Comparison of outcomes of laparoscopic-assisted and total laparoscopic right hemicolectomy for right-sided colon cancer

Abstract

BACKGROUND

Colon cancer is a significant health issue in China, with high incidence and mortality rates. Surgical resection remains the primary treatment, with the introduction of complete mesocolic excision in 2009 improving precision and outcomes. Laparoscopic techniques, including laparoscopic-assisted right hemicolectomy (LARH) and total laparoscopic right hemicolectomy (TLRH), have further advanced colon cancer treatment by reducing trauma, blood loss, and recovery time. While TLRH offers additional benefits such as faster recovery and fewer complications, its adoption has been limited by longer operative times and technical challenges.

AIM

To compare the short-term outcomes of TLRH and LARH for the treatment of right -sided colon cancer and explore the advantages and feasibility of TLRH.

METHODS

Clinical data from 109 right-sided colon cancer patients admitted between January 2019 and May 2021 were retrospectively analyzed. Patients were divided into an observation group (TLRH, n = 50) and a control group (LARH, n = 59). Study variables were operation time, intraoperative bleeding volume, postoperative hospital stays, length of surgical specimen, number of lymph nodes dissected, and postoperative inflammatory factor levels of the two groups of patients. The postoperative complications were analyzed and compared, and survival, recurrence, and remote metastasis rates of the two groups were compared during a 2-year follow-up period.

RESULTS

The TLRH group showed the advantages of reduced intraoperative bleeding, shorter hospital stays, and quicker recovery. Lymph node dissection outcomes were comparable, and postoperative inflammatory markers were lower in the TLRH group. Complication rates were similar. Short-term follow-up (2 years) revealed no significant differences in recurrence, metastasis, or survival rates.

CONCLUSION

Compared to LARH, TLRH offers significant advantages in terms of reducing surgical trauma, lowering postoperative inflammatory factor levels, and mitigating the impact on intestinal function. This approach contributes to a shorter hospital stay and promotes postoperative recovery in patients. The study suggests that TLRH may offer favorable outcomes for colorectal cancer patients.

Key Words: Laparoscopic complete mesocolic excision; Total laparoscopic right hemicolectomy; Laparoscopic-assisted right hemicolectomy; Right-sided colon cancer; Short-term outcomes

Core Tip: This retrospective study compared the outcomes of total laparoscopic right hemicolectomy (TLRH) and laparoscopic-assisted right hemicolectomy in right-sided colon cancer patients. TLRH demonstrated the advantages of reduced intraoperative bleeding, shorter hospital stays, and lower postoperative inflammation, while maintaining similar outcomes in lymph node dissection and complication rate. Additionally, no significant differences were observed in survival, recurrence, or metastasis rates over a 2-year follow-up period. The findings suggest that TLRH is a feasible approach that minimizes surgical trauma and enhances postoperative recovery.

INTRODUCTION

Colon cancer poses a significant health concern in China, ranking as the third most commonly diagnosed cancer, with an estimated incidence rate of 29.5 per 100000 individuals and a mortality rate placing it fifth in the country. Surgical resection remains the primary treatment for colon cancer patients. Traditionally, laparotomy was the standard approach. The introduction of the concept of complete mesocolic excision (CME) in 2009 significantly improved surgical precision[1]. By meticulously minimizing tumor spread and maximizing lymph node clearance, CME aims to enhance patient outcomes, potentially leading to decreased local recurrence rates and improved overall survival[2-4].

The evolution of surgical techniques has introduced laparoscopic approaches, including laparoscopic-assisted right hemicolectomy (LARH) and total laparoscopic right hemicolectomy (TLRH), marking substantial advancements in the field. These approaches offer notable benefits, such as minimized trauma, reduced bleeding, and faster recovery, compared to traditional methods. The safety and efficacy of laparoscopic-assisted colon resections were established through multiple randomized trials in the early 2000s, demonstrating advantages such as decreased morbidity, shorter hospital stays, reduced analgesia requirements, and quicker return of bowel function[5-7].

