Annals of Coloproctology

Video

Tips and tricks for robotic lateral pelvic node dissection: James Chi-Yong Ngu, Nan-Zun Teo; Ann Coloproctol. 2023;39(6):531-531. Published online December 26, 2023; DOI: https://doi.org/10.3393/ac.2023.00766.0109

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Abstract PDF Supplementary Material: Lateral pelvic node dissection can be challenging. In addition to detailed anatomical knowledge of the pelvic side wall, surgeons also need to be proficient in performing fine dissection within the confines of this limited operative field. While the incorporation of robotics can facilitate the safe completion of this technically demanding procedure, this is nonetheless dependent on the way the robotic system is used. This video aims to demonstrate several tips and tricks for performing robotic lateral pelvic node dissection.

Review

Colorectal cancer

Essential anatomy for lateral lymph node dissection: Yuichiro Yokoyama, Hiroaki Nozawa, Kazuhito Sasaki, Koji Murono, Shigenobu Emoto, Hiroyuki Matsuzaki, Shinya Abe, Yuzo Nagai, Yuichiro Yoshioka, Takahide Shinagawa, Hirofumi Sonoda, Daisuke Hojo, Soichiro Ishihara; Ann Coloproctol. 2023;39(6):457-466. Published online December 8, 2023; DOI: https://doi.org/10.3393/ac.2023.00164.0023

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Abstract PDF

In Western countries, the gold-standard therapeutic strategy for rectal cancer is preoperative chemoradiotherapy (CRT) following total mesorectal excision (TME), without lateral lymph node dissection (LLND). However, preoperative CRT has recently been reported to be insufficient to control lateral lymph node recurrence in cases of enlarged lateral lymph nodes before CRT, and LLND is considered necessary in such cases. We performed a literature review on aspects of pelvic anatomy associated with rectal surgery and LLND, and then combined this information with our experience and knowledge of pelvic anatomy. In this review, drawing upon research using a 3-dimensional anatomical model and actual operative views, we aimed to clarify the essential anatomy for LLND. The LLND procedure was developed in Asian countries and can now be safely performed in terms of functional preservation. Nonetheless, the longer operative time, hemorrhage, and higher complication rates with TME accompanied by LLND than with TME alone indicate that LLND is still a challenging procedure. Laparoscopic or robotic LLND has been shown to be useful and is widely performed; however, without a sufficient understanding of anatomical landmarks, misrecognition of vessels and nerves often occurs. To perform safe and accurate LLND, understanding the landmarks of LLND is essential.

Citations

Citations to this article as recorded by

The role of lateral pelvic lymph node dissection in advanced rectal cancer: a review of current evidence and outcomes
Gyu-Seog Choi, Hye Jin Kim
Annals of Coloproctology.2024; 40(4): 363. CrossRef
Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision
Daichi Kitaguchi, Masaaki Ito
Annals of Coloproctology.2024; 40(4): 375. CrossRef

Original Articles

Malignant disease, Rectal cancer,Prognosis and adjuvant therapy,Colorectal cancer

Lateral Pelvic Lymph Node Dissection After Neoadjuvant Chemoradiotherapy in Patients With Rectal Cancer: A Single-Center Experience and Literature Review: Min Chul Kim, Jae Hwan Oh; Ann Coloproctol. 2021;37(6):382-394. Published online December 22, 2021; DOI: https://doi.org/10.3393/ac.2021.00913.0130

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Abstract PDF Supplementary Material

Purpose
We aimed to evaluate the surgicopathological outcomes of lateral pelvic lymph node dissection (LPLD) and long-term oncological outcomes of selective LPLD after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer and compare them to those of total mesorectal excision (TME) alone based on pretreatment magnetic resonance imaging (MRI).
Methods
We compared the TME-alone group (2001–2009, n=102) with the TME with LPLD group (2011–2016, n=69), both groups having lateral lymph nodes (LLNs) of ≥5 mm in short axis diameter. The surgicopathological outcomes were analyzed retrospectively. Oncological outcomes were analyzed using the Kaplan-Meier method.
Results
The rates of overall postoperative 30-day morbidity (42.0% vs. 26.5%, P=0.095) and urinary retention (13.7% vs. 10.1%, P=0.484) were not significantly different between the LPLD and TME-alone groups, respectively. Pathologically proven LLN metastasis was identified in 24 (34.8%) LPLD cases after nCRT. The LPLD group showed a lower 5-year local recurrence (LR) rate (27.9% vs. 4.6%, P<0.001) and better recurrence-free survival (RFS) (59.6% vs. 78.2%, P=0.008) than those of the TME-alone group, while the 5-year overall survival was not significantly different between the 2 groups (76.2% vs. 86.5%, P=0.094).
Conclusion
This study suggests that LPLD is a safe and feasible procedure. The oncological outcomes suggest that selective LPLD improves LR and RFS in patients with clinically suspicious LLNs on pretreatment MRI. Considering that lateral nodal disease is not common, a multicenter large-scale study is necessary.

