VM34 - Lessons Learned from Laparoscopic Extended Right Hemicolectomy with D3 Lymph Node Dissection for Transverse Colon Cancer: Case of Postoperative Bleeding

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Purpose/Background: Purpose/ Background
This video presentation highlights the laparoscopic extended right hemicolectomy, with a focus on the role of lymph node dissection in optimizing oncological outcomes and managing potential complications. The video details the surgical technique, including port placement, apical D3 lymph node dissection, and right colon mobilization.

We will explore techniques for meticulous lymph node retrieval, the impact of thorough dissection on survival outcomes, and the associated risks and complications. By emphasizing the importance of lymph node dissection, this presentation seeks to enhance surgical practice and improve patient outcomes in colorectal surgery.

Methods/Interventions: A 54-year-old male patient with no prior medical history underwent a laparoscopic extended right hemicolectomy with D3 lymph node dissection for hepatic flexure adenocarcinoma. On postoperative day 1, despite stable vital signs, the patient's hemoglobin levels dropped significantly.
An exploratory laparoscopy was performed, revealing a large amount of clotted blood in the abdominal cavity. The abdomen was irrigated and aspirated, with no evidence of active bleeding. A drain was placed, and the surgery was concluded without further complications.

Results/Outcomes: While D3 lymph node dissection is a standard practice in certain parts of Asia, in Western countries, D2 dissection has traditionally been the focus. Some surgeons advocate for D3 dissection in select cases, particularly when there is a high risk of lymphatic spread, such as locally advanced tumors (T3/T4), positive or suspicious lymph nodes, or high-risk histological subtypes.
The lack of consensus surrounding D3 dissection is largely due to the challenges and considerations associated with central lymph node dissection. Given its more extensive nature, there is concern about higher postoperative morbidity, including an increased risk of intra-abdominal infections, prolonged operative time, and extended recovery periods. However, some studies indicate that in experienced hands, these risks can be minimized.
In our case, postoperative morbidity manifested as bleeding. The proximity to major blood vessels increased the complexity of the surgery and posed hemostatic challenges, particularly in areas dense with lymphatic and vascular tissue, which likely contributed to the bleeding. As demonstrated in the video, highly experienced surgeons can mitigate these risks by employing meticulous dissection techniques and ensuring thorough hemostasis at every stage of the procedure.

Conclusion/Discussion: It is not routinely performed in early-stage right colon cancer, as the benefits of such an extensive procedure must be weighed against the increased risks. The decision to perform apical dissection is typically individualized, based on tumor characteristics, preoperative imaging, and intraoperative findings.

More research and clinical trials are needed to confirm its benefits and establish broader guidelines on when D3 dissection should be used.