Mastery of Surgery
5th Edition

142
Radical Groin Dissection
Daniel G. Coit
Indications
Groin dissection is a procedure performed in the treatment of a number of cutaneous malignancies, including melanoma, squamous cell carcinoma, Merkel cell carcinoma, and other skin-appendage tumors metastatic to that nodal basin. Other primary tumor sites potentially metastatic to the superficial groin include the vulva, anus, and penis. Visceral sites potentially metastatic to pelvic nodes include cervix, endometrium, prostate, and bladder. This chapter will deal specifically with lymphadenectomy for metastatic disease to regional nodes, and will not specifically address resection of benign or malignant soft tissue neoplasms of the groin region. Furthermore, it will focus on the technical details of open surgical lymphadenectomy, rather than the minimally invasive laparoscopic approach.
Through the 1980s, perhaps the most common indication for groin dissection was in the elective setting for intermediate-thickness melanomas of the trunk or lower extremities. However, the overall incidence of groin dissection for melanoma has decreased dramatically during the last 20 years. In the absence of prospective data to support routine application of elective lymph node dissection, and with the advent and subsequent widespread application of sentinel lymph node biopsy, the principal indications for this procedure in melanoma have evolved to either selective or completion lymph node dissection in patients with positive sentinel nodes, or therapeutic lymph node dissection for those with clinically positive regional nodes, both in the absence of known distant metastatic disease. The procedure may be unilateral or, in the case of midline primary tumors, bilateral. The procedure may entail removal of inguinofemoral nodes in the superficial groin, that is, those nodes superficial to the inguinal ligament, the ileo-obturator nodes in the deep groin, or both.
Although never formally confirmed in the context of a prospective randomized trial, in the absence of distant disease, few would argue with the therapeutic value of complete lymph node dissection in patients with clinically positive nodes; a substantial proportion of these patients are cured with no further treatment beyond complete surgical resection. On the other hand, the therapeutic value of completion lymph node dissection in patients with a positive sentinel lymph node from melanoma is unknown, and is currently the focus of an ongoing prospective randomized study, the Multicenter Selective Lymphadenectomy II trial.
In patients with known distant metastatic disease, palliative groin dissection may be indicated to achieve control of symptomatic regional disease in the nodal basin. Given the substantial morbidity of the procedure, groin dissection to control potential future symptoms in the presence of known systemic metastases should be done sparingly if at all, and if so, only on a case-by-case basis.
Anatomy
The anatomy of the groin is quite constant. The superficial groin is defined by the femoral triangle, consisting of the sartorius muscle laterally, the adductor magnus and pectineus muscles medially, and the inguinal ligament superiorly. The transition from external iliac to common femoral vessels occurs as they traverse the femoral canal from the pelvis into the thigh. Medially in the femoral canal there are lymphatics containing Cloquet’s lymph node. Proceeding laterally, we encounter the common femoral vein, the common femoral artery, and more laterally, the common femoral nerve. The saphenous vein enters the inferior apex of the femoral triangle at the junction of the adductor magnus and sartorius muscles, and courses through the middle of the triangle, through the fossa ovalis, to drain into the common femoral vein at the saphenofemoral junction. Branches of the saphenofemoral junction include the lateral femoral circumflex, medial femoral circumflex, external pudendal, superficial circumflex iliac, deep circumflex iliac, and superficial epigastric veins. The exact anatomy and caliber of these veins varies from one patient to the next; most of these veins have corresponding arteries. As all of these small vessels traverse the lymphadenectomy specimen, each requires division at both the periphery and center of the lymphadenectomy.
Working cephalad, just above and deep to the inguinal ligament, the common femoral vessels become the external iliac vessels. Laterally, we see the deep circumflex iliac branches, and the inferior epigastric branches arise medially. There are few if any branches of the external iliac vessels. Working cephalad further, we encounter the bifurcation of the common iliac into the internal and external iliac vessels. The internal iliac vessels branch widely. The first branch is the superior gluteal, which traverses the sciatic notch to the buttock, and represents an important source of collateral circulation to the lower leg in the event of external iliac interruption. Other branches include the inferior and superior vesical, the internal pudendal, the obturator, and the superior and middle hemorrhoidal vessels. Not all of these branches can be traced out in every pelvic lymphadenectomy. Traversing the triangle between the external and internal iliac vessels is the obturator nerve, which joins the obturator artery and vein to exit the obturator foramen. Medial to the deep pelvic node compartment is the peritoneum and its contents, including the ureter, rectum, and bladder. The lateral aspect is bordered by the endopelvic fascia.
