsal approach via the caudal approach remains a topic of debate. Mitsutomo\u003csup\u003e[3]\u003c/sup\u003e and Zou Shaonan\u003csup\u003e[4]\u003c/sup\u003e considered that the right retroperitoneal space could be found more easily by the caudal medial approach with the ileocecal region turned upside down than by the caudal medial approach under the ileocolic vessels (ventral), the ileocecal region was then reduced, and ventral dissection and high ligation were performed more easily. In contemporary times, numerous academics have embraced the intermediate approach, which employs the superior mesenteric vein (SMV/SMA) as a guide to address the right hemi-vessel, subsequently revealing and widening the Toldt's Gap, from the center to the lateral, to achieve complete liberation and excision of the right colon. Currently, the intermediate approach is deemed the most appropriate for a thorough tumor resection, albeit it is intricate, perilous, and prone to intraoperative hemorrhage, necessitating a high level of proficiency from the operator.\u003c/p\u003e \u003cp\u003eHence, our objective is to identify a straightforward, readily comprehensible, secure, viable, and consistent with the tenets of radical tumor management technique, with the aim of facilitating novice proficiency, curtailing the learning period, mitigating surgical complexity, and accomplishing the procedure with enhanced safety and expediency. Drawing upon our extensive clinical experience in laparoscopic colon cancer surgery and our comprehensive knowledge of surgical anatomy, we have discovered that the mesentery and the right hemicolon form a continuous, rotating entity that is centered around the superior mesenteric vein (SMV/SMA). Specifically, we have observed that the mesenteric root is attached to the posterior abdominal wall in an upper left to lower right orientation, and that the posterior mesentery represents a naturally occurring, vascular-free Toldt's fusion fascia. Furthermore, we have found that the SMV/SMA can be readily exposed within the posterior mesentery of the colon. The dissection of the superior mesenteric vessels was performed in the fusion fascia space, commencing from the caudal side and proceeding towards the head side, followed by a reversal of direction from the head side to the caudal side, ultimately freeing and treating the right hemicolon tumor. The utilization of a combined approach involving head-tail-side, ventral-dorsal, and medial-lateral directions facilitates a structured and simplified right hemicolon operation, thereby reducing complexity and enhancing pedagogical efficacy. This method is characterized by its safety and minimal bleeding. This study retrospectively examined the clinical data of 56 consecutive patients who underwent laparoscopic radical resection of right colon cancer utilizing a caudal-to-dorsal priority combined with cephalic approach between January 2021 and June 2022 in our department. The objective was to investigate the safety, feasibility, and clinical application value of this surgical approach.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eGeneral information\u003c/h2\u003e \u003cp\u003eAmong the cohort of 56 patients, 35 were identified as male and 21 as female, with a mean age of (59.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5) years and a mean BMI of (23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1) kg/m\u0026sup2;. Specifically, 13 patients were diagnosed with cancer of the cecum, 25 with cancer of the ascending colon, and 18 with cancer of the hepatic flexure of the colon, all of whom were confirmed to have adenocarcinoma of the colon through preoperative colonoscopic biopsy pathology. Additionally, three patients presented with comorbid diabetes mellitus, while seven patients had hypertension. Five patients had a history of abdominal surgery, including two cases of biliary surgery and three cases of caesarean section. The preoperative ASA score ranged from I to III, and no distant metastases were detected in any of the preoperative ancillary examinations. The Ethics Committee of the Affiliated Hospital of Xuzhou Medical University approved the surgical method employed in this study, and informed consent was obtained from all participating patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative preparation:\u003c/h2\u003e \u003cp\u003eThree days prior to the surgical procedure, a liquid diet was initiated and oral laxatives were administered on the morning of the surgery to empty the bowel. Intravenous antibiotics were administered to patients 30 minutes prior to the induction of anesthesia and the commencement of the surgical procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eThe patient assumes a lithotomy position, while the operator stands on the left side, the assistant on the right side, and the scope holder between the legs(Fig.