Reversed anatomy in transanal lateral lymph node dissection: landmarks and pitfalls

Area of Science:

• Surgical Oncology
• Colorectal Surgery
• Minimally Invasive Surgery

Background:

• Lateral lymph node dissection (LLND) is crucial for locally advanced rectal cancer to minimize recurrence.
• Transanal total mesorectal excision (TaTME) is increasingly adopted globally.
• A novel two-team approach combining transabdominal and transanal methods for LLND has been developed.

Purpose of the Study:

• To review the advantages, anatomical landmarks, surgical techniques, and potential pitfalls of transanal LLND (TaLLND).
• To highlight TaLLND's benefits in complex cases, including those with prior pelvic surgery or extensive disease.

Main Methods:

• This narrative review synthesizes information on the TaLLND technique.
• Key procedural steps include S4 nerve identification, lateral space entry, and dissection along major pelvic vessels and nerves.
• The review emphasizes a two-team approach for simultaneous transanal and transabdominal LLND.

Main Results:

• TaLLND provides magnified visualization and enhanced instrument maneuverability in the deep pelvis.
• It offers access to surgical planes unaffected by previous pelvic surgeries.
• The technique is applicable to advanced rectal cancer requiring resection of major pelvic structures.

Conclusions:

• TaLLND presents a valuable advancement in managing locally advanced rectal cancer, potentially overcoming limitations of purely transabdominal LLND.
• The two-team approach utilizing TaTME enhances the quality and feasibility of LLND.
• TaLLND is expected to improve surgical outcomes and reduce local recurrence rates.