- Email: [email protected]
Inguinal Lymphadenectomy for Malignant Melanoma
Inguinal Lymphadenectomy for Malignant Melanoma Waddah B. Al-Refaie, MD, and Merrick I. Ross, MD, FACS
I
nguinal lymphadenectomy has been utilized in the management of melanoma and other cutaneous malignancies, penile cancer, and vulvar carcinoma. Historically, this procedure has been performed either in a therapeutic setting to control known regional lymph node metastases or electively to remove the presumed presence of clinically occult nodal disease. While MacCormac in 1899 reported having performed this operation for penile cancer,1 Basset in 1912 was the first to describe the procedure in depth.2 Superficial and deep inguinal (ilioinguinal) lymphadenectomy involves the extirpation of two contiguous lymph-node bearing compartments extending proximally from the bifurcation of the common iliac vessels and distally to the apex of the femoral triangle. The nodes within the boundaries of the femoral triangle as well as those in the supra-inguinal location make up the superficial compartment while the iliac and obturator nodes define the deep compartment.3,4 The most common contemporary use of this procedure is in the management of regional nodes in patients with melanoma. The routine use of elective dissection has been mostly replaced by the practice of selective lymphadenectomy in patients with positive sentinel nodes. In this setting, the procedure provides important staging information, which helps direct the decision to use systemic adjuvant therapy, as well as durable regional control of disease. In the setting of palpable or bulky inguinal lymphadenopathy, a complete anatomically based dissection is critical to avoid future regional morbidity and can be curative in patients without distant metastases. The intent of this chapter is to discuss the extent of inguinal lymphadenectomy as well as to detail the technical steps in carrying out this procedure in patients with melanoma.
Extent of Inguinal Lymphadenectomy In patients with proven or apparent disease in both the superficial and deep lymph node compartments, complete superficial and deep dissection performed in the same operative setting is standard. However, debate continues about whether melanoma patients with known superficial inguinal node involvement and
From the Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX. Address reprint requests to Dr. Waddah B. Al-Refaie, Fellow in Surgical Oncology, Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, P.O. Box 301402, Houston, TX 772031402. E-mail: [email protected]
90
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.06.005
no apparent synchronous deep nodal disease should undergo simultaneous superficial and deep inguinal dissection or superficial lymphadenectomy only.5 One reason for the controversy is that no prospective randomized trials have shown superiority in survival or regional disease control of one approach over the other. Furthermore, whether or not the addition of the deep component of the surgery increases morbidity, lymphedema in particular, represents a second important controversy. Several retrospective studies have highlighted the importance of performing deep inguinal lymphadenectomy in this setting.6-9 In one study, Hughes and coworkers reviewed 132 patients with melanoma and positive inguinal sentinel nodes who underwent either superficial (n ⫽ 60) or combined superficial and deep lymphadenectomy (n ⫽ 72).8 In the superficial lymphadenectomy group, six patients (10%) later developed pelvic recurrence. On the other hand, in the group that underwent combined superficial and deep inguinal lymphadenectomy, only one patient (1%) developed recurrence in the pelvis (P ⫽ 0.01). In the patients who underwent combined superficial and deep inguinal lymphadenectomy (n ⫽ 72), increasing numbers of involved superficial nodes was correlated with a higher incidence of deep nodal meatastases: four (17%) of 24 patients with one superficial lymph node involved and 24 (51%) of 47 patients with more than one metastatic superficial lymph node were found to have disease in the pelvic nodes, (P ⫽ 0.01). When the 5-year survival rates were compared with those who underwent combined superficial and deep inguinal lymph node dissection, patients without pelvic nodal involvement had a more favorable outcome (47%) than patients with pelvic nodal metastasis (19%) (P ⫽ 0.015). In the same study, the authors identified that negative pelvic nodal status was a predictor of better outcome (hazard ratio 0.6; P ⫽ 0.02). In another