Optimization of Artery-First Approach in Right-Sided Colon Cancer CME: Preoperative CTA Assessment of MCA Branching and MCV–Henle’s Trunk Relationship

Optimization of Artery-First Approach in Right-Sided Colon Cancer CME: Preoperative CTA Assessment of MCA Branching and MCV–Henle’s Trunk Relationship | 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 Optimization of Artery-First Approach in Right-Sided Colon Cancer CME: Preoperative CTA Assessment of MCA Branching and MCV–Henle’s Trunk Relationship Lei Wang, Ge Li, Ying Lv, Ying Wang, Yiheng Xue, Zhongkai Xu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8439616/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Feb, 2026 Read the published version in World Journal of Surgical Oncology → Version 1 posted 12 You are reading this latest preprint version Abstract Backgroud: Vascular injury, particularly involving Henle’s trunk, remains a major challenge during complete mesocolic excision (CME) for right-sided colon cancer. Due to the high anatomical variability of right-sided colonic vessels, the influence of tumor location, and heterogeneity in operative techniques, radical right hemicolectomy (RRC) continues to be a high-risk procedure. This study aims to identify strategies that reduce vascular injury and enhance mesenteric margin integrity in standardized CME surgery. Material and methods: Patients with right-sided colon cancer underwent manual subtraction CTA to determine MCA branching types and MCV–Henle’s trunk configurations. Based on these findings, individualized surgical plans were established emphasizing artery-first, sheath-based dissection. Operative outcomes were compared with those of conventional CME cases regarding intraoperative bleeding, vascular injury rate, and the subjective assessment of mesenteric margin integrity. Results: Preoperative CTA successfully identified MCA and MCV–Henle’s trunk types in >90% of patients. The CTA-guided artery-first group showed significantly fewer venous injuries and improved exposure of the Henle’s trunk and SMV compared with the conventional group. No MCV injuries occurred, and CME specimen integrity improved steadily with experience. Conclusions: Manual subtraction CTA allows accurate visualization of fine vascular anatomy and facilitates a safe, artery-first CME strategy for right-sided colon cancer. CTA-guided sheath dissection reduces intraoperative venous bleeding and improves surgical precision. Right-sided colon cancer Complete mesocolic excision Henle’s trunk Middle colic artery Manual subtraction CTA Artery-first approach Vascular sheath dissection Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Colorectal cancer (CRC) remains one of the most prevalent malignancies worldwide, and right-sided colon cancer represents a certain proportion of these cases[ 1 ]. Radical surgical resection remains a key component of curative treatment. Since Hohenberger et al. introduced the concept of complete mesocolic excision (CME) with central vascular ligation (CVL)[ 2 ], and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) established the D3 dissection criteria[ 3 ], surgical emphasis has shifted toward precise central vascular dissection and intact mesocolic plane preservation. In conventional open CME performed via a lateral-to-medial approach, direct visualization of the superior mesenteric artery (SMA) and the root of its branches, including the right colic artery (RCA) and middle colic artery (MCA), is achievable[ 4 ]. In contrast, the laparoscopic medial-to-lateral approach is widely used and fundamentally alters this anatomic perspective, making the spatial relationship between the MCA, middle colic vein (MCV), and Henle’s gastrocolic trunk more complex [ 5 – 7 ]. In this confined and variable vascular region, inadvertent venous injury can lead to severe bleeding and pancreatic injury [ 8 , 9 ]. Several studies demonstrated that although CME enhances radicality, it also increases intraoperative vascular injuries and bleeding risk[ 10 – 12 ]. Feng Bo et al. further analyzed the classification and variations of Henle’s trunk, revealing that its branches vary markedly among individuals[ 13 ]. Because Henle’s trunk lies dorsal to the superior mesenteric artery (SMA) branches[ 14 ], surgeons who dissect it before handling the arterial feeders may inadvertently cause deep venous hemorrhage that is difficult to manage. Previous anatomical and radiological studies have described variations in the MCA and MCV using CT angiography (CTA) or dissection[ 9 , 15 ]. However, most of these studies were conducted from a radiological perspective, focusing on imaging presentation rather than the intraoperative view required by surgeons. Moreover, many CTA studies fail to visualize small arterial and venous branches simultaneously[ 10 , 16 ], thereby failing to show the complete MCA branches or to assess the vascular anatomy of the ascending and transverse colon together, limiting their direct applicability to surgical planning. Based on our prior work using manual subtraction CTA (MS-CTA) to analyze vascular reconstruction in distal sigmoid colon and rectal cancer after high IMA ligation [ 17 ], we considered that a similar imaging-guided arterial-first approach could be optimized for right colon CME. Over the past several years, more than 400 patients with colorectal cancer at our center have undergone preoperative manual subtraction CTA. We employed MS-CTA based on the arterial and venous phases of routine enhanced CT. This technique achieves near-DSA vascular resolution and allows simultaneous visualization of both the SMA and SMV systems. Through MS-CTA, the MCA branching type and RCA origin can be clearly classified, and the venous drainage pattern of the MCV can be determined. Typically, the MCV right branch drains into Henle’s trunk, the middle branch into the SMV, and the left branch into the IMV. Building on these classical patterns, our recent work has focused on characterizing colonic vascular anatomy using MS-CTA, with the aim of establishing a refined classification system of arterial and venous variations relevant to right-sided colon cancer surgery. By this preoperative vascular mapping, individualized surgical pathway planning can be achieved, including precise identification of arterial ligation points, preservation of MCA left branches when appropriate, and prediction of venous confluence locations. To execute this plan, we predominantly employ intra-sheath dissection for both arterial and venous isolation, ensuring anatomical precision and minimizing vascular injury. These anatomical insights form the basis of an artery-first, intra-sheath CME strategy, which enables safe dissection within the vascular sheath, reduces venous injury, and ensures complete D3 lymphadenectomy. Methods Patient selection A total of 181 patients with right-sided colon cancer who underwent laparoscopic right hemicolectomy at Jinan Central Hospital between March 2022 and July 2025 were retrospectively analyzed. The study group consisted of 96 consecutive cases with preoperative manual subtraction CT angiography (MS-CTA)-guided planning and artery-first intra-sheath dissection performed by the same surgical team according to the designed protocol. The control group included 85 consecutive cases operated on the same period by another team with comparable surgical experience using conventional CME techniques without preoperative MS-CTA guidance. Inclusion criteria were:1). Pathological confirmation of colon adenocarcinoma by preoperative colonoscopic biopsy. 2). No history of previous abdominal surgery. 3). Preoperative enhanced abdominal CT performed routinely. Exclusion criteria: 1). Distant metastasis identified before surgery. 2). Emergency surgery for obstruction or perforation. 