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.