Citations

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MRI-based scoring systems for selective lateral lymph node dissection in locally advanced low rectal cancer after neoadjuvant chemoradiotherapy
Min Jeong Cho, Kyunghwa Han, Hye Jung Shin, Woong Sub Koom, Kang Young Lee, Joo Hee Kim, Joon Seok Lim
European Radiology.2025;[Epub] CrossRef
Feasibility and limitations of combined treatment for lateral pelvic lymph node metastases in rectal cancer
Ying-Zi Zheng, Fang-Fang Yan, Lian-Xiang Luo
World Journal of Clinical Oncology.2024; 15(5): 591. CrossRef
Totally Extraperitoneal Approach for Recurrent Lateral Pelvic Lymph Nodes After Rectal Cancer Surgery
Tae-Gyun Lee, Hongmin Ahn, Hye-Rim Shin, Mi Jeong Choi, Min Hyeong Jo, Heung-Kwon Oh, Duck-Woo Kim, Sung-Bum Kang
Diseases of the Colon & Rectum.2024;[Epub] CrossRef
Identification of lateral pelvic nodes without metastasis in patients with rectal cancer treated with preoperative chemoradiotherapy or chemotherapy based on magnetic resonance imaging
Nobuaki Hoshino, Yudai Fukui, Kohei Ueno, Koya Hida, Kazutaka Obama, Kazuhiro Sakamoto, Hirotoshi Kobayashi, Michio Itabashi, Soichiro Ishihara, Kazushige Kawai, Yoichi Ajioka
Annals of Gastroenterological Surgery.2024; 8(5): 732. CrossRef
Survival analysis in rectal cancer patients after lateral lymph node dissection: Exploring the necessity of nCRT for suspected lateral lymph node metastasis
Jiafei Liu, Peishi Jiang, Zhichun Zhang, Hongjie Yang, Yuanda Zhou, Peng Li, Qingsheng Zeng, Xipeng Zhang, Yi Sun
Current Problems in Surgery.2024; 61(8): 101525. CrossRef
Clinical outcomes of neoadjuvant chemoradiotherapy followed by total mesorectal excision in locally advanced rectal cancer with mesorectal fascia involvement
Jeong Ha Lee, Nalee Kim, Jeong Il Yu, Gyu Sang Yoo, Hee Chul Park, Woo-Yong Lee, Seong Hyeon Yun, Hee Cheol Kim, Yong Beom Cho, Jung Wook Huh, Yoon Ah Park, Jung Kyong Shin, Joon Oh Park, Seung Tae Kim, Young Suk Park, Jeeyun Lee, Won Ki Kang
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Literature research on the low rectal cancer complicated with lateral pelvic lymph node metastasis
Miao He, Jing Fan
Asian Journal of Surgery.2024; 47(10): 4575. CrossRef
Innovációk a colorectalis sebészetben
Balázs Bánky, András Fülöp, Viktória Bencze, Lóránd Lakatos, Petra Rozman, Attila Szijártó
Orvosi Hetilap.2024; 165(2): 43. CrossRef
Meta-analysis of the efficacy and safety of robot-assisted comparative laparoscopic surgery in lateral lymph node dissection for rectal cancer
Hao Shi, Xianhao Yi, Xin Yan, Wenjie Wu, Hui Ouyang, Chengke Ou, Xiangheng Chen
Surgical Endoscopy.2024; 38(10): 5584. CrossRef
The Role of Lateral Pelvic Lymph Node Dissection in Middle and Lower Rectal Cancer (Stage II or III): A Literature Review
Alexandra-Eleftheria Menni, Georgios Tzikos, Patroklos Goulas, Stylianos Apostolidis
Cureus.2024;[Epub] CrossRef
Lateral pelvic lymph node positivity (LPLNP) score: predictive clinic-radiological model of lateral pelvic lymph node involvement in rectal cancer patients
Petr Tsarkov, Vladimir Balaban, Harutyun Babajanyan, Abe Fingerhut, Inna Tulina, Mingze He
International Journal of Colorectal Disease.2024;[Epub] CrossRef
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Xiajuan Xue, Shuijie Lin, Qunzhang Zeng, Yincong Guo
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Kosuke Ozaki, Yusuke Kurose, Kazushige Kawai, Hirotoshi Kobayashi, Michio Itabashi, Yojiro Hashiguchi, Takuya Miura, Akio Shiomi, Tatsuya Harada, Yoichi Ajioka
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Youngbae Jeon, Eun Jung Park
The Ewha Medical Journal.2023;[Epub] CrossRef
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In Ja Park
The Ewha Medical Journal.2022; 45(1): 3. CrossRef
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Hyo Seon Ryu, Jin Kim
Annals of Surgical Treatment and Research.2022; 103(1): 1. CrossRef
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Influence of colonic mesenteric area on the number of lymph node retrieval for colon cancer: a prospective cohort study: Nadir Adnan Hacım, Ahmet Akbaş, Yigit Ulgen, Talar Vartanoglu Aktokmakyan, Serhat Meric, Merve Tokocin, Onder Karabay, Yuksel Altinel; Ann Coloproctol. 2023;39(1):77-84. Published online September 16, 2021; DOI: https://doi.org/10.3393/ac.2021.00444.0063