\u0026nbsp;1A,B). The pneumoperitoneum pressure is maintained at 12-15mmHg. A standard exploration of the abdominal cavity is conducted, with particular attention paid to the peritoneum, omentum, and visceral surface for the presence of metastatic lesions. Upon detection of the primary lesion, the tumor's location and size were identified, and the operative range was established. Following exploration of the abdominal cavity, the greater omentum was positioned above the transverse colon and below the liver, while the small intestine was placed in the left upper abdomen, thereby exposing the root of the ileum mesentery. The assistant successfully grasped the appendix and the ileum mesentery 15 cm away from the ileocecal region without any harm. Our surgical procedure is comprised of seven distinct modules.\u003c/p\u003e \u003cp\u003e1.Tail-side approach\u003c/p\u003e \u003cp\u003eThe surgeon utilized a triangular traction technique by grasping the distal ileum mesentery root at a distance of 1 cm from the caudal aspect. To gain access to the loose layer between Toldts' fascia and the retroperitoneal subfascia (Gerota's fascia), the peritoneum is incised 1 cm cephalad to the right iliac artery using an ultrasound knife. The two fascia's exhibit a slight difference in color, and the vascularity direction within Toldts' fascia is predominantly perpendicular to the long axis of the body, while the direction of capillary vascularity within the retroperitoneal subfascia is mostly parallel to the long axis of the body, which can aid in identifying the correct layer. To prevent harm to the genital vessels and ureter, it is recommended to maintain the seamless integrity of the retroperitoneal subfascia while continuing to widen the gap cephalad. The assistant should utilize grasping forceps on both the left and right sides to lift the ascending colonic mesentery, thereby exposing the junction of the descending and horizontal duodenum medially. Further expansion of the anterior pancreaticoduodenal space along the anterior duodenum is advised. The medial termination point of the separation lies adjacent to the projection of the inferior mesenteric vein, while the lateral boundary extends towards the lateral border of the right kidney and the superior limit is positioned at the junction of the duodenal bulb and descending portion. To demarcate the entire cleared area, gauze strips are positioned anteriorly to both the pancreas and duodenum, serving as the right-hand border(Fig.\u0026nbsp;2A).\u003c/p\u003e \u003cp\u003e2.Superior mesenteric vein dorsal free\u003c/p\u003e \u003cp\u003eThe assistant proceeds to lift the left and right mesentery of the superior mesenteric vein, turning caudally medially. This action results in the unfolding of the dorsal aspect of the superior mesenteric vein and the release of the peritoneum dorsal to the superior mesenteric vein. The area of focus is distal to the confluence of the ileocolic veins and proximal to the level of the gastrocolic trunk (Henle trunk). Subsequently, the assistant prepares the right side of the superior mesenteric vein for clearance by placing gauze in position(Fig.\u0026nbsp;2B).\u003c/p\u003e \u003cp\u003e3. Localization of the mesenteric root of the transverse colon\u003c/p\u003e \u003cp\u003eThe small intestine is situated in the inferior abdominal region. During the surgical procedure, the assistant elevates both the left and middle portions of the transverse mesocolon, while the primary scalpel secures the right side of the ligamentous flexure mesentery. The triangular transverse mesocolon is then extended and unfurled, and the ultrasonic scalpel is employed to incise the mesentery from the base of the left side of the middle colonic artery depression, releasing it in a cephalad direction along the superior border of the pancreas and converging with the posterior wall of the stomach. A gauze strip is filled in as the left border of the entire clearing area(Fig.\u0026nbsp;2C).\u003c/p\u003e \u003cp\u003e4.Lateral cephalic approach\u003c/p\u003e \u003cp\u003eThe caudal traction of the greater omentum and transverse colon is accompanied by the assistant's upward traction of the lateral arterial arches of the greater curvature of the stomach, specifically the right and left sides, while the surgeon simultaneously pulls the omentum caudally to establish a triangular retraction. Starting from the center of the triangle, the greater omentum is incised to access the omental sac. Subsequently, the greater omentum is dissected towards the left and extended towards the right by freeing it along the gastrocolic mesenteric gap. This dissection exposes the gastric mesentery on the cranial side and the colonic mesentery on the caudal side, extending towards the right until the anterior wall of the duodenum and the head of the pancreas are