Minimally Invasive Complete Mesocolic Excision with Extended Lymphadenectomy for Colon Cancer

Patricia Sylla
Minimally Invasive Complete Mesocolic Excision with Extended Lymphadenectomy for Colon Cancer is a topic covered in the ASCRS Textbook of Colon and Rectal Surgery.

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Key Concepts

  • Complete mesocolic excision and central vascular ligation (CME + CVL) refers to en bloc dissection of the colon and mesocolon along the embryologic planes with preservation of the mesocolic envelope, central ligation of the feeding vessels, extended lymphadenectomy, and adequate bowel resection.
  • CME + CVL most closely matches Japanese D3 lymphadenectomy which requires en bloc resection of paracolic (D1), intermediate (D2), and central (D3) nodal stations along the feeding vessels.
  • CME + CVL/D3 dissection increases the risk of potential organ injury, particularly during right colectomy where nodal tissue is dissected off the anterior surface of the superior mesenteric vein and its tributaries. Thorough knowledge of variations in vascular anatomy at the root of the mesentery is needed.
  • In experienced hands, the minimally invasive surgical (MIS) approach to CME + CVL/D3 dissection results in acceptable conversion rates and perioperative and oncologic outcomes equivalent to that of open CME.
  • The lack of standardized operative assessment for CME + D2 vs D3 dissection, and limited adoption of quality indicators to assess CME specimens, has made direct comparison of long-term oncologic outcomes between the groups challenging.
  • There is no conclusive evidence to support routine use of CME + CVL/D3 versus CME + D2 dissection for colon cancer. It should be considered in cases were nodal metastasis is suspected based on preoperative staging and/or intraoperative assessment.
  • Several ongoing randomized controlled trials comparing outcomes between CME + D2 and CME + D3 dissection for colon cancer incorporate video-based assessment of CME techniques and morphometric assessment of CME specimens.
  • There is increasing enthusiasm for MIS CME in Europe and in the USA. Standardization of performance assessment and adoption of CME quality indicators will be needed in order to assess the impact of CME + CVL on long-term oncologic outcomes of right and left colon cancer resections.

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Key Concepts

  • Complete mesocolic excision and central vascular ligation (CME + CVL) refers to en bloc dissection of the colon and mesocolon along the embryologic planes with preservation of the mesocolic envelope, central ligation of the feeding vessels, extended lymphadenectomy, and adequate bowel resection.
  • CME + CVL most closely matches Japanese D3 lymphadenectomy which requires en bloc resection of paracolic (D1), intermediate (D2), and central (D3) nodal stations along the feeding vessels.
  • CME + CVL/D3 dissection increases the risk of potential organ injury, particularly during right colectomy where nodal tissue is dissected off the anterior surface of the superior mesenteric vein and its tributaries. Thorough knowledge of variations in vascular anatomy at the root of the mesentery is needed.
  • In experienced hands, the minimally invasive surgical (MIS) approach to CME + CVL/D3 dissection results in acceptable conversion rates and perioperative and oncologic outcomes equivalent to that of open CME.
  • The lack of standardized operative assessment for CME + D2 vs D3 dissection, and limited adoption of quality indicators to assess CME specimens, has made direct comparison of long-term oncologic outcomes between the groups challenging.
  • There is no conclusive evidence to support routine use of CME + CVL/D3 versus CME + D2 dissection for colon cancer. It should be considered in cases were nodal metastasis is suspected based on preoperative staging and/or intraoperative assessment.
  • Several ongoing randomized controlled trials comparing outcomes between CME + D2 and CME + D3 dissection for colon cancer incorporate video-based assessment of CME techniques and morphometric assessment of CME specimens.
  • There is increasing enthusiasm for MIS CME in Europe and in the USA. Standardization of performance assessment and adoption of CME quality indicators will be needed in order to assess the impact of CME + CVL on long-term oncologic outcomes of right and left colon cancer resections.

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Last updated: January 26, 2022