3). Incomplete clinical data. All procedures were performed by the experienced surgical team with consistent CME principles. The study was approved by the institutional ethics committee, and written informed consent was obtained from all participants. Preoperative manual subtraction CTA All patients in the study group underwent preoperative manual-subtraction CT angiography (MS-CTA) reconstruction using the arterial-phase thin-slice data from conventional contrast-enhanced CT to evaluate the vascular anatomy of the accending and transverse colon. MS-CTA clearly displayed the branching patterns of the middle colic artery (MCA) and the configuration of Henle’s trunk and its middle colic vein (MCV) tributaries (Figure 1A), achieved visualization quality comparable to digital subtraction angiography (DSA, Figure 1B). Moreover, MS-CTA was able to demonstrate the main arterial supply to the middle and left two-thirds of the transverse colon after dissection of the MCA trunk (Figure 1C). In most cases, both arterial and venous branches could be simultaneously visualized by adjusting the window width and level. When venous branches were not well delineated, venous-phase MS-CTA was additionally performed. Preoperative Surgical Pathway Planning Given the significant individual variations in MCA and MCV branching patterns revealed by preoperative MS-CTA, we preoperatively designed individualized surgical pathways. For tumors located in the cecum and ascending colon, the dominant arterial supply was defined following the JSCCR classification of right colon blood supply types. The branching pattern of the MCA (two-branch, three-branch, or presence of an AMCA) was used to determine whether the left branch should be preserved or divided. For tumors at the hepatic flexure, the high, non-common-trunk left branch in the hepatic region of the ascending colon can be preserved, and the accessory middle colic artery (AMCA) in the hepatic region of the transverse colon can also be preserved. This preoperative vascular roadmap from 3 representative cases (Figure 2) enabled surgeons to preoperatively determine the ligation sites of the MCA braches based on the different brache types, and dechiper its spatial relationships to Henle's trunk and the MCV, ensuring that the arterial dissection could be performed first within the vascular sheath at presize location. MS-CTA–guided right hemicolectomy enables individualized MCA dissection In this representative case, preoperative MS-CTA accurately demonstrated the branching pattern of the middle colic artery and its relationship with the superior mesenteric vein, allowing individualized surgical pathway design (Figure 3A). The optimized patient positioning and trocar layout (Figure 3B) facilitated a smooth CME dissection along the mesenteric plane. Intraoperatively, sheath-based dissection of the MCA (Figure 3C) allowed us to divide its right and left branches precisely as planned, thereby confirming the accuracy of the preoperative vascular mapping. No vascular injury or intraoperative bleeding occurred, and mesocolic integrity was maintained throughout the procedure. Intra-sheath dissection of the SMV and Henle’s trunk with page-turning mesocolic excision In the CTA-guided group, intra-sheath dissection of the superior mesenteric vein (SMV) and Henle’s trunk was successfully performed in all cases using a page-turning mesocolic excision technique. This approach treated the mesocolon as a multilayered structure, with vascular sheaths serving as natural anatomical planes. After dividing the root of the middle colic artery (MCA), the superior mesenteric vein (SMV) sheath was carefully opened along its outer border (Figure 4A). The surgeon then proceeded in a “page-turning” manner—from ventral to dorsal and caudal to cranial—to gradually expose the venous branches. Opening the sheath of Henle’s trunk (Figure 4B) enabled clear visualization of the venous confluence, which, based on intraoperative and preoperative CTA findings, exhibited three major branching configurations (Figure 4C): the right gastroepiploic vein (RGEV), the anterior superior pancreaticoduodenal vein (ASPDV), and the accessory right colic vein (accRCV). This CTA-guided, sheath-based dissection allowed each venous tributary to be isolated and divided within a protected tunnel, minimizing traction on fragile veins and substantially reducing the risk of hemorrhage. Operative Procedures and Intraoperative Observation During surgery, an artery-first intra-sheath dissection was performed under laparoscopy. The MCA trunk was isolated and divided within its vascular sheath before venous manipulation, which promoted natural exposure of Henle’s trunk and reduced the risk of injury to cephalad or deep venous branches. Subsequent sheath-based dissection along the SMV and Henle’s trunk allowed stepwise identification and division of venous tributaries, minimizing traction-related hemorrhage while maintaining mesocolic integrity. Because the surgeon stands between the patient’s legs, the direction of mesenteric dissection is essentially parallel to the medial border of the superior mesenteric vein (SMV), proceeding from the medial toward the lateral side. The intraoperative viewing angle is therefore almost identical to that of the MS-CTA reconstructions. As a result, the branching patterns and spatial relationships of the major vessels observed during surgery correspond closely to those demonstrated on CTA. Data Collection and Statistical Analysis Intraoperative and postoperative parameters were prospectively recorded for both groups. In the study group, real-time data on operative duration, vascular injuries, and mesocolic excision completeness were collected. Key procedural steps, including the intrasheath dissection of the middle colic artery (MCA) and the anatomical configuration of Henle’s trunk, were documented photographically in most cases. Additionally, full-length surgical videos were available for 39 study group procedures. For the control group, the designated observers recorded the same set of parameters—including the specific duration of the medial approach phase of the operation—either in real time or by reviewing available intraoperative video recordings, which were obtained for 31 cases. In instances where video recording was unavailable, critical procedural steps were photographically documented. All recorded videos and photographs were subsequently reviewed by the research team to verify the duration of the medial approach and to confirm the occurrence of intraoperative vascular injuries and bleeding events. The total operative time was influenced by multiple confounding factors; therefore, the duration of the medial approach phase was specifically analyzed for greater accuracy. The primary outcomes of the study were the incidence of intraoperative vascular injury, the completeness of the mesocolic plane, and the operative duration of the medial-to-lateral approach. Secondary endpoints included the number of lymph nodes retrieved, postoperative length of hospital stay, and postoperative complication rates. Categorical variables were compared using the χ² or Fisher’s exact test, and continuous variables using the t-test. A p-value < 0.05 was considered statistically significant. Results Baseline characteristics All patients successfully underwent laparoscopic right hemicolectomy without conversion to open surgery. There were no significant differences between the two groups in age, gender, BMI, or tumor location (Table 1, p > 0.05). Table 1. Patients’ characteristics Characteristic CTA-guided group (n=96) Control group (n=85) p-value Age (years) 63.4 ± 8.1 62.7 ± 8.5 0.48 Male/Female 55/41 49/36 0.92 BMI (kg/m²) 23.6 ± 2.7 23.2 ± 2.5 0.36 Tumor location (ascending colon / hepatic flexure) 68 / 28 60 / 25 0.84 Intraoperative outcomes The comparison of operation time between the control and study groups is shown in Figure 5. The median operation time was comparable between the two groups, with similar distribution patterns ranging from approximately 30 to 70 minutes. Although the study group demonstrated a slightly shorter median