Laparoscopy-assisted lateral pelvic lymph node dissection for advanced rectal cancer

In Japan, there has been no indication of laparoscopic surgery for advanced lower rectal cancer because of the problem about the treatment of lateral pelvic lymph node metastasis. We report a new technique which allows lateral pelvic lymph node dissection like in open surgery for advanced rectal cancer. After laparoscopic total mesorectal excision for rectal cancer, a surgical incision of approximately 8 cm is placed in the supra-pubic area. Then, the latero-vesical area of the retroperitoneum, latero-vesical space is dissected bluntly with forceps. The external iliac artery and vein are taped and lymph node dissection is performed. As the external iliac vein is pulled internally, fatty tissue including lymph nodes in the obturator space is separated from the psoas major muscle. After completing of such a procedure, the obturator nerve is indentified in the fatty tissue with surrounding lymph nodes. As the external iliac vein is pulled laterally, fatty tissue including lymph nodes in the oburator space is dissected by fat aspiration procedure (FAP) using a suction tip. FAP is helpful to confirm the vascular system, by which the obturator space is skeletonized and anatomical structures are identified clearly.