Narushima Kazuo, Shuto Kiyohiko, Kosugi Chihiro, Mori Mikito, Hosokawa Isamu, Fujino Masafumi, Takahashi Masahiko, Yamazaki Masato, Shimizu Hiroaki, Miyazawa Yukimasa, Koda Keiji, Miyauchi Hideaki, Ohira Gaku, Hayano Kouichi, Matsubara Hisahiro
Dept. of Surgery, Teikyo University Chiba Medical Center.
Gan To Kagaku Ryoho. 2019 Dec;46(13):2291-2293.
Laparoscopic transverse colectomy is technically difficult. In mini-laparotomy surgery, colectomy for midtransverse colon cancer can easily be performed, but exact D2 lymph node dissection is very difficult for a variety of vessels in the transverse colon. Using 3D-CT imaging, we present a case of D2 lymph node dissection where mini-laparotomy transverse colectomy was performedby a small incision similar to that usedin laparoscopic surgery.
The patient was a 60-yearoldwoman with early transverse colon cancer, which was locatedin the mid-transverse colon. Surgical treatment was plannedfor pT1b(1.5mm)andpVM1 in pathological findings after EMR. Using CT colonography(CTC), the location of the primary tumor was identified. Using simulation CTC(sCTC), composedof CTC and 3D imaging of the arteries andveins, the dominant artery was identified and D2 lymph node dissection was simulated. In addition, body surface 3D imaging and permeable surface 3D imaging of the abdominal trunk were performed. Using body surface 3D-sCTC, composedof sCTC and body surface 3D imaging, the minimum incision to enable D2 lymph node dissection was simulated.
Using sCTC, it was identified that the dominant artery was the right branch of the middle colic artery(MCA Rt)andthe accompanying vein was branchedfrom the gastrocolic trunk(GCT). D2 lymph node dissection to separate the branching root of MCA Rt and the accompanying vein was simulated. Next, surgical incision was simulated using body surface 3D-sCTC. Because the branching roots of MCA Rt andGCT were locatedabout 5 cm cranial from the upper rim of the navel, a 7 cm upper abdominal midline incision was designed in addition to a 2 cm umbilical incision. Mini-laparotomy transverse colectomy with a 7 cm incision was performedin accordance with the simulation. The operation time was 2 hours and5 1 minutes, andbloodloss was due to occult bleeding. The patient was discharged 7 days after surgery without complications, and the final diagnosis was pT1bN0M0, StageⅠwith no recurrence for 4 years and2 months after surgery. The cranial incision from the upper rim of the navel has shrank about 3 cm, and the umbilical incision is not noticeable.
D2 lymph node dissection of minilaparotomy transverse colectomy can be a treatment option for early transverse colon cancer through using body surface 3DsCTC.
腹腔镜横结肠切除术技术难度较大。在小切口剖腹手术中，横结肠癌的结肠切除术相对容易实施，但由于横结肠存在多种血管，精确的D2淋巴结清扫术难度很大。我们通过3D-CT成像技术，展示了一例采用类似腹腔镜手术小切口进行小切口剖腹横结肠切除术并实施D2淋巴结清扫的病例。
患者为一名60岁女性，患有早期横结肠癌，肿瘤位于横结肠中部。在EMR术后病理检查发现为pT1b(1.5mm)和pVM1，计划进行手术治疗。通过CT结肠成像（CTC）确定原发肿瘤的位置。利用由CTC以及动脉和静脉的3D成像组成的模拟CT结肠成像（sCTC），确定优势动脉并模拟D2淋巴结清扫。此外，还进行了腹部躯干的体表3D成像和通透表面3D成像。利用由sCTC和体表3D成像组成的体表3D-sCTC，模拟能够进行D2淋巴结清扫的最小切口。
利用sCTC确定优势动脉为结肠中动脉右支（MCA Rt），伴行静脉从胃结肠干（GCT）分支。模拟了分离MCA Rt分支根部和伴行静脉的D2淋巴结清扫。接下来，利用体表3D-sCTC模拟手术切口。由于MCA Rt和GCT的分支根部位于肚脐上缘上方约5厘米处，除了2厘米的脐部切口外，还设计了一个7厘米的上腹部正中切口。按照模拟结果进行了7厘米切口的小切口剖腹横结肠切除术。手术时间为2小时51分钟，出血为隐匿性出血。患者术后7天出院，无并发症，最终诊断为pT1bN0M0，Ⅰ期，术后4年2个月无复发。肚脐上缘的头侧切口已缩小约3厘米，脐部切口不明显。
通过使用体表3D-sCTC，小切口剖腹横结肠切除术的D2淋巴结清扫可作为早期横结肠癌的一种治疗选择。
