Laparoscopic right hemicolectomy is performed only in 25% of cases in recent survey
The medial-to-lateral and the bottom-to-up are the most frequent approaches used to perform surgery
Top-to-down right hemicolectomy is an infrequent approach
Obesity is an evident aspect complicating surgical dissection
Top-to Down dissection could be an opportunity to use as alternative approach when classical dissection becomes intricate
Introduction and importance: Right colon cancer represents 30 % of colonic malignancies worldwide, and a laparoscopic approach is recommended. Recent surveys show that only 25 % of surgeons perform right hemicolectomies by laparoscopy. Contemporary obesity is rising, and besides being a risk factor for colon cancer, it represents an objective difficulty in performing surgery. These two factors imply a constant and progressive issue facing surgeons.
Case presentation: We describe the case of a 61Y/o woman with 32BMI, a previous left nephrectomy, and neoformation of the right colonic. She underwent laparoscopic right hemicolectomy, using a hybrid top-to-down approach to overcome intraoperative difficulty, consequent to visceral obesity. The postoperative course was uneventful, and she was discharged after five days.
Clinical discussion: The medial-to-lateral approach is the main technique used in laparoscopic right hemicolectomy. Some other techniques are used to perform this intervention, and the top-to-down strategy is adopted only in 4 % of cases. In obese patients, difficulties could be found in vascular and plan dissection. The top-to-down strategy allowed us to deal with some objective difficulties during the procedure, efficiently bypassing them.
Conclusion: Laparoscopy for right colon cancer would be the standard procedure as recommended. Some objective difficulty could be found during interventions, especially in obese patients. The top-to-down dissection is not so frequent and could be considered to deal with intraoperative difficulty. The knowledge of all different strategies and their application might be a possible interchangeably way to solve difficult dissection and increase the spreading of laparoscopy.
Keywords: CME; Colorectal; Complete mesocolic excision; Laparoscopy; Right colon; Right hemicolectomy; colon cancer.