Surgical Technique
Anesthesia
Groin dissection is most commonly performed under either regional or general anesthesia. If pelvic lymphadenectomy is to be undertaken, muscle relaxation is important to achieve adequate exposure, and general endotracheal anesthesia is preferred. Bladder catheterization is generally not necessary unless a prolonged and difficult procedure is anticipated.
Fig. 1. Incision for en bloc superficial and deep groin dissection. An ellipse of skin over the femoral triangle is removed to minimize postoperative skin-edge necrosis.
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Positioning
The patient is generally positioned supine on the operating room table, with the ipsilateral hip slightly abducted and the knee flexed. This opens up the femoral triangle. The knee can be rested on a pillow for support. The surgical field may be prepared and directly squared off, or the entire lower extremity may be prepared and draped into the field, at the discretion of the operating surgeon. We employ compression boots on one or both legs, depending on whether the ipsilateral leg has been prepared into the field.
Incision
There is a variety of incisions that can be used to performed groin dissection. Many of the short-term wound-related complications associated with the superficial groin dissection are a consequence of a vertically oriented incision, which traverses the groin crease. This incision is subject to a great deal of motion and stress, and often fails to heal primarily. Modifications of the vertical incision include the oblique incision oriented along lines of skin tension, either above or below the groin crease. In the case of pelvic lymphadenectomy, exposure can be achieved by extending the vertically oriented incision cephalad to a point 3 to 4 cm medial to the anterior superior iliac spine (Fig. 1). Although this incision does traverse the inguinal crease, division of the inguinal ligament over the femoral vessels affords the potential for an en bloc dissection of both superficial and deep node compartments. This approach also provides excellent access for a more thorough dissection of the most distal external iliac nodes. An alternative to this approach would be a skin crease-infrainguinal incision for the superficial groin and a parallel suprainguinal skin crease or transplant-type incision for the deep groin. These parallel incisions generally heal quite well, but the main disadvantage is the relative lack of access to the most distal external iliac nodes.
If a vertically oriented incision is to be used, it is important to excise an ellipse of skin overlying the femoral triangle, approximately 3 to 4 cm in width. This shortens the length of flaps that need to be dissected, and dramatically diminishes the likelihood of skin-edge necrosis and subsequent superficial wound dehiscence.
Superficial Inguinofemoral Lymphadenectomy
Once the skin incision has been selected and made, skin flaps are raised in the plane just deep to Scarpa’s fascia, circumferentially around the lymph node basin. These flaps should not be too thin because if they are, they will be devascularized, inevitably leading to skin-edge necrosis and delayed wound healing. Branches of the saphenofemoral junction with their corresponding arteries are clipped and divided as they are encountered at the periphery of the lymphadenectomy. Flaps are raised laterally to the sartorius muscle (Fig. 2), medially to the adductor magnus muscle, and inferiorly to the point where these two muscles cross, where the saphenous vein is traditionally identified, clamped, divided, and ligated. Superiorly, skin flaps are raised to include 5 to 6 cm of fatty and lymphatic tissue overlying the inguinal ligament, medially to the level of the external ring, where the spermatic cord (or ligamentum teres) is exposed and preserved. The dissection proceeds to the pubic tubercle, then on down to the pectineus and adductor magnus muscles (Fig. 3). We prefer to take the fascia of the sartorius, adductor magnus, and pectineus muscles, although the therapeutic value of this maneuver is unknown. Some authors have described preservation of the muscle fascia to minimize postoperative morbidity; no strong data exist to support or refute either approach.
Fig. 2. The lateral skin flap is raised first, down to and including the sartorius fascia (muscle). Preservation of the fascia is optional.