duration, the difference was not statistically significant (Figure 5A). The incidence of intraoperative vascular injury was markedly reduced. Specifically, vascular injury occurred in 2 of 96 patients (2.1%) in the study group, compared with 8 of 85 patients (9.4%) in the control group (Figure 5B). This reduction suggests that the preoperative planning of vascular anatomy and the application of the medial approach facilitated safer vessel dissection with fewer complications. No MCV injury occurred in the study group. In contrast, in the control group, venous bleeding primarily occurred during dissection around Henle’s trunk or from injury to MCV branches while dissecting the MCA. Postoperative recovery The mean lymph node yield was comparable between the study group and the control group (19.6 ± 8.1 vs. 20.4 ± 6.9, p = 0.52) (Figure 6A). Postoperative hospital stay was shorter in the MS-CTA group compared with the control group (16.24 ± 9.9 vs. 14.35 ± 7.3 days, p = 0.0045) (Figure 6B). No cases of anastomotic leakage were observed in either group. Postoperative CTA imaging confirmed intact mesocolic vascular reconstruction in the study group, with well-preserved collateral circulation supplying the left transverse colon. Discussion Conventional classifications of colonic vasculature are primarily derived from cadaveric dissections[ 18 ], which, while informative, fail to replicate in vivo vessel positioning due to the loss of vascular tension and sheath structures. Our CTA-based approach reflects physiological vessel relationships and allows dynamic assessment of arterial dominance and collateral flow. In particular, insights from our previous work on the arc of Riolan demonstrated predictable patterns of collateralization, which can be used to anticipate compensatory flow to the transverse colon after selective MCA branch ligation. This understanding helps preserve adequate blood supply while achieving oncologic clearance. The classical laparoscopic medial approach requires root ligation of the RCA with D3 lymphadenectomy along the SMA (stations 213)[ 19 ]. The RCA demonstrates substantial variability: approximately one-third of patients have an independent RCA, while in most cases it arises as a common trunk with the ileocolic artery (ICA) or the right branch of the MCA[ 20 , 21 ]. Without preoperative vascular information, this variation increases technical difficulty and the risk of unplanned vessel injury. For tumors of the cecum and ascending colon, the left branch of the MCA is typically preserved (as the MCA is classically bifurcated)[ 2 ]. In the absence of preoperative vascular imaging, surgeons must rely on intraoperative identification to determine the MCA type. This often results in overdissection of the mesenteric root or, conversely, en bloc ligation of the MCA and MCV right branches to avoid bleeding, both of which compromise oncologic thoroughness by risking incomplete 223 lymph node dissection[ 22 , 23 ]. Using CTA, we identified the dominant feeding artery of the hepatic flexure tumor and determined the division level according to JSCCR D3 principles. For example, in two-branch MCA patterns, both branches could be ligated at the common stem; in three-branch or high left-branch patterns, the left branch was preserved, and the right or middle branch was divided at its root. This approach was particularly relevant for tumors at the hepatic flexure, where AMCA was present in nearly 30% of patients[ 24 ]. When a long-trunk AMCA was identified, the main MCA could be ligated at its root without the need for excessive dissection to preserve the left branch, thus simplifying the procedure and reducing dissection-related risks. When the MCA root was divided (as shown in Fig. 1 C), CTA confirmed intact perfusion to the middle and left two-thirds of the transverse colon via collateral circulation. We employed a sheath-based vascular dissection concept. Arterial phase: Dissection within the SMA sheath allowed early control of the MCA while preserving cephalad MCV tributaries, thus avoiding bleeding from direct SMV branches that are difficult to manage. Venous phase: Venous sheath dissection revealed SMV and Henle’s trunk tributaries sequentially. Each branch was identified and divided under direct vision, minimizing traction-related avulsion. Because the cephalad (head-side) approach had already exposed the gastroepiploic vein up to its confluence with Henle’s trunk, subsequent medial dissection from the root of Henle’s trunk facilitated easy identification of the ASPDV (anterior superior pancreaticoduodenal vein). The trunk of Henle could thus be visualized and preserved safely. This stepwise intra-sheath approach eliminates the need for complicated intraoperative classification of Henle’s trunk as advocated by other observers and ensures effective hemostasis even if venous injury occurs near the SMV confluence. This artery-first, intra-sheath CME technique guided by manual subtraction CTA enables precise preoperative identification of vascular variations, facilitates safe early arterial control and sheath-preserving venous dissection, reduces intraoperative bleeding and improves CME specimen quality and simplifies management of Henle’s trunk and enhances overall surgical safety. This integrated approach offers a practical and reproducible technical framework for laparoscopic right hemicolectomy. By aligning detailed preoperative vascular mapping with controlled intra-sheath dissection, surgeons can achieve both oncologic radicality and safety in the most anatomically complex region of right-sided CME. As a retrospective analysis from a single institution, our findings should be interpreted with caution. The demonstrated feasibility and outcomes, while promising, require validation through prospective, multi-center studies to mitigate institutional bias and establish broader applicability. Abbreviations CME: complete mesocolic excision CVL: central vascular ligation SMA: superior mesenteric artery SMV: superior mesenteric vein RCA: right colic artery RCV: right colic vein MCA: middle colic artery MCV: middle colic vein RGEV: right gastroepiploic vein ASPDV: anterior superior pancreaticoduodenal vein accRCV: accessory right colic vein MS-CTA: manual-subtraction CT angiography Declarations Funding Declaration This study was funded by the Science and Technology Program of Jinan Municipal Health Commission (Grant No. 2021-2-05) and the Shandong Provincial Medical and Health Science and Technology Project (Grant No. 202304011461). The funders had no involvement in any aspect of the research or manuscript preparation. Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of the Jinan Central Hospital (Approval No. 2022-101-01). Written informed consent was obtained from all participants. The study was registered at ClinicalTrials.gov (NCT05674097). Authors’ Contributions Guoqin Liu, Zhongkai Xu and Lei Wang conceived and designed the study. Ge Li, Yiheng Xue, and Ying Lv collected the data. Ying Wang and Lei Wang performed the statistical analysis. Guoqin Liu drafted the manuscript. All authors read and approved the final manuscript. Consent for Publication Not applicable. Availability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. References Dekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet Lond Engl. 2019;394:1467–80. https://doi.org/10.1016/S0140-6736(19)32319-0 Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. 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Cite Share Download PDF Status: Published Journal Publication published 16 Feb, 2026 Read the published version in World Journal of Surgical Oncology → Version 1 posted Editorial decision: Revision requested 10 Jan, 2026 Reviews received at journal 10 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviews received at journal 05 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers invited by journal 02 Jan, 2026 Editor assigned by journal 30 Dec, 2025 Submission checks completed at journal 29 Dec, 2025 First submitted to journal 24 Dec, 2025 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. 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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-8439616","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":569840580,"identity":"6974b3e3-50a1-4c2d-af06-c1eee71f0063","order_by":0,"name":"Lei Wang","email":"","orcid":"","institution":"Jinan Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Wang","suffix":""},{"id":569840581,"identity":"aeee160c-3c2a-49a9-849c-7a67a73a64bb","order_by":1,"name":"Ge Li","email":"","orcid":"","institution":"Jinan Central 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yiheng","middleName":"","lastName":"Xue","suffix":""},{"id":569840585,"identity":"5b6d8d01-cc55-44fc-a511-16230ee22cf6","order_by":5,"name":"Zhongkai Xu","email":"","orcid":"","institution":"Jinan Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhongkai","middleName":"","lastName":"Xu","suffix":""},{"id":569840586,"identity":"83d00e19-8f9f-44e6-a435-ab44de5d1f62","order_by":6,"name":"Guoqin Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYFAC5oYDDBU29W3sjY0PPhCnhRGo5UwaYz/P4WbDGcRqYWBsOcQ4c0Z6mzQHMRrk3RMbD/M2HGA2uPmwQZqBwU5Ot4GAFsMzDxsO8+64w2ZwO7HBuIAh2djsACEtMxKBWs484wFpSZ7BcCBxG3Fa2g5LGNw82HCYhxgt8hIQLQaSMxgbm4nSYsDzsOHgnDNpCfw8ic2MMwyI8It8e/LhD28qbBLY2I8///Ghwk6OoBaDAwkoXALKwbY0JBBUMwpGwSgYBSMdAABDTk5Nw2x3IQAAAABJRU5ErkJggg==","orcid":"","institution":"Jinan Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Guoqin","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-12-24 06:38:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8439616/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8439616/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12957-026-04256-z","type":"published","date":"2026-02-16T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":99594707,"identity":"b5455425-f922-447c-8d5c-15584b3eeb1f","added_by":"auto","created_at":"2026-01-06 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09:21:05","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91607,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/5ab6a6378a1c3b0179abf2cb.html"},{"id":99792870,"identity":"1a4a4176-f9df-46a7-ab57-2d92ebb2ae51","added_by":"auto","created_at":"2026-01-08 13:27:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":463651,"visible":true,"origin":"","legend":"\u003cp\u003eManual subtraction CTA for preoperative vascular imaging.\u003c/p\u003e\n\u003cp\u003e(A) Three-dimensional CTA reconstruction showing the braches of MCA, MCV, and GCT Henle’s trunk from a laparoscopic surgical perspective. (B) Digital subtraction angiography (DSA) of the same patient imaging the consistant MCA branching type. (C) marginal arcade blood flow pathway, postoperative CTA showing the blood flow of the marginal blood vessels originates from the LCA.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/584598d488597b3591b80c1b.png"},{"id":99594696,"identity":"f37b580b-16f8-4e34-9b8a-44384b1b72a5","added_by":"auto","created_at":"2026-01-06 09:21:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":509869,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative surgical pathway planning based on individualized MS-CTA vascular anatomy.\u003c/p\u003e\n\u003cp\u003e(A-C) Representative MS-CTA images illustrating individualized CME dissection pathways (black dashed lines) and arterial transection sites (white short lines) planned according to vascular anatomy and tumor location. Three-dimensional reconstructions clearly depict the ICA, RCA, MCA, and corresponding venous structures, enabling preoperative selection of the optimal artery-first dissection route. (A) a short common trunk of the MCA's right and intermediate branches. (B) the RCA shares a common trunk with the right MCA branch, while the left branch arises independently. (C) a long common trunk of the right and intermediate MCA branches, along with an AMCA. ileocolic artery (ICA), right colic artery (RCA), and middle colic artery (MCA).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/35c972a436b9ee0b34cdc111.png"},{"id":99792582,"identity":"70700ecc-94cb-40de-a4a4-3855db3ff474","added_by":"auto","created_at":"2026-01-08 13:22:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":379045,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative surgical pathway planning, operative positioning and trocar layout, and intrathecal dissection of the middle colic artery (MCA).\u003c/p\u003e\n\u003cp\u003e(A) Preoperative MS-CTA–based surgical pathway planning illustrating individualized vascular anatomy and the designed CME dissection route. (B) Patient positioning and trocar layout. Surgeon (between patient's legs, ports A \u0026amp; B). Assistant \u0026amp; Camera Holder (patient's left, ports C \u0026amp; D). (C) Intraoperative view of intrathecal dissection of the middle colic artery (MCA) sheath, showing precise dissection and safe ligation of the root of the MCA, while the dorsal vascular sheath was preserved to protect the SMV.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/4a97d34f8ce13cbd8264dc10.png"},{"id":99792797,"identity":"2212b8bf-9fdf-474e-ace0-ed3efce900d7","added_by":"auto","created_at":"2026-01-08 13:26:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":352995,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-sheath dissection of the SMV and Henle’s trunk, and classification of venous branching types.\u003c/p\u003e\n\u003cp\u003e(A) Opening of the SMV vascular sheath exposed the mesenteric venous plane, thereby revealing the confluence of Henle’s trunk. (B) Dissection within the Henle’s trunk sheath. (C) Henle’s trunk branching patterns identified consistant intraoperatively by preoperative MS-CTA.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/f8f59c9f2c01853d8975d67e.png"},{"id":99594703,"identity":"844cc273-2140-4333-bf41-877948d3846c","added_by":"auto","created_at":"2026-01-06 09:21:05","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":144021,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of operation time and incidence of vascular injury between the two groups.\u003c/p\u003e\n\u003cp\u003e(A) The mean operation time showed no significant difference between the control group and the study group. (B) The incidence of intraoperative vascular injury was markedly lower in the study group (2.1%) than in the control group (9.4%), indicating that preoperative MS-CTA–based surgical pathway planning effectively reduced the risk of vascular injury during CME.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/a1b95fb213541820cacffa19.png"},{"id":99594699,"identity":"67597c62-199e-4859-bc56-9788e78b86f4","added_by":"auto","created_at":"2026-01-06 09:21:05","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":198651,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of lymph node yield and postoperative hospital stay between the study and control groups.\u003c/p\u003e\n\u003cp\u003e(A) The number of harvested lymph nodes was similar between groups (19.6 ± 8.1 vs. 20.4 ± 6.9, p = 0.52). (B) The postoperative hospital stay was significantly shorter in the MS-CTA group compared with the control group (16.24 ± 9.9 vs. 14.35 ± 7.3 days, p = 0.0045). Data are presented as mean ± SD.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/5a19aa2231e1d7ef7e50428c.png"},{"id":103251504,"identity":"58cc3b55-09a2-4963-9e35-04a42d0e680b","added_by":"auto","created_at":"2026-02-23 16:09:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2713827,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8439616/v1/36494f7c-9d7c-491b-94ec-d6fd844916f5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Optimization of Artery-First Approach in Right-Sided Colon Cancer CME: Preoperative CTA Assessment of MCA Branching and MCV–Henle’s Trunk Relationship","fulltext":[{"header":"Background","content":"\u003cp\u003eColorectal cancer (CRC) remains one of the most prevalent malignancies worldwide, and right-sided colon cancer represents a certain proportion of these cases[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Radical surgical resection remains a key component of curative treatment. Since Hohenberger et al. introduced the concept of complete mesocolic excision (CME) with central vascular ligation (CVL)[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) established the D3 dissection criteria[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], surgical emphasis has shifted toward precise central vascular dissection and intact mesocolic plane preservation.