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Lateral Node Dissection in Rectal Cancer in the Era of Minimally Invasive Surgery

A Step-by-Step Description for the Surgeon Unacquainted with This Complex Procedure with the Use of the Laparoscopic Approach

Perez, Rodrigo Oliva, M.D., Ph.D.1,2,3; São Julião, Guilherme P., M.D.1; Vailati, Bruna Borba, M.D.1; Fernandez, Laura M., M.D.1; Mattacheo, Adrian E., M.D.1; Konishi, Tsuyoshi, M.D., Ph.D.4

doi: 10.1097/DCR.0000000000001182
Technical Note
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INTRODUCTION: Lateral node dissection in rectal cancer has been routinely performed in Eastern countries. Technical and anatomical challenges and potential significant postoperative morbidity associated with the procedure have prevented its implementation into clinical practice in Western countries. However, the minimally invasive approach may offer the opportunity of performing this complex procedure with precise anatomical dissection and minimal intraoperative blood loss. In this setting, proper training and standardization of technical steps is highly warranted for surgeons not fully acquainted with the procedure.

TECHNIQUE: Access to the lateral nodes along the obturator and internal iliac vessels is described by using specific anatomical landmarks. Opening of the peritoneum along the ureter provides access to the region of interest. Dissection of the medial limit is performed preserving the neurovascular bundle and ureter. The lateral dissection is performed along the external iliac vein to provide access to the obturator muscle. Identification of the obturator nerve with blunt dissection of the fat is a critical part of the procedure. Once the lymphatic connections between the inguinal and iliac nodes are transected, dissection is performed along the internal iliac vessels, and branches are separated from the lymphadenectomy specimen.

RESULTS: Evidence supports that lateral node dissection performed for highly selected patients with minimally invasive access leads to less intraoperative blood loss and similar oncological outcomes. Technical steps illustrated in the present video may aid surgeons in performing this procedure with precise anatomical landmarks and minimal risk for intraoperative complications.

CONCLUSIONS: Lateral node dissection for rectal cancer is a procedure that may follow standardized technical steps by using precise anatomical landmarks with the use of minimally invasive approach.

1 Angelita & Joaquim Gama Institute, São Paulo, Brazil

2 University of São Paulo School of Medicine Colorectal Surgery Division, São Paulo, Brazil

3 Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil

4 Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan

Funding/Support: None reported.

Financial Disclosures: None reported.

Correspondence: Rodrigo Oliva Perez, M.D., Ph.D., Rua Manoel da Nóbrega 1564, São Paulo – SP, Brazil 04001-005. E-mail: gamange@uol.com.br; or Tsuyoshi Konishi, M.D., Ph.D., Ariake 3-8-31, Koto-ku, Tokyo, Japan 135-8550. E-mail: tkonishi-tky@umin.ac.jp

© 2018 The American Society of Colon and Rectal Surgeons