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Inguinal lymph node dissection

Borders for radical inguinal LND

Superior – superior margin of external ring to ASIS

Lateral – ASIS and 20 cm inferior

Medial – Pubic tubercle and 15 cm down

Inferior – Apex of the femoral triangle (bordered by medial edge of adductor longus and medial edge sartorius)

Base – Either fascia lata (fascial sparing / modified) or sartorius, femoral vessels and adductor longus

 

 

Technique:

  • Frog leg incision with pillow under the knees, TEDS and SCDs
  • Transverse incision 2 – 3 cm below inguinal ligament (excise needle tract if FNA done)
  • Deep skin flaps using Scarpa’s fascia as the plane to dissect below – gentle retraction of skin with moist sponges on edges and avoiding hooks and crushing skin edges
  • Expose EOA and superficial ring as upper limit of dissection then proceed with LND from cranial to caudal
  • Lymph node dissection using clips for ligation of channels
  • Generally fascial sparing (modified) – fascia lata and fossa ovalis is deep plane (take the deep nodes just within fossa ovalis/saphenous opening of fascia lata)
  • Must take central and superior medial nodes as priority
    • Stay medial to the femoral artery to avoid injuring femoral nerve which lateral to artery
    • A number of tributaries join the saphenous vein around this level (distinguishing saphenous vein from femoral vein, which only has the saphenous vein draining into it)
    • Send packet for frozen section – proceed to radical ILND if positive nodes, or pelvic LND if 3+)
  • If deep dissection / non fascial sparing / radical ILND – saphenous vein may be ligated and divided to access packet of LNs above sartorius and adductor longus muscles – may require sartorius transposition to cover the femoral vessels
    • Sartorius transposition by releasing attachments to ASIS and anchoring to inguinal ligament
  • Drain entering separate incision from below (utilising gravity) – stays in until no output
  • Close skin with stratafix or staples
  • Oral antibiotics and bed rest post-op

 

Complications of ILND

Morbid procedure – reported complications rate 20 – 60 % (probably 40 – 60 %)

Complication rates reduced with modified / superficial / fascial sparing LND.

Complications include:

  • Wound infection (consider prophylactic oral antibiotics)
  • Skin necrosis
  • Wound dehiscence
  • Lymphoedema
  • Lymphocele
  • Cellulitis (chronic)
  • Haematoma
  • DVT/PE (5 – 7 %; prophylaxis should be used)
  • Damage to structures – femoral vessels and nerves

 

 

Factors affecting risk of complications (EAU guidelines)

  • Transverse incision better than S-shaped or vertical
  • Saphenous sparing
  • Fascial sparing
  • Sartorius transposition increases complications
  • Minimally invasive surgery may reduce complications
  • Usual precautions of infection – shaving, prep, prophylactic antibiotics
  • Lymphoedema prevention – massage, skin care, compression garments, occupation therapy, saphenous vein sparing
  • DVT prophylaxis
  • Increased BMI, increased complications
  • Sarcopenia and frailty increases complications
  • Use of ultrasonic devices may increase complications

 

Minimally invasive / robotic LND

  • Longer operative times
  • Equivalent lymph node yields
  • Shorter LOS
  • Lower wound complications
  • All based on retrospective or cohort analyses – no high quality direct comparisons – robots more often used for prophylactic staging dissections cf. cN1/2 – therefore EAU recommends open only for cN1/2 unless in trial setting.
  • No long term oncological data or safety information available.