Surgical steps for right laparoscopic D3 lymphadenectomy in a patient with a giant duodenal diverticulum

Abstract

Laparoscopic D3 Lymphadenectomy (D3-L) for right colon cancer may be associated with improved survival [1]. However, D3-L presents a technical difficulty that can be exacerbated for different anatomical reasons, one of them the presence of a duodenal diverticulum, as in the case presented. In the attached video, a laparoscopic right hemicolectomy with D3-L is performed in an 81-year-old woman with right colon adenocarcinoma who was found on staging computed tomography scan to have a giant duodenal diverticulum. In D3-L, the retroperitoneal dissection must start accessing the Toldt’s fascia as seen in the video. Afterwards, the fusion fascia of Fredet or anterior duodeno-pancreatic fascia must be identified and dissected over the second segment of the duodenum [2]. This allows identification of the gastro colic trunk of Henle (GCTH) avoiding any manipulation of the duodenal diverticulum. Procedure continues with high tie of ileocolic vessels and dissection of Gillot’s trunk. The duodenal diverticulum adds a technical difficulty in the dissection of the GCTH. At this point, an up-to-down fashion manoeuvre is shown in the video after liberation of the hepatic flexure of the colon, which allows identification of the right gastroepiploic artery. The procedure continues with the central ligation of the superior right colic vein (SRCV) as well as the right branch of the middle colic vessels. The pathology report confirmed the presence of the surgical trunk of Gillot and SRCV in the surgical specimen, so it was classified as a complete D3-L based on the accepted parameters [3]. In certain occasions, we can find anatomical alterations that can create challenging dissections. Nonetheless, we must follow the right embryological planes to make a complete D3-L colectomy. This is why we present the case of a patient with a giant duodenal diverticulum, which carries a higher risk of perforation. Moreover, there is an increased risk of bleeding while dissecting the GCTH, especially at the origin of the SMV. The causes for iatrogenic lesions of the SMV are anatomical variations, avulsion of the middle colic vein due to excessive traction and mesenteric involvement of the tumour. In conclusion, D3-L right colectomy is a surgical intervention that can be performed in the presence of anatomical alterations such as a duodenal diverticulum. The knowledge of the embryological development of the digestive tract and surgical anatomy of the right colon facilitates the procedure and reduces the risk of intraoperative complications such as duodenal perforation and intragenic vascular lesions. Furthermore, following embryological planes permits dissection of central lymph nodes to do a complete D3-L, thus improving the survival rates.