title: Multimedia article. Lateral lymph node dissection with preoperative chemoradiation for locally advanced lower rectal cancer through a laparoscopic approach.
abstract: BACKGROUND
  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].
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Laparoscopic LLN dissection can be safely conducted with minimal postoperative complications.
authors.affiliation: 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. tsuyoshikonishi@pop07.odn.ne.jp
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Konishi
authors.forename: Hiroya
authors.initials: H
authors.lastname: Kuroyanagi
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Oya
authors.forename: Masashi
authors.initials: M
authors.lastname: Ueno
authors.forename: Yoshiya
authors.initials: Y
authors.lastname: Fujimoto
authors.forename: Takashi
authors.initials: T
authors.lastname: Akiyoshi
authors.forename: Hidehiko
authors.initials: H
authors.lastname: Yoshimatsu
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Watanabe
authors.forename: Toshiharu
authors.initials: T
authors.lastname: Yamaguchi
authors.forename: Tetsuichiro
authors.initials: T
authors.lastname: Muto
mesh_terms: D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008197:Lymph Node Excision; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome