Re-evaluation of possible vulnerable sites in the lateral pelvic cavity to local recurrence during robot-assisted total
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and Other Interventional Techniques
Re‑evaluation of possible vulnerable sites in the lateral pelvic cavity to local recurrence during robot‑assisted total mesorectal excision Jin Cheon Kim1 · Jin Su Han1 · Jong Lyul Lee1 · Chan Wook Kim1 · Yong Sik Yoon1 · Sung Ho Park2 · Jihun Kim3 Received: 12 April 2020 / Accepted: 16 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Despite mechanical and technical improvements in laparoscopic and robot-assisted (LAR) rectal cancer procedures, the absence of prognostic disparities among various approaches cannot improve the quality of TME. The present study re-evaluated robot-assisted total mesorectal excision (TME) procedures to determine whether these procedures may reveal technical faults that may increase the rate of local recurrence (LR). Methods This study enrolled 886 consecutive patients with rectal cancer, who underwent curative robot-assisted LAR at Asan Medical Center (Seoul, Korea) between July 2010 and August 2017 (the first vs second period; n = 399 vs 487). The quality of TME and lateral pelvic mesorectal excision (LPME) were analyzed, as were LR rates and survival outcomes. Results Complete TME and LPME were achieved in 89.2% and 80.1% of these patients, respectively, with ≤ 1% having incomplete TME excluding intramesorectal excision. LR rates were 13.5 and 14.5 times higher in patients with incomplete TME and LPME, respectively, than in patients with complete TME and LPME (14.8% vs 1.1% and 8.7% vs 0.6%; p 5 years after surgery. Patients with clinical stage III or T4 cancers were treated with preoperative chemoradiotherapy (CRT) at the discretion of the surgeon. Patients with pathologic stage III who did not receive neoadjuvant treatment were administered postoperative CRT. The total radiation dose was 45–50.4 Gy, and chemotherapy consisted of 5-FU plus
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Surgical Endoscopy
leucovorin or capecitabine. All patients provided written informed consent for the entire treatment procedure, and the study protocol was approved by the Institutional Review Board of Asan Medical Center (registration numbers 2019–1003), in accordance with the Declaration of Helsinki.
Total mesorectal excision, with particular attention to lateral pelvic mesorectal excision All patients underwent standard TME, consisting of LAR and ultra-LAR (n = 833) or abdominoperineal resection (APR) (n = 54), as described [11, 12]. Because the hypogastric nerve (HGN) is covered by the pre-HGN fascia (PHF), dissection at the multiple strands binding the FPR and PHF is required [13]. During the last 3 years of this study, a revised LPME procedure was utilized for complete TME. After abdominal procedures, including splenic flexure mobilization in a mesofascial or retrofascial mesocolic fashion, the pelvic procedure continued with sharp dissection between the FPR and PHF until TME was complete (Fig. 1). Downward dissection from the posterior to the anterior half, alternating between the right and left sides posterior and anterior to the late
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