TECHNICAL NOTES
Lateral Node Dissection in Rectal Cancer in the
Era of Minimally Invasive Surgery: A Step-by-
Step Description for the Surgeon Unacquainted
with This Complex Procedure with the Use of the
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Laparoscopic Approach
Rodrigo Oliva Perez, M.D., Ph.D.1,2,3 • Guilherme P. São Julião, M.D.1
Bruna Borba Vailati, M.D.1 • Laura M. Fernandez, M.D.1 • Adrian E. Mattacheo, M.D.1
Tsuyoshi Konishi, M.D., Ph.D.4
1 Angelita & Joaquim Gama Institute, São Paulo, Brazil
2 University of São Paulo School of Medicine Colorectal Surgery Division, São Paulo, Brazil
3 Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil
4 Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
INTRODUCTION:  Lateral node dissection in rectal cancer
has been routinely performed in Eastern countries.
Technical and anatomical challenges and potential
significant postoperative morbidity associated with
the procedure have prevented its implementation into
clinical practice in Western countries. However, the
minimally invasive approach may offer the opportunity
of performing this complex procedure with precise
anatomical dissection and minimal intraoperative blood
loss. In this setting, proper training and standardization
of technical steps is highly warranted for surgeons not
fully acquainted with the procedure.
TECHNIQUE:  Access to the lateral nodes along the
obturator and internal iliac vessels is described by
using specific anatomical landmarks. Opening of the
peritoneum along the ureter provides access to the
region of interest. Dissection of the medial limit is
performed preserving the neurovascular bundle and
ureter. The lateral dissection is performed along the
external iliac vein to provide access to the obturator
Funding/Support: None reported.
Financial Disclosures: None reported.
Correspondence: Rodrigo Oliva Perez, M.D., Ph.D., Rua Manoel da
Nóbrega 1564, São Paulo – SP, Brazil 04001-005. E-mail: gamange@
uol.com.br; or Tsuyoshi Konishi, M.D., Ph.D., Ariake 3-8-31, Koto-ku,
Tokyo, Japan 135-8550. E-mail: tkonishi-tky@umin.ac.jp.
Dis Colon Rectum 2018; 61: 1237–1240
DOI: 10.1097/DCR.0000000000001182
© The ASCRS 2018
DISEASES OF THE COLON & RECTUM VOLUME 61: 10 (2018)
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
muscle. Identification of the obturator nerve with blunt
dissection of the fat is a critical part of the procedure.
Once the lymphatic connections between the inguinal
and iliac nodes are transected, dissection is performed
along the internal iliac vessels, and branches are separated
from the lymphadenectomy specimen.
RESULTS:  Evidence supports that lateral node
dissection performed for highly selected patients with
minimally invasive access leads to less intraoperative
blood loss and similar oncological outcomes. Technical
steps illustrated in the present video may aid surgeons
in performing this procedure with precise anatomical
landmarks and minimal risk for intraoperative
complications.
CONCLUSIONS:  Lateral node dissection for rectal cancer
is a procedure that may follow standardized technical
steps by using precise anatomical landmarks with the use
of minimally invasive approach.
KEY WORDS:  Extended lymphadenectomy; Lateral lymph
node dissection; Rectal cancer.
F
or decades, lateral node dissection (LND) has been
considered as a routine procedure in extraperitonial
(Rb) rectal cancer management in Japan, but has
been almost entirely neglected in Western countries.1 The
complexity of the procedure certainly contributed to its
unpopularity coupled with the potential detrimental con-
sequences associated with sexual and urinary functions
and fecal continence.2 Finally, with the lack of strong on-
cological data to support the routine prophylactic LND,
1237
 1238
consecutive generations in Western countries failed to
implement this surgical procedure into routine practice.3
Regardless of the optimal surgical indications for
LND, select patients with radiological evidence of lateral
node metastases may definitely benefit or even need prop-
er LND during or after total mesorectal excision for rectal
cancers.4
In this article, we provide an illustrated/pictorial de-
scription of the critical steps during laparoscopic LND in
an attempt to facilitate standardization of technique (see
Video, Supplemental Digital Content 1, http://links.lww.
com/DCR/A702).
TECHNIQUE
Anatomical Areas to be Dissected
Previous studies indicate that lateral lymphatic spread
from rectal cancer primarily reaches internal iliac and ob-
turator lymph nodes. Therefore, these 2 areas are the most
important in LND. In contrast, metastases to external iliac
or common iliac areas are extremely rare.