study, Mann and colleagues evaluated 53 melanoma patients with superficial lymph node metastases and observed that the risk of deep lymph node involvement was 32% in those with one to three lymph nodes, and 67% in those with more than three lymph nodes.7 Such information may be helpful in adopting a selective approach to including the deep dissection. Others have used the histologic status of Cloquet’s node (defined as the first node encountered in the femoral canal) as the indicator for the presence or absence of iliac/obturator involvement.9,10 However, according to the current literature, the histological status of Cloquet’s lymph node cannot be the only factor used to determine whether to perform deep inguinal lymphadenectomy. Results from the Netherlands National Cancer Institute demonstrated that the sensitivity
Inguinal lymphadenectomy for malignant melanoma and specificity of Cloquet’s lymph node in predicting deep inguinal lymph node disease were 54% and 90%, respectively, whereas the positive and negative predictive values were 69% and 82%, respectively.9 Further, Shen and coworkers demonstrated that 67% of patients with Cloquet’s lymph node involvement were at risk for deep nodal metastasis, whereas 77% of patients without metastasis to their Cloquet’s lymph nodes did not have pelvic nodal disease.11 In terms of morbidity, no clear cut increase in operative morbidity or lymphedema rate has been associated with the addition of the deep dissection. At our institution, we typically perform deep inguinal lymphadenectomy in patients with (1) biopsy-proven deep inguinal lymph nodes, (2) bulky or suspicious pelvic lymph nodes on cross-sectional imaging, or (3) the presence of palpable (gross) superficial lymphadenopathy. A selective approach to the deep dissection is reserved for patients with positive sentinel nodes and is dependent on the number of sentinel nodes involved, the burden of disease in the sentinel node, and/or the histologic status of Cloquet’s node.
Anatomy It is imperative that surgeons be familiar with the surgical anatomy of the ilioinguinal region. The superficial ingui-
91 nal lymph nodes are located in the femoral triangle, which consists of three boundaries; superior, medial, and lateral: the inguinal ligament, adductor longus muscle, and sartorius muscle, respectively. The apex of the femoral triangle, which defines the distal extent of the dissection, is located where the sartorius muscle crosses over the femoral vessels and abuts the adductor longus muscle. It is important to recognize that additional contiguous superficial nodes are found for some distance above (superior) to the inguinal ligament. The anatomic extent of these supra-inguinal nodes is: superiorly to the level of the umbilicus, medially to the level of the pubic tubercle, laterally to the anterior superior iliac spine, and posteriorly to the level of the external oblique aponeurosis. The pelvic nodes include the iliac and obturator components. The iliac nodes are located within the following anatomic landmarks: the bifurcation of the common iliac artery superiorly, the undersurface of the inguinal ligament inferiorly, the pelvic sidewall laterally, and the lateral border of the bladder medially. The obturator nodes are found deep to the iliac vessels extending superiorly from the bifurcation of the common iliac vein and inferiorly to the pubic ramus and surrounding the obturator nerve, artery, and vein.
W.B. Al-Refaie and M.I. Ross
92
Operative Technique
Figure 1 The patient is placed in a slight frog-leg type of position. The abdominal wall, and ipsilateral inguinal region and proximal thigh, are usually prepared and draped into the surgical field. A lazy-S curvilinear incision is made two finger-breadths medial of the anterior superior iliac spine, crossing the inguinal crease and then extending distally to the apex of the femoral triangle. We usually incorporate an ellipse of skin that contains the previous biopsy site (if one was performed) as part of the specimen. Additionally, if palpable disease is present, an ellipse of skin overlying the disease is similarly included.
Inguinal lymphadenectomy for malignant melanoma
Figure 2 Flaps are raised laterally to the lateral edge of the sartorius muscle and medially to the pubic tubercle and adductor longus muscle at the junctions of the subcutaneous tissue and adipose tissue of the nodal packet. In addition, we raise the flaps superiorly above the inguinal ligament to approximately the level of the umbilicus and inferiorly to the apex of the femoral triangle.
