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

Videoscopic Inguinal Lymphadenectomy

In 2003, Bishoff et al[19] were the first to apply endoscopic technology to groin dissection in patients with penile cancer. Sotelo et al[20] subsequently reported a series of 14 minimally invasive lymphadenectomies for penile cancer in which no wound-related complications were noted. Based on these results, we extended and modified the procedure to include the extent of surgery appropriate for melanoma dissection.[6,21] The following is a description of the standard VIL technique used.

Preparation and Position

After entering the operating room, patients are positioned supine on a split-leg table and the boundaries of the femoral triangle are mapped out with a surgical pen (Fig 2). Appropriate antibiotic prophylaxis is given, and the operative area is shaved and prepared in the standard fashion. The suprapubic region should be included in the field to monitor for crepitus. The surgeon is positioned between the patient's legs and the assistant stands to the outside of the operative limb. Monitors are placed cephalad above each shoulder, with the laparoscopic tower strategically positioned on the side of the operative limb.

Figure 2.

Patient positioned on a split-leg table with the femoral triangle, sentinel lymph node biopsy site, and port locations marked.

Trocar Placement

We prefer to use a three-incision technique, with the first 12-mm port placed 3 cm distal to the apex of the femoral triangle. A scalpel is used to incise the skin and sharply dissect down through the Camper and Scarpa fascias. A space analogous to the one created in the open procedure is then created with blunt-finger dissection, extending out 5 cm on each side from the incision (Fig 3). A balloon trocar is inserted into the 12-mm port site and the dissected space is insufflated to 25 mm Hg for 10 minutes, then the pressure is decreased to 15 mm Hg to prevent end-tidal CO2 elevation. Under direct visualization with a 0-degree scope, two 10-mm short bladeless trocars are inserted approximately a hand's breath from the visualization port. These are positioned 3 cm outside of the medial and lateral boundaries of the previously delineated femoral triangle.

Figure 3.

Correct level for the development of the anterior plane of dissection.

Boundaries of Dissection

At this stage, it is critical to ensure that dissection proceeds in the correct anterior plane. The dissection should be carried superficial to the Scarpa fascia, despite the widely publicized concept that the dissection occurs within the Scarpa fascia.[22] If the glistening undersurface layer of the Scarpa fascia is identified, the flap is too thick and the plane must be changed. The correct tissue plane will appear to have created "drops" of fat on the dermis; the actual thickness is approximately 3 to 5 mm in most patients and allows the surgeon to see the cutaneous vessels when the skin flap is transilluminated with a camera. Ultrasonic shears are then used to complete the definition of the anterior working space between the fibrofatty node-containing packet and the superficial tissue. The sentinel node biopsy cavity may be freed from the anterior scar at this juncture. For primary lesions on the trunk, dissection is continued 5 cm above the inguinal ligament along the abdominal wall with an endoscopic dissecting stick (10-mm diameter endoscopic Kittner) in tandem with ultrasonic shears. Medial and lateral boundaries of the dissection consist of the adductor longus and sartorius muscle fascia, respectively, which should be correlated with the previous skin markings via transillumination. The fibrofatty packet may be rolled inward with an endoscopic sponge or Kittner continuing superiorly and inferiorly as much as possible to assist in defining the posterior tail of the node packet. Small perforating vessels and lymphatics are routinely encountered and should be divided with an ultrasonic dissecting scalpel or clipped. The deep thigh fascia constitutes the posterior boundary. Its violation is readily apparent when reddish muscle fibers are encountered.

Saphenous Vein Division and Vascular Dissection

The saphenous vein should be readily identifiable within the apex of the femoral triangle and divided with the vascular load of an endoscopic linear cutting staple. Careful dissection within the femoral triangle enables identification of the femoral artery pulse as well as the medial femoral vein. Proceeding inferior to superior, the vessels are skeletonized along with all the tissue between the femoral vein and adductor longus. This dissection is more easily made if the packet is elevated, thus allowing the surgeon to easily visualize the dissection plane underneath.

Saphenofemoral Junction Dissection and Transection

Once the vascular dissection is complete, blunt dissection in the saphenofemoral junction is performed to identify the inferior edge of the saphenous vein as it enters the femoral vein. A right-angle dissector and a Hunter grasper are the preferred tools for this maneuver. An endoscopic linear cutting stapler with a vascular load is then used to transect the vein at the saphenofemoral junction. Inferomedial dissection around the femoral vein will allow resection of the deep inguinal nodes, as described by Johnson and Ames.[23] Complete node retrieval should be ensured by continuing the dissection to the level of the femoral canal until the pectineus muscle is visible. A biopsy of the Cloquet node may be done at this point, although we have abandoned this element of complete lymphadenectomy in patients with only sentinel node–positive disease. Fascial attachments may persist to the inguinal ligament (Fig 4). Dissection of the tissue off the fascia can be accomplished by inferior retraction of the nodal packet. Alternatively, this may be accomplished using an ultrasonic dissecting scalpel.

Figure 4.

Release of tissue at the superior border along the inguinal ligament.

Packet Removal, Drain Placement, and Postoperative Management

At this point, the nodal packet is free and is withdrawn in a laparoscopic specimen bag through the apical port. A large packet may necessitate extending the skin incision to extract the specimen. To avoid creating an additional wound, we do not excise the biopsy scar. Instead, we dissect the biopsy cavity up to the level of the scar as part of the anterior dissection, releasing the tissue with the remainder of the node contents. The procedure is completed by placing a 19-French fluted drain through the medial port site. Patients are given a regular diet and encouraged to ambulate the day of the surgery. Discharge is routinely planned for the same day unless a deep pelvic node dissection was performed. The fluted drain stays in place until output is below 30 mL during a 24-hour period.

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