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Abstract PDF

Purpose
The minimum harvested 12 lymph nodes (LNs) is regarded as the limit for accurate staging of nodal status in colorectal cancer patients. Besides the association of the lengths of resected intestinal segments and vascular pedicles, the mesocolic mesenteric area’s impact on LN count has not been studied. We aimed to evaluate the associations between metric variables, including the mesocolic mesentery area on the nodal harvest.
Methods
All consecutive patients who underwent elective colectomy with a curative intention for colon adenocarcinoma were prospectively included. The metric variables included the lengths of resected intestinal segments, vascular pedicle, and colonic mesenteric area. The variables influencing the LN count and the correlation between the total LN count and the specimens’ relevant metric measurements were analyzed.
Results
There were 46 patients with a median age of 64 years. The median count for total LNs was 22, and the LN positivity was 59.2%. There was an inadequate LN yield (<12) in 3 patients (6.1%). No significant associations were found between the adequacy of nodal harvest and the demographic, clinical, and tumoral features (P>0.05). There were significant positive correlations between total LN number and length of vascular pedicle and mesenteric area (r=0.576, P<0.001 and r=0.566, P<0.001).
Conclusion
The length of the vascular pedicle and mesenteric area were significantly correlated with total LN counts. Although there was no significant impact on the length of resected segments, the colonic mesenteric area can be used alone as a measure for the assessment of the nodal yield in colon cancer.

Citations

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Gyung Mo Son, Tae Un Kim, Mi Sook Yun, ChangYeop Kim, In Young Lee, Su Bum Park, Dong-Hoon Shin, Gi Won Ha
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Annals of Coloproctology.2021; 37(6): 434. CrossRef

Video

Malignant disease, Rectal cancer,Minimally invasive surgery,Surgical technique

Standardized Step-by-step Technique Using Surgical Landmarks in Robotic Lateral Pelvic Lymph Node Dissection: Jung Hoon Bae, Wooree Koh, Hyun Ho Kim, Yoon Suk Lee; Ann Coloproctol. 2021;37(1):58-60. Published online September 18, 2020; DOI: https://doi.org/10.3393/ac.2020.08.05

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Abstract PDF Supplementary Material

We aimed to show that a standardized step-by-step robotic approach using surgical landmarks could make lateral pelvic lymph node dissection (LPND) less complicated. We performed robot-assisted LPND consisting of 4 steps using surgical landmarks. The first step is a dissection of uretero-hypogastric fascia, which envelopes the ureter and the hypogastric nerve. The second step is a dissection of the medial side of the external iliac vein located at the lateral border of the obturator lymph nodes (LNs) group. The third step is a dissection of the vesico-hypogastric fascia, which is at the medial border of the obturator LNs group. The final step is a dissection of the internal iliac artery until the Alcock’s canal. Indocyanine green was injected just before surgery around the dentate line to identify the lateral pelvic LNs. Standardization using a robotic approach for LPND guided by surgical landmarks allows a safer and more effective surgery.