93
94
W.B. Al-Refaie and M.I. Ross
Figure 3 Supra-inguinal lymph node dissection is accomplished by continuing the superior extent of the dissection through the subcutaneous tissue and Scarpa’s fascia down to the external oblique aponeurosis/muscle. The entire node-bearing fibro-areolar tissue is then dissected from off the underlying external oblique muscle in a superior-toinferior fashion to the level of the inguinal ligament and from the pubic tubercle medially and the anterior superior iliac spine laterally. In the infra-inguinal location the fascia overlying the medial aspect of the sartorius muscle is incised, sparing the lateral femoral cutaneous nerve. This step allows the surgeon to expose and then skeletonize the femoral vessels. Likewise, the fascia overlying the adductor longus is incised from the pubic tubercle to the apex of the femoral triangle. We traditionally spare the saphenous vein unless gross disease is in close proximity to or surrounds the vein. The lymph-node bearing tissue is skeletonized off the femoral vessels from the apex of the femoral triangle distally and to the inguinal ligament proximally. If the saphenous vein is included as part of the specimen, its stump is transected at the saphenofemoral junction at the level of the foramen ovale. A single suture ligation of the venous stump is usually not recommended because of the width of the vein; instead, a running vascular suture is performed using a 4-0 Prolene suture. Because important node-bearing tissue is present at the very proximal/medial extent of the femoral triangle at the level of the femoral canal between the pubic tubercle and posterior medial wall of the femoral vein, the femoral vein is retracted laterally at this level with a vein retractor to facilitate the dissection of this tissue from off of the underlying pectineus muscle in a medial to lateral fashion. This maneuver provides excellent exposure of the junction between the femoral canal and pelvic retroperitoneum, and represents the junction where Cloquet’s node is often found. Cloquet’s node is removed at this time if the decision to perform a deep dissection is dependent on the histologic status of Cloquet’s node.
Inguinal lymphadenectomy for malignant melanoma
Figure 4 If a deep inguinal dissection is planned, a separate incision is made in the external oblique muscle aponeuroses in a hockey stick fashion, extending from the anterior superior iliac spine and then medially and inferiorly to the level of the external ring, approximately two finger-breadths above the inguinal ligament. At the medial aspect of the incision, the cord structures (in males) are completely skeletonized. At this stage, the external oblique and internal oblique muscles and the transversalis fascia are sequentially incised without entering the peritoneum. The inferior epigastric vessels may be suture-ligated and divided to avoid iatrogenic transection and to better visualize the retroperitoneal structures.
95
96
W.B. Al-Refaie and M.I. Ross
Figure 5 The peritoneum and its contents are retracted medially to expose the iliac fossa. The ipsilateral ureter is identified and preserved as it crosses the common iliac vessels. We prefer using the Bookwalter retractor for selfretaining exposure. The common iliac nodes are dissected off the common iliac artery and vein, and the dissection is continued at the bifurcation to the internal iliac artery allowing the removal of the node bearing tissue between these two vessels. A vessel loop is used to retract the proximal portion of the external iliac artery superiorly to circumferentially skeletonize all the lymph-node bearing tissue inferiorly to the level of the undersurface of the inguinal ligament. The anterior surface of the external iliac vein is skeletonized of all its lymphatic-bearing tissues. The genital femoral nerve is usually preserved as the dissection continues at this level from lateral to medial and off of the lateral extent of the bladder. While we continue the dissection from lateral to medial, all side branches to the specimen are tied and cut or clipped. This completes the iliac portion of the dissection. The lymph node dissection is continued from the pubic tubercle, pubic rami, and lateral aspect of the urinary bladder in a medial to lateral fashion to the obturator vessels and nerve and deep to the iliac vein.
Inguinal lymphadenectomy for malignant melanoma
Figure 6 Obturator nodes are located between the posterior surface of the external iliac vein and the obturator nerve (in an anteroposterior direction) and between the internal iliac artery and the obturator foramen (in a cephalad-caudal direction). To better expose the obturator fossa, a vessel loop is placed around the external iliac vein at its most proximal (superior) extent and retracted ventrally. The obturator nodes are then easily dissected off the undersurface of the external iliac vein from the obturator fossa to the juncture of the internal and external iliac vein. Complete removal of the lymph nodes is performed to the level of the obturator nerve in a proximal to distal manner, keeping the iliac lymph nodes en bloc with the obturator nodes. Surgeons should be aware of the varied pattern of venous drainage of the obturator vein to the iliac vein, as accidental transection may lead to troublesome bleeding.
