Videoscopic Inguinal Lymphadenectomy for Metastatic Melanoma

Benjamin M. Martin, MD; Viraj A. Master, MD, PhD; Keith A. Delman, MD

Disclosures

Cancer Control. 2013;20(4):255-260. 

In This Article

Open Inguinal Lymphadenectomy

Inguinal lymphadenectomy (inguinofemoral, superficial groin, and groin dissections) encompasses the en bloc removal of all fibrofatty tissue within the femoral triangle defined by the inguinal ligament, the sartorius muscle, and the adductor longus. When performing open inguinal lymphadenectomy, a vertically oriented, curvilinear incision is made and skin flaps are raised to facilitate operative exposure. If care is not taken at this point, thinning of the skin flaps can occur, leading to vascular compromise of the tissue and flap necrosis. Established borders of dissection include (a) superolateral (anterior superior iliac spine), (b) superomedial (pubic tubercle), (c) inferolateral (sartorius), and (d) inferomedial (adductor longus). The crossing of the sartorius and adductor longus inferiorly is termed the "apex" of the femoral triangle. Most surgeons regularly sacrifice the saphenous vein although it can be spared. The saphenous vein is divided distally in the apex of the femoral triangle and proximally at the saphenofemoral junction. The femoral artery and vein are anteriorly skeletonized. Beyond the standard inguinal lymphadenectomy performed for urogenital cancers, melanoma-specific dissections also include tissue deep to the fossa ovalis and medial to the femoral vein, superiorly extending to the femoral canal. Dissection is extended superiorly 5 cm above the inguinal ligament to include all nodal tissue superficial to the external oblique aponeurosis. After removal of the nodal packet, sartorius muscle transposition is commonly performed to prevent vessel exposure in the case of wound dehiscence. A drain is placed within the wound bed and brought out through a separate stab incision in the skin. If indicated, deep or pelvic lymphadenectomy can be performed through the same skin incision, although access to the pelvis is regularly performed via a retroperitoneal approach through the abdominal wall.

Multiple studies from high-volume centers have shown the complication rate to be 50% or higher following open inguinal lymphadenectomy (Table).[7,8,9,10,11,12,13,14,15,16,17] Most of the morbidity is directly related to the large incision required for adequate exposure and includes such complications as dehiscence (Fig 1), infection, seroma formation, and skin flap necrosis. Additional complications related to the operation include lymphedema and deep venous thrombosis. Technical modifications to reduce morbidity such as relocating the skin incision, creating thicker skin flaps, preserving the saphenous vein, and omitting sartorius transposition have not substantially decreased complications.[18] Sabel et al[14] showed a significant reduction in wound-related complications when comparing patients undergoing open inguinal lymphadenectomy for sentinel lymph node positive disease (microscopic) or clinically palpable (macroscopic) disease (14% vs 28%; P = .019). Bulky adenopathy may necessitate a larger incision and thinner skin flaps, thus increasing wound-related morbidity. Conversely, the minimally invasive means of inguinal lymphadenectomy may reduce wound complications.

Figure 1.

Wound dehiscence following open inguinal lymphadenectomy.

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