visible. Finally, the posterior gap of the ascending colon is connected to reveal the positioning gauze for the caudal approach. The dissection of the deep gastrocolic mesentery exposes the branches of the Henle trunk, including the right gastroretinal vein on the cephalic side, the superior anterior pancreaticoduodenal vein, and the paramedian right colic vein on the caudal side. The paramedian right colic vein is subjected to free ligation at the root. The main trunk of the superior mesenteric vein is exposed by freeing along the inferior margin of the pancreas towards the deep side. The peritoneal layer covering the root of the transverse colonic mesentery is incised on the left side of the root of the middle colonic artery, thereby exposing the gauze located at the root of the transverse colon. The gauze is then extracted and spread out over the superior mesenteric vein's main trunk, extending towards the gastrocolic mesenteric space, which demarcates the cephalolateral boundary of the entire sweeping region. This procedure concludes the comprehensive demarcation of the gauze strip's wrapping area(Fig.\u0026nbsp;2D).\u003c/p\u003e \u003cp\u003e5. Central mesenteric region clearance(Fig.\u0026nbsp;2E)\u003c/p\u003e \u003cp\u003eThe small intestine is situated in the lower left quadrant of the abdomen. The assistant grasps the mesenteric opening located at the base of the transverse colonic mesentery and elevates the vascular projection of the ileocolon, thereby facilitating the unfolding of the right hemicolectomy. The ileocecal mesentery is incised at the inferior margin of the depression beneath the ileocolon and extends into the posterior interval of the ascending colon. Upon exposing the primary trunk of the superior mesenteric vein, the grasping forceps should be adjusted to a distance of 3 cm from the root of the ileocolic vessels. Subsequently, a pulling force in the direction of 11 points should be applied, while collaborating with an assistant to rectify the central mesenteric region. This maneuver will result in the complete liberation of the dorsal aspect of the superior mesenteric vein and the entire region will be secured (with priority given to the superior mesenteric vein). This marks the point at which the dorsal aspect of the superior mesenteric vein is released. The dissection of the superior mesenteric vein involves a cephalad approach along the left side of the main trunk, with blunt separation occurring 5 mm anterior to the vein and subsequent cutting of the vein surface using an ultrasound knife. This dissection method is deemed relatively safe for anterior dissection of the superior mesenteric vein due to the absence of apparent adhesions to surrounding tissues and the majority of its branches being located on either side of the main trunk. The cephalad removal and dissection of the ileocolic vein and artery at their root, along with the clearance of the 203rd group of lymph nodes, is performed. In cases where the ileocolic artery is situated dorsal to the superior mesenteric vein, dissection of the artery is carried out at the left margin of the superior mesenteric vein. In instances where the right colonic artery or vein is absent, the former is removed at the left margin of the superior mesenteric vein if it is located dorsal to it. Following this, group 213 lymph nodes are cleared. The Henle trunk is then freed cephalad, and the paramedian right colonic vein is dissected and connected to the cephalad free plane. The procedure involves the continued dissection of the middle colonic vein in a cephalad direction towards the superior mesenteric vein and to the left of the Henle trunk. The vein is then ligated at its root to facilitate disconnection and enlargement for connection with the cephalad free plane. Additionally, the middle colonic artery is dissected in a cephalad direction and ligated at its root to enable disconnection. In cases of ascending colon tumours, the bifurcation of the middle colonic artery is further dissected, with the right branch being disconnected while preserving the left branch. Finally, the 223 groups of lymph nodes are cleared. The lymph nodes located in group 223 have been effectively cleared. Subsequently, the cephalic free plane is utilized to completely clear the area, and the gauze is subsequently extracted.\u003c/p\u003e \u003cp\u003e6. Lateral free(Fig.\u0026nbsp;2F)\u003c/p\u003e \u003cp\u003eThe assistant executes a lateral maneuver to extract the transverse colon 10 cm from the colonic hepatic flexure towards the 4 o'clock position, simultaneously drawing the ascending colon 10 cm from the colonic hepatic flexure towards the 6 o'clock position. The hepatic colonic ligament is then carefully opened in proximity to the liver to release the colonic hepatic flexure in an undamaged state. The assistant manipulates the colonic hepatic flexure towards the 3 o'clock position while simultaneously manipulating the appendix towards the 5 o'clock position, thereby separating and spreading the lateral peritoneum of the ascending colon and achieving complete liberation of the right hemicolon. In order to prevent torsion during specimen retrieval, the right hemicocele and omentum are repositioned.