97
98
W.B. Al-Refaie and M.I. Ross
Figure 7 Typically, one round drain is placed via a stab incision laterally full-thickness through the abdominal wall adjacent to the anterior superior iliac spine, and then placed in the pelvis posterior to the iliac vessels.
Inguinal lymphadenectomy for malignant melanoma
Figure 8 The defect in the femoral canal is reconstructed by tacking down the inguinal ligament to Cooper’s ligament with interrupted Prolene sutures. The lateral attachments of the sartorius muscle are dissected off their insertion of the anterior superior iliac spine and rotated on its spared medial blood supply over the femoral vessels. The lateral femoral cutaneous nerve is preserved. The cut surface of the sartorius muscle is secured to the inferior border of the inguinal ligament using absorbable sutures in a U-stitch fashion.
99
100
W.B. Al-Refaie and M.I. Ross
Figure 9 Two additional round drains are laid in the femoral triangle medially and laterally and brought out through stab wound incisions at the apex of the femoral triangle. All drains are secured with a nonabsorbable suture to the skin.
Inguinal lymphadenectomy for malignant melanoma
101
Figure 10 The internal and external oblique muscle/aponeurosis layers are individually closed using nonabsorbable running or interrupted sutures. The medial and lateral aspects of the infra-inguinal flaps are trimmed back approximately 1 cm, to a healthy bleeding level. The dermal edges of the incision are closed with interrupted absorbable sutures, and the skin is approximated with staples, or a running subcuticular stitch.
Postoperative Care For the first 24 hours after surgery, patients receive parental first-generation cephalorins. A nasogastric tube is placed in the operating room and left in place to provide suction for 1 day, unless we have entered the peritoneal cavity or patients demonstrate signs of postoperative ileus. Patients are started on a clear liquid diet and gradually progress to a regular diet, as tolerated. Patient-controlled analgesia is used to control pain, and this is gradually transitioned to oral narcotics as patients begin to tolerate oral intake. In the absence of contraindications, intravenous ketorolac is administered for 48 hours. We typically leave in the urinary catheter to measure urine output and to prevent contamination of the inguinal area from accidental incontinence. Patients can start ambulating as early as the second post-
operative day, but they may need help from the physiotherapist. The pelvic drain is usually removed before discharge. We anticipate that the infrainguinal drains will be in place for 2 to 3 weeks, and therefore, patients are taught about drain care. Drains are left in place until the output does not exceed 50 mL per day for 2 consecutive days. If staples have been used, these are removed 2 to 3 weeks after surgery. Patients are followed closely in the clinic for signs of postoperative incisional infection and other postoperative complications. Patients are fitted for a compression stocking soon after wound healing and are encouraged to wear the stocking early to minimize lymphedema.
References 1. MacCormac W: Five cases of amputation of the penis for epithelioma. Br J Med 1:343, 1886
W.B. Al-Refaie and M.I. Ross
102 2. Basset A. L’epithelioma primitif du clitoris; son retenissement ganglionaire et son traiement operatoire [Thesis]. Paris: G Steinheil; 1912 3. Karakousis CP: Therapeutic node dissections in malignant melanoma. Ann Surg Oncol 5:473-482, 1998 4. Spratt J: Groin dissection. J Surg Oncol 73:243-262, 2000 5. Mack LA, McKinnon JG: Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol 86:189199, 2004 6. Tonouchi H, Ohmori Y, Kobayashi M, et al: Operative morbidity associated with groin dissections. Surg Today 34:413-418, 2004 7. Mann GB, Coit DG: Does the extent of operation influence the progno-
8. 9.
10. 11.
