Robotic Lateral Pelvic Lymph Node Dissection after Neoadjuvant Chemoradiation: View from the West.

1119 DISEASES OF THE COLON & RECTUM VOLUME 61: 9 (2018) Neoadjuvant chemoradiation (nCRT) and total mesorectal excision (TME) are the current standard treatment for locally advanced rectal cancer in Western countries. However, lateral pelvic lymph node (LPLN) metastasis, beyond the TME plane, has increasingly become an important clinical problem. To solve this problem, Japanese surgeons have routinely performed lateral pelvic lymph node dissection (LPLND) and TME for low rectal cancer. In contrast, Western surgeons have not adopted this strategy because of a concern regarding technical difficulty and morbidity, especially in the more obese Western population. Recent data suggest that patients with clinically positive LPLN have a high risk of treatment failure with TME plus either nCRT or LPLND. In particular, the surgical management of residual macroscopically enlarged LPLN after nCRT is an important issue that remains unaddressed in Western series. In our institution, for patients with clinically involved LPLN, we utilize the combined strategy of nCRT and LPLND. This video demonstrates the technique of roboticassisted LPLND in a 38-year-old Western patient who has rectal cancer with the BMI = 29 kg/m. For clarification, we annotated the video with schematic anatomical descriptions (see Video, Supplemental Digital Content 1, http:// links.lww.com/DCR/A697). The dissection is performed along the embryological planes of the lateral compartment. The important anatomical landmarks are identified and the pelvic autonomic nerves are preserved. Meanwhile, all the nodal tissue within these following boundary structures are removed in an en bloc fashion: