Complete mesocolic excision with central vascular ligation is considered to contribute to superior oncological outcomes after colon cancer surgery [1]. For advanced right-sided colon cancer, this surgery sometimes requires lymph node (LN) dissection along the superior mesenteric vein (SMV), with division of the middle colic vessels, or their right branches, at origin [2]. Here, we present cranially approached radical LN dissection along the surgical trunk during laparoscopic right hemicolectomy. The omental bursa is first opened wide, and the gastrocolic trunk of Henle is exposed, using the right gastroepiploic vessels and the accessory right colic vein (ARCV) as landmarks. After division of ARCV, SMV and middle colic vein (MCV) are identified. After dividing MCV at its root, LN dissection along SMV is conducted in a cranial-to-caudal manner. Concurrently, the middle colic artery, or its right branch, is exposed and divided at origin. The transverse colon is then raised ventrally, and LN dissection along SMV using a cranial-to-caudal approach is again performed. The ileocolic and right colic vessels are divided at origin. The ascending and transverse mesocolon, including the pedicles, are then separated from the retroperitoneal tissues, pancreatic head, and duodenum, using a medial approach. The key characteristics in this procedure consist of easy access to pancreas, early division of ARCV and middle colic vessels at origin, and easy dissection along SMV. We performed a laparoscopic colectomy using this approach for 18 patients with rightsided colon cancer. The mean operative time and blood loss were 288 min and 83 ml, respectively. The mean number of harvested LNs was 24. There were 6 cases with positive LN metastasis. There were no recurrent cases at a median follow-up period of 24 months. We consider this approach to be safe and useful for radical LN dissection along SMV for right-sided colon cancers. Keywords
We consider this method as simple and feasible for most laparoscopic surgeons with basic laparoscopic suturing skills. This method might help LTG to become an accepted standard surgical option for treatment of patients with gastric cancer.
The patient was a 91-year-old man with change in nipple appearance, itching and redness, and a palpable breast mass. At presentation, mammary Paget’s disease (PD) was clinically suspected. Skin biopsy was performed and showed epidermis invaded by Paget cells, characterized by hyperchromatic nuclei and abundant pale-staining cytoplasm. Computed tomography and mammary ultrasonography confirmed the absence of an underlying invasive carcinoma, and the patient underwent right mastectomy and sentinel lymph node biopsy (SLNB). Both sentinel lymph nodes were found to be negative perioperatively, and further axillary dissection was not performed. Pathological results revealed no malignancy under the nipple, yet the Paget cells were more widely spread than expected. The patient was followed up without the need of postoperative chemotherapy. Male mammary PD is an extremely rare breast cancer, and there is no standard preoperative assessment or operative procedure. Mammography is many times unable to detect possible underlying breast carcinoma in female patients with mammary PD, and previous studies have reported that the detection rate was less than 50 %. However, some researchers reported that magnetic resonance imaging (MRI) might be more detectable to confirm the extent of the cancer. The extent of the skin change around the nipple is often different from the actual perimeter of Paget cells. In extra-mammary PD, mapping biopsy is known to be useful to determine areas free of cancer. The benefits of SLNB have also been demonstrated for the management of less invasive breast cancers, and previous reports have shown that the use of SLNB is reasonable for treatment of mammary PD without underlying invasive cancer. MRI, mapping biopsy, and SLNB are all less invasive procedures and thus may be suitable for treatment of male mammary PD.
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