Advancements in patient outcomes continued with the introduction of TLRH, showcasing benefits such as decreased conversion rates, faster return of bowel function, shorter hospital stays, and reduced incisional hernia rates. Despite these advantages, the adoption of TLRH has been slow due to increased operative time and required technical skills[8]. This retrospective analysis assessed patients undergoing either TLRH or LARH. The study aimed to investigate various aspects, including lymph node harvest, surgical duration, intraoperative blood loss, postoperative hospital stay, time to the first flatus and defecation, as well as the incidence of complications. Additionally, the research endeavored to compare the short-term outcomes between LARH and TLRH in individuals diagnosed with colon cancer.

MATERIALS AND METHODS

Study design

This retrospective study was conducted to compare the short-term outcomes of LARH and TLRH. Ethical approval for the study was obtained from the Liaocheng People’s Hospital Ethics Committee (approval No. 2022173), and all methods were performed in accordance with the relevant guidelines and regulations. Due to retrospective study design, informed consent was waived by Liaocheng People’s Hospital Ethics Committee.

Inclusion criteria

The inclusion criteria of the present study were as follows: (1) Patients who were diagnosed with right-sided colon cancer via preoperative imaging, colonoscopy biopsy, and postoperative routine histopathology, without distant metastasis; and (2) Patients with complete clinical data and normal functioning of key organs.

Exclusion criteria

Patients were excluded from the present study according to the following criteria: (1) A history of emergency surgeries due to tumors complicated with perforation, bleeding, and obstruction; (2) Distant metastasis observed before the surgery; and (3) A history of previous abdominal surgery or emergency surgery, and patients who underwent preoperative chemoradiotherapy. The study enrolled a total of 109 patients between 2019 and 2021. Among these, 50 patients underwent TLRH, constituting the observation group (TLRH), while 59 patients underwent LARH, forming the control group (LARH).

Laparoscopic CME surgical methods

Both surgical methods were completed in accordance with the total mesorectal excision and tumor-free principle. In both groups, all vascular ligations, lymph node dissections, and bowel mobilizations were performed laparoscopically within the abdominal cavity. In the TLRH group, after bowel mobilization and lymph node dissection, the bowel resection and digestive tract reconstruction were completed intracorporeally. In the LARH group, however, bowel resection and digestive tract reconstruction were performed extracorporeally. The specific steps are as follows:

Based on the principles of CME, a central approach was selected. The posterior peritoneum was opened along the surface of the superior mesenteric vein to enter the Toldt’s space. The ileocolic vessels, right colic vessels (if present), right branches of the middle colic vessels, and accessory right colic veins were exposed, ligated, and divided. Corresponding lymphatic tissues at the vascular roots were cleared. Dissection proceeded laterally along the Toldt’s fascia to the right paracolic gutter, while carefully protecting the right gonadal vessels, ureter, and head of the pancreas/duodenum. The terminal ileal mesentery, ascending colonic mesentery, and right transverse mesocolon were fully mobilized. The lateral peritoneum was opened from the ileocecal region along the right paracolic gutter to the hepatic flexure of the colon. The colon was separated from the retroperitoneum in a lateral-to-medial direction until it met the medial dissection plane. At the mid-transverse colon, the gastrocolic ligament was opened. The ligament was divided lateral to the gastroepiploic vessels. Adhesions between the gallbladder and colon were separated, and the hepatocolic ligament was divided. The transverse colon and ascending colon mesentery were freed from the head to the tail until they joined the medial dissection plane. In the TLRH group, the surgery continued intracorporeally. The ileum was divided 15 cm from the ileocecal junction using a Echelon^® 60 mm linear stapler with a blue staple cartridge (Ethicon Endo-Surgery, United States). The colon was divided at the mid-right transverse colon using the same stapling device. The terminal ileum, cecum, ascending colon, right transverse colon, and part of the greater omentum were completely resected and placed in a specimen bag. The bowel ends were aligned, and the ileum was sutured and fixed to the distal colon approximately 7 cm from the proximal transected end. The blood supply to both ends was checked, and the tension at the anastomosis site was evaluated. Small incisions (1 cm each) were made on the opposite mesenteric side of the proximal and distal ends of the bowel. The intestinal lumen was disinfected with iodine-soaked gauze. The side-to-side ileocolic anastomosis was performed using a linear stapler. After ensuring no bleeding, the common opening was sutured with 2-0 unidirectional barbed suture to complete the anastomosis. The specimen was removed through the upper midline incision. In the LARH group, a midline longitudinal incision was made in the upper abdomen, and the incision was protected with a protective sheath. The tumor and the connected intestinal segment were brought outside the abdominal wall. The ileum was divided and closed 15 cm from the ileocecal junction, and the colon was divided and closed at the mid-right transverse colon. After removing the right hemicolon, an end-to-side anastomosis was performed between the remaining ileum and colon.

