Optimization of artery-first approach in right-sided colon cancer CME: preoperative CTA assessment of MCA branching and MCV–Henle’s trunk relationship

BACKGROUND: Vascular injury, particularly involving Henle's trunk, remains a major challenge during complete mesocolic excision (CME) for right-sided colon cancer. Due to the high anatomical variability of right-sided colonic vessels, the influence of tumor location, and heterogeneity in operative techniques, radical right hemicolectomy (RRC) continues to be a high-risk procedure. This study aims to identify preoperative CTA mapping to reduce vascular injury and enhance mesenteric margin integrity in standardized CME surgery. MATERIAL AND METHODS: A single-center, retrospective observational study was performed. 96 patients underwent preoperative MS-CTA to characterize MCA branching types and MCV-Henle's trunk configurations. Based on these findings, individualized artery-first, sheath-based dissection strategies were applied. Operative outcomes were compared with 85 patients who underwent conventional CME, regarding intraoperative bleeding, vascular injury rate, and the subjective assessment of mesenteric margin integrity. RESULTS: Preoperative MS-CTA successfully identified MCA and MCV-Henle's trunk types in 95.8% of patients, which is concordant with intraoperative findings. The CTA-guided artery-first group showed significantly fewer venous injuries and improved exposure of the Henle's trunk and SMV compared with the conventional group. No MCV injuries occurred in the MS-CTA group; only two cases of minor bleeding from small branches of Henle's trunk were observed and were easily controlled. In addition, the quality of CME specimen integrity showed progressive improvement with increasing surgical experience. CONCLUSIONS: Manual subtraction CTA allows accurate visualization of fine vascular anatomy and facilitates a safe, artery-first CME strategy for right-sided colon cancer. CTA-guided sheath dissection reduces intraoperative vessel injuries and improves precision of the surgery.