\u003c/p\u003e \u003cp\u003eIn conventional open CME performed via a lateral-to-medial approach, direct visualization of the superior mesenteric artery (SMA) and the root of its branches, including the right colic artery (RCA) and middle colic artery (MCA), is achievable[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In contrast, the laparoscopic medial-to-lateral approach is widely used and fundamentally alters this anatomic perspective, making the spatial relationship between the MCA, middle colic vein (MCV), and Henle\u0026rsquo;s gastrocolic trunk more complex [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In this confined and variable vascular region, inadvertent venous injury can lead to severe bleeding and pancreatic injury [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies demonstrated that although CME enhances radicality, it also increases intraoperative vascular injuries and bleeding risk[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Feng Bo et al. further analyzed the classification and variations of Henle\u0026rsquo;s trunk, revealing that its branches vary markedly among individuals[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Because Henle\u0026rsquo;s trunk lies dorsal to the superior mesenteric artery (SMA) branches[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], surgeons who dissect it before handling the arterial feeders may inadvertently cause deep venous hemorrhage that is difficult to manage.\u003c/p\u003e \u003cp\u003ePrevious anatomical and radiological studies have described variations in the MCA and MCV using CT angiography (CTA) or dissection[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, most of these studies were conducted from a radiological perspective, focusing on imaging presentation rather than the intraoperative view required by surgeons. Moreover, many CTA studies fail to visualize small arterial and venous branches simultaneously[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], thereby failing to show the complete MCA branches or to assess the vascular anatomy of the ascending and transverse colon together, limiting their direct applicability to surgical planning.\u003c/p\u003e \u003cp\u003eBased on our prior work using manual subtraction CTA (MS-CTA) to analyze vascular reconstruction in distal sigmoid colon and rectal cancer after high IMA ligation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], we considered that a similar imaging-guided arterial-first approach could be optimized for right colon CME. Over the past several years, more than 400 patients with colorectal cancer at our center have undergone preoperative manual subtraction CTA. We employed MS-CTA based on the arterial and venous phases of routine enhanced CT. This technique achieves near-DSA vascular resolution and allows simultaneous visualization of both the SMA and SMV systems. Through MS-CTA, the MCA branching type and RCA origin can be clearly classified, and the venous drainage pattern of the MCV can be determined. Typically, the MCV right branch drains into Henle\u0026rsquo;s trunk, the middle branch into the SMV, and the left branch into the IMV. Building on these classical patterns, our recent work has focused on characterizing colonic vascular anatomy using MS-CTA, with the aim of establishing a refined classification system of arterial and venous variations relevant to right-sided colon cancer surgery.\u003c/p\u003e \u003cp\u003eBy this preoperative vascular mapping, individualized surgical pathway planning can be achieved, including precise identification of arterial ligation points, preservation of MCA left branches when appropriate, and prediction of venous confluence locations. To execute this plan, we predominantly employ intra-sheath dissection for both arterial and venous isolation, ensuring anatomical precision and minimizing vascular injury. These anatomical insights form the basis of an artery-first, intra-sheath CME strategy, which enables safe dissection within the vascular sheath, reduces venous injury, and ensures complete D3 lymphadenectomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003ePatient selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 181 patients with right-sided colon cancer who underwent laparoscopic right hemicolectomy at Jinan Central Hospital between March 2022 and July 2025 were retrospectively analyzed.\u003c/p\u003e\n\u003cp\u003eThe study group consisted of 96 consecutive cases with preoperative manual subtraction CT angiography (MS-CTA)-guided planning and artery-first intra-sheath dissection performed by the same surgical team according to the designed protocol. The control group included 85 consecutive cases operated on the same period by another team with comparable surgical experience using conventional CME techniques without preoperative MS-CTA guidance.\u003c/p\u003e\n\u003cp\u003eInclusion criteria were:1). Pathological confirmation of colon adenocarcinoma by preoperative colonoscopic biopsy. 2). No history of previous abdominal surgery. 3). Preoperative enhanced abdominal CT performed routinely.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: 1). Distant metastasis identified before surgery. 2). Emergency surgery for obstruction or perforation. 3). Incomplete clinical data.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All procedures were performed by the experienced surgical team with consistent CME principles. The study was approved by the institutional ethics committee, and written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative manual subtraction CTA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients in the study group underwent preoperative manual-subtraction CT angiography (MS-CTA) reconstruction using the arterial-phase thin-slice data from conventional contrast-enhanced CT to evaluate the vascular anatomy of the accending and transverse colon. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMS-CTA clearly displayed the branching patterns of the middle colic artery (MCA) and the configuration of Henle\u0026rsquo;s trunk and its middle colic vein (MCV) tributaries (Figure 1A), achieved visualization quality comparable to digital subtraction angiography (DSA, Figure 1B). Moreover, MS-CTA was able to demonstrate the main arterial supply to the middle and left two-thirds of the transverse colon after dissection of the MCA trunk (Figure 1C). In most cases, both arterial and venous branches could be simultaneously visualized by adjusting the window width and level. When venous branches were not well delineated, venous-phase MS-CTA was additionally performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Surgical Pathway Planning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the significant individual variations in MCA and MCV branching patterns revealed by preoperative MS-CTA, we preoperatively designed individualized surgical pathways. For tumors located in the cecum and ascending colon, the dominant arterial supply was defined following the JSCCR classification of right colon blood supply types. The branching pattern of the MCA (two-branch, three-branch, or presence of an AMCA) was used to determine whether the left branch should be preserved or divided. For tumors at the hepatic flexure, the high, non-common-trunk left branch in the hepatic region of the ascending colon can be preserved, and the accessory middle colic artery (AMCA) in the hepatic region of the transverse colon can also be preserved.