Fig. 3. The medial flap is raised down to the adductor and pectineus muscles. The fatty and lymphatic tissue is dissected off the external oblique fascia, medially to the external inguinal ring, and spermatic cord (ligamentum teres). In this instance, the nodal disease involves the ligamentum teres, and that structure is taken with the specimen.
Fig. 4. Inferiorly, the flap is raised to the apex of the femoral triangle, where the adductor and sartorius muscles cross. In the classic superficial groin dissection, the saphenous vein is taken at this point, although saphenous vein preservation has been proposed to minimize postoperative morbidity.
Fig. 5. Once the flaps are elevated, exposure is maintained with a large self-retaining retractor, and the lymphatic tissue is dissected off the superficial femoral artery (SFA) and vein.
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At the inferior apex of the femoral triangle the saphenous vein is encountered. In the classic inguinofemoral dissection, the saphenous vein is clamped, divided, and ligated at this point (Fig. 4). Again, in an effort to decrease postoperative morbidity, a modification of the procedure that preserves the saphenous vein has been described, and will be discussed later.
Once the skin flaps have been raised, exposure is maintained with a self-retaining retractor (we prefer a Gelpi or Beckman retractor). We then begin dissection of the nodes from the inferior apex of the femoral triangle working cephalad, in the adventitial plane along the superficial femoral artery and vein (Figs. 5 and 6). Care is taken to clip longitudinally oriented lymphatics as they are encountered. Approaching the femoral vessels, the fascia of the adductor and sartorius muscles is once again transected to get into the correct plane. Small arterial branches and venous tributaries are clipped and divided as they are encountered. Working up toward the common femoral vessels, we take the fatty and lymphatic tissue off the inguinal ligament at the lateral aspect of the femoral triangle and dissect this medially off the sartorius muscle. Overly aggressive use of the electrocautery at this point will result in stimulation of the motor branches of the femoral nerve, and should be avoided. The fatty and lymphatic tissues are swept medially, off the common femoral artery. At this point, the saphenofemoral junction is identified and is clamped, divided, and suture-ligated (Fig. 7). The lymphatic tissue is then dissected off the medial aspect of the femoral vein, up toward the femoral canal, together with the fascia of the adductor magnus and pectineus muscles. If the procedure is to be terminated, the superficial inguinofemoral contents are removed and submitted for appropriate pathologic examination (Fig. 8).
At this point, the femoral canal is entered, and an attempt made to identify the so-called node of Cloquet. This maneuver starts by inserting a finger through the femoral canal and manually palpating for enlarged external iliac or obturator nodes. We find that placing a small loop retractor on the inguinal ligament, then reaching under and gently grasping and delivering Cloquet’s node with an Allis clamp works well (Fig. 9). Once removed, Cloquet’s node is submitted for frozen-section examination.
Although Cloquet’s node may not be a reproducible anatomic entity, the concept is that the lymph node lying within the femoral canal represents a bridging node
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between the superficial and deep node contents. The status of this node has been used by many to guide a decision as to whether to proceed to elective deep pelvic node dissection. In melanoma at least, many, but not all, believe that if this node is positive, there is a significant likelihood of deep pelvic node involvement, and the operation should be extended. On the other hand, if this node is negative, there is a low likelihood of clinically occult pelvic nodal involvement, and the operation may be concluded at this point.
Fig. 6. This dissection proceeds from caudad to cephalad, and from lateral to medial.
Fig. 7. When the saphenous vein is being taken with the specimen, the saphenofemoral junction is exposed, clamped, divided, and suture-ligated.
Fig. 8. The superficial groin contents about to be removed from the surgical field.
If the procedure is concluded, the incision is closed. The first step is to close the femoral canal to prevent postoperative femoral hernia. For a secure repair, this involves approximating the inguinal ligament to the lacunar ligament (rather than the pectineus muscle) with one or two interrupted figure-of-eight nonabsorbable sutures (Fig. 10). It is important not to narrow the femoral canal too much with these sutures, to avoid occlusion and/or thrombosis of the common femoral vein. Closed suction drains are placed to deal with postoperative lymphorrhea (Fig. 11). The incision is then closed in layers. We prefer closely spaced interrupted sutures to Scarpa’s fascia to achieve an airtight closure, followed by either a subcuticular suture or clips to the skin.
