 Hi, today we are going to talk about how to perform a laparoscopic D3 right hemicolectomy. How D3 differs from D2 is that in D3 lymph node dissection we go right up to the root of the misentry that is the SMA and the SMV whereas in D2 as you can see we go right up to the root of the misentry but do not expose the SMA or the SMV. The first step is to ask the assistant with his left hand to pull up the transfer column and with his right hand to pull up the iliocecal junction. In doing so you can see now we have lifted the iliocolic pedicle. So you can see the iliocolic pedicle going towards the left and the middle colic or the SMA-SMV complex going towards the cranial part. The first dissection starts almost at the root of the supramazentric artery and the supramazentric vein. Lifting up the iliocolic pedicle as you can see and you can see a faint bluish hue right underneath the left hand of the operating surgeon. So what we have done over here we have just lifted up the iliocolic pedicle and we are dissecting right on the root of the misentry and we are trying to expose layer by layer the supramazentric vein and the supramazentric artery. This is an unedited video of right hemicolectomy. In my opinion for beginners a laparoscopic low anterior section should be the first surgery to perform. Right hemicolectomy is a more radical and a more complex surgery. Now here what we are going to do is we are going to identify the supramazentric vein and we are going to locate the takeoff of the iliocolic pedicle from the supramazentric vein. One important thing here to understand is that we need to give lot of respect in dissecting the vein as compared to the artery. The veins can usually be unforgiving whereas the arteries are usually forgiving and dissecting the arteries be it the iliocolic artery or the right colic or the transverse medial colic artery are usually much easier. Now here you can see we have lifted the iliocolic pedicle and now we can see the supramazentric vein completely exposed and we are just going to go on the top of the supramazentric vein and you can see the takeoff of the iliocolic vein tributary going into the supramazentric vein. Now what we are trying to show you is the lifted up portion of the iliocical junction in turn the iliocolic vessels get lifted up the dissection is being performed towards the assisting surgeon's left hand which is pulling up or lifting up the transverse mesocolon and thereby lifting up the middle colic vein and the artery. The dissection of the D3 lymph nectomy is such that we have to go 5 mm to 1 cm distilled to the iliocolic tributary going into the supramazentric vein. Now here one thing that I want everyone to remember is that unlike what is seen in the books the supramazentric artery does not lie left of the vein it lies behind the supramazentric vein. So the supramazentric artery lies behind the supramazentric vein and not to the left as is usually shown in lot of diagrams lot of pictures which are hand drawn or graphically drawn whereas when we go up towards the transverse colon or towards the pancreas head the supramazentric artery lies to the left and not posterior to the supramazentric vein. Now this is very important to remember because we are standing on the left of the patient and we are going medial to lateral dissection. You can see that we are dissecting right behind the iliocolic vessel and behind the iliocolic vein lies the iliocolic artery taking off from the supramazentric artery. Now what we are trying to do is gain a good length of the iliocolic vein in turn what we are going to get is a good length so as to ligate the iliocolic vein clip them and cut it. Now as you can see this is an unedited video and we are taking lot of time to dissect the iliocolic vein so as to not cause any inadvertent injury to the vein moreover to the junction between the iliocolic vein and the supramazentric vein. At this juncture I usually ask my assistant to leave the iliocolic or the iliocecal junction so as to reduce the traction at the root of the misentry. This also helps in keeping the iliocolic pedicle down without any tension. Now what we are doing now is we are trying to clip the iliocolic vein right at the root of the misentry right at its take off from the supramazentric vein. A layer by layer dissection ensures a complete lymphed anectomy right up to the root of the misentry. I always prefer to put a clip on the specimen side. The reason is that I would not want the field of surgery to get bloody. You can see that we have done the dissection right from the ilioccal junction almost from the ilioccal junction up to the supramazentric vein almost up to the transverse colon level. Now once you cut the iliocolic vein you encounter nothing but the iliocolic artery which lies right behind the iliocolic vein. Now a good thing to remember here is that the anatomy can be very very variable over here. The artery can take off in front of the iliocolic vein or behind a little upwards also. Hence again a layer by layer facial plane dissection will help you in dissecting the artery. Now what we are keeping down or what we are dissecting on is nothing but the supramazentric artery. You can see the pulsation of the supramazentric artery. Now where we are dissecting is the level of the mesocolic fascia which is called as the complete mesocolic excision. If you can appreciate you can see the head of the pancreas behind which we will be seeing later on more clearly. Now the dissection is being performed in the mesentry towards the ilioccal area. We have taken the whole of the mesentry right up to the iliocolic vein the root of the mesentry and that is very important in performing any kind of radical hemicolectomy. The most important reason that we go right up to the central vein or what we call as the central venous ligation. The concept is that we need to take all the fibrophatic tissue overlying the artery and the supramazentric vein so as to clear all the lymphatic tissue. You can see by lifting the iliocolic pedicle we have lifted up the supramazentric artery below. Now what has happened in lifting the iliocecal junction or lifting the pedicle that is the iliocolic pedicle the artery comes from posterior of the supramazentric artery to lateral or to the left of the supramazentric vein. Now as we go cranially that is as we go towards the middle colic the supramazentric artery will lie to the right of the supramazentric vein whereas in the caudal part that is where the dissection is happening right now the supramazentric artery at this level lies to the left of the supramazentric vein or posterior to the supramazentric