Transverse Colon Cancer

Colon Surgery
CONTENTS
1. Anatomical Summary of the Transverse Colon
Definition
Transverse Colon Relations
Vascularization of the Transverse Colon
Lymphatic Drainage
Innervation
2. Definition of Transverse Colon Cancer

3. Surgical Technique

4. Oncologic Fundamentals of Transverse Colon

Surgery

5. Steps in Transverse Colon Oncologic Surgery

Extended Right Hemicolectomy (ERHs) Steps
Steps of the Extended Left Hemicolectomy (LHs)
Segmental Transverse Colectomy Steps
6. Surgical Considerations and Difficulties to
Remember

7. Laparoscopic vs. Conventional Open Surgery

8. Bibliography

Anatomical Summary of
the Transverse Colon
Definition
It is the longest part of the large intestine located
between the hepatic angle of the colon and the splenic
angle. It is attached to the posterior part of the abdomen
by the transverse mesocolon (contains the middle colic
artery and vein, lymph nodes and nerves).
This segment of the colon is very different from the
others, due to its vascularization and because it belongs
to the right and left colon at the same time1-2.
Transverse Colon Relations
Anteriorly it is related to the parietal peritoneum, greater
omentum and rectus abdominis muscles. Posteriorly it is
related to the small intestine and retroperitoneal organs
(pancreas, kidneys, superior mesenteric vessels). Above
it is related to the stomach and part of the liver; and
below to the small intestine(figure 1) 1.
Anatomical relationships between the
colon and retroperitoneal organs
Figure 1. Anatomical relationships.
Transverse Colon Cancer | 3
Vascularization of the Transverse
Colon
The right transverse colon is supplied by the middle
colic artery (branch of the superior mesenteric artery).
The irrigation of the left transverse colon depends on the
ascending branch of the left colic artery (branch of the
inferior mesenteric artery).
The main irrigation of the transverse colon is through the
middle colic artery, although the ascending branch of the
left colic artery also participates in the irrigation of the
distal portion of the transverse colon (figure 2).
Middle colic Riolan arc
artery
Superior Inferior
mesenteric mesenteric
artery artery
Left colic
a r t er y
Figure 2. Transverse colon arterial vascularization.
Venous drainage is performed accompanying the
respective arteries. It is composed of the right and
left networks. The right venous network drains into the
superior mesenteric vein or the right gastroepiploic
vein. The left network drains into the inferior mesenteric
vein2.
Drenaje Linfático
The lymph nodes of the colon are distributed as follows:
1. Epicolics: Applied to the colon wall.
2. Paracolics: Between the marginal vascular arcade
and the colon.
3. Intermediates: Located in the path of the collaterals
of the mesenteric vessels.
4. Main or central: Clustered at the origin of the
superior and inferior mesenteric trunks.

The lymphatic pathways of the transverse colon are
subdivided into two networks. The right network drains
the proximal two thirds and the left network drains the
distal third. In the right network, the lymphatic vessels
accompany the right and middle colic arteries to the
lymph nodes of the superior mesenteric artery, then
continue to the aortic nodes and finally reach the
intestinal lymphatic trunk.
Some of the lymphatic vessels belonging to the left
network accompany the middle colic artery, while most
follow the course of the left colic artery to the lymph
nodes of the inferior mesenteric artery and lumbar lymph
nodes2-3.
Innervation
It is carried out through the autonomic system. It depends
in its right half on the superior mesenteric plexus and in
its left half on the inferior mesenteric plexus2-3.
Definition of Transverse
Colon Cancer
Transverse colon cancer is defined as cancer located
between the hepatic and splenic angle of the colon. They
are rare neoplasms, approximately 10%-15% of colorectal
cancers. It often represents a challenge in choosing
the best surgical procedure based on the location of
the tumor and the extent of lymph node dissection. In
addition, laparoscopic resection makes it technically
demanding, so it was initially excluded from most trials
of laparoscopic colectomy4-5.
Prior to surgery, the exact location of the cancer must
be clear. For this purpose, during the preoperative
colonoscopy, tattooing with Chinese ink of the normal
intestinal wall about 5-10 centimeters before and after
the tumor should be performed. In case of failure of
the tattooing, an intraoperative colonoscopy can be
performed (using CO2 instead of air), although it is
important to aspirate all the gas completely to facilitate
the surgical maneuvers6-7.
Surgical Technique
The surgical options that can be used for transverse
colon cancer, depending on its location, are8-9-10:
• Segmental resections (figure 3):
Transverse Colon Cancer | 4
Segmental resections
Transverse colectomy High left colectomy
Figure 3. Segmental TCC Resections.
- Transverse colectomy:
It is performed in cancers affecting the measured
part of the transverse colon. It involves lymph
node dissection, including ligation of the middle
colic artery at its origin. Mobilization of the
splenic and hepatic flexure is required in almost
all cases, allowing tension-free anastomosis.
This technique has been abandoned in practice in
favor of an extended resection of the right or left
colon, which provides a more secure suture.
- High left colectomy:
It is made in cancer of the splenic angle of the
colon. From the lymphatic point of view, it is
located at the junction of the two mesenteric
circulations, superior and inferior. The left superior
colic artery is ligated at its origin and a transverse-
sigmoid anastomosis is performed. It requires
removal of the distal half of the transverse colon
and the descending colon, although subtotal
colectomy and ileosigmoid anastomosis has
gained popularity in this type of location.
• Extended or extended resections (figure 4).
- Extended right hemicolectomy (ERHs):
It is performed on a tumor located in the hepatic
angle or within 10 centimeters distal to it. It
involves lymph node dissection including ligation
of the ileocolic, right colic and middle colic
arteries at their origin.
- Extended left hemicolectomy (LHs):
It is performed on a tumor located in the splenic
angle or within 10 centimeters proximal to it. It
involves lymph node dissection including ligation
of the left colic artery and the middle colic artery
at its origin.

