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The use of the abdominal rotation flap for inguinal lymph node dissection – revisited
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e323ee324
CORRESPONDENCE AND COMMUNICATION
The use of the abdominal rotation flap for inguinal lymph node dissection e revisited* Sir, Since Bassett’s 1912 description of block dissection of the groin,1 the high morbidity of this procedure has prompted the publication of a number of techniques and modifications to reduce the common complications of wound infection, breakdown and necrosis, seroma and lymphoedema. Published complication rates range from 6 to 20% for wound infection, 17 to 65% for wound breakdown, 6 to 40% for seroma, and 22 to 80% for post-operative lymphoedema.2 A variety of incisions have been popularised, ranging from a vertical or ‘lazy S’ incision, to a low oblique incision parallel to the inguinal ligament with or without skin edge excision. E. Stanley Lee (1955) recognised a number of problems with the radical dissections at that time, namely breakdown of the thin skin flaps, tenting of the skin over the dissected groin leading to collections, drain site sepsis and subsequent lymphoedema. He therefore devised a medially based abdominal rotation flap which he combined with excision of devitalised wound edges, a ‘pin-down stitch’, pressure dressings and a notable absence of drains in his ilio-inguinal dissection patients. Using this technique, occasionally with a laterally based flap where abdominal scars were present, he reported primary healing without oedema in the majority of cases.3 Thirty-years later, Rayment and Evans reported only one episode of wound edge necrosis in thirteen patients using a modification of this technique, including both Sartorius transposition and suction drainage.4 We performed a retrospective review of all patients in our unit (1998e2006) in whom an inguinal block dissection was performed followed by closure with a medially based
* Presentations: Summer BAPRAS 2008. North East Plastic Surgery Meeting 2008.
abdominal rotation flap, similar to the original Stanley Lee technique. With the patient in the supine position, a T-shaped incision is placed at the level of the inguinal ligament, extending the vertical component down the thigh hence providing generous access to the inguinal nodes. Having completed the block dissection the apices of the triangular flaps are marked and excised (Figure 1), and a C-shaped abdominal rotation flap is marked (Figure 1b) and raised based on the superficial inferior epigastric arcade (Figure 1c). The flap is rotated downwards and closed using a combination of Monocryl (ETHICON), Ethilon (ETHICON) and staples, with placement of suction drains (Figure 2). Transposition of the Sartorius muscle was not performed in any of the cases as the abdominal flap was felt to provide sufficient cover for the femoral vessels. Drains were removed when drainage was less than 30 ml over a 24-h period. During the period studied, 29 patients (14 female and 15 male) underwent inguinal node dissection and abdominal rotation flap closure by the senior author. The mean age was 64 years (range 40e84). Surgery was performed in 1 case of metastatic squamous cell carcinoma and 28 patients with metastatic melanoma with mean Breslow thickness of 4.8 mm. We found no major wound dehiscence or flap loss in the series but one patient, an insulin dependent diabetic, experienced partial wound breakdown, which was treated conservatively. Post-operative infection occurred in 12 patients (41%) of whom 5 (17%) required inpatient stay for intravenous antibiotic treatment. The incidence of skin edge necrosis was 6% as experienced by two patients who were smokers and required conservative management with dressings. Postoperative seroma was found in 8 patients (27%) and 11 (38%) experienced lower limb lymphoedema. The mean length of stay was 10 days (range 4e21) as was the mean length of drainage (range 5e18). The medially based, thick abdominal flap used in this series provides a reliable, simple, tension-free technique for wound closure following inguinal block dissection, with an acceptably low complication rate. The occurrence of wound breakdown in two of twenty-nine patients (6%) compares favourably with the published literature and did not require surgical intervention. Although the infection rate was 41% (12 of 29), one third of these settled with oral antibiotics alone and only two
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.02.048
e324
Correspondence and communication
Figure 2
Final wound closure with suction drains.
cell carcinoma of the perineum. However this technique is equally applicable for regional nodal control of other primary malignancies such as urogenital tumours. In patients undergoing more extensive surgery and in particular iliac node dissection, the technique provides ample simultaneous exposure. We feel that the use of the abdominal rotation flap provides a safe, tension-free closure following inguinal node dissection with acceptable complication rates that are comparable to Rayment’s series and are lower than those following S shaped or straight incisions. In addition it avoids the need for sartorius transposition to protect the femoral vessels.
Acknowledgements We are grateful to Ann Irwin, Thomas Mckinnell and the Department of photography at UHND.
References
Figure 1 a) A T-shaped incision is placed at the level of the inguinal ligament, extending the vertical component down the thigh; the apices of the triangular flaps are marked and excised. b) A C-shaped abdominal rotation flap is marked and incised. c) The abdominal flap is raised, based on the superficial inferior epigastric arcade.
patients required surgical drainage. The overall length of scar is clearly greater than most other groin dissection techniques, but appears to be well tolerated. In our series, the majority of patients were being treated for metastatic melanoma, with one patient having metastatic squamous
1. Bassett A. L’epithelioma primitive du clitoris: son retenissement ganglionaire et son traitement operatoire (Thesis). Paris: G Steinheil; 1912. 2. Swan MC, Furniss D, Cassell OCS. Surgical management of metastatic inguinal lymphadenopathy. Br Med J 2004;329:1272e6. 3. Lee ES. Ilio-inguinal block dissection with primary healing. Lancet 1955;10:520e2. 4. Rayment R, Evans DM. Use of an abdominal rotation flap for inguinal lymph node dissection. Br J Plast Surg 1987;40:485e7.
