| Objective: Total mesorectal excision (TME) with lateral pelvic lymph node dissection (LLND) is a standard procedure for lower rectal cancer in Japan. However, ME alone is the international standard surgical procedure for rectal cancer and complete LLND is difficult. Our LLND using both transabdominal and extraperitoneal approach provides a wider visual field through the paravesical space and enables us to perform complete lymph node dissection of these regions. Herein we introduce our LLND procedure and report the clinical and oncological outcomes.Methods: After ME, hypogastric nerves were separated to be preserved. Firstly, common iliac nodes (#273) were dissected; aortic bifurcation nodes (#280) and median sacral nodes (#270) were also dissected through a transabdominal approach. Secondly, after external iliac nodes (#293) dissection was performed to the peripheral side by the abdominal approach as possible. Proximal internal iliac nodes (#263P) were removed and superior vesical artery was separated. Subsequently, the paravesical space was opened widely via an extraperitoneal approach, the external iliac nodes (#293) were completely removed from inguinal ligament. Obturator nodes (#283) were completely dissected while preserving the obturator nerve, resecting the obturator vessels, distal internal iliac nodes (#263D) from the coccygeal muscle (Alcock's canal) were completely dissected while preserving the superior vesical artery and the pelvic plexus, and transecting several inferior vesical arteries.Results: Between 2007 and 2016, we performed ME with LLND for 235 patients with cStageI-III lower rectal cancer. The median operative time was 371 min, and the median blood loss was 610 ml. Postoperative complications developed in 115 (48.9%) patients, and the most frequent one was pelvic cavity infection (including lymphocele) in 40 (17.0%) patients. Temporary urination disorder developed in only 17 (7.2%) patients. Lateral Lymph node metastasis was pathologically found in 57(24.2%) patients. The 5-year local-recurrence-free survival was 84.6% and the numbers of patients with local recurrence were 16 (6.8%). The 5-year overall survival rate excluding cStageIV was 89.5%.Conclusions: Our LLND provides a wider visual field in the pelvic cavity by using both transabdominal and extraperitoneal approach, and results in favorable clinical and oncological outcomes. We introduce our procedure of LLND. However LLND is invasive procedure which needs longer operative time and greater blood loss. So we show laparoscopic LLND as our new procedure securing equivalent range of LLND. |
