Laparoscopic lateral lymph node dissection for locally advanced low rectal cancers: A technical note with video vignette

Lateral lymph node dissection for locally advanced low rectal cancers is a complicated and technically demanding procedure. However, minimally invasive approaches have been attempted in this extended dissection. This report details the surgical technique for laparoscopic lateral lymph node dissection in patients with locally advanced low rectal cancer. Before dissection, the ureter and the autonomic nerves are isolated, keeping them attached to the ureterohypogastric nerve fascia, and the dissection usually involves the obturator nodes and the internal iliac nodes. The inside of the obturator region is dissected along the vesicohypogastric fascia, while the outside along the psoas major and internal obturator muscles. The dissection continues along the internal iliac vessels, superior gluteal vessels, the sacral plexus, inferior vesical vessels, and internal pudendal artery to reach Alcock's canal, where the obturator nodes are removed en bloc . The internal iliac nodes are dissected along the surface and inside the internal iliac vessels. With the aid of the excellent magnified imaging of the complicated anatomy in the deep confined pelvic space, the use of advanced energy devices such as vessel-sealing systems, ultrasonic coagulation devices, or soft coagulations under such an excellent view, the head-down position and positive intraperitoneal pressure, laparoscopic lateral lymph node dissection allows for meticulous procedures with significant reduction in blood loss. Laparoscopic lateral lymph node dissection is feasible and safe for patients with locally advanced low rectal cancer, and enables meticulous dissection with reduced blood loss.