Setup
Lateral node dissection preferably should be performed
after total mesorectal excision (TME) has been completed
and before final primary anastomosis. Following extrac-
tion of the specimen, pneumoperitoneum is reestablished
and the lateral compartment is to be approached. Lateral
node dissection does not require additional trocars. In
general, 4 working trocars in addition to the camera trocar
are sufficient.
The left-sided compartment is usually best ap-
proached from the right side by the surgeon. The right-
sided compartment may be approached from the left side
by the surgeon in its early steps and then from the right
side for its most distal part of dissection.
Step 1: Ureter Dissection and Traction
The ureter should be identified at the level of its crossing
with the iliac vessels and fully individualized to allow trac-
tion by the use of an “endoloop.” The peritoneum covering
the ureter should be opened until the vas deferens (males)
or uterine artery crosses (females). Once this point is
reached, a clip is applied to the “endoloop” to apply medial
traction to the ureter and to establish the medial boundary
of dissection. There is no need to fully skeletonize the ure-
ter down to the vas deferens/uterine artery. In fact, leaving
its dorsal attachment as a sheath of connective tissue con-
nected to the inferior hypogastric nerve bundle will deter-
mine the medial curtain of the lateral node compartment.
Step 2: The Medial Wall
There is a “fascia” separating the fat from the ureter
and inferior hypogastric nerves from the lateral node
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
Perez et al: Lateral Node Dissection in Rectal Cancer
c­ompartment fat that needs to be separated toward the
dorsal or posterior limit of dissection. This will usually
lead to the identification of multiple arterial and venous
branches to the bladder that should not be approached at
this time. In female patients, most frequently, the uterine
artery on each side will branch off from the umbilical ar-
tery, crossing the ureter medially.
In fact, attempts to identify the exact anatomy at this
point in dissection may damage the neurovascular bundle
and be counterproductive. This step of dissection is not
entirely complete until one can clearly connect to the me-
sorectal compartment. This will create a medial wall that
is formed by the ureter and the nerve branches (S3 and
S4) that should be preserved. In the distal limit of this
dissection, one will see the internal obturator muscle at-
tachments to the levator muscle complex that will com-
municate with the lateral dissection. This will usually lead
to the creation of a connection between this compartment
and the mesorectal compartment that is completely empty
following the previously completed TME.
Step 3: The Lateral Wall
One now should be looking laterally to the external iliac
artery frequently covering the external iliac vein behind
it. By applying gentle traction to the artery or its attached
peritoneum, the vein should be fully dissected from its
medial side to allow removal of all fatty tissue and lead-
ing to the identification of the psoas (first) and internal
obturator (second) muscles. An accessory obturator vein
often branches off the most distal part of the external iliac
vein that should be promptly ligated with a clip. Dissec-
tion should also not proceed beyond the vas deferens/
round ligament.
This is the lateral boundary of dissection and should
leave the obturator muscle fascia naked of any attach-
ments until communicating with the dissection of the me-
dial wall. Here, small venous branches from the obturator
fatty tissue penetrate into the muscle wall, which are dealt
with by harmonic or sealing devices without the need for
clips. The obturator foramen, obturator vessels, and obtu-
rator nerve are seen and properly identified. Cautious use
of energy devices should be taken to avoid any injuries.
Step 4: Obturator Vessels and Nerve
Once the distal end of the obturator vessels are ligated at
the level of the obturator foramen entry point, lymphatic
vessels connecting the lateral to the inguinal compartment
are also identified and properly secured with a clip to avoid
postoperative lymphorrhea. Blunt dissection of the obtu-
rator nerve to allow removal of its surrounding fatty tissue
without thermal injury is performed proximally until the
bifurcation of internal and external iliac vein where the
obturator nerve comes behind. Here, lymphatic connec-
tions to common iliac lymph nodes are ligated with clips
to prevent postoperative lymphorrhea. This is the proxi-
 DISEASES OF THE COLON & RECTUM VOLUME 61: 10 (2018)
mal end of the dissection of the lateral node compartment.
The obturator vessels are ligated (with clips) at their origin
that can be identified by exposing internal iliac artery and
vein. Caution is needed because the origins of obturator
artery and vein may vary.