\u003c/p\u003e \u003cp\u003e7. Anastomosis(Fig.\u0026nbsp;3)\u003c/p\u003e \u003cp\u003eAn incision was created in the upper abdomen, measuring approximately 5 cm in length, to access the right hemicolectomy and greater omentum. The resection of the ileum, including the tumor and right hemicolectomy, was performed, followed by an anastomosis of the lateral ileo-transverse colon outside the body. The pneumoperitoneum was reconstructed, and the mesenteric fissure was sutured. A drainage tube was placed in the right upper abdomen, and the intestinal tube was inserted before closing the abdomen.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eObservation index\u003c/h2\u003e \u003cp\u003eDuring the perioperative period, patients were monitored for various factors such as operation duration, intraoperative hemorrhage, duration of postoperative fatigue, resumption of liquid diet, incidence of postoperative complications, length of hospital stay, and postoperative pathology, which encompassed the tumor's characteristics, number of cleared lymph nodes, and stage of the tumor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative follow up\u003c/h2\u003e \u003cp\u003eThe study employed outpatient and telephone follow-up methods to document the recurrence of tumors and the quality of life of the patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical processing\u003c/h2\u003e \u003cp\u003eData were analysed using SPSS 22.0 software. Normally distributed measures are expressed as (_x\u003c/p\u003e \u003cp\u003e\u0026plusmn;s) and skewed measures are expressed as M (range).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePerioperative results\u003c/p\u003e \u003cp\u003eAll 56 cases were successfully completed without any surgical interventions. The mean operative time was (153.8\u0026thinsp;\u0026plusmn;\u0026thinsp;42.5) minutes, the average intraoperative bleeding was (53.3\u0026thinsp;\u0026plusmn;\u0026thinsp;21.3) milliliters, the average time to first gas after surgery was (58.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6) hours, the average time to resume liquid diet was (68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6) hours, and the average postoperative hospital stay was (6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0) days. Following surgery, two cases of lymphatic fistula and one case of anastomotic bleeding occurred, all of which were resolved through conservative treatment. No perioperative deaths were reported.\u003c/p\u003e \u003cp\u003ePostoperative pathological findings\u003c/p\u003e \u003cp\u003eAll of the tumors observed were identified as adenocarcinomas, with an average of 20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 lymph nodes cleared. The distribution of tumor stages was as follows: 8 cases were classified as stage I, 19 cases as stage II\u003csub\u003eA\u003c/sub\u003e, 11 cases as stage II\u003csub\u003eB\u003c/sub\u003e, 12 cases as stage III\u003csub\u003eA\u003c/sub\u003e, and 6 cases as stage III\u003csub\u003eB\u003c/sub\u003e.\u003c/p\u003e \u003cp\u003eResults of follow-up visits\u003c/p\u003e \u003cp\u003eChemotherapy was standardized based on post-operative pathological staging, and patients were subsequently monitored for 12 months post-operatively. No instances of recurrence, metastasis, or mortality were observed during this follow-up period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn 2009, a group of German scholars led by Hohenberger introduced the concept of CME, which involves the complete resection of the mesentery surrounding the rectum\u003csup\u003e[7]\u003c/sup\u003e. Throughout the course of human embryonic development, the posterior wall of the ascending colon and the posterior lobe of the ascending mesentery undergo fusion with the peritoneum of the posterior abdominal wall, ultimately resulting in the formation of the right Toldt fusion fascia. This fascia, in conjunction with the anterior lobe of the right hemicolectum (posterior peritoneum), envelops the nerves, blood vessels, and lymphatic adipose tissue contained within, thereby creating the ascending colonic mesentery. The ascending colonic mesentery, in combination with the transverse colonic mesentery, ultimately culminates in the formation of the right hemicolectum. The right Toldt fusion fascia is incised within the surgical plane for right hemicolectomy, known as the right Toldt space. This space is contiguous with the left Toldt space laterally, and is further partitioned into