The retroperitoneal approach to vessel‐sparing D3 lymph node dissection in left‐sided colorectal cancer resections: a video vignette

Laparoscopic colorectal surgery has become a standard of care in colorectal cancer surgery, providing comparable long-term outcomes to those in open surgery [1]. Yet, it may be not applicable for some patients, compromised by cardiovascular and respiratory diseases, obesity and previous surgery, associated with adhesions [2]. The retroperitoneal approach may become a solution for compromised patients. A surgical procedure with high vascular ligation of the inferior mesenteric artery with extraperitoneal approach was proposed by Hany et al. [3]. However, high vessel ligation in most cases requires mobilization of the splenic flexure and may be associated with an increased risk of anastomotic leakage [4]. We perform low vascular ligation and preserve the left colic artery in the case of sigmoid and rectal cancer surgery, reaching apical lymph node dissection due to skeletonization of the inferior mesenteric artery, which stands for vascular-oriented complete lymph node dissection [5]. In this paper, we describe the approach to D3 lymph node dissection with left colic artery preservation and inferior mesenteric artery skeletonization from the retroperitoneal space (Video S1). Preoperatively, inferior mesenteric anatomy features, left colic artery branching pattern and spatial relationships with the inferior mesenteric vein are described with the use of CT scan and 3D reconstruction to safely perform this procedure. First, the para-umbilical optical trocar is placed to introduce a 30° optical system. Then, the SILS™ Port (Covidien, Ethicon) is inserted into the retroperitoneal space via a 4-cm incision, made 2 cm below and parallel to the anterior superior iliac spine in the left flank under the control of the optical system. As soon as carbon dioxide insufflation starts, the pneumodissection aids to enter the proper space of dissection. The first landmark, which should be visualized, is the left psoas muscle. The dissection proceeds cranially and medially up to the lower edge of the horizontal part of the duodenum, which is the cranial landmark. Throughout latero-medial dissection in cranial dissection, special attention should be paid to the following structures: (1) gonadal vessels; (2) the ureter as the main posterior landmark for this approach, which passes medial to gonadal vessels; (3) Gerota's fascia, which presents the posterior border of dissection and should be preserved. The ureter is followed until it crosses the left common iliac artery—the caudal landmark. The dissection continues along the left iliac artery until identification of the aorta—the medial landmark, which is skeletonized until the horizontal part of the duodenum. The parietal fascia, attaching the root of the mesocolon to the aorta, is cut at this level, so the mesocolon is mobilized dorsally and cranially. Then, the aorta is exposed medially to the left splanchnic nerve, and the inferior mesenteric artery is identified. The inferior mesenteric artery is skeletonized from its origin until the left colic artery and sigmoid artery debranching. The left colic artery is skeletonized until the passage of the inferior mesenteric vein, and the apical mesocolic tissue is mobilized and excised. Finally, we pass from the retroperitoneal space into the space between the presacral fascia and mesorectal fascia and perform the posterior mobilization of the mesorectum. As soon as the colon is mobilized at the level of the proximal and distal resection margins, the approach is converted from the retroperitoneal into the transabdominal. When the mesocolon is fully mobilized dorsally, the parietal fascia along Toldt's line is cut to finish the mesocolon excision laterally. Medially at the level of the inferior mesenteric artery root and the left colic artery debranching the parietal fascia is cut along the right side of the aorta to free the medial border of the mesocolon. As soon as the mesocolon is mobilized 5 cm distally from the tumour margin, the colon is cut by linear stapler. Then, the sigmoid-rectal anastomosis is performed. The blood loss was 50 mL. The length of the procedure was 250 min. The retroperitoneal step took 90 min. The lymph node harvest reached 22 lymph nodes per specimen, one of which was metastatic. In the early postoperative period the pain syndrome was lower than 1 point out of 10 on the visual analogue scale, and less epidural injection of ropivacaine mesylate was needed. This case report shows the feasibility of the retroperitoneal approach in artery-sparing and vascular-oriented apical lymph node dissection. The anatomical landmarks are available from this site, so the complete lymph node dissection can be managed with this approach. Sergey K. Efetov, Ph.D. (Conceptualization; Data curation; Investigation; Supervision; Validation; Writing – original draft); Albina A. Zubayraeva (Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft); Polina D. Panova, MD (Data curation; Investigation; Figures curation). None. The authors declare no conflicts of interest. The study was conducted according to the ethical principles declared in the WMA Declaration of the Helsinki Declaration 1964 (revised in 2003). Video S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.