Department of Gastroenterological Surgery, Cancer Institute Hospital, and Department of Surgery, Teikyo University School of Medicine, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
Surg Endosc. 2011 Jul;25(7):2358-9. doi: 10.1007/s00464-010-1531-y. Epub 2011 Feb 7.
Lateral lymph node (LLN) dissection contributes to a decrease in local recurrence and prolongs survival in locally advanced lower rectal cancer patients as compared with total mesorectal excision (TME) alone [1, 2]. However, this procedure is also accompanied by increased bleeding and postoperative complications [3, 4]. Recently, laparoscopic TME has become a safe and feasible approach for lower rectal cancer even after preoperative chemoradiation [5-7]. Laparoscopic LLN dissection could be the next promising approach and could not only provide a survival benefit but also minimize bleeding and postoperative complications with enhanced visualization, as reported in gynecological and urological malignancies [8, 9].
A total of 14 patients underwent laparoscopic LLN dissection with TME after preoperative chemoradiation. Our standardized procedure for LLN dissection is seen in the video. After completion of TME, as described previously [5, 6], the obturator nerve is identified between the external and internal iliac arteries and the obturator lymph nodes are dissected along this nerve to reach the obturator foramen. The internal iliac lymph nodes are dissected along the surface of the internal iliac vein, carefully preserving the pelvic nerve plexus.
The procedure was successfully accomplished in all cases without conversion to laparotomy. The median amount of bleeding and operative time were 25 (range=5-1190) ml and 413 (range=277-596) min, respectively. The median number of retrieved lymph nodes was 23 (range=14-33), and eight cases had metastasis in the retrieved LLNs. Postoperative recovery was excellent, with median time to flatus of 1 (range=1-2) day. Postoperative complications included three wound infections, one anastomotic leakage, and one presacral abscess, and all recovered without surgical intervention. There was no urinary dysfunction. After a mean follow-up of 17 (range=8-43) months, all 14 patients were alive without recurrence.
Laparoscopic LLN dissection can be safely conducted with minimal postoperative complications.
与单纯直肠系膜全切除（TME）相比，侧方淋巴结清扫（LLN）可降低局部复发率并延长局部晚期低位直肠癌患者的生存时间[1,2]。然而，该手术也伴随着出血量增加和术后并发症增加[3,4]。最近，即使在术前放化疗后，腹腔镜 TME 也成为了一种安全可行的低位直肠癌治疗方法[5-7]。腹腔镜 LLN 清扫术可能是一种有前途的方法，不仅可以提供生存获益，还可以通过增强可视化来最小化出血和术后并发症，在妇科和泌尿科恶性肿瘤中已有报道[8,9]。
共有 14 例患者在术前放化疗后接受了腹腔镜 LLN 清扫术加 TME。我们的 LLN 清扫标准化操作流程见视频。完成 TME 后，如前所述[5,6]，在髂外动脉和髂内动脉之间识别闭孔神经，并沿着这条神经清扫闭孔淋巴结以到达闭孔。沿着髂内静脉表面清扫髂内淋巴结，小心保留盆腔神经丛。
所有病例均成功完成手术，无中转开腹。术中出血量和手术时间中位数分别为 25（范围=5-1190）ml 和 413（范围=277-596）min。平均清扫淋巴结 23（范围=14-33）枚，8 例清扫淋巴结有转移。术后恢复良好，中位排气时间为 1（范围=1-2）天。术后并发症包括 3 例伤口感染、1 例吻合口漏和 1 例直肠前间隙脓肿，均无需手术干预即可恢复。无尿功能障碍。平均随访 17（范围=8-43）个月后，所有 14 例患者均存活且无复发。
腹腔镜 LLN 清扫术可以安全进行，术后并发症少。