the pre-pancreatic and post-pancreatic spaces at the hepatic flexure of the colon. The space extends caudally to the posterior aspect of the rectum\u003csup\u003e[8]\u003c/sup\u003e. This approach aligns more closely with the principle of aggressive tumor management, enhances the prognosis of individuals with colon cancer, markedly diminishes the 5-year incidence of local recurrence of colon cancer, and elevates the 5-year survival rate associated with the tumor\u003csup\u003e[7]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePerforming a right hemicolectomy presents challenges due to the prevalence of vascular anatomical variation, the complexity of complete mesocolic excision (CME) surgery, and the absence of palpation, particularly in laparoscopic procedures. However, the safety and efficacy of laparoscopic radical surgery for right hemicolectomy have been preliminarily validated in terms of tumor radicality\u003csup\u003e[9\u0026ndash;11]\u003c/sup\u003e. The complexity of laparoscopic complete mesocolic excision (CME) of right hemicolectomy is attributed to the stringent demands on the mastery of free space, release of blood vessels, and clearance of root lymph nodes. The selection of the surgical approach for this procedure has been a topic of debate, and a consensus has yet to be reached. The available surgical approaches comprise central, caudal, cephalic, and mixed approaches, with the complete central approach centered on the superior mesenteric vein being the most frequently employed\u003csup\u003e[12\u0026ndash;16]\u003c/sup\u003e. The prevalent surgical techniques encompass central, caudal, cephalic, and mixed approaches, among which the completely central approach targeting the superior mesenteric vein is the most frequently employed. Nevertheless, the central approach poses challenges in terms of visualizing the superior mesenteric artery, discerning crucial anatomical structures, and reaching anatomical planes, particularly in patients with obesity or severe abdominal adhesions, or for inexperienced surgeons\u003csup\u003e[17,18]\u003c/sup\u003e. The caudal ventral approach is divided into a caudal ventral lateral approach and a dorsal lateral approach\u003csup\u003e[19]\u003c/sup\u003e. The caudal ventral lateral approach, also known as the caudal median approach, involves making an incision into the right retroperitoneal space at a natural fold located below the ventral ileocolic vessels in the ventral part of the ileocecum. On the other hand, the caudal dorsolateral approach entails turning the ileocecal region cephalad and making an incision into the right retroperitoneal space at the yellow-white junction line, which is located 1.0\u0026ndash;2.0 cm above the right common iliac artery and corresponds to the dorsal projection of the root of the small bowel mesentery. The ventral approach presents a higher likelihood of traversing an incorrect gap compared to the dorsal approach, particularly among novice practitioners. In the event of accessing the retroperitoneal space beneath the ileocolic vessels, thin patients may be susceptible to inadvertent penetration of the colonic mesentery, whereas obese patients may encounter challenges in identifying anatomical landmarks, as well as hypertrophy of the mesentery and inconspicuous vascular elevation, which may impede entry into the appropriate surgical plane. Given this predicament, our center has developed a comprehensive approach to ensure consistency in surgical quality by implementing process-based quality control measures at every stage of the operation. This approach involves combining the expertise gained from performing laparoscopic right hemicolectomy CME surgery with the da Vinci robot-assisted hybrid access right hemicolectomy CME surgery, resulting in a level-first caudal-dorsal-first combined cephalad approach.\u003c/p\u003e \u003cp\u003eDrawing upon a comprehensive analysis of laparoscopic radical treatment of right hemicolectomy across multiple healthcare facilities\u003csup\u003e[20\u0026ndash;22]\u003c/sup\u003e, the surgical team practically summarized the advantages and disadvantages of different approaches and gradually carried out laparoscopic CME of right hemicolectomy with caudal-dorsal priority combined with cephalic approach. The findings of the present investigation indicate that the perioperative complication rate was 5.3% (3/56), which was comparable to that of the caudal-medial approach, thereby establishing the safety and feasibility of the procedure. With regard to radical tumour treatment, the mean number of lymph nodes excised in this study was (20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9), satisfying the criteria for radical tumour treatment. Our observations suggest that the caudodorsal preferential combined with the cephalolateral approach confers several benefits: ⑴The