Nationwide variations in the execution of minimally invasive right hemicolectomy and short-term outcomes: first phase of the RIGHT study

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Although minimally invasive right hemicolectomy (MIRH) has become the standard of care to treat patients with right-sided colon cancer, substantial variation in the execution and implementation of proven beneficial elements that impact clinical outcomes exists. Within the Dutch national RIGHT project, a Delphi consensus was conducted that established an evidence-based, standardized technique for MIRH, including: low intra-abdominal pressure (IAP), complete mesocolic excision (CME) with central dissection along the superior mesenteric vein (SMV) and central vascular ligation (CVL) of segmental vessels, an intracorporeal anastomosis, and specimen extraction through a Pfannenstiel incision (see File S1 and File S2)1,2. The aim of the RIGHT project is to implement this standardized technique for MIRH nationwide in order to improve clinical outcomes. Within the first phase of the RIGHT study, the aim was to evaluate the nationwide variation of the elements of MIRH for right-sided colon cancer. The RIGHT study is a multicentre national prospective cohort study, that started in October 2021 in the Netherlands, with 43 participating hospitals (43 of 71 = 60.6% of Dutch hospitals). Patients undergoing planned MIRH (both conventional laparoscopic and robot-assisted) for right-sided non-locally advanced stage 1–3 colon cancer were included. During the first phase (October 2021—August 2022), participating surgeons were instructed to perform the MIRH according to their routine practice. An essential aspect of this study is that surgeons were required to make a video recording of the entire procedure and to take a picture of both the front and back of the specimen. The quality of mesocolic excision was scored according to Benz, ranging from 0 to 3, where a lower score indicates a more extensive mesocolic excision, with Benz 0 corresponding to CME3. A total of 414 patients were included in phase 1. See Fig. S1 for the inclusion flowchart and Table S1 for the baseline patient characteristics. Table 1 provides an overview of all procedural variations within MIRH among the participating Dutch surgeons. The median IAP applied during surgery was 12 mmHg, ranging from 7 to 15 mmHg. Anastomoses were most often performed intracorporeally (80.9%), mostly in an isoperistaltic configuration (80.7%), and almost exclusively constructed using a stapler (96.3%). In 77.3% of cases, the specimen was extracted through a Pfannenstiel incision. The distribution of the Benz classification was as follows: 23% of cases were Benz 0, 30% of cases were Benz 1, 37% of cases were Benz 2, and 10% of cases were Benz 3. Fig. S2 provides some examples of the different Benz categories. Table S2 summarizes 90-day postoperative complications, which occurred in 25.9% of cases. Anastomotic leakage was noted in 2.7% of cases and the 90-day mortality rate was 0.7%. The median duration of hospital stay was 3 days and the readmission rate was 10.5%. Overview of variations within minimally invasive right hemicolectomy Values are n (%) unless otherwise indicated. *Benz classification: Benz 0 (true complete mesocolic excision specimen), the stalks of the ileocolic vessels and middle colic vessels are connected by tissue of the surgical trunk (lymphatic tissue package covering the superior mesenteric vein) and the mesocolic window has a complete medial frame of mesocolic tissue; Benz 1, the stalks of the ileocolic and middle colic vessels are present, but are not connected by tissue, and the frame of the mesocolic window is not complete with regard to its medial aspect; Benz 2, the stalks of the ileocolic vessels are present, with more than 50% of the anticipated length according to the geometric configuration of the specimen, but the middle colic vessels are not detectable, and the frame of the window has medial and cranial defects; and Benz 3, the ileocoloic vessels have an amputated appearance (less than 50% of the anticipated length according to the geometric configuration of the specimen) and the window is not detectable. Overview of variations within minimally invasive right hemicolectomy Values are n (%) unless otherwise indicated. *Benz classification: Benz 0 (true complete mesocolic excision specimen), the stalks of the ileocolic vessels and middle colic vessels are connected by tissue of the surgical trunk (lymphatic tissue package covering the superior mesenteric vein) and the mesocolic window has a complete medial frame of mesocolic tissue; Benz 1, the stalks of the ileocolic and middle colic vessels are present, but are not connected by tissue, and the frame of the mesocolic window is not complete with regard to its medial aspect; Benz 2, the stalks of the ileocolic vessels are present, with more than 50% of the anticipated length according to the geometric configuration of the specimen, but the middle colic vessels are not detectable, and the frame of the window has medial and cranial defects; and Benz 3, the ileocoloic vessels have an amputated appearance (less than 50% of the anticipated length according to the geometric configuration of the specimen) and the window is not detectable. This first phase of the RIGHT study shows that, in the participating hospitals, a high percentage of MIRH operations are performed with the established evidence-based ‘new’ techniques (such as intracorporeal anastomosis and Pfannenstiel extraction) and with acceptable short-term morbidity. However, specimen evaluation demonstrated that a minority of the patients underwent a CME with central SMV dissection and CVL of segmental vessels, implying that this recent development and guideline recommendation is not yet broadly implemented in the Netherlands. An intact mesocolon with central ligation of the vessels (optimal D2 dissection, thus CME) is believed to reduce the risk of recurrence and improve long-term survival4,5. Controversy exists in the literature regarding the definition of CME and whether a D3 dissection is an integral part of CME6. However, SMV dissection with CVL alone should result in a good-quality D2 dissection, resulting in a specimen that contains a surgical trunk medial to the supraduodenal window that connects the ileocolic and right colic pedicles. The recent RELARC trial did not show superiority regarding 3-year disease-free survival of extended D3 dissection versus D2 dissection7. However, both study groups underwent CVL with the aim of an intact mesocolic specimen. The fact that an optimal D2 dissection was achieved in only a minority of the patients in the present study highlights the importance of implementation programmes to help the surgical community to adapt to the recommendations of up-to-date guidelines. An intracorporeal anastomosis was performed in a remarkably high proportion of patients. Several systematic reviews have highlighted the benefits of intracorporeal anastomosis versus extracorporeal anastomosis in MIRH, showing reduced short-term morbidity, decreased duration of hospital stay, and quicker recovery of bowel function8. Similarly, the use of a Pfannenstiel incision for specimen extraction in the present study is higher than generally reported. The previous literature consistently reports that Pfannenstiel extraction is advantageous for patients, with a lower incisional hernia rate compared with midline and other incisions9. The median IAP applied in this study was 12 mmHg. A recent RCT has demonstrated that maintaining a lower IAP at 8 mmHg, in comparison with 12 mmHg, resulted in decreased acute pain scores, a reduction in 30-day infectious complications, diminished surgical-site hypoxia and inflammatory markers, reduced postoperative cytokine production, and a higher-quality recovery10. In the next phases of the RIGHT study, all key elements of the consensus-based standardized technique for MIRH will be included in training and proctoring, with continuous monitoring, including video recording, specimen pictures, CT imaging and clinical outcomes. This means that CME w

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