To the Editors:

I personally appreciate the valuable comments from Konishi et al.1 regarding our article cited here. My colleagues and I also feel encouraged to see that combined resection of the iliac vessels for lateral pelvic lymph node dissection can be safely performed through laparoscopic approach, as purportedly has been performed for 11 cases by Dr. Kuroyanagi and colleagues. In our article, we discussed that combined resection of the iliac vessels in addition to lateral pelvic lymph node dissection was technically unfeasible just because we have been without such prior experiences.2

Dr. Konishi et al. also commented that their lymph node harvest, median number of 23, was much higher than that in our series. We would like to clarify that our lymph node harvest, 6 in median number, is just for a unilateral lateral pelvic lymph node station explored, which is in addition to the number of mesorectal lymph nodes harvested through a standard total mesorectal excision.

Lateral pelvic lymph node dissection, either performed by laparoscopic approach or traditional open surgery, created yet unresolved contentious issues. We dubbed this surgical procedure the “Japanese spirits” because both colorectal surgeons and patients themselves in Japan have been worshipping the efficacy of this procedure, although the Western surgeons contended that lateral node involvement of rectal cancer was just an indicator of poor prognosis and removing it or not was unrelated to patients’ overall survival.3,4 However, as surgeons, we believe that surgical removal of an involved lymph node, but not any other treatment modality, can provide the only chance for the cure of the patients. Moreover, the treatment of rectal cancer has evolved to the era of multimodal and individualized therapy. Therefore, a single surgical procedure is currently not appropriate for all patients. We feel that laparoscopic approach is a good choice for patients requiring a lateral pelvic lymph node dissection, since it can juggle complete cancer clearance and the minimal invasiveness of patients. In 1996, the author visited Dr. Moriya in National Cancer Center Hospital, Tokyo, Japan, to learn the original surgical technique of lateral pelvic lymph node dissection.5 We feel that ligation of internal iliac artery is indicated when obvious vascular encasement of cancer is noted. However, in the present case series and even in my observing Dr. Moriya’s operation, the percentage for the necessity of vessel transection is not as high as pointed out by Dr. Konishi et al.