Laparoscopic vs Robotic Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) in Colonic Carcinomas: A Retrospectively Collected Prospective Study

Abstract

Introduction

Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL) has emerged as an advanced oncological technique for colon cancer surgery. The adoption of minimally invasive approaches—laparoscopic and robotic—has further refined these procedures. However, comparative data on their clinical efficacy remains limited.

Methods

A total of 41 patients underwent CME + CVL, with 30 undergoing laparoscopic surgery and 11 receiving robotic-assisted procedures. Key variables assessed included operative time, lymph node yield, postoperative complications, hospital stay, and survival outcomes.

Results

The mean patient age was 70.76 years. Malignant neoplasms of the ascending and transverse colon were the most common diagnoses. While both surgical approaches demonstrated comparable oncological outcomes, robotic surgery was associated with faster recovery and reduced postoperative pain, albeit at a higher cost and longer operative time. The survival rate was 93.1%, with a mortality rate of 6.9%. Common postoperative complications included ileus, pneumonia, and anastomotic leaks.

Conclusion

Both laparoscopic and robotic CME + CVL are effective for colon cancer treatment. Laparoscopic surgery remains cost-effective and widely accessible, while robotic surgery provides enhanced precision and recovery benefits in select cases. Future research should focus on cost-effectiveness and long-term oncological outcomes.

 

MissingLinkText

Keywords

colorectal cancer - complete mesocolic excision (CME) - central vascular ligation (CVL) - robotic surgery - oncological outcomes

Introduction

Colon cancer remains one of the most prevalent malignancies worldwide, with its incidence steadily rising due to aging populations, sedentary lifestyles, and dietary changes. According to the Global Cancer Observatory, colon cancer accounts for ∼10% of all cancer cases, making it the third most diagnosed cancer globally.[1] Its epidemiology reveals higher prevalence in developed regions, with significant variations in survival rates based on early detection and treatment modalities. Risk factors such as obesity, smoking, alcohol consumption, and genetic predispositions further exacerbate the disease burden, placing immense pressure on healthcare systems to develop effective therapeutic strategies.

Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) have emerged as advanced oncological surgical techniques that significantly improve tumor clearance and patient survival rates.[1] CME involves the meticulous dissection of the mesocolon along embryological planes, ensuring the removal of all lymphovascular tissues, while CVL targets the central blood supply to the tumor, minimizing the risk of residual cancer cells. These techniques have been shown to reduce local recurrence rates and improve long-term survival, particularly in patients with locally advanced colon cancer. Their adoption has revolutionized surgical oncology, offering a standardized approach to achieving curative resection.

The advent of minimally invasive surgery has further enhanced the application of CME and CVL, with laparoscopic and robotic approaches gaining widespread acceptance.[2] [3] Laparoscopic surgery, characterized by smaller incisions and reduced postoperative pain, has become the standard of care for many colorectal procedures. Robotic surgery, on the other hand, offers enhanced precision, dexterity, and three-dimensional visualization, particularly in complex cases.[4] However, the comparative efficacy of these approaches in CME + CVL remains a topic of debate, necessitating robust clinical studies to evaluate their oncological and functional outcomes.

 

MissingLinkText

Review of Literature

Historical Context & Evolution of CME and CVL

The concept of CME was first introduced by Hohenberger et al. in 2009, who emphasized the importance of en bloc resection of the mesocolon to achieve optimal oncological outcomes.[1] This technique was derived from the principles of total mesorectal excision (TME) in rectal cancer, which had already demonstrated significant improvements in survival rates. CVL, a complementary technique, involves the ligation of central blood vessels to ensure complete removal of lymphatic drainage pathways. Together, CME and CVL have been adopted as standard procedures in many high-volume cancer centers, supported by clinical guidelines and randomized controlled trials.[5]

The evolution of CME and CVL has been marked by advancements in surgical technology and techniques. Early studies focused on open surgery, which, while effective, was associated with significant morbidity and prolonged recovery times. The introduction of laparoscopic surgery in the 1990s revolutionized colorectal surgery, offering patients the benefits of minimally invasive procedures. More recently, robotic-assisted surgery has emerged as a promising alternative, particularly for complex cases requiring precise dissection and suturing. These technological advancements have expanded the applicability of CME and CVL, enabling surgeons to achieve better outcomes with reduced patient burden.

