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

Conventional open lateral lymph node (LLN) dissection performed along the internal iliac vessels frequently results in increased bleeding and postoperative complications [1, 2]. However, laparoscopic LLN dissection is a feasible, oncologically acceptable alternative [3-6]. We have developed a laparoscopic autonomic nerve-preserving technique for LLN dissection based on the vesicohypogastric fascia (VF) and ureterohypogastric nerve fascia (UNF) [7]. Surgical and oncological outcomes were compared between 12 patients undergoing laparoscopic hemi-LLN dissection and 13 patients undergoing conventional open hemi-LLN dissection. Our standardized procedure for LLN dissection is shown in the video. The number of harvested LLNs and the postoperative hospital stay was similar in both groups. In the open dissection (OD) and laparoscopic dissection (LD) groups, the median operation times were 373.3 and 443.1 min, respectively. However, the median (range) blood loss was 38.8 (20-75) ml in the LD group versus 836.9 (365-2060) ml in the OD group. One LD patient had anastomotic leakage and one had hydronephrosis. One OD patient had anastomotic leakage, four had small bowel obstruction, three had wound infection and one had lymphatic leakage. Postoperative recovery was faster in the LD group: The median time to resumption of oral intake was 3.3 (2-6) days, versus 8.7 (3-34) days in the OD group. There was one case of grade 2 urinary retention in the LD group, but there were five cases of grade 2 or 3 urinary retention in the OD group. Surgical curability was R0 in all LD patients, whereas 7 of 13 patients were R0 in the OD group. After a mean follow-up of 24.4 (16.2-45.3) months, all LD patients were alive without recurrence. After 31.5 (6-63) months, three OD patients had local recurrence and two had distant metastasis. Laparoscopic LLN dissection based on VF and UNF is feasible, with acceptable surgical and oncological outcomes.