Note: Injuries to the obturator nerve are fortunately infre-
quent. Prolonged traction or even thermal injuries may
lead to only transient and minimal weakness during the
adduction of the lower limbs postoperatively. Complete
transection of the nerve is even less frequent. Even in
these cases, function has been reported to recover com-
pletely due to double innervation by sciatic nerves and
the compensatory mechanisms from other adduction
muscles.5
Step 5: The Umbilical Artery and the
Division of the Lateral Compartment
Traction should be applied gently to the vas deferens/
round ligament and its peritoneal sheath anteriorly (or al-
ternatively by placing a suture around it). This will provide
optimal exposure of the umbilical artery. The lymphatic
tissue of the lateral node compartment to be removed is
now only attached to its dorsal and anterior aspects. With-
in it runs the umbilical artery originating from the internal
iliac artery. This anatomical landmark divides the lateral
nodal compartment in 2: lateral (obturator) and medial
(internal iliac). Preserving the umbilical artery (when pos-
sible) will also preserve its primary branch (superior vesi-
cal artery) and should be attempted to minimize urinary
dysfunctional consequences.
Anatomic variations: The superior vesical artery may
branch from the internal iliac, just after the umbilical
artery or directly from the umbilical artery. Proximal to
the branches of the umbilical artery, the superior gluteus
artery comes off from the main internal iliac artery. This
artery is to be preserved because it runs very close to the
sciatic nerve. Finally, in female patients, the uterine artery
comes off most commonly from the umbilical artery or
sometimes just distal to this from the main internal iliac
artery.
Dissection here should be to skeletonize the umbili-
cal artery, removing all tissue surrounding the artery and
the superior vesical branch. In the case of suspicious nodes
along the artery, the best alternative is to ligate it at its ori-
gin to allow en bloc removal in this area.
The fatty tissue lateral to the umbilical artery includes
lateral/obturator nodes, whereas the fatty tissue between
the umbilical artery and the hypogastric plexus/ureter in-
cludes the medial/internal iliac nodes.
Following exposure of the umbilical artery, dissection
follows the avascular plane between bladder and lateral
adipose tissue (vesicohypogastric fascia) that constitutes
the internal border of obturator nodal compartment.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
1239
During this dissection, you will see entry points of vesical
vessels into neurovascular bundle, which are left without
division at this point. In the distal limit of this dissection,
you will end up by encountering the internal obturator
muscle.
Step 6: The Dorsal Limits
Distal and slightly to the side of the origin of the umbili-
cal artery, the internal iliac artery branches off to shortly
give rise to inferior vesical artery branches. Inferior vesi-
cal arterial and venous branches are encountered and
properly ligated both at the origin of the internal iliac
vessels and at the roof of the dissection close to the blad-
der. Ligation of these vessels is not mandatory but often
required as this is the common place for lateral nodal
metastasis.
Note: Dissection around distal part of internal iliac vessels
(pudendal artery/vein) where inferior vesical vessels come
off may be the most “dangerous” part of the procedure be-
cause of the risk of significant venous bleeding.
Step 7: The Anterior Limit
Finally, there will be only the anterior bit for resection.
Here, there are the inferior and superior vesical vessels at-
taching to the bladder that should be ligated or preserved
according to the previous strategy adopted. In the most
distal part of dissection, you will find the neurovascular
bundle that should be preserved (if not directly invaded by
metastatic nodes). Dissection is complete and the speci-
men may be removed as a single specimen.
RESULTS
The only prospective randomized study that performed
in Japan compared prophylactic bilateral lateral pelvic
node resection and TME with TME alone in locally ad-
vanced rectal cancer failed to demonstrate noninferior-
ity for the TME-alone group.3 However, the study was
performed for patients with unsuspected lateral node
metastases and outside the setting of neoadjuvant chemo-
radiation. Therefore, evidence for the use of prophylactic
LND is still lacking in the setting of prior neoadjuvant
chemoradiation.
CONCLUSIONS
Lateral pelvic node dissection is a procedure that should
be considered for inclusion in the armamentarium of
colorectal surgeons in the setting of referral centers with a
specific focus in the multidisciplinary management of rec-
tal cancer. Standardization of the procedure by minimally
invasive surgery may facilitate the dissection and provide
optimal early and oncological outcomes.
 1240
However, before such a technique is implemented into
clinical practice, formal training with structured courses
and, most likely, cadaveric dissections should be consid-
ered for training surgeons not fully acquainted with the
procedure (as it has been suggested for other newly de-
veloped procedures).6 This could potentially abbreviate
learning curves while decreasing the risk of intraoperative
complications/injuries in the early adoption phase. Also,
proctoring of the initial experience may further provide
confidence and safety with this technically challenging
procedure. Finally, as refinement of precise indication for
the procedure evolves, selection of ideal candidates will
also be critical for achieving optimal outcomes.
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