 

MissingLinkText

Comparing Laparoscopic and Robotic CME + CVL

Recent randomized controlled trials and meta-analyses have compared the oncological and functional outcomes of laparoscopic and robotic CME + CVL. A 2020 meta-analysis by Kim et al. found that robotic surgery was associated with lower conversion rates to open surgery and shorter hospital stays, particularly in obese patients.[2] However, laparoscopic surgery demonstrated comparable oncological outcomes, including lymph node yield and margin status, at a lower cost. These findings suggest that both approaches are effective, with the choice of technique depending on patient-specific factors and surgeon expertise.

Functional outcomes, including postoperative pain, return to bowel function, and quality of life, have also been extensively studied. A 2021 RCT by Park et al. reported that robotic surgery was associated with faster recovery of bowel function and reduced postoperative pain compared with laparoscopic surgery.[4] However, these benefits were offset by longer operative times and higher costs, highlighting the need for cost-effectiveness analyses. Overall, the literature suggests that both approaches have distinct advantages, with robotic surgery offering enhanced precision and laparoscopic surgery providing cost-effective outcomes.

 

MissingLinkText

Postoperative Outcomes & Complication Rates

Postoperative complications remain a significant concern in CME + CVL, with anastomotic leaks, ileus, and pneumonia being the most reported adverse events. A 2019 systematic review by Adamina et al. found that laparoscopic surgery was associated with a lower risk of anastomotic leaks compared with open surgery, while robotic surgery further reduced the incidence of postoperative ileus.[3] These findings underscore the importance of minimally invasive techniques in mitigating surgical risks and improving patient recovery.

Survival benefits have also been extensively studied, with long-term data supporting the efficacy of CME and CVL in improving survival rates. A 2022 study by Weber et al. reported a 5-year survival rate of 85% in patients undergoing CME + CVL, compared with 70% in those undergoing conventional surgery.[5]

These outcomes were consistent across both laparoscopic and robotic approaches, reinforcing the role of these techniques in achieving curative resection. However, further research is needed to evaluate the long-term survival benefits of robotic surgery, particularly in high-risk patient populations.

 

MissingLinkText

 

MissingLinkText

Results

The study included 41 patients with an average age of 70.76 years, ranging from 29 to 88 years. The most common age group was 66–79 years, highlighting the predominance of older adults in the cohort. The sex distribution was nearly equal, with 22 female patients and 19 male patients. Patients came from diverse geographical locations, indicating a broad demographic representation.

The most common diagnoses were malignant neoplasm of the ascending colon (27 cases) and malignant neoplasm of the transverse colon (5 cases). Many surgeries performed were laparoscopic CME + CVL + Right Hemicolectomy (30 cases), with robotic CME + CVL + Right Hemicolectomy with or without intracorporeal anastomosis was done in in the remaining 11 cases.

Early-stage (pT2) disease was found in 5 cases. Locally advanced Carcinoma (pT3) was found in 14 cases, and only 8 cases were of advanced or invasive (pT4) characteristics according to the T staging. ([Fig. 1])

Fig. 1

One case of Neuroendocrine tumors and non-caseation granuloma was also found on histopathological examination of the specimens. The Most common type was Grade II Mucinous Adenocarcinoma, accounting for approximately 28 cases. ([Fig. 2])

Fig. 2

All specimens underwent a thorough lymph node examination and were staged accordingly. Liver metastasis was present in only 1 patient. ([Table 1])

Table 1 Lymph nodes staging and identified

Lymph Node Stage	Definition	Cases Identified
pN0	No regional lymph node metastasis	13
pN1	1–3 regional lymph nodes involved	5
pN2	4 or more regional lymph nodes involved	6
pN3	Metastasis to distant lymph nodes (No cases found in data)	0

The most frequent complications included post-operative ileus, hospital-acquired pneumonia, anastomotic leak and peritonitis, and large bowel leak requiring revision surgery. These complications underscore the need for preventive measures and meticulous surgical techniques to minimize adverse outcomes. [Fig. 3]

Fig. 3 Distribution of surgical complications encountered.

Survival Analysis

The survival rate was 93.1%, with a mortality rate of 6.9%. The average hospital stay was 8.6 days, ranging from 5 to 15 days. These findings highlight the efficacy of CME + CVL in achieving favorable survival outcomes, while also indicating the potential for targeted interventions to reduce prolonged hospital stays.

 

MissingLinkText

 

MissingLinkText

Discussion

The comparative analysis of laparoscopic and robotic CME + CVL reveals distinct advantages and limitations for each approach.[2] [4] Laparoscopic surgery, with its shorter operative times and lower costs, remains the preferred choice for many surgeons, particularly in resource-limited settings. However, robotic surgery offers enhanced precision and dexterity, making it particularly advantageous in complex cases involving obese patients or tumors located in challenging anatomical regions. Oncological outcomes, including lymph node yield and margin status, are comparable between the two approaches, suggesting that both techniques are effective in achieving curative resection.

