• CUSUM methodology
• Lateral pelvic lymph node dissection
• Learning curve
• Rectal cancer
• Robotic surgery

• Humans
• Learning Curve
• Retrospective Studies
• Robotic Surgical Procedures/methods
• Robotic Surgical Procedures/adverse effects
• Middle Aged
• Rectal Neoplasms/surgery
• Male
• Female
• Lymph Node Excision/methods
• Operative Time
• Aged
• Neoplasm Staging
• Prophylactic Surgical Procedures/methods
• Prophylactic Surgical Procedures/statistics & numerical data
• Postoperative Complications/prevention & control
• Postoperative Complications/etiology
• Clinical Competence/statistics & numerical data

• Extended mesorectal excision
• Laparoscopic surgery
• Rectal cancer
• Robotic-assisted surgery
• eTME

• Humans
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Lymph Node Excision/adverse effects
• Lymph Node Excision/methods
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectum/surgery
• Robotic Surgical Procedures/adverse effects
• Robotic Surgical Procedures/methods
• Treatment Outcome

• laparoscopic surgery
• lateral pelvic lymph node
• rectal cancer
• surgical dissection
• survival

• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectal Neoplasms/mortality
• Lymph Node Excision/methods
• Lymph Node Excision/adverse effects
• Male
• Female
• Laparoscopy/methods
• Laparoscopy/adverse effects
• Middle Aged
• Retrospective Studies
• Aged
• Adult
• Postoperative Complications/epidemiology
• Lymphatic Metastasis
• Operative Time
• Feasibility Studies
• Treatment Outcome
• Disease-Free Survival
• Pelvis

• Chemoradiation
• Lateral pelvic node dissection
• Local recurrence
• Rectal neoplasms
• Total neoadjuvant therapy

• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Laparoscopy/methods
• Lymph Node Excision/methods
• Robotic Surgical Procedures/methods
• Robotic Surgical Procedures/adverse effects
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Length of Stay
• Rectum/surgery
• Rectum/pathology
• Treatment Outcome

• Feasibility
• Lateral pelvic lymph node
• Rectal cancer
• Robot-assisted surgery

• Male
• Humans
• Prospective Studies
• Robotics
• Robotic Surgical Procedures/methods
• Lymph Node Excision/adverse effects
• Rectal Neoplasms/pathology
• Lymphatic Metastasis
• Retrospective Studies
• Treatment Outcome

• lateral pelvic lymph node dissection
• pelvic sidewall
• rectal cancer
• robotic

We aimed to evaluate the surgicopathological outcomes of lateral pelvic lymph node dissection (LPLD) and long-term oncological outcomes of selective LPLD after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer and compare them to those of total mesorectal excision (TME) alone based on pretreatment magnetic resonance imaging (MRI).

We compared the TME-alone group (2001–2009, n=102) with the TME with LPLD group (2011–2016, n=69), both groups having lateral lymph nodes (LLNs) of ≥5 mm in short axis diameter. The surgicopathological outcomes were analyzed retrospectively. Oncological outcomes were analyzed using the Kaplan-Meier method.

The rates of overall postoperative 30-day morbidity (42.0% vs. 26.5%, P=0.095) and urinary retention (13.7% vs. 10.1%, P=0.484) were not significantly different between the LPLD and TME-alone groups, respectively. Pathologically proven LLN metastasis was identified in 24 (34.8%) LPLD cases after nCRT. The LPLD group showed a lower 5-year local recurrence (LR) rate (27.9% vs. 4.6%, P<0.001) and better recurrence-free survival (RFS) (59.6% vs. 78.2%, P=0.008) than those of the TME-alone group, while the 5-year overall survival was not significantly different between the 2 groups (76.2% vs. 86.5%, P=0.094).

This study suggests that LPLD is a safe and feasible procedure. The oncological outcomes suggest that selective LPLD improves LR and RFS in patients with clinically suspicious LLNs on pretreatment MRI. Considering that lateral nodal disease is not common, a multicenter large-scale study is necessary.

• Lateral pelvic lymph node dissection
• Neoadjuvant chemoradiotherapy
• Rectal cancer

• Colorectal neoplasm
• Minimally invasive surgery
• Robotic surgery

• Colonic Neoplasms/surgery
• Humans
• Laparoscopy
• Learning Curve
• Operative Time
• Rectal Neoplasms/surgery
• Robotic Surgical Procedures/economics
• Robotic Surgical Procedures/education
• Robotic Surgical Procedures/instrumentation

• Disease-free survival
• Laparoscopy
• Lymph node excision
• Lymph nodes
• Neoplasm recurrence
• Overall survival
• Rectal neoplasms
• Robotic surgical procedures

• Lateral pelvic lymph nodes
• Low rectal cancer

We aimed to show that a standardized step-by-step robotic approach using surgical landmarks could make lateral pelvic lymph node dissection (LPND) less complicated. We performed robot-assisted LPND consisting of 4 steps using surgical landmarks. The first step is a dissection of uretero-hypogastric fascia, which envelopes the ureter and the hypogastric nerve. The second step is a dissection of the medial side of the external iliac vein located at the lateral border of the obturator lymph nodes (LNs) group. The third step is a dissection of the vesico-hypogastric fascia, which is at the medial border of the obturator LNs group. The final step is a dissection of the internal iliac artery until the Alcock’s canal. Indocyanine green was injected just before surgery around the dentate line to identify the lateral pelvic LNs. Standardization using a robotic approach for LPND guided by surgical landmarks allows a safer and more effective surgery.