radicality of the tumor is established through decreased surgical complexity, particularly in patients with higher levels of obesity or adhesion, thereby facilitating the acquisition of the complete mesocolic excision technique for the junior attending surgeon performing a right hemicolectomy. The determination of the right border of the sweep involves the retention of a gauze strip, thereby facilitating access to the superior pancreatic space from the root of the transverse colonic mesentery, leading to the omental sac. Similarly, the determination of the left border of the sweep entails the retention of a gauze strip. Ultimately, the omental sac can be reached through the lateral aspect of the vascular arch of the greater curvature of the stomach, specifically on the left side. This approach allows for the separation of the gastrocolic mesenteric space towards the right. These three spaces are readily identifiable, particularly in patients with obesity or significant abdominal adhesions. ⑵ Minimize intraoperative vascular injury resulting from indeterminate anatomical planes. The surgical trunk vessels present a challenging aspect of the right hemicolectomy procedure. Employing a mixed approach, the surgical trunk's left, right, and cephalic sides are isolated from the surrounding tissues using gauze strips. This is particularly crucial after the dorsal release of the superior mesenteric vein (SMV), which tethers the entire central clearance area and reflects the fundamental principles of complete mesocolic excision (CME) surgery. Subsequently, the vessels of the surgical trunk are cleared and disconnected sequentially, leading to a notable decrease in intraoperative vascular injury and bleeding. ⑶ The number of intraoperative position changes was minimized, necessitating only a single adjustment of the patient's position throughout the entirety of the procedure. ⑷Facilitating the sequential execution of surgical procedures facilitates the implementation of standardized training programs for novice surgeons, expediting their comprehension and proficiency in performing right hemicolectomy CME surgery, and consequently reducing the duration of the learning process for right hemicolectomy. ⑸The planned intraoperative strategy incorporates three cephalocaudal combinations to mitigate complexity and enhance safety. The internal and external combination circumvents spatial constraints and tension in the caudal approach while upholding the no-touch principle. The ventral-dorsal combination optimizes the degree of curettage and alleviates the challenges associated with the primary operative axis for dorsal management of SMA/V. The utilization of a mixed approach consisting of cephalocaudal echo, ventral-dorsal echo, and medial-external echo liberation facilitates a procedural method for performing right hemicolectomy, which enhances the attainment of complete mesocolic excision (CME) surgery, diminishes the complexity of the procedure, minimizes intraoperative bleeding and non-operative time, optimizes the training of novice surgeons, and is replicable irrespective of the patient's condition or the clinical proficiency of the responsible surgeon.\u003c/p\u003e \u003cp\u003eThis study is subject to certain limitations, namely its single-centre clinical design and the absence of comparative data between laparoscopic right hemicolectomy and conventional methods, as well as a lack of long-term follow-up on oncological outcomes. Efforts are currently underway to gather data in this regard. Preliminary results indicate that the caudodorsal preferential combined cephalic surgical approach to laparoscopic right hemicolectomy is a safe and feasible option with clinical utility and adherence to surgical oncology principles. Moreover, this approach can aid in reducing the learning curve for surgeons performing laparoscopic right hemicolectomy and ensuring surgical safety.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eDisclosures Zhang Xuan, Wang Kai, Fu HaiXiao, Li TengTeng, Sun Xu, Fu Wei have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFW and ZX performed the operation and drafted the manuscript. LTT and SX analyzed the data and designed the research. FHX and WK contributed to manuscript revision. LTT and ZX Conceived the idea, designed the research, and finalized the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was partially supported by the Science and Technology Development Fund Project of Affiliated Hospital of Xuzhou Medical University (XYFM2020042)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eJ Yan;MG Ying;D Zhou, etal. A prospective randomized control trial of the approach for laparoscopic right hemi-colectomy: medial-to-lateral versus lateral-to-medial[J]. CHINESE JOURNAL OF GASTROINTESTINAL SURGERY,2010,13(6):403\u0026ndash;405. DOI:10.3760/cma.j.issn.1671-0274.2010.06.006.