Since its establishment in 2009, the Southern Chinese Laparoscopic Colorectal Surgical Study (SCLCSS) group has been dedicated to promoting patients’ quality of life through minimally invasive surgery. The multicenter database was launched by combining existing datasets from members of the SCLCSS group. The clinical data of 3640 consecutive colon cancer patients who underwent either open (n = 2419) or laparoscopic (n = 1221) surgery at 11 specialized institutions between January 2000 and June 2009 were recorded in the database[9]. All data were documented respectively using unified case report form (CRF) and the data collection protocol was approved by the local ethics committees. All participants signed informed consent statements.

A total of 247 patients who underwent extended right hemicolectomy for cancer located at the hepatic flexure or within 10 cm distal to the hepatic flexure were registered from May 2006 to May 2009 in our database. Twenty-seven patients were excluded from the present analysis due to advanced stage (stage IV), recurrent disease, emergency surgery, or palliative surgery. Finally, a total of 220 consecutive patients who underwent either LERH (n = 119) or OERH (n = 101) were included in the present series. The surgical approach was chosen based on an understanding of the risks and benefits inherent to laparoscopic and open resection, without any pressure from the surgeon.

Extended right hemicolectomy with D3 lymphadenectomy was implemented with radical intention when the patient was confirmed with colon cancer located at the hepatic flexure or within 10 cm distal to the hepatic flexure and the clinical stage was II or III at preoperative examination by colonoscopy, abdominal enhanced computed tomography, and chest X-ray. The clinical characteristics, surgical outcomes, and oncologic outcomes of patients in the two groups were compared. The NCCN guidelines for colon cancer (v.1.2012) were used for clinical and pathological staging.

The patient was placed in the supine position with legs apart during LERH with D3 lymphadenectomy. A 10-mm 30° rigid laparoscope was used through an observational port located at the umbilicus. A 12-mm trocar located 10 cm below the umbilicus, and a 5-mm trocar at McBurney’s point were placed for surgeon standing between the legs. Two other 5-mm trocars, located at the opposite McBurney’s point and the left subcostal area, were used for assistance. A medial-to-lateral approach was used during the LERH. In the medial dissection, the D3 lymphadenectomy involved sequential dissection (central ligation) at the roots of the ileocolic vessels, right colic vessels, middle colic vessels, and right gastroepiploic vessels. The subsequent colon dissection involved 10 cm of normal bowel distal to the lesion and at least 10 cm of distal ileum. An extracorporeal functional end-to-end or side-to-side ileotransverse colon anastomosis was performed via a 3- to 5-cm paramidline incision.

During OERH, a lateral-to-medial approach was used for D3 lymphadenectomy and mobilization of colon. A 15- to 20-cm right upper quadrant incision was used. The resection range of colon and mesocolon and D3 lymphadenectomy was performed as the same as the procedures in the LERH. A functional end-to-end or side-to-side ileotransverse colon anastomosis was then constructed.

Although there were differences between the centers in the surgical instruments, vessel occlusion, and the operative approach (lateral-to-medial in LERH) in a minority of operations, the majority of procedures in most of the centers were implemented as above.

A major complication was defined as any complication requiring reoperation or interventional therapy, and a minor complication was defined as a complication that could be managed conservatively. Overall survival was calculated from the operation date to the date of death from all causes. Disease-free survival was calculated from the operation date to the date of recurrence or metastasis. In this study, patients with a high-risk stage II or stage III tumor were recommended to receive postoperative adjuvant chemotherapy with 5-fluorouracil-based regimens. The last follow-up was in September 2009.

Continuous variables were compared using the Student’s t test and expressed as mean ± SD and variables with non-normal distribution were reported as the median (range). Categorical variables were compared using the pearson χ² test or the two-tailed Fisher’s exact test as appropriate. The survival data were analyzed by the Kaplan-Meier method and compared by the log-rank test. A P value of < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS (version 16.0).

The patients’ clinicopathologic characteristics are summarized in Table 1. The mean age of patients in the LERH and OERH group was 61.3 and 64.5 years, respectively. There were no significant differences in age, gender, body mass index (BMI), history of previous abdominal surgery, tumor location, and tumor stage between the two groups.

The mean operative time was significantly longer in the LERH group than that in the OERH group (257.8 ± 67.6 min vs 173.1 ± 52.0 min, P < 0.0001). However, estimated blood loss was lower in the LERH group compared with the OERH group [100 (100-200) mL vs 150 (100-200) mL, P < 0.0001]. There were no significant differences in tumor size, length of resection margins, number of lymph nodes harvested, or the pathologic R0 resection. Conversion was required in nine patients (7.6%) in the LERH group. The reasons for conversion were technically difficult dissection in four patients, severe adhesion in three patients, and uncontrolled bleeding in two patients (Table 2).

