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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer Toshiki Mukai, Takashi Akiyoshi, Masashi Ueno, Yosuke Fukunaga, Satoshi Nagayama, Yoshiya Fujimoto, Tsuyoshi Konishi, Atsushi Ikeda & Toshiharu Yamaguchi Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
Keywords Laparoscopic surgery; rectal cancer; total pelvic exenteration Correspondence Takashi Akiyoshi, Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan. Tel: +81 3 3520 0111 Fax: +81 3 3520 0141 Email: [email protected] Received: 5 April 2013; revised 17 May 2013; accepted 21 May 2013
Abstract Total pelvic exenteration (TPE) may be the only procedure that can cure T4 rectal cancer that directly invades the urinary bladder or prostate. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection for advanced primary rectal cancer. A 62-year-old man diagnosed with advanced lower rectal cancer (T4bN0M0) underwent laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy. Ligation of the dorsal vein complex was performed under direct visualization through the perineal approach, and the large perineal defect was reconstructed using bilateral V-Y advancement of the gluteus maximus musculocutaneous flaps. The ileal conduit was constructed extracorporeally through an extended umbilical port that was extended to 4 cm. The total operative time was 831 min and estimated blood loss was 600 mL. Laparoscopic TPE appears to be safe and feasible in selected patients.
DOI:10.1111/ases.12047
Introduction
Case Presentation
Laparoscopic surgery for colorectal cancer has been widely performed in recent years, although its long-term oncological efficacy remains controversial because of a lack of data (1–3). Total mesorectal excision is the standard procedure for lower rectal cancer, but in some patients with T4 rectal cancer that directly invades the urinary bladder or prostate, total pelvic exenteration (TPE) may be the only procedure that cures (4). Some cases of laparoscopic and robotic TPE for gynecological or urological malignancies have been reported (5–8), but reports of laparoscopic TPE for advanced primary rectal cancer are scarce. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer.
A 62-year-old man was referred to our hospital for tenesmus. A fixed ulcerated tumor was felt at the anterior rectum, 4 cm from the anal verge. Histopathologic examination revealed moderate differentiated adenocarcinoma. CT and MRI showed the tumor was contiguous with the seminal vesicles, bladder, prostate and internal obturator muscle (T4b) without evidence of lymph node (N0) or distant metastasis (M0) (Figure 1). After construction of a sigmoid loop colostomy, the patient received neoadjuvant chemoradiotherapy using S1 and oxaliplatin at a total dose of 50.4 Gy. After total pelvic irradiation including the lateral pelvic area, MRI showed a more than 30% reduction in tumor size (partial response). However, the boundaries between the tumor and bladder, seminal vesicles, prostate, internal obturator
314
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic total pelvic exenteration
T Mukai et al.
Figure 1 Contrast-enhanced MRI show the tumor directly invading the seminal vesicles, bladder and prostate, and a close margin between it and the internal obturator muscles. CRT, chemoradiotheraphy.
muscle and levator ani muscle were consistently unclear (Figure 1). We performed laparoscopic TPE 6 weeks after chemoradiotherapy. The patient was placed in a lithotomy position under general and epidural anesthesia. Five ports were placed as follows: a 12-mm port at the umbilicus for the scope, 12-mm ports at the lower right and left quadrants, and 5-mm ports at the upper right and left abdominal quadrants. The patient was placed in a steep Trendelenburg position to displace the small bowel out of the pelvis. Medial-to-lateral retroperitoneal dissection was performed, and the inferior mesenteric artery was divided, preserving the left colic artery. After the mesentery of the sigmoid colon was divided, the sigmoid colon was transected with a linear stapler (Echelon 60 Gold; Ethicon Endo-Surgery, Cincinnati, USA) in immediate proximity to the sigmoidostomy. The left ureter was sharply dissected to the level of the ureterovesical junction, where it was clipped and divided. The same procedure was carried out on the right side. The umbilical incision was extended to 4 cm to place a ureteral catheter to monitor urine volume. Catheters were placed in the proximal ureters bilaterally and pulled out through the side of the 5-mm ports. Pneumoperitoneum was maintained using an ALEXIS Wound Retractor (Applied Medical, Rancho Santa Margarita, USA) and a surgical glove.