Data collection and observation indicators

Various parameters were meticulously collected and compared between the two groups. Duration of surgery, resected specimens, the number of lymph nodes dissected, postoperative inflammatory tumor necrosis factor-α (TNF-α) and C-reactive protein (CRP) levels, and complication rates were recorded in both the observation group and control group. Statistical analyses of recurrence rate and mortality rate during a 2-year follow-up period were conducted, and data were compared between the two groups.

Inflammatory factor evaluation

In our pursuit of understanding the nuanced differences between LARH and TLRH, we conducted an in-depth analysis of inflammatory factors. We measured the levels of TNF-α and CRP. These measurements were taken prior to surgery and at postoperative intervals of 1 days and 3 days.

Statistical analysis

Statistical analyses were performed using SPSS 23.0. Continuous variables are expressed as the mean ± SD and were compared using the t test. Categorical variables are presented as [n (%)] and were compared using the χ² test or rank-sum test. P values < 0.05 were considered indicative of statistically significant differences. The missing data were addressed through appropriate statistical methods or imputation techniques.

RESULTS

A total of 109 cases were included in this study. After thorough statistical analysis, the study revealed no significant differences in age, sex, body mass index, tumor stage, or accompanying diseases between the two groups. The observation group included 23 males and 27 females, with a mean age of (55.37 ± 9.65) years. The tumor-node-metastasis stage distribution was as follows: 5 cases at stage I, 14 at stage II, and 31 cases at stage III. The control group had 29 males and 30 females, with a mean age of (52.37 ± 8.35) years. Tumor-node-metastasis stage distribution in this group was 7 cases at stage I, 22 cases at stage II, and 30 cases at stage III (Table 1).

Table 1 General clinical data and surgery-related indexes of the two groups (n = 109), mean ± SD.

Basic information		Observation group (n = 50)	Control group (n = 59)	P value
Sex	Male	23	29	0.743
	Female	27	30
Age (years)	< 60 years	30	35	0.943
	≥ 60 years	20	24
TNM stage	I	5	7	0.744
	II	14	22
	III	31	30
Accompanying diseases	High blood pressure	13	18	0.603
	Diabetes	6	8	0.808
	Coronary heart disease	5	5	0.783
BMI (kg/m2)		24.69 ± 5.71	25.66 ± 6.06	0.393
Operation time (minutes)		171.1 ± 11.0	161.4 ± 9.1	0.000
Intraoperative blood volume (mL)		154.6 ± 21.9	179.8 ± 23.5	0.000
Postoperative hospital stays (days)		6.43 ± 0.63	7.59 ± 2.19	0.000
Postoperative drainage time (days)		5.18 ± 0.40	5.31 ± 0.78	0.296
Time to anal exhaust (days)		2.49 ± 0.33	2.68 ± 0.31	0.004
Length of resected specimens (cm)		37.8 ± 1.5	38.3 ± 1.6	0.083
Average number of lymph nodes dissected		25.8 ± 2.4	25.9 ± 1.6	0.691

TNM: Tumor-node-metastasis; BMI: Body mass index.

Comparison of relevant indexes between the two groups

The duration of surgery in the observation group (TLRH) was longer than that of the control group (LARH), the intraoperative bleeding in the observation group was lower than that of the control group, and hospital stays, postoperative drainage time, and anal exhaust time were shorter in the observation group. Specific comparison values are displayed in Table 1.

Comparison of inflammatory factor levels between the two groups

Before surgery, there were no statistically significant differences in the levels of TNF-α or CRP between the two groups, indicating comparability at baseline. However, on both the first and third days following surgery, a noticeable shift was observed. In the observation group, the levels of TNF-α and CRP consistently remained lower than those in the control group, and this difference reached statistical significance (Table 2). This temporal pattern suggests a distinct postoperative immunological response in the observation group, reinforcing the potential impact of the surgical intervention on inflammatory markers.