sis in patients with melanoma metastatic to inguinal nodes? Ann Surg Oncol 6:263-271, 1999 Hughes TM, Thomas JM: Combined inguinal and pelvic lymph node dissection for stage III melanoma. Br J Surg 86:1493-1498, 1999 Strobbe LJ, Jonk A, Hart AA, et al: The value of Cloquet’s node in predicting melanoma nodal metastases in the pelvic lymph node basin. Ann Surg Oncol 8:209-214, 2001 Coit DG, Brennan MF: Extent of lymph node dissection in melanoma of the trunk or lower extremity. Arch Surg 124:162-166, 1989 Shen P, Conforti AM, Essner R, et al: Is the node of Cloquet the sentinel node for the iliac/obturator node group? Cancer J 6:93-97, 2000
I
nguinal lymphadenectomy has been utilized in the management of melanoma and other cutaneous malignancies, penile cancer, and vulvar carcinoma. Historically, this procedure has been performed either in a therapeutic setting to control known regional lymph node metastases or electively to remove the presumed presence of clinically occult nodal disease. While MacCormac in 1899 reported having performed this operation for penile cancer,1 Basset in 1912 was the first to describe the procedure in depth.2 Superficial and deep inguinal (ilioinguinal) lymphadenectomy involves the extirpation of two contiguous lymph-node bearing compartments extending proximally from the bifurcation of the common iliac vessels and distally to the apex of the femoral triangle. The nodes within the boundaries of the femoral triangle as well as those in the supra-inguinal location make up the superficial compartment while the iliac and obturator nodes define the deep compartment.3,4 The most common contemporary use of this procedure is in the management of regional nodes in patients with melanoma. The routine use of elective dissection has been mostly replaced by the practice of selective lymphadenectomy in patients with positive sentinel nodes. In this setting, the procedure provides important staging information, which helps direct the decision to use systemic adjuvant therapy, as well as durable regional control of disease. In the setting of palpable or bulky inguinal lymphadenopathy, a complete anatomically based dissection is critical to avoid future regional morbidity and can be curative in patients without distant metastases. The intent of this chapter is to discuss the extent of inguinal lymphadenectomy as well as to detail the technical steps in carrying out this procedure in patients with melanoma.
Extent of Inguinal Lymphadenectomy In patients with proven or apparent disease in both the superficial and deep lymph node compartments, complete superficial and deep dissection performed in the same operative setting is standard. However, debate continues about whether melanoma patients with known superficial inguinal node involvement and
From the Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX. Address reprint requests to Dr. Waddah B. Al-Refaie, Fellow in Surgical Oncology, Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, P.O. Box 301402, Houston, TX 772031402. E-mail: [email protected]
90
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.06.005
no apparent synchronous deep nodal disease should undergo simultaneous superficial and deep inguinal dissection or superficial lymphadenectomy only.5 One reason for the controversy is that no prospective randomized trials have shown superiority in survival or regional disease control of one approach over the other. Furthermore, whether or not the addition of the deep component of the surgery increases morbidity, lymphedema in particular, represents a second important controversy. Several retrospective studies have highlighted the importance of performing deep inguinal lymphadenectomy in this setting.6-9 In one study, Hughes and coworkers reviewed 132 patients with melanoma and positive inguinal sentinel nodes who underwent either superficial (n ⫽ 60) or combined superficial and deep lymphadenectomy (n ⫽ 72).8 In the superficial lymphadenectomy group, six patients (10%) later developed pelvic recurrence. On the other hand, in the group that underwent combined superficial and deep inguinal lymphadenectomy, only one patient (1%) developed recurrence in the pelvis (P ⫽ 0.01). In the patients who underwent combined superficial and deep inguinal lymphadenectomy (n ⫽ 72), increasing numbers of involved superficial nodes was correlated with a higher incidence of deep nodal meatastases: four (17%) of 24 patients with one superficial lymph node involved and 24 (51%) of 47 patients with more than one metastatic superficial lymph node were found to have disease in the pelvic nodes, (P ⫽ 0.01). When the 5-year survival rates were compared with those who underwent combined superficial and deep inguinal lymph node dissection, patients without pelvic nodal involvement had a more