• Lateral pelvic lymph node dissection
• Rectal neoplasms
• Robotic surgical procedures

The number of patients undergoing robotic surgery for rectal cancer has rapidly increased in Japan, since the government approved the procedure for national insurance coverage in April 2018. Robotic surgery has the potential to overcome some limitations of laparoscopic surgery, especially in the narrow pelvis, providing a three-dimensional view, articulated instruments, and a stable camera platform. Although meta-analyses and randomized controlled trials have failed to demonstrate the superiority of robotic surgery over laparoscopic surgery with respect to the short-term clinical outcomes, the published findings suggest that robotic surgery may be potentially beneficial for patients who are obese, male, or patients undergoing sphincter-preserving surgery for rectal cancer. The safety and feasibility of robotic surgery for lateral lymph node dissection, the standard procedure for locally advanced lower rectal cancer in Japan, have been demonstrated in some retrospective studies. However, additional prospective, randomized trials are required to determine the actual benefits of robotic surgery to ameliorate the urogenital and oncological outcomes. The cost of this approach is a long-standing principal concern. A literature search showed that the cost of robotic surgery for rectal cancer was 1.3-2.5 times higher per patient than that for the laparoscopic approach. We herein describe our surgical technique using a da Vinci Surgical System (S/Si/Xi) with 10 years of experience in performing robotic surgery. We also review current evidence regarding short-term clinical and long-term oncological outcomes, lateral lymph node dissection, and the cost of the procedure.

• Laparoscopic surgery
• Lateral lymph node dissection
• Mesorectal excision
• Minimally invasive surgery
• Rectal cancer
• Robotic surgery

In the era of neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision, overall oncological outcomes after curative resection of rectal cancer are excellent, with local recurrence rates as low as 5–10%. However, lateral nodal disease is a major cause of local recurrence after neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision. Patients with lateral nodal disease have a local recurrence rate of up to 30%. The oncological benefits of lateral pelvic lymph node dissection (LPLND) in reducing local recurrence, particularly in the lateral compartment, have been demonstrated. Although LPLND is not standard in Western countries, technical improvements in minimally invasive surgery have resulted in rapid technical standardization of this complicated procedure. The feasibility and short- and long-term outcomes of laparoscopic and robotic LPLND have been reported widely. A minimally invasive approach has the advantages of less bleeding and providing a better surgical view of the deep pelvic anatomy than an open approach. With precise autonomic nerve preservation, postoperative genitourinary dysfunction has been reported to be minimal. We review recent evidence on the management of lateral nodal disease in rectal cancer and technical improvements of LPLND, focusing on laparoscopic and robotic LPLND.

• Laparoscopic
• Lateral lymph node dissection
• Rectal cancer
• Robotic

As robotic surgery is increasingly performed in patients with colorectal diseases, understanding proper port placement for robotic colorectal surgery is necessary. This review summarizes current port placement during robotic surgery for colorectal diseases and provides future perspective on port placements.

PubMed were searched from January 2009 to December 2018 using a combination of the search terms “robotic” [MeSH], “colon” [MeSH], “rectum” [MeSH], “colorectal” [MeSH], and “colorectal surgery” [MeSH]. Studies related to port placement were identified and included in the current study if they used the da Vinci S, Si, or Xi robotic system and if they described port placement.

This review included 77 studies including a total of 3,145 operations. Fifty studies described port placement for left-sided and mesorectal excision; 17, 3, and 7 studies assessed port placement for right-sided colectomy, rectopexy, transanal surgery, respectively; and one study assessed surgery with reduced port placement. Recent literatures show that the single-docking technique included mobilization of the second and third robotic arms for the different parts without movement of patient cart and similar to previous dual or triple-docking technique. Besides, use of the da Vinci Xi system allowed a more simplified port configuration.

Robot-assisted colorectal surgery can be efficiently achieved with successful port placement without movement of patient cart dependent on the type of surgery and the robotic system.

• Colon
• Rectum
• Robotic surgical procedure
• Robotics
• Surgery

• Medical Knowledge
• Patient Care
• Practice-Based Learning and Improvement
• cumulative sum
• multiple regression analysis
• rectal surgery
• robotic surgery

• Adult
• Aged
• Aged, 80 and over
• Digestive System Surgical Procedures/education
• Digestive System Surgical Procedures/methods
• Female
• Humans
• Learning Curve
• Lymph Node Excision/education
• Lymph Node Excision/methods
• Male
• Middle Aged
• Rectum/surgery
• Regression Analysis
• Retrospective Studies
• Robotic Surgical Procedures/education

• Lateral lymph node dissection
• Long-term outcome
• Open surgery
• Rectal cancer
• Robotic-assisted laparoscopic surgery

• Laparoscopic surgery
• Lateral pelvic lymph node dissection
• Robotic surgery

Although lateral pelvic lymph node (LPN) metastasis is a major cause of local recurrence in patients with rectal cancer, controversy still remains on the treatment of suspected LPN metastasis, “suspicious LPN”. We aimed to determine the optimal treatment strategies for suspicious LPN, in patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy (CRT).

