Laparoscopic Extended Lower Rectal Cancer Resection with En Bloc Lateral Lymph Node Dissection (Wang’s Approach)

Abstract

Lateral lymph node metastasis of middle and lower rectal cancer is an objective fact and a route of lymphatic drainage of the rectum. The incidence of lateral lymph node metastasis is reported to be 9%–25%, which is related to the selection of cases in each center. Because of the inconsistency of positive rates and the high technical difficulty, lateral lymph node dissection in rectal cancer remains controversial. It is a matter of concept and technique: in terms of concept, the focus is whether it should be done; in terms of technique, the focus is whether it can be done. In both open and conventional laparoscopic procedures, specimen resection is performed before lymph node dissection. To perform NOSES, the specimen should be extracted while remaining the integrity of it, which leads us to ponder how to perform the en bloc resection. Technically, performing en bloc resection is extremely difficult, and cannot be achieved through conventional surgical approaches. In this chapter, an alternative approach is introduced. This approach has not been officially named yet, so it is hereby referred to as “Wang’s approach.” This chapter also demonstrates that extended middle and lower rectal cancer resection with en bloc lateral lymph node dissection can be achieved. In this chapter, NOSES IE combined with en bloc lateral lymph node dissection is introduced.