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until the distal rectum is completely and circumferentially isolated from the plane of the levator ani muscle, where the mesorectum thins out and is virtually absent.

level of proximal resection, is now prepared along with its mesocolon. The marginal arcade is identied, doubly ligated and divided. The corresponding colon is thus transected using a linear endostapler. Subsequent dissection differs from ISR in that, once the plane of the levator ani muscle is reached, further dissection through the hiatal ligament and the raphe of iliococcygeus and pubococcygeus muscle is commenced in a perpendicular direction through the perineum, to encompass the entire EAS complex in the resection. Such posterior dissection is then prolonged laterally, and the pelvic oor is divided bilaterally. Any hematic oozing is carefully controlled with the bipolar forceps, to facilitate subsequent perineal rendez-vous. Dissection of the anterior aspect of the anorectum follows, which proceeds transab­dominally as deep as possible, mostly using the scissors with minimal energy dis­persion and constant care paid to avoid any direct or thermal damage to the vagina or membranous urethra. Finally, from the left portion of the greater omentum, a well-vascularized pedicle is created whenever possible and brought into the pelvis to reduce the risk of postoperative herniation through the pelvic defect. Then, the robot is undocked and the perineal phase of the procedure is commenced with the patient in the lithotomy position, with the lower limbs in stirrups and the buttocks centimeters off the edge of the operating table. The anus is usually sutured to limit contamination and favoring traction of the future specimen. An elliptical incision is created circumferentially around the anus to include the entire sphincter complex, and possibly extended in a specic direction to ensure adequate circumferential margins if any residual disease exists around the anal canal. The ischiorectal space is progressively dissected on both sides before proceeding with posterior and ante­rior dissection. Posteriorly, just above the coccyx, the anococcygeal ligament is divided to join the plane of abdominal dissection. At this point, usually after accu­rate digital exploration, the levator muscle is divided circumferentially until the specimen is released completely except for its anterior attachments. During this phase, according to tumor site and extent, we advocate a “selective extra-elevator (cylindrical) dissection” where needed, to ensure adequate circumferential surgical margins. The proximal end of the specimen is inverted and pulled out of the perineum, leaving it anchored only by its anterior attachments. With adequate trac­tion and gentle exposure provided by the assistant, the specimen is entirely excised with sharp dissection. Direct assistance by gentle digital palpation of the rectovagi­nal or rectourethral septum is usually helpful to supervise the appropriate plane of division. The perineal wound is generously irrigated with saline. Careful perineal closure is crucial, as wound-related complications are responsible for most of the postoperative morbidity following robotic APR.A layer-by-layer reapproximation is the preferred method of closure, with the aim of minimizing the residual dead space. Finally, the descending colon is exteriorized in the left ank, usually utilizing the R5 port incision. Port incisions are closed in a conventional fashion and the end colostomy is eventually matured.

2023;93(3):510–21.

rence [12]. Since the rate of metastatic LPN in prophylactic LPND is lower than 10% [9], some authors have suggested selective LPND after preoperative CRT for patients with suspicious LPN [11]. Debate still exists on the optimal criteria for the denition of suspicious LPN, but most authors consider the short or long axis of the largest LPN on pre- [11, 13–16] or post-treatment imaging [13, 17]. An interna­tional multicenter study by the Lateral Node Study Consortium re-evaluated the pretreatment MRI of 1216 patients with LARC. They identied a signicantly higher risk of local recurrence (19.5%) and lateral local recurrence (15%) at 5years in patients with LPN equal to or greater than 7mm in short axis on pretreatment MRI [11]. The indication for LPND at the Colorectal Cancer Center at Kyungpook National University Hospital is an enlarged suspicious lymph node in the pelvic sidewall on pretreatment MRI with a short axis greater than 5mm, regardless of response to preoperative treatment [18, 19].

LPND is considered by most surgeons a technically demanding procedure. The risk of intraoperative bleeding and postoperative genitourinary dysfunction limited its diffusion in the West [20]. Nonetheless, data from specialized Eastern centers demonstrated that the slight increase in short-term complications and functional morbidity is offset by improved long-term oncological outcomes. Data from the JCOG0212 trial comparing 351 patients receiving open TME plus prophylactic bilateral LPND, with 350 undergoing TME alone, reported increased intraoperative blood loss (576mL vs. 337mL, p<0.001) in the LPND group, but no differences in terms of severe complications and anastomotic leak [21]. Moreover, laparoscopic LPND compared to the open approach showed reduced blood loss, shorter hospital stay, and a higher number of retrieved lymph nodes [22, 23]. The robotic platform represents an optimal option for LPND, providing good traction and counter­traction, high-quality images and stable camera, as well as articulating and precise instruments for ne dissection. In fact, robotic LPND is associated with decreased intraoperative blood loss and lower rate of urinary retention compared to the lapa­roscopic approach [18]. Moreover, initial evaluation of long-term outcomes showed comparable local recurrence rates and disease-free survival of robotic and laparo­scopic LPND [19]. Despite the advantages of the robotic platform, LPND remains technically demanding. Analysis of 100 patients undergoing robotic TME plus LPND showed a learning phase of about 50 cases. Even in the competence phase, urinary dysfunction represented the most frequent complication, although the inci­dence decreased from the learning to the competence phase (39.4% vs. 16.7%) [24].

8. Tsukamoto S, Fujita S, Ota M, etal. Long-term follow-up of the randomized trial of mesorec­tal excision with or without lateral lymph node dissection in rectal cancer (JCOG0212). Br J Surg. 2020;107(5):586–94.

9. Fujita S, Mizusawa J, Kanemitsu Y, et al. Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212). Ann Surg. 2017;266(2):201–7.