The concept of total mesorectal excision (TME) as proposed by Heald et al. (1) in the early 80’s resulted in significantly better oncological outcomes in rectal cancer surgery (1-3). TME also raised the issue of better outcomes in colon

Transl Gastrointest Cancer 2015;4(3):185-188 www.amepc. org/tgc The concept of total mesorectal excision (TME) as proposed by Heald et al. (1) in the early 80’s resulted in significantly better oncological outcomes in rectal cancer surgery (1-3). TME also raised the issue of better outcomes in colon cancer surgery, which, until then, was not standardized and the reports in the literature displayed a great deal of heterogeneity and high recurrence rates (4-7). In 2009 and in parallel to the TME concept, came the first report and description of the complete mesocolic excision (CME) with central vascular ligation (CVL) from the Erlangen group of Hohenberger (8), with quite impressive oncological outcomes and an overall 5-year survival reaching up to 70% for stage III colon cancer patients. They also showed that it is a safe and feasible technique which bears at least the same morbidity and mortality as the “so called” standard technique (8). CME with CVL consists of two main components. Firstly, it aims at the preservation of intact fasciae of the mesocolon between which relevant lymph nodes are contained. Secondly, the vessels that supply the tumor colon site must be ligated at their origin, namely (I) at the level of the superior mesenteric vein for right sided lesions, and (II) at the level of the take-off of the inferior mesenteric artery for left sided lesions. In this way the nerves of the celiac plexus, which run along the superior mesenteric artery, and the hypogastric plexus, which runs on the aorta, respectively, are protected, and the removal of the complete mesocolon and the maximum lymph node yield is achieved. The concept of CME with CVL has been strongly criticized. At the beginning the criticism was on the novelty of the technique. Many supported that it is a concept already implemented by the majority of colorectal surgeons, in particular for tumors of the left colon (9,10). In addition, the issue of reproducibility of the technique due to the high level of expertise necessary was raised. Many experienced and skillful colorectal surgeons claimed that some steps of the CME with CVL, as described by Hohenberger et al. (8), were very technically demanding, some were unnecessary, and because of that the technique was rendered very difficult to teach and to reproduce (11-14). Furthermore, reports from Japan also demonstrated that perhaps the main element of the technique is the CVL, because they showed similar results not by removing longer specimens but by removing more radically the supplying vessels (15). The establishment of CME with CVL in the mind of many, at first skeptical, colorectal surgeons came when the leading group of pathologists from Leeds, which is involved in almost all the techniques used by pathologists to assess and measure surgical quality in rectal surgery, published the first morphometric criteria of macroscopical and microscopical assessment of colon cancers specimen (16). In this way, the superiority of the CME with CVL, as far as the quality of the surgical specimen is concerned, was proven (16). Thereafter, reports by many groups followed comparing the CME with CVL with retrospective cohorts of conventional colectomies and contemporarily the first reports concerning laparoscopic CME appeared in the literature (12,17-30). The results from all these studies were rather conflicting, probably due to the fact that conventional colectomy is not at all standardized and that surgeons Editorial