Deep Ileo-obturator Lymphadenectomy
If pelvic lymphadenectomy (ileo-obturator lymphadenectomy) is to be performed—and this is anticipated ahead of time based on imaging studies—Cloquet’s node need not be sampled, and the entire lymph node package, both superficial and deep, can be removed in continuity by extending the incision cephalad and dividing the inguinal ligament (see following discussion). If the superficial groin contents have been removed previously, then the pelvic nodes can be approached through a suprainguinal skin crease type of incision. That incision should be placed low enough to enable access to the distal most external iliac nodes, and should be long enough to provide adequate exposure and access to the more proximal pelvic nodes.
If Cloquet’s node is positive on frozen section, and the deep pelvic portion of the lymph node dissection is to be done in continuity, the skin incision is extended cephalad, up toward a point 3 to 4 cm medial to the anterior superior iliac, as previously described. The skin and subcutaneous tissues are divided. The fascia of the external oblique muscle is divided lateral to the
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rectus abdominus muscle in the direction of its fibers, bringing that incision down toward the inguinal ligament at the level of the femoral vessels. Prior to dividing the inguinal ligament, the retroperitoneum is entered. This is done by grasping the internal oblique muscle lateral to the rectus muscle and dividing it in the direction of the previous incision. An areolar plane is entered just deep to the transversalis fascia. Great care is taken at this point not to violate the peritoneum. The peritoneum and its contents are then bluntly dissected off the undersurface of the transversalis muscle laterally and the femoral vessels in the depth of the incision. We prefer to retract the inferolateral aspect of the abdominal wall with Kocher clamps to facilitate this access to the retroperitoneum.
Fig. 9. Cloquet’s node is delivered through the femoral canal, medial to the femoral vein, with an Allis clamp.
The incision is then developed more cephalad, dividing the abdominal wall muscles to the level of the anterior superior iliac spine, and caudad down toward the femoral canal. A finger is placed through the femoral canal to protect the femoral vessels as the ligament is divided at this level. At this point, complete exposure of the pelvis can be achieved, as the peritoneum and its contents are bluntly dissected and retracted superomedially. We find that a multiblade self-retaining retractor (such as Bookwalter or Thompson) at this point is invaluable to provide and maintain exposure (Fig. 12). Deep Richardson-type blades are placed to retract the peritoneum superiorly and medially, to retract the bladder medially, and to retract the abdominal wall laterally. This generally affords excellent exposure to the lower retroperitoneum and pelvis. As with all self-retaining retractors, care must be taken at this point to avoid sustained pressure on the femoral nerve so as to prevent postoperative nerve palsy.
Fig. 10. The femoral canal is closed to avoid postoperative herniation, using a figure-of-eight nonabsorbable suture to approximate the lacunar ligament to the inguinal ligament. Care is taken not to narrow the canal too much, to avoid narrowing the femoral vein. The sponge is helpful for exposure and is removed prior to tying the suture.
Fig. 11. After the femoral canal is reconstructed, closed suction drains are placed and the superficial groin dissection wound is closed in layers.
We initiate the pelvic lymphadenectomy at the level of the common iliac artery and vein. The lateral aspect of the dissection is the ileofemoral nerve, a nerve that has often been divided distal to the inguinal ligament in the course of the superficial groin dissection. The fatty and lymphatic tissue is gently dissected off the distal common iliac vessels. It should be noted that the lymphatics completely encircle the external iliac vessels, and the specimen may need to be bivalved to remove it completely. This dissection may be facilitated by gentle retraction of the external artery and/or vein using soft-rubber vessel loops. Care should be taken not to occlude the vessels during the course of this retraction. Proceeding from cephalad to caudad, and from lateral to medial, we then dissect all of the nodal tissue down along the hypogastric (internal iliac) vessels. In so doing, the origin of the obturator nerve is encountered as it courses through the triangle formed by the internal and external vessels (Fig. 13). In a thin patient, one can often visualize
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the superior gluteal, superior vesical, and obturator vessels. The hemorrhoidal vessels can be quite difficult to see because of limited exposure. All of the fatty and lymphatic tissue is dissected off the endopelvic fascia, preserving the named vessels insofar as possible, and preserving throughout the structure and function of the obturator nerve. In the absence of grossly involved nodal disease, much of this portion of the dissection can be done bluntly, as the nodal tissue easily separates from the neurovascular structures.
