Achilles Heel of Lateral Pelvic Lymph Node Dissection

Aims: To demonstrate a crucial step in Lateral Pelvic Lymph node dissection (LPLND).

Materials-Methods: Robotic Pelvic Lymph node dissection after short-course radiotherapy and nine cycles of Folinic acid+5-Fluorouracil+Oxaliplatin (FOLFOX) in a 35-year-old gentleman diagnosed with middle third rectal adenocarcinoma. The patient & attender have given their informed consent.

Results: There is evidence that LPLND reduces Lateral Local Recurrence rates (LLR) in patients with suspicious lateral nodes. It is essential to clear the complete template of lateral nodes, especially the inferior vesical nodes, to achieve a decrease in LLR. Adipose tissue around the inferior vesical artery (IVA) is the most frequent site of metastasis. Very frequently middle rectal artery (MRA) arises from or forms a common trunk with IVA. The growing evidence that lymphatics around the MRA forms the anatomical basis of lateral nodal spread & the high frequency of MRA arising from IVA makes these nodes the first echelon of lateral group of nodes. Clearing all the nodes while preserving the IVA is technically & anatomically challenging. The learning curve for LPLND is relatively longer. However, preserving nerves and unilateral IVA is essential to prevent postoperative urinary dysfunctions. The surgeon controlled stable camera platform & endo wrist technology of the robot allowing seven degrees of freedom, partly helps in overcoming the technical challenges in dissecting this crucial area.

Besides its recognized ergonomic benefits, robotics enables enhanced vision and dexterity within the narrow confines of lateral space of the pelvis. This allows for precise dissection around vascular and neural structures, better preservation of autonomic nerves, and eventually, a potential for increased nodal yield and improved clearance.

Conclusion: Considering the functional, oncological, technical & anatomical implications of dissecting the inferior vesical area, we call it the Achilles heel.