A Modified Technique of Laparoscopic Lateral Lymph Node Dissection Combining Fascia-Oriented Dissection and Routine Upfront Distal Visceral Vessels Ligation for Mid to Low-Lying Rectal Cancer.

INTRODUCTION Lateral pelvic recurrence can be a cause of local failure after surgery for low rectal cancer. Lateral lymph node dissection is often performed in East Asia for patients with enlarged lateral lymph nodes or because of the presence of risk factors. However, the outcomes of the conventional lateral lymph node dissection are unsatisfactory, with a considerably high local recurrence rate for patients with positive lateral nodes. Here, we introduce a modified technique to improve lateral nodes clearance. TECHNIQUE This modified technique has 4 key steps: 1) separation of the ureterohypogastric nerve fascia medially, 2) identification of the visceral pelvic fascia and dissection along the inferior vesical or vaginal veins down to the pelvic floor, 3) division of the distal ends of visceral vessels according to the orientation of ureterohypogastric nerve fascia and visceral pelvic fascia for better nerve preservation, and 4) en bloc dissection through a lateral approach over the surfaces of the sacral plexus and piriformis muscle to reveal the course of distal internal iliac vessels before the division of visceral veins. RESULTS Twenty-nine patients underwent laparoscopic lateral lymph node dissection successively with no conversion. The median blood loss for each lateral procedure was 37.5 mL (range, 0-300.0 mL). Eleven lateral nodes (median; range, 1-22 lateral nodes) were harvested for each lateral side. There was no perioperative mortality, and 4 patients developed major complications (Clavien-Dindo III-IV). CONCLUSION This modified technique characterized by the routine division of visceral vessels based on ureterohypogastric nerve fascia and visceral pelvic fascia is feasible and safe. It provides good lymph node harvest, autonomic nerve preservation, and improved bleeding control. Additional investigation is warranted to evaluate the safety, functional outcomes, and oncologic outcomes.