vein. Now we have just ligated the iliocolic artery and we are ready to cut and lift the whole of the mesocolon. Now the next part of the dissection will be the mesocolic fascia. You can see this is a completely avascular zone all you can see the clear avascular zone fibro fatty tissue with loose areola tissue separating between the mesocolon the misentry of the colon and the diodenum and the head of the pancreas. Now what is happening here is we are pushing the diodenum and the head of the pancreas down and we are lifting all the mesentry of the ascending colon and the hepatic flexure up with the help of the left hand instrument of the surgeon. You can see we are dissecting right on the diodenum and once the diodenum is pushed down we will encounter nothing but the gerotas fascia and you can see we are pushing down the gerotas fascia and taking up the mesocolic fascia. This ensures that we are in the right plane it also ensures that we need not always identify the ureters because if you are in the right plane of the mesocolic fascia and the gerotas fascia below then you are always going to keep the ureters within the gerotas fascia and not injure it. Now that is exactly what we are trying to do over here a combination of sharp and blunt dissection will ensure that we are staying in the right plane. This is the loose areola tissue that separates the mesocolic fascia above from the gerotas fascia below. You can see the small vessels running right over the gerotas fascia which is nothing but the part of the gerotas fascia and what we have lifted up is the mesocolon also having all the mesocolic vessels the ilocolic vessels as well. Now we are going to dissect in the second part of the duodenum we have already dissected the third part of the duodenum completely we are going to go cranially on the second part of the duodenum the whole idea is to completely devoid the second part of the duodenum and the whole of the head of the pancreas from all the loose areola tissue and once you are in this plane the dissection becomes less bloody because you are going right up to the root of the mesentry and only thing that you are going to encounter are the three vessels that is the ilocolic pedicle the right colic if it is present which is usually present in 45 to 50% of patients and the middle colic vessels and you can see that this is the right colic probably the right colic artery of the pedicle of the right the right colic pedicle which are not usually very very well developed and need not require a ligation also the classical location of a right colic pedicle is to take off from the level of the head of the pancreas and run across the second and the junction of the second and the third part of the duodenum now the whole of the mesocolon is lifted up the hepatic flexure and the ascending colon is lifted up and that is why we can see the right colic vessels now just being cut are lifted up now once the right colic vessels are also lifted are cut the next vessel that you one can encounter is the henley's loop the takeoff of the middle colic artery and the vein now here there are a lot of variations that can happen the left and the right branch can have a common trunk and then divide the left can take off the left middle colic can take off from the gastrocolic trunk sometimes from the loop of henley and that is why a very precarious and a very now what we are doing is the identification of the loop of henley and the middle colic vein you can see that the assistant surgeon has lifted up the transverse mesocolon in doing so you can identify the middle colic vein and the middle colic artery now this is a case wherein we need not perform an extended hemicolectomy and hence we do not have to ligate the root of the middle colic vein but we just need to take the left branch of the middle colic vein which is going to be much tougher because then you have to dissect the common trunk and the left colic and the right colic branches you can see what the section we performed earlier this is the extension of the same now we are just going to go between the gerotas fascia and the middle and the mesocolic fascia and try to reach the lateral abdominal wall and also try to lift all of the colon and see the liver from underneath and again repeat that this is a medial to lateral dissection and all the dissection is being taken place from the left of the patient and we are going from medial to lateral you can see the second part of the deode deode neum being dissected the gauze is lying on the head of the panterias and slowly with blunt and sharp dissection we are cutting the fascia above the deode neum pushing the deode neum down and taking the colon up now once the colon is taken up we go between the gerotas and the mesocolic fascia ensuring a complete mesocolic excision with a good CVL that is central venous ligation a terminology frequently used in the western literature whereas a D3 lymphoenectomy which is a terminology more frequently used in the Japanese literature I can see the blues ariola tissue between the gerotas and the mesocolon this is relatively a very easy dissection if you're in the right plane of course if you have gone into the wrong plane then it makes things very very messy and you can see the terminal branches within the within the misentry of this small intestine and we have reached almost up to the terminal ilium these are the vessels which can be clipped ligated so on and so forth there will be many such vessels because now we are not at the root of the misentry but we are going more towards the bubble the small bubble now you can see the hole of the gerotas fascia you can see the bulge of the renal fat overlying is the clean gerotas fascia and what where we are dissecting right now is actually the lateral abdominal ball which is being seen from underneath when we do the dissection of the toes from the above that is how we do in a general you know in an open hemicolectomy we just have to incise the toe line and you will see that the whole dissection was already performed from underneath okay now coming back to business now this is the precarious part this is the important part of the dissection the more challenging part of the dissection is making the whole of the of the head of the pancreas completely devoid of the fat the whole of the head of the pancreas is completely devoid of the fat so as to gain access to the root of the misentry now you can see the superior miscentric vein underneath at 12 o'clock position completely bare you can see the inferior pancreatic vein the loop of henley coming up to the right of the harmonic is the middle colic root