Robotic Lateral Pelvic Lymph Node Dissection

Neoadjuvant (chemo)radiotherapy followed by total mesorectal excision (TME) has been a standard practice for c-Stage II–III rectal cancer in the Western countries. With improved surgical management in the central pelvis, majority of pelvic local recurrence has now shifted to the lateral pelvic compartment (Fig. 11.1). Lateral pelvic lymph node dissection (LPLND) has been performed for decades by Japanese surgeons as a standard practice for mid-low rectal cancer extending below the peritoneal reflexion. A recent international observational studies by the Lateral Node Consortium demonstrated oncologic benefits of adding LPLND to TME after neoadjuvant (chemo)radiotherapy in patients with enlarged lateral lymph nodes. LPLND is a great armamentarium of colorectal surgeons in the setting of referral centers. Autonomic nerve-preserving technique is important for minimizing postoperative urinary and sexual dysfunction. Anatomical plane-oriented dissection of the obturator and internal iliac compartments is required to achieve safe and complete lymph node dissection. A robotic approach provides more advanced knowledge of pelvic anatomy particularly outside of the TME. Standardization of this procedure may facilitate the dissection and provide optimal early and oncological outcomes. In this chapter, step-by-step procedures and technical tips of robotic LPLND are presented.