Of 377 patients who received preoperative CRT for rectal cancer between 2006 and 2013, 84 (22.3%) had suspicious LPNs on pretreatment MRI. Patients’ characteristics, MRI findings, operative and pathologic findings, and oncologic outcomes were analyzed retrospectively.

Of 84 patients with suspicious LPNs, 61 showed good response to CRT on posttreatment MRI (short-axis LPN diameter < 5 mm). Among them, 31 patients underwent TME alone (group A), and 30 underwent TME plus LPND (group B). The remaining 23 patients had persistently suspicious LPNs on post-CRT MRI and underwent TME plus LPND (group C). Pathologic LPN metastasis was confirmed in five patients (16.7%) in group B and 15 (62.5%) in group C. Local recurrence developed in 7 (22.6%), 0 (0%), and 4 (17.4%) patients in groups A, B, and C, respectively. Five patients (16.1%) in group A developed in situ LPN recurrences. The 3-year disease-free survival rates were 53.7%, 74.2%, and 46.9% in groups A, B, and C, respectively.

Study findings suggested that LPND cannot be omitted for patients with suspicious LPNs on pretreatment MRI even with good response to CRT. Findings from pretreatment MRI should be considered to determine whether LPND is indicated.

• lateral pelvic lymph node dissection
• locally advanced rectal cancer
• preoperative chemoradiation

• Laparoscopic surgery
• Oncological outcomes
• Rectal cancer
• Robotic surgery

• Laparoscopic surgery
• Oncological outcomes
• Rectal cancer
• Robotic surgery

• Adenocarcinoma/mortality
• Adenocarcinoma/surgery
• Adenocarcinoma/therapy
• Adult
• Aged
• Aged, 80 and over
• Chemoradiotherapy, Adjuvant
• Female
• Follow-Up Studies
• Humans
• Laparoscopy
• Male
• Middle Aged
• Neoadjuvant Therapy
• Rectal Neoplasms/mortality
• Rectal Neoplasms/surgery
• Rectal Neoplasms/therapy
• Rectum/surgery
• Retrospective Studies
• Robotic Surgical Procedures
• Survival Analysis

• Extra-regional
• colorectal cancer
• lymph node
• surgical management and metastasis

• Colorectal Neoplasms/pathology
• Colorectal Neoplasms/surgery
• Colorectal Neoplasms/therapy
• Humans
• Lymph Node Excision/methods
• Lymphatic Metastasis
• Neoplasm Recurrence, Local
• Prognosis
• Survival Rate

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer. Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.

• Rectal cancer
• Total mesorectal excision
• Laparoscopic surgery
• Extended surgery
• Lateral pelvic lymph node dissection
• Pelvic exenteration

• Humans
• Laparoscopy/adverse effects
• Laparoscopy/mortality
• Neoplasm Recurrence, Local
• Postoperative Complications/etiology
• Rectal Neoplasms/diagnostic imaging
• Rectal Neoplasms/mortality
• Rectal Neoplasms/pathology
• Rectal Neoplasms/surgery
• Risk Factors
• Treatment Outcome

• Lateral lymph node dissection
• Open surgery
• Rectal cancer
• Robotic-assisted laparoscopic surgery
• Short-term outcome

Magnetic resonance imaging (MRI) in rectal cancer was first investigated in 1999 and has become almost mandatory in planning rectal cancer treatment. MRI has a high accuracy in predicting circumferential resection margin involvement and is used to plan neoadjuvant therapy. The accuracy of MRI in assessing mesorectal lymph nodes remains moderate, as there are no reliable criteria to assess nodal involvement. MRI seems to be good in assessing peritoneal involvement in upper rectal cancer; this however has been assessed in only a few studies and needs further research. For low rectal cancers, mesorectum is thin at the level of levator ani especially in relation to prostate; so predicting circumferential resection margin involvement is not easy. However high spatial resolution coronal imaging shows levator muscles, sphincter complex and intersphincteric plane accurately. This is used to stage low rectal tumors and plan plane of surgery (standard surgery, intersphincteric resection, Extralevator abdominoperineal resection). While most centres perform MRI post chemoradiotherapy, its role in accurate staging post neoadjuvant therapy remains debatable. THe role of Diffusion weighted MRI post neoadjuvant therapy is being evaluated in research settings.

• Magnetic resonance imaging
• Rectal cancer
• Surgeon

• Chemoradiotherapy
• Diffusion Magnetic Resonance Imaging
• Ferric Compounds/chemistry
• Humans
• Magnetic Resonance Imaging
• Neoadjuvant Therapy
• Neoplasm Staging
• Rectal Neoplasms/pathology
• Rectal Neoplasms/surgery
• Reproducibility of Results
• Treatment Outcome

• Laparoscopy
• Lymph node excision
• Rectal neoplasms
• Robotics