A technique of laparoscopic lateral pelvic lymph node dissection based on vesicohypogastric fascia and ureterohypogastric nerve fascia for advanced low rectal cancer.

Akiyo Matsumoto, MD, Kaida Arita, MD. Tsuchiura Kyodo General Hospital

Background: Conventional open lateral pelvic lymph node dissection (LLND) has been performed along internal iliac vessels and their branches. But it was accompanied by increased bleeding and postoperative complications. We have developed laparoscopic autonomic preserving technique for LLND based on vesicohypogastric fascia (VF) and ureterohypogastric nerve fascia (UNF). VF includes the internal iliac vessels, the internal pudendal vessels and the superior and inferior vesical vessels. UNF includes the ureter, the hypogastric nerve, the pelvic splanchnic nerves (S2-S4) and the pelvic plexus. Both two fasciae join together on the surface of urinary bladder and adhere to the tendinous muscle of levator ani muscles.

Methods: We evaluated laparoscopic hemi-lateral pelvic lymph node dissection based on VF and UNF (12 patients), compared to conventional open hemi-lateral pelvic lymph node dissection (13 patients).

In our laparoscopic LLND, the obturator region was firstly dissected between external iliac vessels and VF, and then, the internal iliac region between VF and UNF was dissected. Our standardized procedure for LLND and surgical and oncological outcomes are seen in the video.

Results: Operative time and number of harvested LPLN were almost similar in both approaches. But median amount of bleeding was 38.8 (range: 20-75) ml of Laparoscopic approach (Lap), compared to 836.9 (range: 365-2060) ml of open approach (Op). Postoperative hospital stay was shorter in Lap with median time of 22.1 (range: 12-50) days, compared to 31.7 (range: 13-105) days of Op. Postoperative recovery was excellent in Lap, with median time to tolerate diet of 3.3 (range: 2-6) days, compared to 8.7 (range: 3-34) days of Op. Postoperative complications increased in Op, with 1 anastmotic leakage, 4 small bowel obstructions, 3 wound infections and 1 lymphatic leakage. Importantly we had only 1 urinary retention of grade 2 in Lap, compared to 4 urinary retentions of Grade 2 and 1 urinary retention of grade 3 in Op. Surgical curability was R0 in all Lap. But R0 operations were performed for only 7 patients in Op. After a mean follow up of 24.4 (range: 16.2-45.3) months, all 12 patients of Lap were alive without recurrence. But during a mean follow up of 31.5 (range: 6.0-63.0) months, 3 patients of local recurrence and 2 patients of distant metastasis were found in Op.

Conclusions: Laparoscopic LLND based on both two fasciae makes it easier comprehensible to perform lymphadenectomy in the lateral pelvic areas, preserving these autonomic nerves. Surgical and oncological outcomes were feasible.

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