Laparoscopic lateral pelvic lymph node dissection for locally advanced rectal cancer

Mitsuyoshi Ota, MD, PhD1, Jun Watanabe, MD, PhD2, Atsushi Ishibe, MD, PhD3, Hirokazu Suwa, MD1, Masashi Momiyama, MD, PhD3, Yasushi Ichikawa, MD, PhD4, Chikara Kunisaki, MD, PhD1, Itaru Endo3. 1Gastroenterological Center, Yokohama City University Medical Center, 2Surgery, Yokosuka Kyosai Hospital, 3Department of Gastroenterological Surgery, Yokohama City University, 4Department of Clinical Oncology, Yokohama City University

Purpose: Lateral pelvic node metastases occur in 10 to 20 % of locally advanced rectal cancer. Less invasive and effective lymph node dissection of lateral pelvic lesion is required when skipping routine preoperative radiation therapy.  We developed the technique for laparoscopic lateral pelvic node dissection (LLPND) and assessed its feasibility.

Methods: Two areas of lateral pelvic region are dissected. One of which is the area along the obturator artery running in front of the internal obturator muscle. The other is the area along the internal iliac artery and its visceral branches which is enveloped in the endopelvic fascia with pelvic organs and its dominant nerves. To avoid nerve injury, the pelvic plexus should be separated from the internal iliac artery and its branches.

Results: From April 2012 to March 2015, 52 patients with clinical Stage II/III rectal cancer underwent total mesorectal excision with LLPND. None of the patients received preoperative radiation therapy. Forty two of the 52 patients received neoadjuvant chemotherapy. Sphincter preserving operation was performed in 46 patients (79.3%). Average operation time and blood loss were 411 minutes and 193ml respectively. Clavien-Dindo Grade 3 or worse morbidity rate was 5.8% and none of the patients required urinary clean intermittent catheterization or fecal incontinence. Average number of harvested lymph nodes of lateral pelvic region was 11.6. Lateral pelvic node metastases existed in 8 (15.4%) patients; 5 in the internal iliac artery and its visceral brunch area, 1 in internal obturator area and 2 in both areas.

Conclusion: Laparoscopic lateral pelvic node dissection can be performed safely. Together with neoadjuvant chemotherapy, it may become an effective alternative for radiation therapy in locally advanced rectal cancer.

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