Dorsal dissection was then performed in the avascular plane between the mesorectum and the parietal pelvic fascia. The hypogastric nerves were divided bilaterally at their bifurcations from the superior hypogastric plexus. The dorsal dissection was carried out to the level of the levator ani muscle. The peritoneum overlying the external iliac artery was incised up to the medial umbilical ligaments, and the vas deferens was divided. The Retzius space and the paravesical space were sharply dissected to the level of the endopelvic fascia. Bilateral en bloc lateral pelvic lymph node dissection was performed. The external iliac artery and vein were exposed as the lateral border of dissection. The lymphatic tissue was dissected laterally along the surface of the internal obturator muscle, dorsally along the sciatic nerve, and down to the level of levator ani muscle. The obturator vessels were divided, but the obturator nerve was preserved. The main trunk of the internal iliac artery was divided distal to the superior gluteal artery, and the distal part of the internal iliac artery (internal pudendal artery) was divided at the entry point to Alcock’s canal. The surface of the internal iliac vein was exposed, and the inferior vesical veins were divided at their origins. The plane of retrorectal and lateral dissection was connected with the division of the pelvic splanchnic nerves. The endopelvic fascia and puboprostatic ligament
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
315
Laparoscopic total pelvic exenteration
T Mukai et al.
was incised, and the dorsal vein complex was completely exposed (Figure 2). The patient’s position was changed to a jackknife position. After the closure of the anus, a fusiform-shaped perineal incision was extended posteriorly to the level of the coccyx. The gluteus maximus muscle was exposed and the levator ani muscle was divided laterally at its origin from the tendinous arch. The right internal obturator muscle was partially resected for a clear surgical margin. Most intraoperative bleeding occurred at this point. After a transfixing ligation of the dorsal vein complex with direct visualization, the urethra and dorsal vein complex were divided, and the entire specimen was removed through the inferior pelvic opening. The large perineal defect was reconstructed using bilateral V-Y advancement of gluteus maximus musculocutaneous flaps. We changed the patient’s position to a lithotomy position (Figure 3), and an ileal conduit reservoir was constructed extracorporeally thorough the umbilical incision (Figure 4). Total operative time was 831 min, and estimated blood loss was 600 mL. There were no intraoperative complications. Although postoperative
Figure 2 The dorsal vein complex was exposed. Note the cut line of the endopelvic fascia (arrows). Bl, bladder; Pr, prostate.
ileus occurred and required an ileus tube, the patient was discharged on postoperative day 29 without a perineal wound or pelvic dead space infection. Pathological tumor stages were ypT4a and ypN0, and the circumferential resection margin was negative. Histological assessment of response to chemoradiotherapy was grade 2.
Discussion Laparoscopic surgery has become common for colorectal cancer. Its advantages include reduced postoperative pain, reduced blood loss, and more importantly, good visualization in the deep pelvis (1–3). However, the role of laparoscopic surgery for T4b colorectal cancer that invades neighboring organs remains controversial (9). Reports on laparoscopic TPE for advanced rectal cancer are scarce, although a small case series of laparoscopic TPE for gynecological and urological malignancies has been reported (5–8). To our knowledge, this is the first report of laparoscopic TPE with en bloc lateral lymph node dissection for advanced lower rectal cancer. We performed en bloc lateral lymph node dissection with combined resection of the internal iliac artery to
Figure 3 Laparoscopic view after the completion of total pelvic exenteration with en bloc lateral lymph node dissection and reconstruction of the perineal wound.
c Figure 4 (a) Abdominal and (b) perineal operative wound. (c) Resected specimen.
316
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic total pelvic exenteration
T Mukai et al.
minimize the chance of a positive resection margin. Laparoscopic lateral lymph node dissection after total mesorectal excision has been standardized in our institution (10), and we could therefore safely perform laparoscopic en bloc resection of pelvic structures and the rectum. Because of the complexity of the procedure, this should be performed by laparoscopic surgeons who have had extensive experience with laparoscopic total mesorectal excision and lateral lymph node dissection. With regard to the patient selection, patients with tumors in which invasion is limited to the anterior pelvic organ are good candidates for laparoscopic TPE because a clear circumferential resection margin can be easily obtained. In contrast, laparoscopic TPE for bulky tumors or tumors invading to the higher sacrum would be technically very challenging, and it might not be appropriate to perform laparoscopic surgery on these tumors. To minimize blood loss, control of the dorsal vein complex is an important aspect of laparoscopic TPE. Laparoscopic suture ligation is one option (11), but this step can be performed under direct visualization through the perineal approach if the patient is in a jackknife position. However, this could lead to a longer operative time because of the two position changes. In conclusion, laparoscopic TPE appears to be safe and feasible and could be a procedure of choice in selected patients.
