title: The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision.
abstract: BACKGROUND
  Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand.
  
  
  METHODS
  The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed.
  
  
  RESULTS
  Surgical time was longer (144.8 vs. 202.5 min; p < 0.000) and postoperative stay shorter (8.0 vs. 10.5 days; p < 0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097 mm(2); CON, 15,788 mm(2); p = 0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p = 0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n = 0) and postoperative mortality (UFA, 0/28; CON, 1/51; p = 1.0).
  
  
  CONCLUSIONS
  Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.
authors.affiliation: Klinik für Allgemein, Viszeral und Kinderchirurgie, Kliniken Böblingen, Bunsenstr. 120, 71032, Böblingen, Germany. stefanrolfbenz@web.de.
authors.forename: Stefan
authors.initials: S
authors.lastname: Benz
authors.affiliation: Institut für Pathologie, Ruhruniversität Bochum, Bochum, Germany.
authors.forename: Yu
authors.initials: Y
authors.lastname: Tam
authors.affiliation: Institut für Pathologie, Ruhruniversität Bochum, Bochum, Germany.
authors.forename: Andrea
authors.initials: A
authors.lastname: Tannapfel
authors.affiliation: Institut für Pathologie, Ruhruniversität Bochum, Bochum, Germany.
authors.forename: Ingo
authors.initials: I
authors.lastname: Stricker
mesh_terms: D000328:Adult; D000368:Aged; D057868:Anastomotic Leak / Q000601:surgery; D016022:Case-Control Studies; D003082:Colectomy / Q000379:methods*; D003110:Colonic Neoplasms / Q000601:surgery*; D004386:Duodenum / Q000601:surgery; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008646:Mesocolon / Q000601:surgery*; D008875:Middle Aged; D061646:Operative Time
keywords: CME; Colon cancer; Complete mesocolic excision; Laparoscopic hemicolectomy; Right hemicolectomy; Uncinate process first approach