favorable outcome (47%) than patients with pelvic nodal metastasis (19%) (P ⫽ 0.015). In the same study, the authors identified that negative pelvic nodal status was a predictor of better outcome (hazard ratio 0.6; P ⫽ 0.02). In another study, Mann and colleagues evaluated 53 melanoma patients with superficial lymph node metastases and observed that the risk of deep lymph node involvement was 32% in those with one to three lymph nodes, and 67% in those with more than three lymph nodes.7 Such information may be helpful in adopting a selective approach to including the deep dissection. Others have used the histologic status of Cloquet’s node (defined as the first node encountered in the femoral canal) as the indicator for the presence or absence of iliac/obturator involvement.9,10 However, according to the current literature, the histological status of Cloquet’s lymph node cannot be the only factor used to determine whether to perform deep inguinal lymphadenectomy. Results from the Netherlands National Cancer Institute demonstrated that the sensitivity
Inguinal lymphadenectomy for malignant melanoma and specificity of Cloquet’s lymph node in predicting deep inguinal lymph node disease were 54% and 90%, respectively, whereas the positive and negative predictive values were 69% and 82%, respectively.9 Further, Shen and coworkers demonstrated that 67% of patients with Cloquet’s lymph node involvement were at risk for deep nodal metastasis, whereas 77% of patients without metastasis to their Cloquet’s lymph nodes did not have pelvic nodal disease.11 In terms of morbidity, no clear cut increase in operative morbidity or lymphedema rate has been associated with the addition of the deep dissection. At our institution, we typically perform deep inguinal lymphadenectomy in patients with (1) biopsy-proven deep inguinal lymph nodes, (2) bulky or suspicious pelvic lymph nodes on cross-sectional imaging, or (3) the presence of palpable (gross) superficial lymphadenopathy. A selective approach to the deep dissection is reserved for patients with positive sentinel nodes and is dependent on the number of sentinel nodes involved, the burden of disease in the sentinel node, and/or the histologic status of Cloquet’s node.
Anatomy It is imperative that surgeons be familiar with the surgical anatomy of the ilioinguinal region. The superficial ingui-
91 nal lymph nodes are located in the femoral triangle, which consists of three boundaries; superior, medial, and lateral: the inguinal ligament, adductor longus muscle, and sartorius muscle, respectively. The apex of the femoral triangle, which defines the distal extent of the dissection, is located where the sartorius muscle crosses over the femoral vessels and abuts the adductor longus muscle. It is important to recognize that additional contiguous superficial nodes are found for some distance above (superior) to the inguinal ligament. The anatomic extent of these supra-inguinal nodes is: superiorly to the level of the umbilicus, medially to the level of the pubic tubercle, laterally to the anterior superior iliac spine, and posteriorly to the level of the external oblique aponeurosis. The pelvic nodes include the iliac and obturator components. The iliac nodes are located within the following anatomic landmarks: the bifurcation of the common iliac artery superiorly, the undersurface of the inguinal ligament inferiorly, the pelvic sidewall laterally, and the lateral border of the bladder medially. The obturator nodes are found deep to the iliac vessels extending superiorly from the bifurcation of the common iliac vein and inferiorly to the pubic ramus and surrounding the obturator nerve, artery, and vein.
W.B. Al-Refaie and M.I. Ross
92
Operative Technique
Figure 1 The patient is placed in a slight frog-leg type of position. The abdominal wall, and ipsilateral inguinal region and proximal thigh, are usually prepared and draped into the surgical field. A lazy-S curvilinear incision is made two finger-breadths medial of the anterior superior iliac spine, crossing the inguinal crease and then extending distally to the apex of the femoral triangle. We usually incorporate an ellipse of skin that contains the previous biopsy site (if one was performed) as part of the specimen. Additionally, if palpable disease is present, an ellipse of skin overlying the disease is similarly included.
Inguinal lymphadenectomy for malignant melanoma
Figure 2 Flaps are raised laterally to the lateral edge of the sartorius muscle and medially to the pubic tubercle and adductor longus muscle at the junctions of the subcutaneous tissue and adipose tissue of the nodal packet. In addition, we raise the flaps superiorly above the inguinal ligament to approximately the level of the umbilicus and inferiorly to the apex of the femoral triangle.
