Robotic complete mesocolic excision for right colon cancer:Learning curve,training,techniques,approach,platforms,and future perspectives

Colon cancer has the fifth highest incidence worldwide and has the sixth highest mortality.Compared with rectal cancer,colon cancer currently has the worst 5-year overall survival for patients with stage II and III disease.Complete mesocolic excision has been developed as a standardized and optimized surgical technique for the excision of colon cancers.This technique has traditionally been performed through an open approach since laparoscopy is generally considered technically challenging.The robotic approach has been slowly implemented for colon cancer,but the newest robotic platforms allow for a safer and optimized approach for right colon cancer.Several robotic approaches have been developed and explored.The expansion of the current robotic platform ecosystem is gradually providing new outputs in the application of the robotic approach to complete mesocolic excision.This review gains an oversight of existing literature on robotic complete mesocolic excision for right colon cancer(learning curve,training,techniques,approach,platforms,and future perspectives).

Clinical Outcomes of Complete Mesocolic Excision for Right-Sided Colon Cancer Using 3D Laparoscopy versus 2D Laparoscopy

Objective:To study the clinical outcomes of complete mesocolic excision(CME)for right-sided colon cancer using 3D(three-dimensional)laparoscopy compared to 2D(two-dimensional)laparoscopy.Methods:From January 2022 to December 2023,58 patients with right-sided colon cancer treated at the Affiliated Hospital of Hebei Engineering University were randomly divided into a 3D laparoscopy group(observation group)and a 2D laparoscopy group(control group),with 29 patients in each group.Intraoperative blood loss,postoperative time to first flatulence,length of hospital stay,and incidence of complications in both groups were recorded.Results:There was a statistically significant difference in intraoperative blood loss between the two groups(P<0.05).There was no statistically significant difference in the time to first flatulence between the groups(P>0.05).However,there was a statistically significant difference in the length of hospital stay(P<0.05)and the incidence of complications(P<0.05)between the two groups.Conclusion:3D laparoscopy for CME can reduce intraoperative blood loss,shorten hospital stay,and decrease postoperative complications,showing significant clinical advantages over traditional 2D laparoscopy.

Complete mesocolic excision: Lessons from anatomy translating to better oncologic outcome

Since the introduction of complete mesocolic excision(CME) for colon cancer, the oncologic outcome of patients has been greatly improved, which has led to a longer survival and a lower recurrence, just like the total mesorectum excision for rectal cancer. Despite the fact that the exact anatomy of the organ is one of the most vital things for surgeons to conduct surgery, no team has really studied the exact structure of the mesocolon and related attachments for CME, until the mesocolonic anatomy was first formally characterized in 2012. Therefore, this article mainly focuses on the anatomy development of the mesocolon and the achievement in this field. Meanwhile, we introduce the latest progress in laparoscopic surgery for colon cancer achieved by our team.

Laparoscopic complete mesocolic excision: West meets East

Complete mesocolic excision is a relatively new concept in western literature. It follows the same concept of total mesorectal excision and units&#x02019; routinely performing complete mesocolic excisions have good pathological results as well as good improvements in overall survival, disease free survival and local recurrence. And yet unlike total mesorectal excision, uptake in the West has been relatively slow with many units sceptical of the true benefits gained by taking up a more technically challenging and potentially more morbid procedure when there is a paucity of literature to support these claims. This article reviews complete mesocolic excision for colon cancer, attempting to identify the risks and benefits of the technique and particularly looking at the reasons why its uptake has not been universal. It also discusses the similarities of a complete mesocolic excision to a colon resection with a D3 lymphadenectomy as well as the role of a laparoscopic approach to this technique. Considering a D3 lymphadenectomy has been the standard of care for stage II and III colon cancers in many of our Asian neighbours for over 20 years, combining this data with data on complete mesocolic excision may provide enough evidence to support or refute the need for complete mesocolic excisions. Maybe there might be lessons to be learnt from our colleagues in the east.

Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis

AIM To compare the effectiveness of laparoscopic complete mesocolic excision (CME) with central vascular ligation (L-CME) with its open (O-CME) counterpart. METHODS We conducted an electronic search of the PubMed/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, SciELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen (lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individual studies. RESULTS A total of one RCT and eleven CCTs (four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes (MD = -1.06, 95%CI: -3.65 to 1.53, P = 0.42), and tumor to high tie distance (MD = 14.26 cm, 95%CI: -4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group (MD = 11.75 cm2, 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions (OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I2 = 28%) and disease-free (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I2 = 0%) survival. CONCLUSION The laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.

Laparoscopic complete mesocolic excisions for colonic cancer in the last decade:Five-year survival in a single centre

AIM To analyse clinical and long-term oncologic results after laparoscopic complete mesocolic excision(CME) for colonic cancer over a 10-year period.METHODS Consecutive patients who received laparoscopic CME at our hospital from 2007 to 2017 were prospectively registered and retrospectively analysed. In total, 341 patients were included with tumour-nodal-metastasis(TNM) stages 0-Ⅲ.RESULTS The mean age of the patients was 71.9 years. The median length of stay was 5 d. The mean lymph node harvest was 17.8. The mortality rate was 1.2%. Fifteen patients were reoperated on for anastomotic leaks. The local recurrence rate was 2.3%. Five-year TTR and cancer-specific survival CSS were 83.1% and 90.3%. The location of the tumour was not a significant variable for survival in unadjusted and adjusted survival analysis. TNM stage and anastomotic leaks were significant variables with respect to survival.CONCLUSION Laparoscopic CME results in acceptable complication rates and long-term oncologic results. It is important to avoid anastomotic leaks because of their negative effect on survival.

Does cranial-medial mixed dominant approach have a unique advantage for laparoscopic right hemicolectomy with complete mesocolic excision?

BACKGROUND Complete mesocolic excision(CME)with central vascular ligation(CVL)was proposed by Hohenberger in 2009.The CME principle has gradually become the technical standard for colon cancer surgery.How to achieve CME with CVL in laparoscopic right hemicolectomy(LRH)is controversial,and a unified standard approach is not yet available.In recent years,the authors’team has integrated the theory of membrane anatomy,tried to combine the cephalic approach with the classic medial approach(MA)for technical optimization,and proposed a cranialmedial mixed dominant approach(CMA).AIM To explore the feasibility of operational approaches for LRH with CME.METHODS In this retrospective cohort study,the clinical data of 57 patients with right-sided colon cancer(TNM stage I,II,or III)who underwent LRH with CME from January 2016 to June 2020 were collected and summarized.There were 31 patients in the traditional MA group and 26 in the CMA group.RESULTS There were no significant differences in baseline data between the two groups.The operation was shorter and the number of lymph nodes dissected was higher in the CMA group than in the MA group,but there was no significant difference in the number of positive lymph nodes,intraoperative blood loss,postoperative exhaust time,feeding time,postoperative hospital stay or postoperative complication incidence.CONCLUSION Our study shows that the CMA is a safe and feasible procedure for LRH with CME and has a unique advantage.

Feasibility and efficacy of laparoscopic radical right hemicolectomy with complete mesocolic excision using an‘artery-first’approach

Background:According to previous guidelines,the lymph nodes around the right side of the superior mesenteric artery(SMA)should be dissected and removed en bloc.However,due to the technical challenge and the risk of complications,most surgeons perform the dissection along the axis of the superior mesenteric vein(SMV).Herein,we described an‘artery-first’approach for laparoscopic radical extended right hemicolectomy with complete mesocolic excision(CME).Methods:A total of 22 cases were collected from January to October 2016.The right side of the SMA and SMV were exposed and separated,and the No.203,No.213 and No.223 lymph nodes were dissected en bloc.Toldt’s fascia was dissected and expanded laterally to the ascending colon,cranial to the pancreas head.The caudal root of the mesentery and lateral attachments of the ascending colon were completely mobilized.Results:There were 9 male and 13 female patients,with a mean age of 63.1(range,39–83)years and the mean body mass index was 24.6(range,18.3–37.7)kg/m^(2).The mean operative time was 192.5(range,145–240)minutes and the mean intraoperative blood loss was 55.0(range,10–300)ml.The mean number of harvested lymph nodes was 27.0(range,13–55)and the time to flatus and hospital stay were 35.0(range,26–120)hours and 7.5(range,5–20)days,respectively.Minor complications occurred in two patients and no post-operative death was observed.Conclusions:The preliminary results suggest that the reported approach may be a feasible and safe procedure that is more in accordance with the principles of CME.