R. Taghizadeh A.R. Barnard V. Fung R.B. Berry Department of Plastic Surgery, University Hospital of North Durham, North Road, County Durham DH1 5TW, UK E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
The use of the abdominal rotation flap for inguinal lymph node dissection e revisited* Sir, Since Bassett’s 1912 description of block dissection of the groin,1 the high morbidity of this procedure has prompted the publication of a number of techniques and modifications to reduce the common complications of wound infection, breakdown and necrosis, seroma and lymphoedema. Published complication rates range from 6 to 20% for wound infection, 17 to 65% for wound breakdown, 6 to 40% for seroma, and 22 to 80% for post-operative lymphoedema.2 A variety of incisions have been popularised, ranging from a vertical or ‘lazy S’ incision, to a low oblique incision parallel to the inguinal ligament with or without skin edge excision. E. Stanley Lee (1955) recognised a number of problems with the radical dissections at that time, namely breakdown of the thin skin flaps, tenting of the skin over the dissected groin leading to collections, drain site sepsis and subsequent lymphoedema. He therefore devised a medially based abdominal rotation flap which he combined with excision of devitalised wound edges, a ‘pin-down stitch’, pressure dressings and a notable absence of drains in his ilio-inguinal dissection patients. Using this technique, occasionally with a laterally based flap where abdominal scars were present, he reported primary healing without oedema in the majority of cases.3 Thirty-years later, Rayment and Evans reported only one episode of wound edge necrosis in thirteen patients using a modification of this technique, including both Sartorius transposition and suction drainage.4 We performed a retrospective review of all patients in our unit (1998e2006) in whom an inguinal block dissection was performed followed by closure with a medially based
* Presentations: Summer BAPRAS 2008. North East Plastic Surgery Meeting 2008.
abdominal rotation flap, similar to the original Stanley Lee technique. With the patient in the supine position, a T-shaped incision is placed at the level of the inguinal ligament, extending the vertical component down the thigh hence providing generous access to the inguinal nodes. Having completed the block dissection the apices of the triangular flaps are marked and excised (Figure 1), and a C-shaped abdominal rotation flap is marked (Figure 1b) and raised based on the superficial inferior epigastric arcade (Figure 1c). The flap is rotated downwards and closed using a combination of Monocryl (ETHICON), Ethilon (ETHICON) and staples, with placement of suction drains (Figure 2). Transposition of the Sartorius muscle was not performed in any of the cases as the abdominal flap was felt to provide sufficient cover for the femoral vessels. Drains were removed when drainage was less than 30 ml over a 24-h period. During the period studied, 29 patients (14 female and 15 male) underwent inguinal node dissection and abdominal rotation flap closure by the senior author. The mean age was 64 years (range 40e84). Surgery was performed in 1 case of metastatic squamous cell carcinoma and 28 patients with metastatic melanoma with mean Breslow thickness of 4.8 mm. We found no major wound dehiscence or flap loss in the series but one patient, an insulin dependent diabetic, experienced partial wound breakdown, which was treated conservatively. Post-operative infection occurred in 12 patients (41%) of whom 5 (17%) required inpatient stay for intravenous antibiotic treatment. The incidence of skin edge necrosis was 6% as experienced by two patients who were smokers and required conservative management with dressings. Postoperative seroma was found in 8 patients (27%) and 11 (38%) experienced lower limb lymphoedema. The mean length of stay was 10 days (range 4e21) as was the mean length of drainage (range 5e18). The medially based, thick abdominal flap used in this series provides a reliable, simple, tension-free technique for wound closure following inguinal block dissection, with an acceptably low complication rate. The occurrence of wound breakdown in two of twenty-nine patients (6%) compares favourably with the published literature and did not require surgical intervention. Although the infection rate was 41% (12 of 29), one third of these settled with oral antibiotics alone and only two
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.02.048
e324
Correspondence and communication
Figure 2
Final wound closure with suction drains.
cell carcinoma of the perineum. However this technique is equally applicable for regional nodal control of other primary malignancies such as urogenital tumours. In patients undergoing more extensive surgery and in particular iliac node dissection, the technique provides ample simultaneous exposure. We feel that the use of the abdominal rotation flap provides a safe, tension-free closure following inguinal node dissection with acceptable complication rates that are comparable to Rayment’s series and are lower than those following S shaped or straight incisions. In addition it avoids the need for sartorius transposition to protect the femoral vessels.
Acknowledgements We are grateful to Ann Irwin, Thomas Mckinnell and the Department of photography at UHND.
References
Figure 1 a) A T-shaped incision is placed at the level of the inguinal ligament, extending the vertical component down the thigh; the apices of the triangular flaps are marked and excised. b) A C-shaped abdominal rotation flap is marked and incised. c) The abdominal flap is raised, based on the superficial inferior epigastric arcade.
patients required surgical drainage. The overall length of scar is clearly greater than most other groin dissection techniques, but appears to be well tolerated. In our series, the majority of patients were being treated for metastatic melanoma, with one patient having metastatic squamous
1. Bassett A. L’epithelioma primitive du clitoris: son retenissement ganglionaire et son traitement operatoire (Thesis). Paris: G Steinheil; 1912. 2. Swan MC, Furniss D, Cassell OCS. Surgical management of metastatic inguinal lymphadenopathy. Br Med J 2004;329:1272e6. 3. Lee ES. Ilio-inguinal block dissection with primary healing. Lancet 1955;10:520e2. 4. Rayment R, Evans DM. Use of an abdominal rotation flap for inguinal lymph node dissection. Br J Plast Surg 1987;40:485e7.
R. Taghizadeh A.R. Barnard V. Fung R.B. Berry Department of Plastic Surgery, University Hospital of North Durham, North Road, County Durham DH1 5TW, UK E-mail address: [email protected]