Acknowledgment
2.
3.
4.
5.
6.
7.
8.
9.
10.
The authors have no conflicts of interest or financial ties to disclose.
References 1. Guillou PJ, Quirke P, Thorpe H et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial):
11.
Multicentre, randomised controlled trial. Lancet 2005; 365: 1718–1726. Buunen M, Veldkamp R, Hop WC et al. Survival after laparoscopic surgery versus open surgery for colon cancer: Long-term outcome of a randomised clinical trial. Lancet Oncol 2009; 10: 44–52. Kang SB, Park JW, Jeong SY et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11: 637–645. Ishiguro S, Akasu T, Fujita S et al. Pelvic exenteration for clinical T4 rectal cancer: Oncologic outcome in 93 patients at a single institution over a 30-year period. Surgery 2009; 145: 189–195. Pomel C, Rouzier R, Pocard M et al. Laparoscopic total pelvic exenteration for cervical cancer relapse. Gynecol Oncol 2003; 91: 616–618. Martinez A, Filleron T, Vitse L et al. Laparoscopic pelvic exenteration for gynaecological malignancy: Is there any advantage? Gynecol Oncol 2011; 120: 374–379. Kaufmann OG, Young JL, Sountoulides P et al. Robotic radical anterior pelvic exenteration: The UCI experience. Minim Invasive Ther Allied Technol 2011; 20: 240–246. Ferron G, Querleu D, Martel P et al. Laparoscopy-assisted vaginal pelvic exenteration. Gynecol Oncol 2006; 100: 551– 555. Nagasue Y, Akiyoshi T, Ueno M et al. Laparoscopic versus open multivisceral resection for primary colorectal cancer: Comparison of perioperative outcomes. J Gastrointest Surg 2013. 17: 1299–1305. Konishi T, Kuroyanagi H, Oya M et al. Multimedia article. Lateral lymph node dissection with preoperative chemoradiation for locally advanced lower rectal cancer through a laparoscopic approach. Surg Endosc 2011; 25: 2358–2359. Sasaki H, Miki J, Kimura T et al. Upfront transection and subsequent ligation of the dorsal vein complex during laparoscopic radical prostatectomy. Int J Urol 2010; 17: 960–961.
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
317
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer Toshiki Mukai, Takashi Akiyoshi, Masashi Ueno, Yosuke Fukunaga, Satoshi Nagayama, Yoshiya Fujimoto, Tsuyoshi Konishi, Atsushi Ikeda & Toshiharu Yamaguchi Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
Keywords Laparoscopic surgery; rectal cancer; total pelvic exenteration Correspondence Takashi Akiyoshi, Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan. Tel: +81 3 3520 0111 Fax: +81 3 3520 0141 Email: [email protected] Received: 5 April 2013; revised 17 May 2013; accepted 21 May 2013
Abstract Total pelvic exenteration (TPE) may be the only procedure that can cure T4 rectal cancer that directly invades the urinary bladder or prostate. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection for advanced primary rectal cancer. A 62-year-old man diagnosed with advanced lower rectal cancer (T4bN0M0) underwent laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy. Ligation of the dorsal vein complex was performed under direct visualization through the perineal approach, and the large perineal defect was reconstructed using bilateral V-Y advancement of the gluteus maximus musculocutaneous flaps. The ileal conduit was constructed extracorporeally through an extended umbilical port that was extended to 4 cm. The total operative time was 831 min and estimated blood loss was 600 mL. Laparoscopic TPE appears to be safe and feasible in selected patients.
DOI:10.1111/ases.12047
Introduction
Case Presentation
Laparoscopic surgery for colorectal cancer has been widely performed in recent years, although its long-term oncological efficacy remains controversial because of a lack of data (1–3). Total mesorectal excision is the standard procedure for lower rectal cancer, but in some patients with T4 rectal cancer that directly invades the urinary bladder or prostate, total pelvic exenteration (TPE) may be the only procedure that cures (4). Some cases of laparoscopic and robotic TPE for gynecological or urological malignancies have been reported (5–8), but reports of laparoscopic TPE for advanced primary rectal cancer are scarce. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer.
