Total laparoscopic right colectomy: The duodenal window first approach

Background Total laparoscopic right colectomy (TLRC) is a demanding procedure requiring laparoscopic skills and expertise in surgical oncology. Identifying the correct plane of dissection may be difficult. A correct management of ileocecal and right colic vascular pedicles is pivotal to achieve an oncological resection and the adequate blood supply of ileal and colic stumps. Methods We describe a technique for TLRC with a duodenum-first approach. Using three ports, dividing the "duodenal window", ileocecal and right colic vascular pedicles, and the right ureter are easily identified. The procedure is completed with an intracorporal stapled side-by-side anastomosis. Results In 2014, 19 patients underwent TLRC using this technique. The median operative time was 178 min (132-237 min) and median intraoperative blood loss reached 60 mL (10-400). Conversion rate was 15.8%. No urinary tract, vascular, duodenal injury or anastomotic fistula were reported. Fifteen patients (79%) underwent a colectomy for cancer with a median of 16 (7-27) harvested lymph-nodes and 100% of R0-resection. Minor morbidity (Clavien-Dindo I-II) was 52.6% mainly related to cardiopulmonary complications (26.3%). Severe morbidity (Clavien-Dindo ≥ III) was 10.5% (two patients), including one reoperation (due to a sepsis related to an intra-abdominal abscess) and one death (due to complications of an aortic aneurism). Median hospital stay was 7 days (2-23 days). Long-term outcomes are unremarkable. Conclusions Using three trocars, the "duodenal window" approach to TLRC is technically feasible and safe, with good outcomes. The early access to the duodenum and the exposure of ilea-cecal and right colic pedicles rationalizes the procedure.