\u003c/p\u003e\n\u003cp\u003eThis preoperative vascular roadmap from 3 representative cases (Figure 2) enabled surgeons to preoperatively determine the ligation sites of the MCA braches based on the different brache types, and dechiper its spatial relationships to Henle\u0026apos;s trunk and the MCV, ensuring that the arterial dissection could be performed first within the vascular sheath at presize location.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMS-CTA\u0026ndash;guided right hemicolectomy enables individualized MCA dissection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this representative case, preoperative MS-CTA accurately demonstrated the branching pattern of the middle colic artery and its relationship with the superior mesenteric vein, allowing individualized surgical pathway design (Figure 3A). The optimized patient positioning and trocar layout (Figure 3B) facilitated a smooth CME dissection along the mesenteric plane. Intraoperatively, sheath-based dissection of the MCA (Figure 3C) allowed us to divide its right and left branches\u0026nbsp;precisely as planned, thereby confirming the accuracy of the preoperative vascular mapping. No vascular injury or intraoperative bleeding occurred, and mesocolic integrity was maintained throughout the procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntra-sheath dissection of the SMV and Henle\u0026rsquo;s trunk with page-turning mesocolic excision\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the CTA-guided group, intra-sheath dissection of the superior mesenteric vein (SMV) and Henle\u0026rsquo;s trunk was successfully performed in all cases using a page-turning mesocolic excision technique.\u003c/p\u003e\n\u003cp\u003eThis approach treated the mesocolon as a multilayered structure, with vascular sheaths serving as natural anatomical planes. After dividing the root of the middle colic artery (MCA), the superior mesenteric vein (SMV) sheath was carefully opened along its outer border (Figure 4A). The surgeon then proceeded in a \u0026ldquo;page-turning\u0026rdquo; manner\u0026mdash;from ventral to dorsal and caudal to cranial\u0026mdash;to gradually expose the venous branches. Opening the sheath of Henle\u0026rsquo;s trunk (Figure 4B) enabled clear visualization of the venous confluence, which, based on intraoperative and preoperative CTA findings, exhibited three major branching configurations (Figure 4C): the right gastroepiploic vein (RGEV), the anterior superior pancreaticoduodenal vein (ASPDV), and the accessory right colic vein (accRCV). This CTA-guided, sheath-based dissection allowed each venous tributary to be isolated and divided within a protected tunnel, minimizing traction on fragile veins and substantially reducing the risk of hemorrhage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Procedures and Intraoperative Observation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring surgery, an artery-first intra-sheath dissection was performed under laparoscopy. The MCA trunk was isolated and divided within its vascular sheath before venous manipulation, which promoted natural exposure of Henle\u0026rsquo;s trunk and reduced the risk of injury to cephalad or deep venous branches. Subsequent sheath-based dissection along the SMV and Henle\u0026rsquo;s trunk allowed stepwise identification and division of venous tributaries, minimizing traction-related hemorrhage while maintaining mesocolic integrity.\u003c/p\u003e\n\u003cp\u003eBecause the surgeon stands between the patient\u0026rsquo;s legs, the direction of mesenteric dissection is essentially parallel to the medial border of the superior mesenteric vein (SMV), proceeding from the medial toward the lateral side. The intraoperative viewing angle is therefore almost identical to that of the MS-CTA reconstructions. As a result, the branching patterns and spatial relationships of the major vessels observed during surgery correspond closely to those demonstrated on CTA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntraoperative and postoperative parameters were prospectively recorded for both groups. In the study group, real-time data on operative duration, vascular injuries, and mesocolic excision completeness were collected. Key procedural steps, including the intrasheath dissection of the middle colic artery (MCA) and the anatomical configuration of Henle\u0026rsquo;s trunk, were documented photographically in most cases. Additionally, full-length surgical videos were available for 39 study group procedures. For the control group, the designated observers recorded the same set of parameters\u0026mdash;including the specific duration of the medial approach phase of the operation\u0026mdash;either in real time or by reviewing available intraoperative video recordings, which were obtained for 31 cases. In instances where video recording was unavailable, critical procedural steps were photographically documented.\u003c/p\u003e\n\u003cp\u003eAll recorded videos and photographs were subsequently reviewed by the research team to verify the duration of the medial approach and to confirm the occurrence of intraoperative vascular injuries and bleeding events. The total operative time was influenced by multiple confounding factors; therefore, the duration of the medial approach phase was specifically analyzed for greater accuracy.\u003c/p\u003e\n\u003cp\u003eThe primary outcomes of the study were the incidence of intraoperative vascular injury, the completeness of the mesocolic plane, and the operative duration of the medial-to-lateral approach.\u003c/p\u003e\n\u003cp\u003eSecondary endpoints included the number of lymph nodes retrieved, postoperative length of hospital stay, and postoperative complication rates.\u003c/p\u003e\n\u003cp\u003eCategorical variables were compared using the \u0026chi;\u0026sup2; or Fisher\u0026rsquo;s exact test, and continuous variables using the t-test. A p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients successfully underwent laparoscopic right hemicolectomy without conversion to open surgery. There were no significant differences between the two groups in age, gender, BMI, or tumor location (Table 1, p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eTable 1. Patients\u0026rsquo; characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCTA-guided group (n=96)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eControl group (n=85)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.4 \u0026plusmn; 8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.7 \u0026plusmn; 8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMale/Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55/41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49/36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.6 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.2 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTumor location (ascending colon / hepatic flexure)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68 / 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60 / 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe comparison of operation time between the control and study groups is shown in Figure 5. The median operation time was comparable between the two groups, with similar distribution patterns ranging from approximately 30 to 70 minutes. Although the study group demonstrated a slightly shorter median duration, the difference was not statistically significant (Figure 5A).\u003c/p\u003e\n\u003cp\u003eThe incidence of intraoperative vascular injury was markedly reduced. Specifically, vascular injury occurred in 2 of 96 patients (2.1%) in the study group, compared with 8 of 85 patients (9.4%) in the control group (Figure 5B). This reduction suggests that the preoperative planning of vascular anatomy and the application of the medial approach facilitated safer vessel dissection with fewer complications.