Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 28, 2021; 27(24): 3654-3667
Published online Jun 28, 2021. doi: 10.3748/wjg.v27.i24.3654
Laparoscopic lateral lymph node dissection in two fascial spaces for locally advanced lower rectal cancer
Hui-Hong Jiang, Hai-Long Liu, A-Jian Li, Wen-Chao Wang, Liang Lv, Jian Peng, Zhi-Hui Pan, Yi Chang, Mou-Bin Lin
Hui-Hong Jiang, Hai-Long Liu, A-Jian Li, Wen-Chao Wang, Liang Lv, Jian Peng, Zhi-Hui Pan, Yi Chang, Mou-Bin Lin, Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, China
Hui-Hong Jiang, Hai-Long Liu, Yi Chang, Mou-Bin Lin, Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai 200090, China
Author contributions: Lin MB conceived the study and was the corresponding author; Jiang HH, Liu HL, Li AJ and Wang WC performed the study; Lv L, Peng J and Pan ZH helped collect the data; Liu HL and Chang Y analyzed and interpreted the data; Jiang HH drafted the manuscript; Jiang HH and Liu HL shared first co-authorship.
Supported by The National Natural Science Foundation of China, No. 81874201.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Yangpu Hospital, Tongji University School of Medicine, No. LL-2020-KXJS-004.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mou-Bin Lin, MD, Surgeon, Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, No. 450 Tengyue Road, Shanghai 200090, China. 1500142@tongji.edu.cn
Received: December 15, 2020
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
ARTICLE HIGHLIGHTS
Research background

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.

Research motivation-

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.

Research objectives

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.

Research methods

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.

Research results

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.

Research conclusions

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.

Research perspectives

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.