Fig. 12. When an en bloc superficial and deep groin dissection is to be performed, the incision is extended superolaterally, and the retroperitoneum entered. The peritoneum and its contents are retracted superomedially with a multiblade self-retaining retractor, affording excellent exposure to the lower retroperitoneum and pelvis.
Fig. 13. As the pelvic node dissection proceeds from cephalad to caudad, the nodal tissue is swept down off the internal and external iliac vessels, exposing the obturator nerve.
Fig. 14. The surgical field after en bloc removal of the superficial and deep groin contents.
Next, the nodes are dissected off the bladder medially, down toward the obturator foramen, and then up toward the external iliac vessels and inguinal ligament (Fig. 14). In many instances, particularly when combined superficial and deep dissection is anticipated, the entire lymph node specimen can be removed en bloc. The specimen should be marked to assist the pathologist with orientation, and then submitted for appropriate pathologic examination (Fig. 15).
Once hemostasis is verified, the wound is closed. Deep pelvic drains are not necessary. The retractor is removed and the peritoneum and its contents are returned to the pelvis. The internal oblique and transversus abdominal muscles are closed with a running No. 0 absorbable suture down as far as closure can be completed without undue tension. Care is taken in closing this layer not to violate the peritoneum medially. The external oblique muscle is closed with a similar running No. 0 absorbable suture. This often leaves a very large femoral canal (Fig. 16). Medially, the femoral canal is closed with figure-of-eight sutures of nonabsorbable suture to approximate the inguinal ligament to the lacunar ligament, as previously described for closure of the superficial groin dissection.
At this point, a judgment needs to be made as to whether the residual defect through which the iliac vessels exit the pelvis into the thigh is snug enough to avoid a postoperative hernia. If not, a useful method to prevent peritoneal herniation through an incompetent femoral canal after pelvic lymphadenectomy is to transpose the sartorius muscle over the femoral vessels, under the inguinal ligament (see following discussion). An alternative to sartorius muscle transposition would be to insert a piece of nonabsorbable mesh, fixed to the undersurface of the abdominal wall, then tucked up into the retroperitoneum, over the iliac vessels.
Once the deep pelvic closure is complete, closure of the superficial groin is completed as previously described (Fig. 17).
Fig. 15. The superficial and deep groin dissection specimen should be oriented to assist in the pathologic examination.
Fig. 16. After the layers of the abdominal wall are closed following deep groin dissection, there is often a large defect at the femoral canal. If this cannot be closed by approximating the lacunar ligament to the inguinal ligament (Fig. 10), either sartorius muscle transposition or prosthetic mesh can be employed.
Fig. 17. Final appearance after wound closure.
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Local Muscle Flaps
The sartorius muscle can be exceedingly useful in certain instances. In the case of an obese patient with a high likelihood of wound failure, the sartorius flap is helpful in covering the femoral vessels so as to minimize their exposure should the wound break down. This can be particularly important in patients who have had radiation to the groin. Additionally, the sartorius flap can be used to fill the femoral canal following closure after pelvic lymphadenectomy when simple closure is insufficient. Although some have suggested sartorius muscle transposition may increase the incidence of postoperative edema, this observation has not been subject to rigorous evaluation.
The sartorius flap is easily developed and quite reliable, with minimal donor site morbidity. The muscle’s origin is on the anterior superior iliac spine, and it courses down to the medial knee, to insert on the anterior tibia. Its blood supply is segmental, proximally derived from the deep femoral circulation. The flap is developed by encircling the muscle origin with a finger, taking care to protect the underlying femoral nerve and iliopsoas complex. The muscle is detached from the anterior superior iliac spine as high as possible, and then freed up for a length sufficient to permit its rotation over to cover the femoral vessels. This usually entails sacrifice of no more than one of the segmental vascular branches. It is important not to devascularize this muscle flap in the course of mobilization because its vitality is essential to protect the underlying vessels. Once adequately mobilized, the muscle flap is rotated over the vessels, and then secured to the undersurface of the inguinal ligament and to the adductor magnus muscle with interrupted absorbable sutures. This very nicely covers the vessels and fills the femoral canal.
