Published online Jun 28, 2021. doi: 10.3748/wjg.v27.i24.3654
Peer-review started: December 15, 2020
First decision: January 6, 2021
Revised: January 20, 2021
Accepted: February 24, 2021
Article in press: February 24, 2021
Published online: June 28, 2021
Processing time: 189 Days and 21.3 Hours
Lateral lymph node (LLN) metastasis is a major cause for local recurrence in rectal cancer. In Japan, LLN dissection (LLND) is the standard treatment for locally advanced low rectal cancer (LALRC). However, the procedure is complicated with significant morbidity. In recent years, with the rise of “fascia anatomy”, more and more surgeons began to explore LLND based on the fascial space approach.
LLND is a challenging procedure due to its technical difficulty and higher incidence of complications. The development of “fascia anatomy” provides a new sight for improving the accuracy and safety of laparoscopic LLND. However, the detailed anatomy is not clear and a standard surgical procedure has not yet been established.
We developed a technique of laparoscopic LLND in two fascial spaces formed by three layers of fasciae. This study aimed to describe the surgical procedure on an anatomical basis and to summarizes our preliminary surgical experiences in the treatment of LALRC.
Detailed pelvic dissections were performed in 24 cadavers, and the fasciae and spaces related to LLND were observed and described. 20 patients with LALRC received 3D-laparoscopic total mesorectal excision with LLND at our hospital from July 2018 to October 2020, and their surgical videos and clinical data were analyzed.
The urogenital fascia lies posterolateral to the rectum, and the hypogastric nerve and ureter are observed to be enveloped in it; vesicohypogastric fascia shows a triangle shape formed by the umbilical artery, the tendinous arch of the pelvic fascia and the lateral border of the bladder. In all 24 cadavers, urogenital fascia, vesicohypogastric fascia and obturator fascia (parietal fascia) were located lateral to the rectum in a medial-to-lateral direction and form the Okabayashi's pararectal space and paravesical space, respectively, which were the surgical area for LLND. Laparoscopic LLND was performed successfully in all 20 LALRC patients with a median postoperative hospitalization of 10 (7-20) d. The median operating time was 178 (152-243) min, with a median blood loss of 55 (25-150) mL. The median number of harvested LLNs was 8.6 (6-12), and 7 patients (35.0 %) had LLN metastasis. Postoperative complications included lymph leakage and lower limb pain in 1 case, respectively.
This study indicated that urogenital fascia, vesicohypogastric fascia and parietal fascia lie side by side in the pelvis and formed two spaces (Latzko's pararectal space and paravesical space), which were the surgical area for LLND. Performing LLND in two fascial spaces is a feasible surgical approach, which improves surgical safety while ensuring radical tumor resection.
The present study preliminarily explored the clinical significance of laparoscopic LLND in two fascial spaces for treating LALRC. However, large studies with long-term follow-up and more detailed clinical data are needed to confirm these findings.