Cranial-first approach of laparoscopic left colectomy for T4 descending colon cancer invading the Gerota\u2019s fascia

Atsushi Ogura,Tsukasa Aritake,Kenji Takagi,Satoru Kawai,Ryutaro Kobayashi,Kiyotaka Kawai,Satoaki Kamiya,Takashi Maeda,Natsuki Nagano

doi:10.1186/s40792-019-0720-8

Abstract

BackgroundThe safety and feasibility of laparoscopic colectomy for T4 colorectal cancer remain controversial. We believe that setting a “Goal” that will guide the surgeons in returning from the deep layer could be the key to safe en bloc resection of neighboring organs. For descending colon cancer, the cranial-first approach makes it possible to clearly visualize the pancreas and origin of the transverse mesocolon, leading to safe splenic flexure mobilization and complete mesocolic excision, which is the strongest advantage of this approach.Case presentationA 75-year-old woman was diagnosed with T4 descending colon cancer invading the Gerota’s fascia. We performed laparoscopic left colectomy using the cranial-first approach to set a “Goal” at the inferior border of the pancreas for safe resection of the Gerota’s fascia. The total operative time was 233 min, and the estimated blood loss was 98 ml. She was discharged after surgery without postoperative complications. Pathological findings revealed the invasion into the Gerota’s fascia, and the resection margin was negative for cancer.ConclusionsThe cranial-first approach of laparoscopic left colectomy appears to be safe and feasible and could be a promising method for selected patients with T4 descending colon cancer invading the Gerota’s fascia.

Highlights

The safety and feasibility of laparoscopic colectomy for T4 colorectal cancer remain controversial
Laparoscopic colectomy for left-sided colon cancer is technically demanding owing to the complicated anatomy around the pancreas and transverse mesocolon [1]
For complete mesocolic excision (CME), dissection of the transverse mesocolon is necessary in the proximity of the pancreas

Summary

Background

Laparoscopic colectomy for left-sided colon cancer is technically demanding owing to the complicated anatomy around the pancreas and transverse mesocolon [1]. For left-sided colon cancer, the cranial-first approach is one of the promising procedures for obtaining better surgical outcomes; it has been reported previously [2] This approach involves dissection of the superior layer of the mesocolon and transverse mesocolon at the. We report the first case of cranial-first approach of laparoscopic left colectomy for T4 descending colon cancer invading the Gerota’s fascia. 3. Medial approach for safe resection of the Gerota’s fascia For obtaining a sufficient surgical margin, we dissected the Gerota’s fascia and exposed the surface of the left kidney just behind the tumor. At the most medial side of the mesocolon behind the IMV, we could detect the layer between the posterior lobe of the mesocolon and Gerota’s fascia; we cut the posterior lobe above the gauze that was placed as the “Goal” during the cranial approach.

Discussion

Conclusions