A 62-year-old man was referred to our hospital for tenesmus. A fixed ulcerated tumor was felt at the anterior rectum, 4 cm from the anal verge. Histopathologic examination revealed moderate differentiated adenocarcinoma. CT and MRI showed the tumor was contiguous with the seminal vesicles, bladder, prostate and internal obturator muscle (T4b) without evidence of lymph node (N0) or distant metastasis (M0) (Figure 1). After construction of a sigmoid loop colostomy, the patient received neoadjuvant chemoradiotherapy using S1 and oxaliplatin at a total dose of 50.4 Gy. After total pelvic irradiation including the lateral pelvic area, MRI showed a more than 30% reduction in tumor size (partial response). However, the boundaries between the tumor and bladder, seminal vesicles, prostate, internal obturator
314
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic total pelvic exenteration
T Mukai et al.
Figure 1 Contrast-enhanced MRI show the tumor directly invading the seminal vesicles, bladder and prostate, and a close margin between it and the internal obturator muscles. CRT, chemoradiotheraphy.
muscle and levator ani muscle were consistently unclear (Figure 1). We performed laparoscopic TPE 6 weeks after chemoradiotherapy. The patient was placed in a lithotomy position under general and epidural anesthesia. Five ports were placed as follows: a 12-mm port at the umbilicus for the scope, 12-mm ports at the lower right and left quadrants, and 5-mm ports at the upper right and left abdominal quadrants. The patient was placed in a steep Trendelenburg position to displace the small bowel out of the pelvis. Medial-to-lateral retroperitoneal dissection was performed, and the inferior mesenteric artery was divided, preserving the left colic artery. After the mesentery of the sigmoid colon was divided, the sigmoid colon was transected with a linear stapler (Echelon 60 Gold; Ethicon Endo-Surgery, Cincinnati, USA) in immediate proximity to the sigmoidostomy. The left ureter was sharply dissected to the level of the ureterovesical junction, where it was clipped and divided. The same procedure was carried out on the right side. The umbilical incision was extended to 4 cm to place a ureteral catheter to monitor urine volume. Catheters were placed in the proximal ureters bilaterally and pulled out through the side of the 5-mm ports. Pneumoperitoneum was maintained using an ALEXIS Wound Retractor (Applied Medical, Rancho Santa Margarita, USA) and a surgical glove.
Dorsal dissection was then performed in the avascular plane between the mesorectum and the parietal pelvic fascia. The hypogastric nerves were divided bilaterally at their bifurcations from the superior hypogastric plexus. The dorsal dissection was carried out to the level of the levator ani muscle. The peritoneum overlying the external iliac artery was incised up to the medial umbilical ligaments, and the vas deferens was divided. The Retzius space and the paravesical space were sharply dissected to the level of the endopelvic fascia. Bilateral en bloc lateral pelvic lymph node dissection was performed. The external iliac artery and vein were exposed as the lateral border of dissection. The lymphatic tissue was dissected laterally along the surface of the internal obturator muscle, dorsally along the sciatic nerve, and down to the level of levator ani muscle. The obturator vessels were divided, but the obturator nerve was preserved. The main trunk of the internal iliac artery was divided distal to the superior gluteal artery, and the distal part of the internal iliac artery (internal pudendal artery) was divided at the entry point to Alcock’s canal. The surface of the internal iliac vein was exposed, and the inferior vesical veins were divided at their origins. The plane of retrorectal and lateral dissection was connected with the division of the pelvic splanchnic nerves. The endopelvic fascia and puboprostatic ligament
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
315
Laparoscopic total pelvic exenteration
T Mukai et al.
was incised, and the dorsal vein complex was completely exposed (Figure 2). The patient’s position was changed to a jackknife position. After the closure of the anus, a fusiform-shaped perineal incision was extended posteriorly to the level of the coccyx. The gluteus maximus muscle was exposed and the levator ani muscle was divided laterally at its origin from the tendinous arch. The right internal obturator muscle was partially resected for a clear surgical margin. Most intraoperative bleeding occurred at this point. After a transfixing ligation of the dorsal vein complex with direct visualization, the urethra and dorsal vein complex were divided, and the entire specimen was removed through the inferior pelvic opening. The large perineal defect was reconstructed using bilateral V-Y advancement of gluteus maximus musculocutaneous flaps. We changed the patient’s position to a lithotomy position (Figure 3), and an ileal conduit reservoir was constructed extracorporeally thorough the umbilical incision (Figure 4). Total operative time was 831 min, and estimated blood loss was 600 mL. There were no intraoperative complications. Although postoperative
Figure 2 The dorsal vein complex was exposed. Note the cut line of the endopelvic fascia (arrows). Bl, bladder; Pr, prostate.
ileus occurred and required an ileus tube, the patient was discharged on postoperative day 29 without a perineal wound or pelvic dead space infection. Pathological tumor stages were ypT4a and ypN0, and the circumferential resection margin was negative. Histological assessment of response to chemoradiotherapy was grade 2.
