Part of this process includes designation of high-risk procedures, including TME, to specialized centers with high-volume surgeons to ensure that surgical standards are consistently achieved. This is controversial as the absolute number of cases needed to overcome the learning curve for prociency remains unclear. Historically, high-volume surgeons (>20 cases) had fewer complications and need for post­procedural interventions compared to lower-volume surgeons [38]. A more recent database analysis supports that surgeons with a cumulative 5-year experience of >25 rectal resections had signicantly lower rates of major events (OR=0.82) and surgi­cal complications (OR 0.71) [39]. There are very few reports on the learning curve for laparoscopic resection of the rectum. In the randomized controlled trials outlined above, high volume was a requirement for participation. Z6051 required that sur­geons be credentialed for laparoscopic and open TME rectal resection and submit 20 operative and path reports as well as an unedited recording of a laparoscopic pelvic dissection for review. ROLARR required 30 rectal cancer resections per surgeon prior to credentialing. Certainly the excellent results reported in recent literature have become the expectation for clinical practice, and colorectal surgeons who intend to manage rectal cancer should, therefore, undergo the same degree of scrutiny.