Table 2 Comparison of inflammatory factor levels between the two groups, mean ± SD.

Group	TNF-α (ng/mL)			CRP (ng/mL)
	Preoperative	1 day after operation	3 days after operation	Preoperative	1 day after operation	3 days after operation
Observation group	8.04 ± 0.71	57.47 ± 2.19	12.14 ± 0.24	17.23 ± 1.36	160.40 ± 9.64	81.43 ± 4.26
Control group	10.25 ± 1.15	58.60 ± 1.91	30.21 ± 1.42	16.98 ± 4.36	165.18 ± 11.2	108.54 ± 3.24
P value	0.739	0.025	0.000	0.172	0.013	0.000

TNF-α: Tumor necrosis factor-α; CRP: C-reactive protein.

Comparison of complications between the two groups

The comparison of complications between the two groups revealed that there was no statistically significant difference in the rate of incision infection, lung infection, intestinal obstruction, or anastomotic leakage. The observation group demonstrated a lower incision infection rate compared to the control group, which may be attributed to the smaller incision size (Table 3).

Table 3 Complications of patients with right-sided colon cancer in the two groups, n (%).

Group	Intestinal obstruction	Anastomotic leakage	Incision infection	Lung infection	Total
Observation group (n = 50)	2 (4.0)	2 (4.0)	2 (4.0)	6(12)	12 (24.0)
Control group (n = 59)	3 (5.0)	1 (1.7)	7 (11.9)	8(13.6)	19 (32.2)
P value	1.000	0.884	0.255	0.808	0.344

Comparison of incidence, recurrence, and mortality rates between the two groups

There were no statistically significant differences in the recurrence rate or distant metastasis rate between the observation group and the control group during the 2-year follow-up period (Table 4). Additionally, the survival rate of patients in the observation group showed no significant difference compared to that of the control group (Figure 1).

Figure 1 Overall survival rates in the observation group and control group. P value: Kaplan-Meier/Log-Rank test.

Table 4 Comparison of distant metastasis rate, recurrence rate, and mortality between the two groups, n (%).

Group	Distant metastasis incidence rate at 2 years	Recurrence rate at 2 years	Mortality at 2 years
Observation group	7 (14.0)	8 (16.0)	6 (12.0)
Control group	9 (15.3)	11 (18.6)	10 (16.9)
P value	0.854	0.717	0.467

DISCUSSION

The incidence of colon cancer, especially right-sided cases, has been steadily rising in recent years[9]. Surgical resection remains a critical component of treatment, with laparoscopic right hemicolectomy emerging as a preferred minimally invasive option over traditional laparotomy. This technique not only reduces trauma and stress responses but also facilitates faster postoperative recovery. Furthermore, it maintains the structural integrity of the mesocolon and anterior renal fascia, which improves procedural safety and allows for more accurate lymph node dissection aided by enhanced anatomical visualization. Laparoscopic CME has emerged as a low-trauma, minimally invasive alternative for managing right-sided colon cancer[10,11]. Numerous studies, including those by Sheng et al[12] and Huang et al[13], have validated the safety and efficacy of laparoscopic CME. This approach achieves outcomes comparable to open surgery in terms of radical resection and short-term survival. Notable benefits include faster recovery, reduced intraoperative bleeding, shorter hospital stays, and more extensive lymph node dissection[14-16]. Further research has consistently confirmed the feasibility and clinical advantages of laparoscopic CME[17,18]. Evidence from prior studies suggests that CME significantly enhances the prognosis of colon cancer patients. For instance, patients undergoing CME achieved a 4-year disease-free survival rate of 85.8%, compared to 75.9% in the traditional surgery group (P = 0.001)[19]. Similarly, Jeong et al[20] reported an improvement in the 5-year survival rate, rising from 78.1% (1984-2006) to 89.1% (2002-2016) following CME. These findings underscore the oncological benefits of CME, particularly in improving disease-free and overall survival outcomes.

A study highlights notable improvements in intraoperative blood loss, postoperative hospital stay duration, time to anal exhaust, and the number of lymph nodes dissected in laparoscopic CME for right-sided colon cancer[21]. The visual magnification provided by the laparoscope ensures a clear surgical pathway, a broader field of view, enhanced anatomical identification, reduced blood loss, and prevention of organ injury, all of which contribute to a smoother recovery[22]. Additionally, this approach significantly reduces stress responses and inflammation, as demonstrated by lower levels of inflammatory markers.

