Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery

Since the 19th century,appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors.This approach can be applied to any surgery for gastrointestinal cancer.During surgery for colon and rectal cancer,an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease.The adequate number of lymph nodes to be removed is standardized and reported by several guidelines.It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients.Our review focuses on the concept of“complete mesenteric excision(CME)with central vascular ligation(CVL),”a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years.The aim of this study was to evaluate the evolution of this approach over the years,its potential oncologic benefits and potential risks,and the improvements offered by laparoscopic techniques.Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin(CVL)which guarantees removal of a larger number of lymph nodes.The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery,providing the same oncologic results as open surgery.This has been widely applied to colorectal cancer surgery;however,CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzesresults of these procedures in terms of oncological outcomes, technical feasibilityand complexity, especially within the context of minimally invasive surgery.

Benefits of minimally invasive surgery in the treatment of gastric cancer

We read with great interest the article that retrospectively analyzed 814 patients with primary gastric cancer,who underwent minimally invasive R0 gastrectomy between 2009 and 2014 by grouping them in laparoscopic vs robotic procedures.The results of the study highlighted that age,American Society of Anesthesiologists status,gastrectomy type and pathological T and N status were the main prognostic factors of minimally invasive gastrectomy and showed how the robotic approach may improve long-term outcomes of advanced gastric cancer.According to most of the current literature,robotic surgery is associated with a statistically longer operating time when compared to open and laparoscopic surgery;however,looking at the adequacy of resection,defined by negative surgical margins and number of lymph nodes removed,it seems that robotic surgery gives better results in terms of the 5-year overall survival and recurrencefree survival.The robotic approach to gastric cancer surgery aims to overcome the difficulties and technical limitations of laparoscopy in major surgery.The threedimensional vision,articulation of the instruments and good ergonomics for the surgeon allow for accurate and precise movements which facilitate the complex steps of surgery such as lymph node dissection,esophagus-jejunal anastomosis packaging and reproducing the technical accuracy of open surgery.If the literature,as well as the analyzed study,offers us countless data regarding the short-term oncological results of robotic surgery in the treatment of gastric cancer,satisfactory data on long-term follow-up are lacking,so future studies are necessary.