of the middle colic vessel and this is the loop of henley where we are dissecting right now and what we observed in this patient was that this was also the gastrocolic trunk wherein there were two left branch of the middle colic taking off one was taking off from the gastrocolic trunk that is being defined right now so you can see the left branch going towards the colon and and the right going towards the gastrocolic gastroepiploic the right gastroepiploic taking off from the gastro colic trunk so here the gastrocolic trunk that is the junction of the gastroepiploic the right gastroepiploic and the middle colic in this case it was little aberrant in the way that the left colic was joining the gastroepiploid to form the gastrocolic trunk which would drain into the superior miscentric vein as you can see however there was another vessel that we had seen the middle colic trunk the main middle colic trunk that also we will be dissecting in a short while so the whole of the right hemicolectomy happens in a fashion that you tend to keep on mobilizing the colon now we have made a rent through and through from medial to lateral dissection and we can see the lateral abdominal wall and the liver underneath and that ensures that we have lifted up of all the mesocolic fascia and the mesocolon along with into the specimen without actually touching the tumor so this is a totally no touch technique wherein the tumor is not at all touched and that is why it is very important to first do a central venous ligation now you can see this is the middle colic going right into the and this is the middle colic artery so the middle colic vein going right into the superior miscentric vein the junction and you could also see the middle colic artery at the root of the whole idea is to bring all that fibro fatty tissue containing all the lymphatics and the lymph nodes up towards the bifurcation of the left and the right middle colic branches or there is a left branch taking off from the gastro colic trunk over here which will be cut it appears to be a more minor branch and what curves above is the right gastropyloic on now you can see the middle colic main branch dividing into the left and the right branches of the middle colic or here we have to spare the right branch of the middle colic so as to perform a good vascular anastomosis and at the same time bring all the lymphatic tissue and the lymph nodes up up to the level of the left middle colic branch so there were two left middle colic branches one from the gastro colic trunk and the other from the main middle colic trunk you can see the left middle colic being completely bad and you can see the whole of the middle colic vessel also completely bad of all the lymphatic and fibro fatty tissue ensuring that we have done an adequate lymphedinectomy specifically chosen this to be a unadherited video so as to one can get an idea of the retractions that the assistant surgeon has to perform also the retractions that the surgeon has to perform being very close to the gastro colic trunk again after cleaning the camera we go back in and we have done our retro colic dissection completely now we come back to the gastro colic momentum to reach the lesser sac however you will see that most of the dissection has already been performed from underneath and this is the total line that we're just going to in size which will ensure that the whole of the specimen was actually already dissected from underneath the colon from the medial to lateral approach i'm just asking my surgeon my assistant surgeon to lift the mesocolon and the stomach with his left hand so as to enter the lesser sac by cutting the gastro colic momentum becomes easier when we enter we know that we have divided the left branch of the middle colic the gastro the right colic and the ilio colic vessels and hence all the mobilization and all the dissection has already been performed and you can see all the dissection was already performed from the retro colic approach and the hepatic flexures the proximal transverse colon the ascending colon and the cecum are completely mobilized we are going in the plane between the gastro colic momentum again you can see the loose areola fibro fatty tissue ensuring that we are in the right plane the head of the pancreas is completely bare of all the fibro fatty tissue the deodenum the second part of the deodenum and the third part of deodenum can be seen from above and all this dissection is now made easy because all this dissection was already done from underneath we send the middle colic lymph nodal tissue separately actually aids in a good lymph nodal yield when you separate out the nodes and send it for for your pathological evaluation even better would be that you accompany the specimen along with you to the pathologist and sit with the pathologist to to explain the clips that you have put now this is the white clip that we had put from underneath and that's the clip that was already put so we have gone right up to the root of the mesentery and brought the clips into the specimen this is the lymph nodal dissection at the level of the loop of Henley and the gastro colic trunk so bearing all the all the artery and the veins had it been an extended hemicolectomy the things would have been much easier because you just need to ligate the the root of the mesentery making things much easier now here what we had to do is we had to separate out the left branch and the right branches of the middle colic and still bring all the lymph nodal tissue from the root of the mesentery to the to the point of division of the left branch of the middle colic which takes some effort so again I would suggest that for beginners a low anterior resection or abdominal perineal resection is much easier the video of the low anterior resection anatomy the APR has is already there on my channel on the other in the other video however a middle colic is a more challenging surgery I'm still evolving and trying to perform better every in every surgery because this is a more challenging surgery because you have to encounter a lot of arteries and veins a variable anatomy up to the root of the mesentery so we're just clipping the terminal branches of the ilio colic which are going into the ilium and we just divide it with an endovascular stapler sorry an endogia stapler and bring the specimen out and with a 5-centimeter incision the specimen is brought out and an extra corporeal nostromosis is performed so that was all about the video I hope you liked it you can subscribe to our channel and we can discuss any inputs anything that you can help me in improving thank you very much