Quality assessment of surgery for colorectal cancer:Where do we stand?

Quality assurance in surgery has been one of the most important topics of debate among colorectal surgeons in the past decade.It has produced new surgical standards that led in part to the impressive oncological outcomes we see in many units today.Total mesorectal excision,complete mesocolic excision(CME),and the Japanese D3 lymphadenectomy are now benchmark techniques embraced by many surgeons and widely recommended by surgical societies.However,there are still ongoing discrepancies in outcomes largely based on surgeon performance.This is one of the main reasons why many countries have shifted colorectal cancer surgery only to high volume centers.Defining markers of surgical quality is thus a perquisite to ensure that standards and oncological outcomes are met at an institutional level.With the evolution of CME surgery,various quality markers have been described,mostly based on measurements on the surgical specimen and lymph node yield,while others have proposed radiological markers(i.e.arterial stumps)measured on postoperative scans as part of the routine cancer follow-up.There is no ideal marker;however,taken together and assembled into a new score or set of criteria may become a future point of reference for reporting outcomes of colorectal cancer surgery in research studies and defining subspecialization requirements both at an individual and hospital level.

Historical development of mesenteric anatomy provides a universally applicable anatomic paradigm for complete/total mesocolic excision

Although total mesorectal excision has now become the‘gold standard’for the surgical management of rectal cancer,this is not so for colon cancer.Recent data,provided by Hohenberger and West et al.and others,have demonstrated excellent oncological outcomes when mesenterectomy is extensive(as is implicit in the concept of a‘high tie’)and the mesenteric package not violated.Such studies highlight the importance of understanding the basics of the mesenteric organ(including the small intestinal mesentery,mesocolon,mesosigmoid and mesorectum)and of abiding to principles of planar surgery.In this review,we first offer classic descriptions of the mesocolon and then detail contemporary thinking.In so doing,we provide an anatomical basis for safe and effective complete mesocolic excision(CME)in the management of colon cancer.Finally we list opportunities associated with the new anatomical paradigm,demonstrating benefits across multiple disciplines.Perhaps most importantly,we feel that a crystallized view of mesenteric anatomy will overcome factors that have hindered the general uptake of CME.

Bowel function and quality of life after minimally invasive colectomy with D3 lymphadenectomy for right-sided colon adenocarcinoma

BACKGROUND Changes in bowel function after right-sided colectomy are not well understood compared to those associated with left-sided colectomy or rectal resection.In particular,there are concerns about bowel function after right-sided colectomy with complete mesocolic excision,which has become popular in the West.AIM To evaluate the functional outcomes of patients who underwent right-sided colectomy with D3 lymphadenectomy for colon cancer.METHODS Functional data from patients who underwent minimally invasive right-sided colectomy for colon cancer from October 2017 to September 2018 were prospectively collected.Functional outcomes were evaluated preoperatively and at 3,6,12,and 18 mo postoperatively.RESULTS Prior to surgery,57 patients answered the questionnaire,and 47 responded at three months,52 at 6 mo,52 at 12 mo,and 25 at 18 mo postoperatively.Most scales of quality of life and bowel function improved significantly over time.Urgency persisted to a high degree throughout the period without a significant change over time.The use of medications for defecation was about 10%over the entire period.Gas(P=0.023)and fecal frequency(P<0.001)increased,and bowel dysfunction group(P=0.028)was more common among patients taking medication.At six months,resected bowel and colon lengths were significantly different as a risk factor between the dysfunction group and the no dysfunction group[odd ratio(OR):1.095,P=0.026;OR:1.147,P=0.031,respectively]in univariate analysis,but not in multivariate analysis.CONCLUSION Despite D3 lymphadenectomy,most bowel symptoms improved over time after right-sided colectomy using a minimally invasive approach,and continuous medication was needed in only approximately 10%of patients.

Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer:A case report

BACKGROUND Pure natural orifice transluminal endoscopic surgery(NOTES)for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges,including loss of triangulation,in-line orientation,and instrument collision.Transvaginal(v)NOTES,however,can overcome these technical challenges.We report a case of pure vNOTES right hemicolectomy for colon cancer,attached with surgical video.CASE SUMMARY A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy.Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons.The operative time was 200 min and the estimated blood loss was 30 mL.No intraoperative or postoperative complications occurred within 30 d after the surgery.The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3.The patient was discharged at postoperative day 6.The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.CONCLUSION vNOTES right hemicolectomy,performed by well-experienced surgeons,overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.

2D vs 3D laparoscopic right colectomy:A propensity score-matching comparison of personal experience with systematic review and meta-analysis

BACKGROUND The benefits of laparoscopic approach for right colectomy have been well established.However,the technical difficulty to construct the intra-corporeal anastomosis is still cumbersome.AIM To analyze the results of 3D and 2D laparoscopic right colectomy and to compare it to the published series through a systematic review and meta-analysis.METHODS A retrospective study with propensity score matching analysis of patients undergoing laparoscopic right colectomy at Umbria2 Hospitals from January 2014 to March 2020 was performed.A systematic review was accomplished comparing 2D and 3D right colectomy.RESULTS In the personal series 47 patients of the 2D group were matched to 47 patients of the 3D group.The 3D group showed a favorable trend in terms of mean operative time(170.7±32.9 min vs 183.8±35.4 min;P=0.053)and a significant lower anastomotic time(16.9±2.3 min vs 19.6±2.9 min,P<0.001).The complete mesocolic excision(CME)subgroups analysis showed a shorter anastomotic time(16.5±1.8 min vs 19.9±3.0 min;P<0.001)and operative time(175.0±38.5 min vs 193.7±37.1 min;P=0.063)in the 3D group.Six studies and our series were included in the meta-analysis with 551 patients(2D group:291;3D group:260).The pooled analysis demonstrated a significant difference in favour of the 3D group regarding the operative time(P<0.001)and the anastomotic time(P<0.001)while no differences were identified between groups in terms of blood loss(P=0.827),LNH yield(P=0.243),time to first flatus(P=0.333),postoperative complications(P=0.718)and length of stay(P=0.835).CONCLUSION The meta-analysis results showed that 3D laparoscopic right colectomy shortens operative and anastomotic time without affecting the standard lymphadenectomy.In our series,the advantage of the 3D system becomes evident when CME and/or more complex associated procedure are requested significantly reducing both the total operative and the anastomotic time.

Re-examination of the standardization of colon cancer surgery

The standardization of colon cancer surgery has been an area of intense interest.The recent establishment of the complete mesocolic excision(CME)technique has defined the operative approach for colon cancer surgeries and enabled the collection of high-quality oncological specimens for histopathological evaluation.Standard for the Diagnosis and Treatment of Colorectal Cancer(2010),issued by the Ministry of Health of China,has provided legal bases for the treatment of colorectal cancers.However,certain confusions remain due to lack of detailed guidelines for operations.This raised the key question:‘‘What is the standardized colon cancer surgery?’’The present study re-examined the core ideas of General Rules for Clinical and Pathological Studies on Cancer of the Colon,Rectum and Anus(seventh edition)published by the Japanese Society for Cancer of the Colon and Rectum.CME-related studies published in English academic journals between April 2009 and July 2012 were surveyed and analysed.Several technical issues related to the requirement of R0 resection were analysed,including the theoretical basis for the safety range of bowel resection and the rational determination of the range of regional lymph node dissection.