Discussion Laparoscopic surgery has become common for colorectal cancer. Its advantages include reduced postoperative pain, reduced blood loss, and more importantly, good visualization in the deep pelvis (1–3). However, the role of laparoscopic surgery for T4b colorectal cancer that invades neighboring organs remains controversial (9). Reports on laparoscopic TPE for advanced rectal cancer are scarce, although a small case series of laparoscopic TPE for gynecological and urological malignancies has been reported (5–8). To our knowledge, this is the first report of laparoscopic TPE with en bloc lateral lymph node dissection for advanced lower rectal cancer. We performed en bloc lateral lymph node dissection with combined resection of the internal iliac artery to
Figure 3 Laparoscopic view after the completion of total pelvic exenteration with en bloc lateral lymph node dissection and reconstruction of the perineal wound.
c Figure 4 (a) Abdominal and (b) perineal operative wound. (c) Resected specimen.
316
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic total pelvic exenteration
T Mukai et al.
minimize the chance of a positive resection margin. Laparoscopic lateral lymph node dissection after total mesorectal excision has been standardized in our institution (10), and we could therefore safely perform laparoscopic en bloc resection of pelvic structures and the rectum. Because of the complexity of the procedure, this should be performed by laparoscopic surgeons who have had extensive experience with laparoscopic total mesorectal excision and lateral lymph node dissection. With regard to the patient selection, patients with tumors in which invasion is limited to the anterior pelvic organ are good candidates for laparoscopic TPE because a clear circumferential resection margin can be easily obtained. In contrast, laparoscopic TPE for bulky tumors or tumors invading to the higher sacrum would be technically very challenging, and it might not be appropriate to perform laparoscopic surgery on these tumors. To minimize blood loss, control of the dorsal vein complex is an important aspect of laparoscopic TPE. Laparoscopic suture ligation is one option (11), but this step can be performed under direct visualization through the perineal approach if the patient is in a jackknife position. However, this could lead to a longer operative time because of the two position changes. In conclusion, laparoscopic TPE appears to be safe and feasible and could be a procedure of choice in selected patients.
Acknowledgment
2.
3.
4.
5.
6.
7.
8.
9.
10.
The authors have no conflicts of interest or financial ties to disclose.
References 1. Guillou PJ, Quirke P, Thorpe H et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial):
11.
Multicentre, randomised controlled trial. Lancet 2005; 365: 1718–1726. Buunen M, Veldkamp R, Hop WC et al. Survival after laparoscopic surgery versus open surgery for colon cancer: Long-term outcome of a randomised clinical trial. Lancet Oncol 2009; 10: 44–52. Kang SB, Park JW, Jeong SY et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11: 637–645. Ishiguro S, Akasu T, Fujita S et al. Pelvic exenteration for clinical T4 rectal cancer: Oncologic outcome in 93 patients at a single institution over a 30-year period. Surgery 2009; 145: 189–195. Pomel C, Rouzier R, Pocard M et al. Laparoscopic total pelvic exenteration for cervical cancer relapse. Gynecol Oncol 2003; 91: 616–618. Martinez A, Filleron T, Vitse L et al. Laparoscopic pelvic exenteration for gynaecological malignancy: Is there any advantage? Gynecol Oncol 2011; 120: 374–379. Kaufmann OG, Young JL, Sountoulides P et al. Robotic radical anterior pelvic exenteration: The UCI experience. Minim Invasive Ther Allied Technol 2011; 20: 240–246. Ferron G, Querleu D, Martel P et al. Laparoscopy-assisted vaginal pelvic exenteration. Gynecol Oncol 2006; 100: 551– 555. Nagasue Y, Akiyoshi T, Ueno M et al. Laparoscopic versus open multivisceral resection for primary colorectal cancer: Comparison of perioperative outcomes. J Gastrointest Surg 2013. 17: 1299–1305. Konishi T, Kuroyanagi H, Oya M et al. Multimedia article. Lateral lymph node dissection with preoperative chemoradiation for locally advanced lower rectal cancer through a laparoscopic approach. Surg Endosc 2011; 25: 2358–2359. Sasaki H, Miki J, Kimura T et al. Upfront transection and subsequent ligation of the dorsal vein complex during laparoscopic radical prostatectomy. Int J Urol 2010; 17: 960–961.
Asian J Endosc Surg 6 (2013) 314–317 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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