Segmental resections
Extended Extended Subtotal
right colectomy left colectomy colectomy
Figure 4. Extended or Extended TCC Resections.
It is not uncommon to need to mobilize the
right angle of the colon in order to perform the
anastomosis after the extended ICH has been
performed. Additional surgical techniques that
can be used include (figure 5):
Deloyers Maneuvers Transmesenteric
Figure 5. Deloyers maneuvers and transmesenteric .
» Transmesenteric descent of the colon consists
of introducing the proximal colon through an
avascular window in the terminal part of the
ileal mesentery11.
» The Deloyers procedure involves an
anastomosis between the proximal colon and
the rectum-sigmoid after mobilization of the
entire colon and rotation, while preserving the
ileocolic junction and the ileocolic artery (the
right colon tilts around the pedicle of the right
angle after detachment of Toldt’s fascia)12-13.
- Subtotal colectomy:
It is performed in transverse colon tumors
with associated synchronous pathology in the
proximal colon. It involves lymph node dissection
with ligation of the right colic, middle colic and left
colic vessels (resection of the right, transverse
and left colon with ileo-sigmoid anastomosis).
Transverse Colon Cancer | 5
Oncologic Fundamentals
of Transverse Colon
Surgery
The main elements of oncologic surgery of the transverse
colon (laparoscopic or open) are essentially as follows
(figure 6):
Radial margin
Lengthwise margin
Central margin
Figure 6. The anatomic-oncologic limits of colon surgery.
1. Achieving a central resection margin: By central
vascular ligation with complete mesocolic excision.
2. Achieving a longitudinal resection margin: By
means of intestinal section with adequate proximal
and distal margins.
3. Achieve a radial resection margin: Which in the
broadest sense may include en bloc excision
of advanced local spread, e.g., adjacent organs
(stomach, spleen, pancreas or abdominal wall).
Finally, mobilization and anastomosis are performed.
1. To achieve a central resection margin, central
vascular ligation must be performed following the
concept of complete mesocolic excision. For this,
a radical dissection (D3, Japanese classification)
of the lymph nodes of the colon with removal of
the paracolic lymph nodes (group 1), intermediate
lymph nodes (group 2) and central lymph nodes
(group 3) with central vascular ligation should be
performed14. This is one of the keys to the complete
mesocolic excision introduced by Hohenberger et al
in colon cancer. With this technique they obtained
a reduction in the 5-year local recurrence rate from
6.5% to 3.6%15. After this study, complete excision
of the mesocolon has been considered as an
important contribution to the standardization of
colon cancer surgeries16-17-18-19-20-21.

