Inguinal LND.pptx

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1. Inguinal LND Techniques Lucy S.

2. Outline Anatomy Indication T ypes of inguinal LND Complications SLNB

3. Anatomy Superficial and deep groups Anatomically separated by the fascia lata of the thigh

4. Superficial Group 4 – 25 LNs Divided in to 5 anatomic groups

5. Deep Group Lie medial to the femoral vein Cephalad – node of cloquet Drain to the external iliac LNs progress to the common iliac and para aortic nodes

6. Indications Penile carcinoma Vulvar carcinoma Anal cancers Melanoma with involvement of inguinal LNs Carcinoma affecting the lower limb

7. Controversies Low-volume nodal involvement in a sentinel lymph node ----------------------------------------------------------------------------------- The Multicenter Selective Lymphadenectomy Trial-2 (MSLT-2 trial)

8. Incisions for Inguinal Lymphadenectomy

9. Classic Inguinal LND ( Daseler ) Landmarks

10. Techniques Incision (6-10cm), 2-4cm inferior & parallel to the inguinal ligament C arryout incision to the S carpa’s fascia Raise skin fla p Identify and ligate saphenous vein Mobilize superficial nodal tissue

11. Techniques Con’t … * Identify and preserve lateral cutaneous femoral nerve Extend dissection 2cm above the inguinal ligament Expose femoral canal Excise cloquet node

12. Techniques Con’t …

13. P elvic lymph node dissection Bulky disease in the superficial groin Four or more superficial inguinal nodes are positive Positive Cloquet node Evidence by PET/CT of disease

14. Modified Inguinal LND ( Catalona ) Key aspects Shorter skin incision Limited dissection P reservation of saphenous vein Eliminating the need to transpose the Sartorius muscle

15. Modified Inguinal LND Techniques Patient position – frog legged position Place pillow below the knee for support P lace foley catheter Incision (6-8cm) , 3-4cm below and parallel to the inguinal ligament

16. Techniques Con’t … Incise down to the scarpa’s fascia Preserve subcutaneous tissue over the camper’s fascia Identify saphenous vein D issect the superficial areolar and nodal tissue off the saphenous vein to the fascia lata Ligate and divide venous branches contributing to saphenous vein * Saphenous vein is preserved

17. Techniques Con’t … Dissection carried superiorly upto 2cm cephalad to the inguinal ligament I nferior dissection to ~ 4cm below the incision S pecimen sent for frozen section evaluation wound irrigated and closed A closed suction drainage (5-7 days)

18. Enlarged or Ulcerated nodes Indurate skin Leave a 2cm margin F emoral vessel involvement – anterior wall resection with reconstruction or venous ligation Large skin defects – tensor fascia lata or gracilis myocutanous flap

19. Videoscopic Inguinal Lymphadenectomy W ith laparoscopic equipment Lower wound complication Longer time

20. Videoscopic Inguinal Lymphadenectomy

21. Complications Skin flap necrosis

22. Complications Con’t … Lower limb lymphedema

23. Complications Con’t … Wound infection Tromboembolic problems

24. Sentinel Lymph Node Biopsy Standard of care for patients at high risk for nodal metastases In clinical stage I /II melanoma with tumor thickness from 1-4 mm and clinically negative node basins 0.76-1.00 mm with specific features >4.00 mm tumors and clinically negative nodes

25. SLNB con’t … Preoperative lymphoscintigraphy Direct intraoperative visualization of draining lymphatic patterns using a blue dye Identifies 15% to 20% of micrometastatic ds. M iss up to 12% of true-positive nodes

26. References UpToDate

27. Thank You!