93
94
W.B. Al-Refaie and M.I. Ross
Figure 3 Supra-inguinal lymph node dissection is accomplished by continuing the superior extent of the dissection through the subcutaneous tissue and Scarpa’s fascia down to the external oblique aponeurosis/muscle. The entire node-bearing fibro-areolar tissue is then dissected from off the underlying external oblique muscle in a superior-toinferior fashion to the level of the inguinal ligament and from the pubic tubercle medially and the anterior superior iliac spine laterally. In the infra-inguinal location the fascia overlying the medial aspect of the sartorius muscle is incised, sparing the lateral femoral cutaneous nerve. This step allows the surgeon to expose and then skeletonize the femoral vessels. Likewise, the fascia overlying the adductor longus is incised from the pubic tubercle to the apex of the femoral triangle. We traditionally spare the saphenous vein unless gross disease is in close proximity to or surrounds the vein. The lymph-node bearing tissue is skeletonized off the femoral vessels from the apex of the femoral triangle distally and to the inguinal ligament proximally. If the saphenous vein is included as part of the specimen, its stump is transected at the saphenofemoral junction at the level of the foramen ovale. A single suture ligation of the venous stump is usually not recommended because of the width of the vein; instead, a running vascular suture is performed using a 4-0 Prolene suture. Because important node-bearing tissue is present at the very proximal/medial extent of the femoral triangle at the level of the femoral canal between the pubic tubercle and posterior medial wall of the femoral vein, the femoral vein is retracted laterally at this level with a vein retractor to facilitate the dissection of this tissue from off of the underlying pectineus muscle in a medial to lateral fashion. This maneuver provides excellent exposure of the junction between the femoral canal and pelvic retroperitoneum, and represents the junction where Cloquet’s node is often found. Cloquet’s node is removed at this time if the decision to perform a deep dissection is dependent on the histologic status of Cloquet’s node.
Inguinal lymphadenectomy for malignant melanoma
Figure 4 If a deep inguinal dissection is planned, a separate incision is made in the external oblique muscle aponeuroses in a hockey stick fashion, extending from the anterior superior iliac spine and then medially and inferiorly to the level of the external ring, approximately two finger-breadths above the inguinal ligament. At the medial aspect of the incision, the cord structures (in males) are completely skeletonized. At this stage, the external oblique and internal oblique muscles and the transversalis fascia are sequentially incised without entering the peritoneum. The inferior epigastric vessels may be suture-ligated and divided to avoid iatrogenic transection and to better visualize the retroperitoneal structures.
95
96
W.B. Al-Refaie and M.I. Ross
Figure 5 The peritoneum and its contents are retracted medially to expose the iliac fossa. The ipsilateral ureter is identified and preserved as it crosses the common iliac vessels. We prefer using the Bookwalter retractor for selfretaining exposure. The common iliac nodes are dissected off the common iliac artery and vein, and the dissection is continued at the bifurcation to the internal iliac artery allowing the removal of the node bearing tissue between these two vessels. A vessel loop is used to retract the proximal portion of the external iliac artery superiorly to circumferentially skeletonize all the lymph-node bearing tissue inferiorly to the level of the undersurface of the inguinal ligament. The anterior surface of the external iliac vein is skeletonized of all its lymphatic-bearing tissues. The genital femoral nerve is usually preserved as the dissection continues at this level from lateral to medial and off of the lateral extent of the bladder. While we continue the dissection from lateral to medial, all side branches to the specimen are tied and cut or clipped. This completes the iliac portion of the dissection. The lymph node dissection is continued from the pubic tubercle, pubic rami, and lateral aspect of the urinary bladder in a medial to lateral fashion to the obturator vessels and nerve and deep to the iliac vein.
Inguinal lymphadenectomy for malignant melanoma
Figure 6 Obturator nodes are located between the posterior surface of the external iliac vein and the obturator nerve (in an anteroposterior direction) and between the internal iliac artery and the obturator foramen (in a cephalad-caudal direction). To better expose the obturator fossa, a vessel loop is placed around the external iliac vein at its most proximal (superior) extent and retracted ventrally. The obturator nodes are then easily dissected off the undersurface of the external iliac vein from the obturator fossa to the juncture of the internal and external iliac vein. Complete removal of the lymph nodes is performed to the level of the obturator nerve in a proximal to distal manner, keeping the iliac lymph nodes en bloc with the obturator nodes. Surgeons should be aware of the varied pattern of venous drainage of the obturator vein to the iliac vein, as accidental transection may lead to troublesome bleeding.
97
98
W.B. Al-Refaie and M.I. Ross
Figure 7 Typically, one round drain is placed via a stab incision laterally full-thickness through the abdominal wall adjacent to the anterior superior iliac spine, and then placed in the pelvis posterior to the iliac vessels.