\u003c/p\u003e\n\u003cp\u003eNo MCV injury occurred in the study group. In contrast, in the control group, venous bleeding primarily occurred during dissection around Henle\u0026rsquo;s trunk or from injury to MCV branches while dissecting the MCA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean lymph node yield was comparable between the study group and the control group (19.6 \u0026plusmn; 8.1 vs. 20.4 \u0026plusmn; 6.9, p = 0.52) (Figure 6A). Postoperative hospital stay was shorter in the MS-CTA group compared with the control group (16.24 \u0026plusmn; 9.9 vs. 14.35 \u0026plusmn; 7.3 days, p = 0.0045) (Figure 6B). No cases of anastomotic leakage were observed in either group. Postoperative CTA imaging confirmed intact mesocolic vascular reconstruction in the study group, with well-preserved collateral circulation supplying the left transverse colon.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eConventional classifications of colonic vasculature are primarily derived from cadaveric dissections[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which, while informative, fail to replicate in vivo vessel positioning due to the loss of vascular tension and sheath structures. Our CTA-based approach reflects physiological vessel relationships and allows dynamic assessment of arterial dominance and collateral flow. In particular, insights from our previous work on the arc of Riolan demonstrated predictable patterns of collateralization, which can be used to anticipate compensatory flow to the transverse colon after selective MCA branch ligation. This understanding helps preserve adequate blood supply while achieving oncologic clearance.\u003c/p\u003e \u003cp\u003eThe classical laparoscopic medial approach requires root ligation of the RCA with D3 lymphadenectomy along the SMA (stations 213)[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The RCA demonstrates substantial variability: approximately one-third of patients have an independent RCA, while in most cases it arises as a common trunk with the ileocolic artery (ICA) or the right branch of the MCA[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Without preoperative vascular information, this variation increases technical difficulty and the risk of unplanned vessel injury.\u003c/p\u003e \u003cp\u003eFor tumors of the cecum and ascending colon, the left branch of the MCA is typically preserved (as the MCA is classically bifurcated)[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the absence of preoperative vascular imaging, surgeons must rely on intraoperative identification to determine the MCA type. This often results in overdissection of the mesenteric root or, conversely, en bloc ligation of the MCA and MCV right branches to avoid bleeding, both of which compromise oncologic thoroughness by risking incomplete 223 lymph node dissection[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUsing CTA, we identified the dominant feeding artery of the hepatic flexure tumor and determined the division level according to JSCCR D3 principles. For example, in two-branch MCA patterns, both branches could be ligated at the common stem; in three-branch or high left-branch patterns, the left branch was preserved, and the right or middle branch was divided at its root. This approach was particularly relevant for tumors at the hepatic flexure, where AMCA was present in nearly 30% of patients[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. When a long-trunk AMCA was identified, the main MCA could be ligated at its root without the need for excessive dissection to preserve the left branch, thus simplifying the procedure and reducing dissection-related risks. When the MCA root was divided (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC), CTA confirmed intact perfusion to the middle and left two-thirds of the transverse colon via collateral circulation.\u003c/p\u003e \u003cp\u003eWe employed a sheath-based vascular dissection concept. Arterial phase: Dissection within the SMA sheath allowed early control of the MCA while preserving cephalad MCV tributaries, thus avoiding bleeding from direct SMV branches that are difficult to manage. Venous phase: Venous sheath dissection revealed SMV and Henle\u0026rsquo;s trunk tributaries sequentially. Each branch was identified and divided under direct vision, minimizing traction-related avulsion.\u003c/p\u003e \u003cp\u003eBecause the cephalad (head-side) approach had already exposed the gastroepiploic vein up to its confluence with Henle\u0026rsquo;s trunk, subsequent medial dissection from the root of Henle\u0026rsquo;s trunk facilitated easy identification of the ASPDV (anterior superior pancreaticoduodenal vein). The trunk of Henle could thus be visualized and preserved safely.\u003c/p\u003e \u003cp\u003eThis stepwise intra-sheath approach eliminates the need for complicated intraoperative classification of Henle\u0026rsquo;s trunk as advocated by other observers and ensures effective hemostasis even if venous injury occurs near the SMV confluence.\u003c/p\u003e \u003cp\u003eThis artery-first, intra-sheath CME technique guided by manual subtraction CTA enables precise preoperative identification of vascular variations, facilitates safe early arterial control and sheath-preserving venous dissection, reduces intraoperative bleeding and improves CME specimen quality and simplifies management of Henle\u0026rsquo;s trunk and enhances overall surgical safety.\u003c/p\u003e \u003cp\u003eThis integrated approach offers a practical and reproducible technical framework for laparoscopic right hemicolectomy. By aligning detailed preoperative vascular mapping with controlled intra-sheath dissection, surgeons can achieve both oncologic radicality and safety in the most anatomically complex region of right-sided CME.\u003c/p\u003e \u003cp\u003eAs a retrospective analysis from a single institution, our findings should be interpreted with caution. The demonstrated feasibility and outcomes, while promising, require validation through prospective, multi-center studies to mitigate institutional bias and establish broader applicability.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eCME: complete mesocolic excision\u003c/p\u003e\n\u003cp\u003eCVL: central vascular ligation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSMA: superior mesenteric artery\u003c/p\u003e\n\u003cp\u003eSMV: superior mesenteric vein\u003c/p\u003e\n\u003cp\u003eRCA: right colic artery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCV: right colic vein\u003c/p\u003e\n\u003cp\u003eMCA: middle colic artery\u003c/p\u003e\n\u003cp\u003eMCV: middle colic vein\u003c/p\u003e\n\u003cp\u003eRGEV: right gastroepiploic vein\u003c/p\u003e\n\u003cp\u003eASPDV: anterior superior pancreaticoduodenal vein\u003c/p\u003e\n\u003cp\u003eaccRCV: accessory right colic vein\u003c/p\u003e\n\u003cp\u003eMS-CTA: manual-subtraction CT angiography\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eFunding Declaration\u003c/h3\u003e\n\u003cp\u003eThis study was funded by the Science and Technology Program of Jinan Municipal Health Commission (Grant No. 2021-2-05) and the Shandong Provincial Medical and Health Science and Technology Project (Grant No. 202304011461). The funders had no involvement in any aspect of the research or manuscript preparation.\u003c/p\u003e\n\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of the Jinan Central Hospital (Approval No. 2022-101-01). Written informed consent was obtained from all participants. The study was registered at ClinicalTrials.gov (NCT05674097).