2. An oncologic resection of the colon should
have proximal and distal margins (longitudinal
resection margins) of at least 5 to 10 cm to obtain
a sufficient number of lymph nodes. Insofar as a
colonic resection does not involve considerable
functional sequelae, the margin is usually sufficient.
The intramural extension of cancers through the
submucosal lymphatic pathways does not usually
exceed 4 cm. In practice, it is the vascular supply
that dictates the extent of surgery. If the tumor
extends on both sides of two arterial branches,
both segments should be removed. Moreover, the
prognosis does not depend on the length of the
resected colon, but on the lymph node clearance
performed14-22-23.
Intestinal anastomosis can be performed
intracorporeally or extracorporeally, with the
following execution techniques (figures 7 - 8) 24-25-
26-27
: (ERHs) Steps
- Mechanics: It is performed with a latero-lateral
iso or antiperistaltic linear stapler. The stapler
insertion enterotomy is usually closed with a
continuous suture with 3/0 thread. Optionally,
the circular stapler can be used in ileo-colic
anastomosis or subtotal colectomies.
EXTRACORPOREAL ANASTOMOSIS
Manual anastomosis SSA Mechanical anastomosis: linear stapler SSA
Figure 7. Extracorporeal anastomosis.
INTRACORPOREAL ANASTOMOSIS
Manual Side-to-side Mechanical: linear stapler
Figure 8. Intracorporeal anastomosis.
Transverse Colon Cancer | 6
- Manual: As with mechanical suturing, it can be
performed latero-laterally (iso- or anti-peristaltic),
latero-terminally or termino-terminally. The
performance of a suture in one plane or in two
planes does not make any difference with regard
to the relevant clinical outcomes, but a greater
number of resources are used in the two-plane
anastomosis.
The use of mechanical suture is indicated in cases of
ileum-colon anastomosis. For colorectal anastomoses,
mechanical suturing is likely to offer adequate results
and its use is recommended.
Steps in Transverse
Colon Oncologic Surgery
Extended Right Hemicolectomy
The right mesocolon and retroperitoneum are divided
exposing the ventral aspect of the superior mesenteric
vein. The ileocolic vessels, right colic vessels and middle
colic vessels were identified 21-28-29-30-31-32.
The following steps are performed:
1. In the laparoscopic approach the positioning of
the patient and the trocars is as follows: patient
in modified lithotomy position. Four trocars
are inserted: two 5 mm and two 12 mm (one
corresponds to the optical trocar/Hasson for the 30
degree camera immediately above the umbilicus).
Circular stapler The surgeon can be positioned between the legs or
to the left. (figures 9 - 11).
In the Open surgery, surgical access is performed by
medial, periumbilical incision, widened as needed,
upwards or downwards depending on the operative
findings. An abdominal retractor (Balfour, Alexis,
Thompson or Omni type) is inserted.
TROCARS PLACEMENT
Circular stapler
ERHs LHs H TRANSVERSE
Figure 9. Position of the patient and surgeon.

ABDOMINAL CAVITY APPROACH
Hasson Technique
Veress needle Optical Trocar
(direct vision)
Figure 10. Position of the trocars.
Surgeon position
ERHs LHs H TRANSVERSE
Figure 11. Abdominal cavity approach techniques.
2. Isolation of the right vascular pedicle (ileocolic
and middle colic) with excision of the complete
mesocolon and central vascular ligation of the
vascular pedicles. It can be performed by different
methods (endograpator with vascular load, clips or
sealing with bipolar or harmonic scalpel).
3. Release of the right colon from medial to lateral
retromesenteric keeping the dissection plane in
front of Toldt’s fascia.
4. Inferior mobilization of the ileum and lateral
mobilization of the right colon.
5. Externalization, resection and extracorporeal
anastomosis or resection and intracorporeal
anastomosis with subsequent removal of the
specimen through an assist incision, mid-
superumbilical area (figure 12).
Incision, assistance and extraction of the surgical specimen.
Figure 12. Incision, assistance and extraction of the surgical specimen.
Transverse Colon Cancer | 7
Some surgical problems that can occur during ERHs are:
• Injury to the superior mesenteric vessels.
• Lesion of the right gastro-epiploic vein or venous
trunk of Henle.
• Lesion of the upper and descending portion of the
duodenum.
• Gerota fat penetration (during medial to lateral
mobilization).
• Torsion of the ileum during anastomosis.
Steps of the Extended Left
Hemicolectomy (LHs)
In an extended left hemicolectomy, the entire left colon
is resected, from the transverse third to the rectosigmoid
junction.
The high left hemicolectomy or left segmental colectomy
requires removal of the distal half of the transverse
colon and the descending colon. The left superior colic
artery and the middle colic artery are ligated.
The following steps are performed in the LHs10-21-28-31-
33
:
1. In the laparoscopic approach the positioning of the
patient and the trocars is as follows: the patient is
placed in the forced Trendelemburg position and
in right lateral decubitus with the legs open and
positioned in such a way that the thighs are in line
with the abdomen. Two or three 5 mm and two 12
mm trocars are placed (one corresponds to the
optical/Hasson trocar for the 30-degree camera
which is placed supraumbilically). To work in the
lower left quadrant, the surgeon and the assistant
carrying the camera are positioned to the right of
the patient and the first assistant to the left. To
mobilize the splenic angle, the surgeon is positioned
between the patient’s legs. (figures 9 - 11).
In open surgery, surgical access is by midline
incision from a point midway between the xiphoid
appendix and the umbilicus to the level of the
pubis. The abdomen is explored and an abdominal
retractor is inserted.
2. Isolation and division of the left colic and middle
colic vessels with their central vascular ligation and
complete mesocolic excision.
3. Dissection from medial to lateral in front of Toldt’s
fascia, gonadal vessels and ureter up to the left
parietocolic. Lateral mobilization of the left colon
and descent of the splenic angle.
4. Distal section, exteriorization, proximal division
of the colon and extracorporeal anastomosis or
resection and intracorporeal anastomosis with
subsequent removal of the specimen by assist
incision, usually suprapubic area. (figure 12).