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In Kyeong Kim, Jung Hoon Bae, In Kyu Lee, Yoon Suk Lee
Colorectal Disease.2025;[Epub] CrossRef
MRI-based scoring systems for selective lateral lymph node dissection in locally advanced low rectal cancer after neoadjuvant chemoradiotherapy
Min Jeong Cho, Kyunghwa Han, Hye Jung Shin, Woong Sub Koom, Kang Young Lee, Joo Hee Kim, Joon Seok Lim
European Radiology.2025;[Epub] CrossRef
The use of indocyanine green for lateral lymph node dissection in rectal cancer—preliminary data from an emerging procedure: a systematic review of the literature
D. Kehagias, C. Lampropoulos, A. Bellou, I. Kehagias
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Shuichi Morizane, Jun Miki, Masaki Shimbo, Toru Kanno, Noriyoshi Miura, Yuta Yamada, Takeshi Yamasaki, Takashi Saika, Atsushi Takenaka
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Original Articles

Initial Clinical Experience with Robotic Lateral Pelvic Lymph Node Dissection for Advanced Rectal Cancer: Ju-A Park, Gyu-Seog Choi, Jun Seok Park, Soo Yeun Park; J Korean Soc Coloproctol. 2012;28(5):265-270. Published online October 31, 2012; DOI: https://doi.org/10.3393/jksc.2012.28.5.265

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Abstract PDF

Purpose

This study was conducted to evaluate the technical feasibility and safety of robotic extended lateral pelvic lymph node dissection (LPLD) in patients with advanced low rectal cancer.

Methods

A review of a prospectively-collected database at Kyungpook National University Medical Center from January 2011 to November revealed a series of 8 consecutive robotic LPLD cases with a preoperative diagnosis of lateral node metastasis. Data regarding patient demographics, operating time, perioperative blood loss, surgical morbidity, lateral lymph node status, and functional outcome were analyzed.

Results

In all eight patients, the procedures were completed without conversion to open surgery. The mean operative time of extended pelvic node dissection was 38 minutes (range, 20 to 51 minutes), the mean number of lateral lymph nodes harvested was 4.1 (range, 1 to 13), and 3 patients (38%) were found to have lymph node metastases. Postoperative mortality and morbidity were 0% and 25%, respectively, but, there was no LPLD-related morbidity. The mean hospital stay was 7.5 days (range, 5 to 12 days).

Conclusion

Robotic LPLD is safe and feasible, with the advantage of being a minimally invasive approach. Further large-scale studies comparing robotic and conventional surgery with long-term follow-up evaluation are needed to confirm these findings.

Citations

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Techniques in Coloproctology.2025;[Epub] CrossRef
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Tarek A. Awad, Eslam Hassan, Safa Baqar, Hugh Mackenzie, Sebastian Smolarek
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Mohamed Ali Chaouch, Mohammad Iqbal Hussain, Adriano Carneiro da Costa, Alessandro Mazzotta, Bassem Krimi, Amine Gouader, Eddy Cotte, Jim Khan, Hani Oweira, Tsutomu Kumamoto
PLOS ONE.2024; 19(5): e0304031. CrossRef
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Gyu-Seog Choi, Hye Jin Kim
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Effect on the Local Recurrence and the Survival of Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection in Rectal Cancer.: Choi, Byung Gwan , Kim, Hyung Soo , Seo, Kyeong Won , Ju, Jae Kyoon , Ryu, Seong Yeob , Park, Young Kyu , Kim, Hyeong Rok , Kim, Dong Yi , Kim, Young Jin; J Korean Soc Coloproctol. 2007;23(1):46-52.; DOI: https://doi.org/10.3393/jksc.2007.23.1.46

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Abstract PDF: PURPOSE
One of the most common sites of recurrence after a curative resection of rectal cancer is the pelvis, and local control is a major goal of surgical treatment. The advantages of lateral pelvic lymph node dissection are regarded as questionable because lateral pelvic lymph node metastasis does not occur so frequently and because a lateral lymphadenectomy has a negative influence on the postoperative quality of life. The aim of this study was to clarify if lateral pelvic lymph node dissection (LPLD) conferred any benefit.
METHODS
A total of 769 patients who underwent curative surgery for rectal cancer between 1981 and 2005 at the Department of Surgery, OOO Hospital, were reviewed retrospectively. One hundred ninety-three of these patients underwent a lateral pelvic lymph node dissection, and 576 patients had a total mesorectal excision with high ligation of the IMA.
RESULTS
There was no difference in pathological characteristics between the two groups. Patients who underwent a lateral pelvic lymph node dissection had no statistically significant difference in terms of the 5-year survival rate at stage II and III (64% vs 65% at stage II, P=0.391; 49% vs 47% at stage III, P=0.815).
CONCLUSIONS
A lateral pelvic lymph node dissection has no advantage as part of a standard operation for rectal cancer. A total mesorectal excision alone has good local control and survival compared with a lateral pelvic lymph node dissection.

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