\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; Contributions\u003c/h3\u003e\n\u003cp\u003eGuoqin Liu, Zhongkai Xu and Lei Wang conceived and designed the study. Ge Li, Yiheng Xue, and Ying Lv collected the data. Ying Wang and Lei Wang performed the statistical analysis. Guoqin Liu drafted the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eConsent for Publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of Data and Materials\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting Interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet Lond Engl. 2019;394:1467\u0026ndash;80. https://doi.org/10.1016/S0140-6736(19)32319-0\u003c/li\u003e\n\u003cli\u003eHohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. 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Updat Surg. 2022;74:117\u0026ndash;26. https://doi.org/10.1007/s13304-021-01144-x\u003c/li\u003e\n\u003cli\u003eVeldkamp R, Kuhry E, Hop WCJ, Jeekel J, Kazemier G, Bonjer HJ, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6:477\u0026ndash;84. https://doi.org/10.1016/S1470-2045(05)70221-7\u003c/li\u003e\n\u003cli\u003eHe Z, Yang C, Diao D, Wu D, Fingerhut A, Sun Y, et al. Anatomic patterns and clinical significance of gastrocolic trunk of Henl\u0026eacute; in laparoscopic right colectomy for colon cancer: Results of the HeLaRC trial. Int J Surg Lond Engl. 2022;104:106718. https://doi.org/10.1016/j.ijsu.2022.106718\u003c/li\u003e\n\u003cli\u003eZhang JL, Guo XC, Liu J, Zhang JX, Wu T, Wang PY, et al. [Preoperative evaluation using multi-slice spiral CT angiography of right-side colon vascular in laparoscopic radical operation for right colon cancer]. Zhonghua Wai Ke Za Zhi. 2019;57:927\u0026ndash;33. https://doi.org/10.3760/cma.j.issn.0529-5815.2019.12.011\u003c/li\u003e\n\u003cli\u003eWang Y, Zhang C, Zhang D, Fu Z, Sun Y. Clinical outcome of laparoscopic complete mesocolic excision in the treatment of right colon cancer. World J Surg Oncol. 2017;15:174. https://doi.org/10.1186/s12957-017-1236-y\u003c/li\u003e\n\u003cli\u003eXie D, Yu C, Gao C, Osaiweran H, Hu J, Gong J. An Optimal Approach for Laparoscopic D3 Lymphadenectomy Plus Complete Mesocolic Excision (D3+CME) for Right-Sided Colon Cancer. Ann Surg Oncol. 2017;24:1312\u0026ndash;3. https://doi.org/10.1245/s10434-016-5722-1\u003c/li\u003e\n\u003cli\u003eWang Y, Wang L, Liang M, Xu Z, Xue Y, Liu G. Verification of blood flow path reconstruction mechanism in distal sigmoid colon and rectal cancer after high IMA ligation through preoperative and postoperative comparison by manual subtraction CTA. 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Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: A comprehensive review. World J Gastrointest Surg. 2016;8:106\u0026ndash;14. https://doi.org/10.4240/wjgs.v8.i2.106\u003c/li\u003e\n\u003cli\u003eD\u0026iacute;az-Vico T, Fern\u0026aacute;ndez-Hevia M, Su\u0026aacute;rez-S\u0026aacute;nchez A, Garc\u0026iacute;a-Guti\u0026eacute;rrez C, Mihic-G\u0026oacute;ngora L, Fern\u0026aacute;ndez-Mart\u0026iacute;nez D, et al. Complete Mesocolic Excision and D3 Lymphadenectomy versus Conventional Colectomy for Colon Cancer: A Systematic Review and Meta-Analysis. Ann Surg Oncol. 2021;28:8823\u0026ndash;37. https://doi.org/10.1245/s10434-021-10186-9\u003c/li\u003e\n\u003cli\u003eCrane J, Hamed M, Borucki JP, El-Hadi A, Shaikh I, Stearns AT. Complete mesocolic excision versus conventional surgery for colon cancer: A systematic review and meta-analysis. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2021;23:1670\u0026ndash;86. https://doi.org/10.1111/codi.15644\u003c/li\u003e\n\u003cli\u003eWang Y, Shu W, Ouyang A, Wang L, Sun Y, Liu G. The New Concept of Physiological \u0026ldquo;Riolan\u0026rsquo;s Arch\u0026rdquo; and the Reconstruction Mechanism of Pathological Riolan\u0026rsquo;s Arch After High Ligation of the Inferior Mesenteric Artery by CT Angiography-Based Small Vessel Imaging. Front Physiol. 2021;12:641290. https://doi.org/10.3389/fphys.2021.641290\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Right-sided colon cancer, Complete mesocolic excision, Henle’s trunk, Middle colic artery, Manual subtraction CTA, Artery-first approach, Vascular sheath dissection","lastPublishedDoi":"10.21203/rs.3.rs-8439616/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8439616/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgroud:\u003c/strong\u003e\u003cbr\u003e\nVascular injury, particularly involving Henle’s trunk, remains a major challenge during complete mesocolic excision (CME) for right-sided colon cancer. Due to the high anatomical variability of right-sided colonic vessels, the influence of tumor location, and heterogeneity in operative techniques, radical right hemicolectomy (RRC) continues to be a high-risk procedure. This study aims to identify strategies that reduce vascular injury and enhance mesenteric margin integrity in standardized CME surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and methods:\u003c/strong\u003e\u003cbr\u003e\nPatients with right-sided colon cancer underwent manual subtraction CTA to determine MCA branching types and MCV–Henle’s trunk configurations. Based on these findings, individualized surgical plans were established emphasizing artery-first, sheath-based dissection. Operative outcomes were compared with those of conventional CME cases regarding intraoperative bleeding, vascular injury rate, and the subjective assessment of mesenteric margin integrity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nPreoperative CTA successfully identified MCA and MCV–Henle’s trunk types in \u0026gt;90% of patients. The CTA-guided artery-first group showed significantly fewer venous injuries and improved exposure of the Henle’s trunk and SMV compared with the conventional group. No MCV injuries occurred, and CME specimen integrity improved steadily with experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nManual subtraction CTA allows accurate visualization of fine vascular anatomy and facilitates a safe, artery-first CME strategy for right-sided colon cancer. CTA-guided sheath dissection reduces intraoperative venous bleeding and improves surgical precision.\u003c/p\u003e","manuscriptTitle":"Optimization of Artery-First Approach in Right-Sided Colon Cancer CME: Preoperative CTA Assessment of MCA Branching and MCV–Henle’s Trunk Relationship","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-06 09:20:56","doi":"10.21203/rs.3.rs-8439616/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-10T12:32:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-10T12:27:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322637869324922882280366637147501222176","date":"2026-01-07T14:36:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-05T21:31:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50928694027529795250534726741140377104","date":"2026-01-05T17:55:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229726538802114822761307074202473244769","date":"2026-01-05T17:21:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104115275384875385360869102269029621835","date":"2026-01-05T05:56:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79910967321445349007636444268173677262","date":"2026-01-03T18:25:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-03T04:56:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-30T08:02:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-29T12:35:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2025-12-24T06:26:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a4e0ef4-0062-4bb7-9508-d32616580317","owner":[],"postedDate":"January 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:07:28+00:00","versionOfRecord":{"articleIdentity":"rs-8439616","link":"https://doi.org/10.1186/s12957-026-04256-z","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2026-02-16 15:57:40","publishedOnDateReadable":"February 16th, 2026"},"versionCreatedAt":"2026-01-06 09:20:56","video":"","vorDoi":"10.1186/s12957-026-04256-z","vorDoiUrl":"https://doi.org/10.1186/s12957-026-04256-z","workflowStages":[]},"version":"v1","identity":"rs-8439616","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8439616","identity":"rs-8439616","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}