Total laparoscopic right colectomy: The duodenal window first approach.
BACKGROUND
Total laparoscopic right colectomy (TLRC) is a demanding procedure requiring laparoscopic skills and expertise in surgical oncology. Identifying the correct plane of dissection may be difficult. A correct management of ileocecal and right colic vascular pedicles is pivotal to achieve an oncological resection and the adequate blood supply of ileal and colic stumps.


METHODS
We describe a technique for TLRC with a duodenum-first approach. Using three ports, dividing the "duodenal window", ileocecal and right colic vascular pedicles, and the right ureter are easily identified. The procedure is completed with an intracorporal stapled side-by-side anastomosis.


RESULTS
In 2014, 19 patients underwent TLRC using this technique. The median operative time was 178 min (132-237 min) and median intraoperative blood loss reached 60 mL (10-400). Conversion rate was 15.8%. No urinary tract, vascular, duodenal injury or anastomotic fistula were reported. Fifteen patients (79%) underwent a colectomy for cancer with a median of 16 (7-27) harvested lymph-nodes and 100% of R0-resection. Minor morbidity (Clavien-Dindo I-II) was 52.6% mainly related to cardiopulmonary complications (26.3%). Severe morbidity (Clavien-Dindo ≥ III) was 10.5% (two patients), including one reoperation (due to a sepsis related to an intra-abdominal abscess) and one death (due to complications of an aortic aneurism). Median hospital stay was 7 days (2-23 days). Long-term outcomes are unremarkable.


CONCLUSIONS
Using three trocars, the "duodenal window" approach to TLRC is technically feasible and safe, with good outcomes. The early access to the duodenum and the exposure of ilea-cecal and right colic pedicles rationalizes the procedure.
Service de Chirurgie Digestive, Centre Hospitalier Simone Veil, Eaubonne, France; Laboratoire d'Ethique Médicale et de Médecine Légale, Université Paris Descartes, Paris, France. Electronic address: spleen2008@live.fr.
Alban
A
Zarzavadjian Le Bian
Service de Chirurgie Digestive, Centre Hospitalier Simone Veil, Eaubonne, France; Service de Transplantation Hépatique et de Chirurgie Hépatique Biliaire et Pancréatique, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot, Clichy, France.
Manuela
M
Cesaretti
Service de Chirurgie Digestive, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Université Paris Sud, France.
Claude
C
Smadja
Dipartimento di Scienze Chirurgiche, Università Degli Studi di Parma, Parma, Italy.
Renato
R
Costi
D000714:Anastomosis, Surgical; D003082:Colectomy / Q000379:methods*; D003110:Colonic Neoplasms / Q000601:surgery*; D004378:Duodenal Diseases / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D011183:Postoperative Complications; D016896:Treatment Outcome
Duodenal window approach; Total laparoscopic right colectomy