Some surgical problems of LHs are:
• Difficulty in identifying the inferior mesenteric artery
and left colic artery.
• Injury to the hypogastric nerve plexuses.
• Injury to the left ureter.
• Splenic capsule tear.
Segmental Transverse Colectomy
Steps
It involves ligation of the middle colic artery (MCA) at its
origin and the right and left colic angles must be mobilized
to allow tension-free anastomosis. The transverse
colon and its mesocolon are elevated and stretched for
identification of the middle colic vessels10-21-28-31-32.
The steps of transverse colectomy are as follows:
1. In the laparoscopic approach the positioning of
the patient and the trocars is as follows: patient
in supine decubitus and antitrendelemburg. The
surgeon is positioned between the patient’s legs
(later the surgeon is usually changed to the patient’s
left). The trocars are arranged as shown in the figure
below. (figures 9-12).
In open surgery the access route is usually a
supraumbilical midline incision that if necessary is
extended to become infraumbilical; also, a bilateral
subcostal incision can be performed. The surgeon
is positioned to the right of the patient.
2. Identification of the lesion and the middle colic
vessels with central vascular ligation of the same.
For dissection of the middle colic artery it must be
sectioned at its point of separation from the MCA
at the level of the base of the pancreas. To achieve
this, the peritoneum overlying the MCA is opened
from right to left and a dissection plane is created
to the left of the MCA. Access behind the middle
colic vessels is best achieved by proceeding from
left to right with the surgeon working to the left of
the patient. After ligation of the MCL, an area of
transverse colon is chosen as the distal transection
line and the transverse mesocolon is divided in the
direction of the bowel wall.
In obese patients, to identify the origin of the middle
colic artery, the “medial approach” described by
Fujita et al. can be performed, with ventral exposure
of the superior mesenteric vein and a cephalic
dissection towards the caudal portion of the
pancreas34. Ichichara describes the approach to the
MCA by rotation of the transverse mesocolon about
90 degrees, its identification and central ligation35.
3. Resection and anastomosis manual/mechanical
(intra/extracorporeal)
4. Externalization of the specimen by assistance,
supraumbilical or suprapubic incision. (figure 12).
Transverse Colon Cancer | 8
Surgical Considerations
and Difficulties to
Remember
• Lymphatic drainage from the proximal transverse
colon, including the hepatic angle of the colon,
is usually directed into the right or middle colic
system; it is rarely directed into the ileocolic
system. The central portion of the transverse colon
drains through the middle colic system. Lymphatic
drainage of the distal transverse colon, including
the splenic flexure, is via the right and left colic
systems.
• Laparoscopic surgery for transverse colon cancer
is very important lymph node dissection around
the origin of the middle colic artery, according to
the concept of complete mesocolic excision with
central vascular ligation.
• A minimum number of 12 nodes examined has been
defined as a quality parameter after colic resection
for cancer; however, many studies have shown that
the more nodes examined, the more lymph node
metastases are diagnosed, finding an association
between number of nodes examined and survival in
stage II cancer.
• Mobilization of the hepatic angle of the colon can
be performed by incising the right upper lateral
peritoneal reflection (as with mobilization of the
ascending colon) or by placing the colon in a medial
position.
• The gastrocolic venous trunk or trunk of Henle is
an important vascular structure located at the
duodenopancreatic junction that all surgeons
performing colon cancer surgery should be aware
of. It is formed by the joint confluence of the right
gastroepiploic vein and the right colic vein, to which
the anterior superior pancreaticoduodenal vein joins
in a more or less constant manner. Traction during
mobilization of the hepatic flexure and ligation of the
right colic vessels can accidentally tear or disinsert
either an anterior superior pancreaticoduodenal
vein or the right gastroepiploic vein. In such cases
the bleeding from the field is very troublesome and
sometimes burdensome for the surgeon.
• The retroperitoneal anatomical entities to which
the hepatic angle is related are the right kidney
and ureter, as well as the descending portion of the
duodenum and the gonadal vessels.
• The separation of the posterior gastric wall from
the transverse mesocolon must be performed
with extreme care.