Inguinal lymphadenectomy for malignant melanoma
Figure 8 The defect in the femoral canal is reconstructed by tacking down the inguinal ligament to Cooper’s ligament with interrupted Prolene sutures. The lateral attachments of the sartorius muscle are dissected off their insertion of the anterior superior iliac spine and rotated on its spared medial blood supply over the femoral vessels. The lateral femoral cutaneous nerve is preserved. The cut surface of the sartorius muscle is secured to the inferior border of the inguinal ligament using absorbable sutures in a U-stitch fashion.
99
100
W.B. Al-Refaie and M.I. Ross
Figure 9 Two additional round drains are laid in the femoral triangle medially and laterally and brought out through stab wound incisions at the apex of the femoral triangle. All drains are secured with a nonabsorbable suture to the skin.
Inguinal lymphadenectomy for malignant melanoma
101
Figure 10 The internal and external oblique muscle/aponeurosis layers are individually closed using nonabsorbable running or interrupted sutures. The medial and lateral aspects of the infra-inguinal flaps are trimmed back approximately 1 cm, to a healthy bleeding level. The dermal edges of the incision are closed with interrupted absorbable sutures, and the skin is approximated with staples, or a running subcuticular stitch.
Postoperative Care For the first 24 hours after surgery, patients receive parental first-generation cephalorins. A nasogastric tube is placed in the operating room and left in place to provide suction for 1 day, unless we have entered the peritoneal cavity or patients demonstrate signs of postoperative ileus. Patients are started on a clear liquid diet and gradually progress to a regular diet, as tolerated. Patient-controlled analgesia is used to control pain, and this is gradually transitioned to oral narcotics as patients begin to tolerate oral intake. In the absence of contraindications, intravenous ketorolac is administered for 48 hours. We typically leave in the urinary catheter to measure urine output and to prevent contamination of the inguinal area from accidental incontinence. Patients can start ambulating as early as the second post-
operative day, but they may need help from the physiotherapist. The pelvic drain is usually removed before discharge. We anticipate that the infrainguinal drains will be in place for 2 to 3 weeks, and therefore, patients are taught about drain care. Drains are left in place until the output does not exceed 50 mL per day for 2 consecutive days. If staples have been used, these are removed 2 to 3 weeks after surgery. Patients are followed closely in the clinic for signs of postoperative incisional infection and other postoperative complications. Patients are fitted for a compression stocking soon after wound healing and are encouraged to wear the stocking early to minimize lymphedema.
References 1. MacCormac W: Five cases of amputation of the penis for epithelioma. Br J Med 1:343, 1886
W.B. Al-Refaie and M.I. Ross
102 2. Basset A. L’epithelioma primitif du clitoris; son retenissement ganglionaire et son traiement operatoire [Thesis]. Paris: G Steinheil; 1912 3. Karakousis CP: Therapeutic node dissections in malignant melanoma. Ann Surg Oncol 5:473-482, 1998 4. Spratt J: Groin dissection. J Surg Oncol 73:243-262, 2000 5. Mack LA, McKinnon JG: Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol 86:189199, 2004 6. Tonouchi H, Ohmori Y, Kobayashi M, et al: Operative morbidity associated with groin dissections. Surg Today 34:413-418, 2004 7. Mann GB, Coit DG: Does the extent of operation influence the progno-
8. 9.
10. 11.
sis in patients with melanoma metastatic to inguinal nodes? Ann Surg Oncol 6:263-271, 1999 Hughes TM, Thomas JM: Combined inguinal and pelvic lymph node dissection for stage III melanoma. Br J Surg 86:1493-1498, 1999 Strobbe LJ, Jonk A, Hart AA, et al: The value of Cloquet’s node in predicting melanoma nodal metastases in the pelvic lymph node basin. Ann Surg Oncol 8:209-214, 2001 Coit DG, Brennan MF: Extent of lymph node dissection in melanoma of the trunk or lower extremity. Arch Surg 124:162-166, 1989 Shen P, Conforti AM, Essner R, et al: Is the node of Cloquet the sentinel node for the iliac/obturator node group? Cancer J 6:93-97, 2000