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFujita J, Uyama I, Sugioka A, Komori Y, Matsui H, Hasumi A. Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer. Surg Today. 2001;31(1):93\u0026ndash;96. doi:10.1007/s005950170230.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMitsutomo. Laparoscopic surgery for colorectal cancer [M]. Liaoning Science and Technology Press, 2015.116-133.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspaan\u003eZou L, Xiong W, Li H, et al. Efficacy analysis of laparoscopic radical right hemicolectomy using caudal-to-cranial approach. Zhonghua Wei Chang Wai Ke Za Zhi. 2015;18(11):1124\u0026ndash;1127.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZheng B, Wang N, Wu T, et al. Comparison of cranial-to-caudal medial versus traditional medial approach in laparoscopic right hemicolectomy: a case-control study. Zhonghua Wei Chang Wai Ke Za Zhi. 2015;18(8):812\u0026ndash;816.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLi F, Zhou X, Wang B, et al. Comparison between different approaches applied in laparoscopic right hemi-colectomy: A systematic review and network meta-analysis. Int J Surg. 2017;48:74\u0026ndash;82. doi:10.1016/j.ijsu.2017.10.029.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation\u0026ndash;technical notes and outcome. Colorectal Dis. 2009;11(4):354\u0026ndash;365. doi:10.1111/j.1463-1318.2008.01735.x.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGong Jianping. Surgical membrane anatomy - the new foundation of surgical science. Chinese Journal of Experimental Surgery, 2015,32(2):225\u0026ndash;226.DOI:10.3760/cma.j.issn.1001-9030.2015.02.003.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXiao Y, Qiu H, Wu B, et al. Outcome of laparoscopic radical right hemicolectomy with complete mesocolic resection and D\u003csub\u003e3\u003c/sub\u003e lymphadenectomy. Chinese Journal of Surgery2014, 52(04)249-249DOI:10.3760/cma.j.issn.0529-5815.2014.04.003.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMorini A, Zizzo M, Giunta A. D3 Lymphadenectomy in Right Hemicolectomy: Current Vision and New Perspectives [published online ahead of print, 2023 Jan 3]. Surg Innov. 2023;15533506221150550. doi:10.1177/15533506221150550.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSiani LM, Pulica C. Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: Long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery. Scand J Surg. 2015;104(4):219\u0026ndash;226. doi:10.1177/1457496914557017.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShin JK, Kim HC, Lee WY, et al. Laparoscopic modified mesocolic excision with central vascular ligation in right-sided colon cancer shows better short- and long-term outcomes compared with the open approach in propensity score analysis. Surg Endosc. 2018;32(6):2721\u0026ndash;2731. doi:10.1007/s00464-017-5970-6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePetz W, Ribero D, Bertani E, et al. Suprapubic approach for robotic complete mesocolic excision in right colectomy: Oncologic safety and short-term outcomes of an original technique. Eur J Surg Oncol. 2017;43(11):2060\u0026ndash;2066. doi:10.1016/j.ejso.2017.07.020.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMatsuda T, Sumi Y, Yamashita K, et al. Anatomy of the Transverse Mesocolon Based on Embryology for Laparoscopic Complete Mesocolic Excision of Right-Sided Colon Cancer. Ann Surg Oncol. 2017;24(12):3673. doi:10.1245/s10434-017-6070-5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZurleni T, Cassiano A, Gjoni E, et al. Surgical and oncological outcomes after complete mesocolic excision in right-sided colon cancer compared with conventional surgery: a retrospective, single-institution study [published correction appears in Int J Colorectal Dis. 2017 Dec 7;:]. Int J Colorectal Dis. 2018;33(1):1\u0026ndash;8. doi:10.1007/s00384-017-2917-2.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFeng B, Sun J, Ling TL, et al. Laparoscopic complete mesocolic excision (CME) with medial access for right-hemi colon cancer: feasibility and technical strategies. Surg Endosc. 2012;26(12):3669\u0026ndash;3675. doi:10.1007/s00464-012-2435-9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMatsuda T, Sumi Y, Yamashita K, et al. Anatomy of the Transverse Mesocolon Based on Embryology for Laparoscopic Complete Mesocolic Excision of Right-Sided Colon Cancer. Ann Surg Oncol. 2017;24(12):3673. doi:10.1245/s10434-017-6070-5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDu S, Zhang B, Liu Y, et al. A novel and safe approach: middle cranial approach for laparoscopic right hemicolon cancer surgery with complete mesocolic excision. Surg Endosc. 2018;32(5):2567\u0026ndash;2574. doi:10.1007/s00464-017-5982-2.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEnomoto M, Katsumata K, Tago T, et al. Laparoscopic modified complete mesocolic excision for right-sided colon cancer. Tech Coloproctol. 