The approach to intracorporeal anastomosis in laparoscopic right hemicolectomy has undergone significant evolution. Historically, LARH with extracorporeal anastomosis was widely practiced. However, concerns over increased risk and technical challenges drove the exploration of totally laparoscopic techniques. In laparoscopic-assisted procedures, tissue dissection was performed laparoscopically, but anastomosis was completed extracorporeally. This technique, first introduced by Estour in 1993, was later standardized by Senagore and Nelson in 2004, with additional refinements by Estour in 2011[23]. Recent studies have highlighted challenges with extracorporeal anastomosis, such as requiring greater transverse colon mobilization, which can increase the risk of postoperative bleeding. By contrast, TLRH, introduced by Azagra in 1994 and standardized by Ghavami in 2008, performs both tissue dissection and anastomosis intracorporeally. While critics argue that this approach’s increased technical complexity may lead to higher complication rates and longer operative times, advancements in stapling and suturing technology have greatly streamlined intracorporeal procedures, reducing these risks and improving surgical efficiency.

The comparable surgical specimen length and number of dissected lymph nodes between the TLRH and LARH groups underscore the surgical proficiency in achieving oncological objectives. The longer total operation time and anastomosis time in the TLRH group, mitigated by fewer instances of intraoperative bleeding, shorter postoperative hospital stays, and reduced postoperative anal exhaust time, necessitate a nuanced interpretation. The extended operative times may reflect the complexity of TLRH, potentially requiring meticulous surgical techniques. However, the reduced bleeding in TLRH aligns with studies associating minimized blood loss with improved recovery. The shorter postoperative parameters in the TLRH group suggest potential benefits in terms of patient comfort and healthcare resource utilization. Compared to TLRH, LARH often requires more extensive bowel mobilization to extract the intestine through the small incision. In patients with large tumors or significant intra-abdominal fat, this may necessitate enlarging the skin incision, potentially causing excessive traction on the bowel and increasing the risk of colon or mesentery damage. In contrast, intracorporeal anastomosis can mitigate these challenges by minimizing incision size and enhancing the overall minimally invasive nature of the procedure. The corresponding decrease in postoperative levels of TNF-α and CRP in the TLRH group implies a mitigated inflammatory cascade, potentially influencing early recovery and reducing the risk of inflammatory-related complications. While the overall complication rate is comparable, the trend towards a lower incision infection rate in the TLRH group, albeit not statistically significant, underscores the potential benefits of smaller incisions. Minimizing incision-related complications is critical to improving the safety and recovery of patients undergoing minimally invasive procedures. The 2-year follow-up data revealed no significant differences in survival, recurrence, or distant metastasis rate between TLRH and LARH, confirming their oncological equivalence. These findings are consistent with the existing literature, which supports the safety and efficacy of both approaches in delivering comparable oncological outcomes. Clinicians can be reassured that short-term differences in outcomes, such as reduced bleeding and faster recovery with TLRH, do not compromise the long-term integrity of either surgical method. These findings hold practical implications for clinical decision-making. Surgeons may consider the nuanced advantages of TLRH, such as reduced bleeding and shorter hospital stays, particularly in patients where minimizing these factors is crucial. The lack of significant differences in short-term oncological outcomes ensures that both TLRH and LARH remain viable options, allowing for individualized treatment plans tailored to patient-specific considerations.

CONCLUSION

In conclusion, TLRH demonstrates significant benefits, including reduced surgical trauma, lower postoperative inflammatory factor levels, and less impact on intestinal function compared to LARH. This approach results in a shorter hospital stay and facilitates postoperative recovery. In summary, our study highlights the advantages of TLRH over LARH, showcasing comparable postoperative complication rates. Both procedures exhibit similar short-term outcomes in terms of survival, recurrence, and distant metastasis rates. Considering these findings, TLRH emerges as a preferable option for patients undergoing right-sided colon cancer surgery. These insights contribute to informed clinical decision-making and potential refinements in treatment protocols for individuals with right-sided colon cancer. Our results suggest that TLRH is a safe and feasible approach for treating right-sided colon cancer, emphasizing the need for further research to comprehensively validate these findings.