The mean time to first flatus (2.7 ± 1.0 d vs 3.2 ± 0.9 d, P < 0.0001), start of a liquid diet (3.6 ± 1.0 d vs 4.2 ± 1.0 d, P < 0.0001), and postoperative hospital stay (11.4 ± 4.7 d vs 12.8 ± 5.6 d, P = 0.009) were significantly shorter in the LERH group than in the OERH group. Postoperative complications occurred in 14 patients (11.8%) in the LERH group and 18 patients (17.6%) in the OERH group (P = 0.215). Major complications were experienced by two patients (1.7%) in the LERH group (anastomotic stenosis and ileus in one patient each) and three patients (3.0%) in the OERH group (anastomotic stenosis, ileus, and hemorrhage in one patient each) (P = 0.663). Minor complications occurred in 12 patients (10.1%) in the LERH group and 15 patients (14.9%) in the OERH group (P = 0.308). The mortality rate within 30 d after surgery between the two groups was comparable (0.8% vs 1.0%, P = 0.907) (Table 3).

Seven patients (5.9%) in the LERH group and eight patients (7.8%) in the OERH group were lost to follow-up. The median duration of follow-up was 30 mo (range 3-60 mo) for the LERH group and 27 mo (range 4-60 mo) for the OERH group (P = 0.632). The 3-year cumulative overall survival was 92.0% in the LERH group and 84.4% in the OERH group (P = 0.209) (Figure 1A). The 3-year cumulative disease-free survival was 84.6% in the LERH group and 76.6% in the OERH group (P = 0.191) (Figure 1B).

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Figure 1 Survival outcomes. A: Cumulative overall survival rate during a 3-year interval in the LERH and OERH groups (92.0% vs 84.4%, P = 0.209; Log-rank test); B: Cumulative disease-free survival rate during a 3-year interval in the LERH and OERH groups (84.6% vs 76.6%, P = 0.191; Log-rank test). LERH: Laparoscopic extended right hemicolectomy; OERH: Open extended right hemicolectomy.

This study is subject to several limitations. Firstly, the retrospective design has the inherent weakness of being observational or nonexperimental. Secondly, the findings may lack generalizability due to the relatively short median follow-up time. Nonetheless, this multicenter study suggests a role of laparoscopic extended right hemicolectomy with D3 lymphadenectomy for the treatment of cancer located at or within 10 cm distal to the hepatic flexure.

Results of this study suggest that for colon cancer located at the hepatic flexure or within 10 cm distal to the hepatic flexure, LERH with D3 lymphadenectomy is a technically feasible and safe procedure, yielding comparable short-term oncologic outcomes to open surgery. However, studies of long-term effects in randomized clinical trials are warranted.

Laparoscopic colectomy for the treatment of colon cancer has been accepted because of the earlier recovery and comparable long-term results based on a number of randomized controlled trails (RCTs). Laparoscopic extended right hemicolectomy (LERH) with D3 lymphadenectomy for colon cancer was excluded from majority of the RCTs because of the technical difficulty.

Laparoscopic surgery has been suggested as an alternative treatment for colon cancer because of both the short-term advantages and the comparable long-term oncologic outcomes when compared to open surgery. LERH with D3 lymphadenectomy was performed cautiously because it is highly technically demanding. With the improvement in surgical techniques, surgeon’s experience, and renewal instruments, extended right hemicolectomy with D3 lymphadenectomy has subsequently been attempted in laparoscopic surgery.

LERH with D3 lymphadenectomy is challenging mainly because of technical difficulty in dissecting the lymph nodes around the origin of the middle colic vessels and right gastroepiploic vessels, and handling the intricacies of venous anatomy at the gastrocolic trunk of Henle. This multicenter retrospective study evaluates the feasibility, safety, and oncologic outcomes of LERH with D3 lymphadenectomy. The superior short-term outcomes and equivalent 3-year oncologic outcomes suggest that LERH with D3 lymphadenectomy should not be excluded from the management of the patients with tumor located at the hepatic flexure or within 10 cm distal to the hepatic flexure.

The study results suggest that LERH with D3 lymphadenectomy for colon cancer is a technically feasible and safe procedure, yielding comparable 3-year oncologic outcomes to those of open surgery.

Tumor located at or within 10 cm distal to the hepatic flexure has an increased risk of infra-pyloric lymph node metastasis. Extended right hemicolectomy with D3 lymphadenectomy which was defined as the ileocolic, right colic, middle colic, and right gastroepiploic vessels were ligated at their origins in sequence and the bowel mobilization was performed at least 10 cm from the margins of the tumor.

The authors reported a well written and interesting paper in the field of mini-invasive right colon surgery. The results are clear and well described.