• Careful separation of the transverse mesocolon
from the neck of the pancreas is of fundamental
importance. The entrance of the MCA at the
antimesenteric border of the transverse colon is
very close to the pancreatic neck. The presence of
adhesions in this region constitutes an additional
risk.
• The left mesocolon is less vascularized than the
right. The arcus of Riolano may be present in the
most cranial portion of the mesocolon. It is an
artery that connects the inferior mesenteric arteries
(via the left colic artery) to the superior mesenteric
artery (via the middle colic artery).
• The posterior area of the splenic flexure of the colon
is usually not lined with peritoneum and is attached
to the posterior abdominal wall. Occasionally,
it is completely lined with peritoneum and its
mesocolon is attached to the distal body and tail of
the pancreas.
• The splenocolic ligament (a remnant of the left end
of the transverse mesocolon) forms a peritoneal
bridge between the splenic angle and the lower
spleen. The left gastroepiploic artery and some
aberrant inferior vessels may be in its proximity.
Excessive traction on the splenic pole may result in
a tear of the splenic pole with copious hemorrhage.
The ligament must be cut after isolation by clips or
ligatures.
• The phrenocolic ligament, which is located between
the splenic flexure of the colon and the diaphragm
at the level of the tenth rib in the mid-axillary line,
forms a fold in which the spleen rests. This ligament
must be divided to mobilize the splenic flexure.
• To avoid ureteral injury it is necessary to stick to
the anatomical plane of coalescence between
the mesocolon and the retroperitoneum, always
dissecting above. If injury occurs, the most
important thing is to be aware of it and to assess its
type and extent.
Laparoscopic vs.
Conventional Open
Surgery
Since the first report of laparoscopic colon resection,36
several prospective controlled trials have demonstrated
that laparoscopic surgery for colon cancer has similar
short-term benefits and long-term oncologic outcomes
compared to open surgery.37-38-39-40-41.
However, transverse colon cancer was excluded from the
above trials for several reasons.10-30-31-32-42-43-44-45:
Transverse Colon Cancer | 9
• Because of anatomical and localization difficulties.
The type of surgical procedure and the extent
of lymph node dissection vary according to the
location of the cancer.
• Because of technical difficulties. Laparoscopic
surgery for transverse colon cancer requires
excellent surgical skills due to the technical difficulty
of lymph node dissection around the middle colic
vessels. Mobilization of the transverse colon
involves dissection around critical organs such as
the duodenum, pancreas, spleen and base of the
mesenteric vessels with the venous complexity of
the gastrocolic trunk of Henle, which can lead to
serious complications if dissection occurs along
the wrong plane.
• Because of learning difficulties due to low incidence
and the need for consecutive cases to overcome
the learning curve.
The clinical outcomes of laparoscopic surgery and
conventional open surgery for transverse colon cancer are
similar. However, in terms of blood loss, return of bowel
function and oral intake, laparoscopic surgery is better
than conventional open surgery. In addition, the long-
term stability of laparoscopic colon oncologic surgery
has been accepted as an alternative to conventional
open surgery. 28-31-33-44-45-46-47-50.
Se necesitan grandes estudios controlados prospectivos
y aleatorizados a largo plazo para confirmar la seguridad
y eficacia oncológica de la resección laparoscópica del
cáncer de colon transverso y permitirse incluirlo como
un procedimiento laparoscópico de rutina.
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