2022;26(1):71\u0026ndash;73. doi:10.1007/s10151-021-02495-8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFeng H, Zhao XW, Zhang Z, et al. Laparoscopic Complete Mesocolic Excision for Stage II/III Left-Sided Colon Cancers: A Prospective Study and Comparison with D3 Lymph Node Dissection. J Laparoendosc Adv Surg Tech A. 2016;26(8):606\u0026ndash;613. doi:10.1089/lap.2016.0120.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSato S, Sugano N, Shiozawa M, et al. Application and outcomes of a standardized lymphadenectomy in laparoscopic right hemicolectomy requiring ligation of the middle colic artery. Tech Coloproctol. 2021;25(2):223\u0026ndash;227. doi:10.1007/s10151-020-02388-2.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWidmar M, Keskin M, Strombom P, et al. Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches. Colorectal Dis. 2017;19(10):888\u0026ndash;894. doi:10.1111/codi.13786.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Right hemi-colon neoplasms, Laparoscopy surgery, caudal-to-dorsal access, caudal-to-dorsal access","lastPublishedDoi":"10.21203/rs.3.rs-4064639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4064639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe objective of this study is to examine the safety and feasibility of laparoscopic total colonic mesenteric resection for radical right hemicolectomy, utilizing a caudal-to-dorsal priority access approach in combination with a cephalic approach.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study aims to conduct a retrospective analysis of the clinical data of 56 patients diagnosed with right hemi-colon cancer, who underwent radical right hemi-colon resection through laparoscopic total colonic mesenteric resection with caudal-to-dorsal priority, combined with cephalic approach, between January 2021 and June 2022.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll 56 cases were completed without any instances of open surgery. The average operative time was (153.8\u0026thinsp;\u0026plusmn;\u0026thinsp;42.5) minutes, with an average intraoperative bleeding of (53.3\u0026thinsp;\u0026plusmn;\u0026thinsp;21.3) mL. The average time to first gas after surgery was (58.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6) hours, while the average time to return to a liquid diet was (68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6) hours. The average postoperative hospital stay was (6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0) days. Following surgery, two cases of lymphatic fistula and one case of anastomotic bleeding were reported. Following conservative treatment, all cases were cured, and no perioperative deaths were reported. Post-operative pathological results indicated that all cases were diagnosed with adenocarcinoma, with an average of 20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 lymph nodes cleared. Tumor staging revealed 8 cases in stage I, 19 cases in stage IIA, 11 cases in stage IIB, 12 cases in stage IIIA, and 6 cases in stage IIIB. During the 12-month postoperative follow-up, no instances of recurrence, metastasis, or death were observed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe utilization of a caudal-to-dorsal priority in conjunction with a cephalic approach during laparoscopic radical resection of right hemicolectomy is a secure and viable method that aligns with the fundamental principles of radical oncology. This technique can aid in reducing the learning curve for surgeons performing laparoscopic right hemicolectomy and in guaranteeing surgical safety.\u003c/p\u003e","manuscriptTitle":"Clinical application of the caudal-to-dorsal priority combined with cephalic approach in laparoscopic radical resection of right colon cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-05 21:02:47","doi":"10.21203/rs.3.rs-4064639/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"321104613775014623535842055942593971861","date":"2024-08-02T17:01:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119405227920508532736692430256077072677","date":"2024-06-25T11:59:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-28T17:43:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-02T11:21:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-02T11:16:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Oncology","date":"2024-03-10T11:19:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ea6f746-3809-4996-8775-a1d897b1b6b0","owner":[],"postedDate":"April 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-05T21:02:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-05 21:02:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4064639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4064639","identity":"rs-4064639","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}