In instances where very bulky ulcerated nodal metastases have been removed with significant amounts of skin over the femoral triangle, or in instances of groin dissection following nodal basin irradiation, more extensive myocutaneous flaps may be required. Very reliable flap coverage can be achieved with either the rectus abdominus flap or the tensor fascia lata flap, depending on which feeding vessels are available following lymphadenectomy. When such flaps are anticipated, it is imperative that the operating surgeon work closely with the plastic surgeon preoperatively to plan to preserve the necessary
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blood supply to these myocutaneous flaps.
Surgical Variations
Saphenous Vein Preservation
A number of authors have advocated saphenous vein preservation as a way to minimize postoperative morbidity of this procedure, especially lymphedema. Although it is not clear that sacrifice of the saphenous vein improves the oncologic results of most groin dissections, unless the vein itself is intimately associated with malignant lymphadenopathy, neither has it ever been shown in any prospective fashion that preservation of this vein leads to substantial diminution in the morbidity of the procedure. Thus, preservation of the saphenous vein becomes almost a matter of personal style and preference, rather than a recommendation to be embraced with strong conviction.
Minimally Invasive Approaches
Addressing the concern that at least a component of the morbidity of superficial groin dissection is related to the incision used, at least one group has reported on a small experience performing this procedure using minimally invasive techniques. They showed that this is a feasible technique in experienced hands, but there has been no formal comparison of this to the more conventional open approach, to quantify differences in cost, length of stay, short- and long-term morbidity, and perhaps most importantly, the adequacy of the operation in terms of locoregional control.
Although laparoscopic staging and treatment of pelvic nodes is becoming much more widely accepted in the management of patients with prostate, bladder, and gynecologic malignancy, this approach has not yet been widely adopted in the treatment of metastatic pelvic lymphadenopathy from cutaneous malignancy. A few reports have appeared describing a combination of open superficial groin dissection with laparoscopic deep pelvic lymphadenectomy for melanoma, confirming the feasibility of this approach, without long-term follow up. The abdominal incision required to achieve retroperitoneal exposure in patients undergoing pelvic lymphadenopathy clearly results in longer length of hospital stay and ultimate recovery. If the laparoscopic approach to pelvic nodes can be shown to be comparable with the open operation in other respects, then it would seem to be an entirely reasonable alternative.
Perioperative Care
Many unsubstantiated recommendations have been made regarding the perioperative care of patients undergoing groin dissection, in an effort to make impact on short- and long-term complications.
Most patients receive at least preoperative if not also postoperative prophylactic antibiotics, despite findings from at least one small and probably underpowered prospective randomized trial that was unable to demonstrate any benefit. If antibiotics are given, most evidence suggests that they should be limited to a single preoperative dose, given within 1 hour prior to skin incision. Repeated and long-term use of antibiotics is to be discouraged.
Many patients also receive perioperative prophylactic heparin to minimize the probability of deep venous thrombosis (DVT). An older small, prospective, randomized trial evaluating the impact of prophylactic unfractionated heparin was unable to demonstrate any reduction in DVT, at the expense of a slightly increased risk of bleeding complications. No comparable trial using low molecular weight heparin has been performed. In the absence of a specific contraindication, it would seem reasonable to use the same DVT prophylactic regimen as employed in other major surgical procedures.
We prefer early ambulation, either on the day of or the morning after surgery. Patients undergoing superficial groin dissection are usually discharged on the day of or the day after surgery, and those undergoing pelvic lymphadenectomy usually require 3 or 4 days in hospital to achieve adequate pain control and to resume a normal diet. Prior to discharge, patients are instructed in drain management as the amount of drainage usually determines when the drains are ready for removal. Closed suction drains are left in until the output is consistently less than 50 mL/day for a few consecutive days, usually 2 to 3 weeks. In rare cases of persistent high drain output exceeding those guidelines, drains may generally be safely removed at 4 to 5weeks, once the flaps are firmly adherent to underlying muscle, without significant adverse sequelae.
