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Review
. 2017 Nov;30(5):346-356.
doi: 10.1055/s-0037-1606112. Epub 2017 Nov 27.

Is There Any Reason to Still Consider Lateral Lymph Node Dissection in Rectal Cancer? Rationale and Technique

Miranda Kusters  1   2 , Keisuke Uehara  3 , Cornelis J H van de Velde  2 , Yoshihiro Moriya  4
Affiliations
Review

Is There Any Reason to Still Consider Lateral Lymph Node Dissection in Rectal Cancer? Rationale and Technique

Miranda Kusters et al. Clin Colon Rectal Surg. 2017 Nov.

Abstract

Nodal dissemination in locally advanced rectal cancer occurs mainly in two directions: upward and lateral. Lateral node involvement has been demonstrated; however, lateral lymph node dissection (LLND) is not routinely performed in Western countries and the focus is more on neoadjuvant treatment regimens. The main reasons for this are the high morbidity associated with the operation and the uncertain oncological benefit. There is, however, recent evidence that in selected cases, neoadjuvant treatment combined with total mesorectal excision only might not be sufficient. In this article, the historical developments in the East and the West, the current evidence regarding lateral nodal disease, and the surgical steps in the LLND are discussed.

Keywords: lateral nodes; local recurrence; rectal cancer.

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Conflict of interest statement

Conflict of interest None.

Figures

Fig. 1
Fig. 1
Pictures after LLND by traditional open approach. LLND, lateral lymph node dissection.
Fig. 2
Fig. 2
(a) The operating surgeon stands on the right side of the patient during the left-sided LLND. (b) The surgeon moves to the left side when the right-sided LLND is performed. At that time, the camera should be inserted from the left upper port. (C) Assistant holding camera; (S) surgeon; (A) assisting surgeon; LLND, lateral lymph node dissection.
Fig. 3
Fig. 3
(a) A scheme of lateral pelvis. (b) Three partitions are shown. 1, hypogastric nerve to the pelvic plexus; 2, main trunk of the internal iliac vessels and several branches to the urinary bladder, prostate, and neurovascular bundle; 3, internal obturator muscle.
Fig. 4
Fig. 4
(a) The ureter should be fully mobilized. (b) The medial border is the hypogastric nerve. (c) The lateral borders are the common and internal iliac vessels. (d) Dorsally, the sacral periosteum is exposed. (e) The distal end of the area A is around the first branch of the inferior vesicle vessel. (f) The medial border of the obturator space is opened. (g) The dorsal edge of the external iliac vein is exposed. (h) Dissection is proceeded down along to the internal obturator muscle. (i) The obturator nerve is preserved, but the obturator vessels are dissected. (j) The roots of the obturator vessels are divided. (k) The fat tissue of obturator space is completely removed. (l) The view after LLND with total autonomic nerve preservation. LLND, lateral lymph node dissection.
Fig. 5
Fig. 5
(a) View after combined resection of the main trunk of the internal iliac artery and vein. The sacral nerve plexus is fully exposed at the bottom. (b) The main trunk of the internal iliac vein is usually preserved and only the trunk of the artery is divided.
See this image and copyright information in PMC

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