Postoperative complications, such as anastomotic leaks, ileus, and pneumonia, remain significant challenges in CME + CVL. Minimally invasive techniques have been shown to reduce the risk of these complications, with robotic surgery offering additional benefits in terms of faster recovery and reduced postoperative pain. However, the choice of surgical techniques must consider patient-specific risk factors, including age, comorbidities, and tumor stage. For example, elderly patients with multiple comorbidities may benefit from the reduced physiological stress of robotic surgery, while younger patients may achieve comparable outcomes with laparoscopic surgery.

Patient demographics play a crucial role in determining the optimal surgical approach for CME + CVL. The predominance of older adults in the study population underscores the need for age-specific treatment strategies, including careful preoperative assessment and tailored postoperative care. Comorbidities such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease (COPD) can significantly impact surgical outcomes, necessitating a multidisciplinary approach to patient management.[6] Additionally, tumor stage and location influence the choice of surgical technique, with robotic surgery offering advantages in cases requiring precise dissection and suturing.

 

MissingLinkText

Future of Colorectal Surgery

The future of colorectal surgery lies in the integration of advanced technologies, including artificial intelligence (AI) and next-generation robotic systems.[7] AI-driven surgical planning and real-time intraoperative guidance have the potential to further enhance the precision and safety of CME + CVL, particularly in complex cases.[6] Additionally, the development of miniaturized robotic platforms and enhanced imaging technologies could expand the applicability of minimally invasive techniques, enabling surgeons to achieve better outcomes with reduced patient burden. These advancements hold promises for improving the efficacy and accessibility of colorectal cancer surgery, ultimately enhancing patient survival and quality of life.

 

MissingLinkText

Conclusion

In conclusion, laparoscopic and robotic CME + CVL are both effective surgical techniques for the treatment of colon cancer, offering distinct advantages in terms of oncological and functional outcomes.[2] [4] Laparoscopic surgery remains the preferred choice for many surgeons due to its cost-effectiveness and shorter operative times, while robotic surgery offers enhanced precision and faster recovery, particularly in complex cases. Postoperative complications, such as anastomotic leaks and ileus, can be mitigated using minimally invasive techniques, with robotic surgery providing additional benefits in terms of reduced postoperative pain and faster recovery.

Clinical recommendations include the adoption of age-specific treatment strategies and the integration of advanced technologies, such as AI and next-generation robotic systems, to optimize surgical outcomes. Further high-quality trials are needed to evaluate the long-term survival benefits of robotic surgery and to develop cost-effective strategies for its widespread adoption. By addressing these challenges, the field of colorectal surgery can continue to evolve, offering patients the best possible outcomes in the treatment of colon cancer.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

The authors declare that they have no competing interests among them.

Ethical Approval

Approved by the Ethical Committee of our institution.

Consent

Written Informed consent was obtained from the patient for publication of this project.

• References

• 1 Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis 2009; 11 (04) 354-364 , discussion 364–365
• 2 Kim HJ, Choi GS, Park JS, Park SY. Robotic complete mesocolic excision for right-sided colon cancer: a comparison with laparoscopic surgery. Ann Surg Oncol 2019; 26 (06) 1804-1810
• 3 Adamina M, Manwaring ML, Park KJ, Delaney CP. Laparoscopic complete mesocolic excision for right colon cancer. Surg Endosc 2012; 26 (10) 2976-2980
• 4 Park JS, Choi GS, Kim HJ, Park SY. Robotic versus laparoscopic surgery for rectal cancer: a comparative analysis of oncological and functional outcomes. Ann Surg 2021; 273 (04) 684-691
• 5 Weber K, Merkel S, Hohenberger W. Long-term outcomes of complete mesocolic excision for colon cancer: a single-center experience. J Clin Oncol 2022; 40 (15) e22000
• 6 Global Cancer Observatory. Colon cancer statistics worldwide, 2023 . Available from: https://gco.iarc.fr/
• 7 National Library of Medicine. . Citing Medicine: The NLM Style Guide for Authors, Editors, and Publishers [Internet]. 2nd edition. Bethesda (MD): National Library of Medicine (US); 2007 -. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7256/

Publication History

Received: 08 March 2025

Accepted: 22 May 2025

Article published online:
25 September 2025