We instruct the patients to keep their legs elevated when they are not walking to avoid short-term edema. Others have advocated early institution of elastic compression stockings. The impact of these recommendations on the ultimate degree of lymphedema is unknown. In the long term, once the drains are out and the wound is healed, we encourage patients to resume their normal activities.
Complications
Adverse events following superficial and deep groin dissection can be separated into short- and long-term events. In the short term, the most common complication recorded following groin dissection is wound infection. The severity of infection can range from a mild cellulitis to infection of an underlying seroma with abscess formation. Wound infection may be associated with skin-edge necrosis from devascularized flaps. If the infection does not respond to oral or parenteral antibiotics, the wound may need to be formally opened and drained. These complications can be quite devastating, particularly in obese patients, those who are most likely to experience them. Large open wounds may be treated with repeated wet-to-dry gauze packing, or by application of a vacuum wound care system. Fortunately, virtually all of these wounds will heal within 3 to 6 weeks with aggressive local wound care, no matter how bad they look initially.
Any surgical procedure is associated with a small but finite incidence of bleeding and/or DVT. The latter can be quite difficult to detect clinically because the ipsilateral leg is often somewhat swollen. The clinician should have a low threshold for obtaining a Doppler ultrasound study of the venous circulation if there is any clinical suspicion of DVT.
Another inevitable sequela of this operation is sacrifice of some of the cutaneous nerve branches enervating the anterior thigh. This often leads to a troubling sense of numbness. Patients should be counseled prior to surgery to expect this so they are not surprised by it.
The most universal and troubling long-term complication of groin dissection is lymphedema. Although the true incidence of lymphedema is impossible to quantify based on retrospective studies, in large part because of inconsistent definitions of the condition, it is my observation that virtually everyone who has a groin dissection will develop some degree of lymphatic stasis in the leg. This can range from quite mild, almost unnoticeable, to quite severe and disabling. Significant lymphedema is often predicted by the amount of lymphatic drainage retrieved by the postoperative suction drains. Identified risk factors for lymphedema consistently include patient obesity and older age, and less consistently include operative factors such as thin skin
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flaps, transverse incisions, sacrifice of the saphenous vein or muscle fascia, and transposition of the sartorius muscle. It is not clear that deep groin dissection contributes much to the overall incidence/severity of lymphedema. The incidence/severity of lymphedema is increased if adjuvant radiation therapy is to be used as a component of treatment. Although techniques such as omental flap transposition have been proposed, unfortunately to date there are no proven prophylactic strategies to minimize the incidence/severity of lymphedema.
Management of lymphedema ranges from simple maneuvers, including leg elevation and compression stockings, to more aggressive and time-consuming lymphedema regimens, including sequential pump therapy and manual massage. In cases of moderate-to-severe lymphedema, there is some evidence to suggest that these more intensive regimens may reduce some of the long-term sequelae. Diuretics are generally ineffective in ameliorating lymphedema following lymph node dissection.
Patients who develop chronic long-term lymphedema are more susceptible to cellulitis, presumably because of impaired lymphatic clearance of bacteria. These patients should be vigilant about breaks in the skin, including trauma and even fungal foot infections. Any episodes of cellulitis should be treated aggressively.
Summary
Groin dissection is an operation performed for malignancy involving inguinofemoral and/or ileo-obturator lymph nodes. With the advent of sentinel lymph node biopsy, this procedure is being undertaken much less commonly for cutaneous malignancies, no longer for the 80% of melanoma patients with histologically negative nodes. Nonetheless, in the patients who require the procedure, it still results in very substantial and almost inevitable short- and long-term morbidity, morbidity for which there is no known preventive maneuver. The likelihood of long-term lymphedema is not clearly related to technical details of the procedure, proponents of individual techniques notwithstanding. Patients should be fully informed about these expectations preoperatively to help them cope with them following this procedure.
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