Inguinal lymph node dissection
- This operation is performed to excise metastatic nodes from the leg, perineum, and gluteal regions.
- Inguinal node dissection involves removal of all fibro-fatty tissue and lymphatic from the Femoral triangle - which is found by the inguinal ligament, Sartorius and adductor longus. It should also include the superficial nodal group which sits above the inguinal ligament.
Inguinal lymph node dissection, page 1
Operative steps
- Incision
- Vertical incision mid-point inguinal ligament extending ~7cm below or
- Vertical lazy s-extended wound to a point 3-4 cm medial to ASIS if performing deep as well
- Skin flaps
- Raise skin flaps just deep to Scarpa’s fascia circumferentially around LN basin
- Laterally to Sartorius/superficial iliac circumflex vessels
- Medially to adductor magnus
- Inferiorly to the point where the two muscles meet (where saphenous vein is traditionally identified and divided)
- Superiorly extends to 2cm superior to inguinal ligament
- Place self-retaining retractor
- Raise skin flaps just deep to Scarpa’s fascia circumferentially around LN basin
- Identify the aponeurosis
- Of the adductor longus muscle of the thigh and the sartorius muscle and cut through it along the medial border of the sartorius and lateral border of adductor
- While preserving the lateral and intermediate cutaneous nerves of the thigh.
- This is the lateral and medial border of the dissection and the fascia inbetween these two incision are taken en-bloc
- Of the adductor longus muscle of the thigh and the sartorius muscle and cut through it along the medial border of the sartorius and lateral border of adductor
- At the lower edge of the dissection, the greater saphenous vein can be ligated (or preserved)
- Approach to the inguinal region (deep phase)
- Incise the aponeurosis of the adductor longus muscle and sartorius muscle aponeurosis
- Up to the inguinal ligament and down to the V
- From the medial side dissect until the femoral vein is exposed
- From the lateral side dissect until the femoral artery is exposed taking care to preserve the nerve
- Identify the superficial iliac circumflex, superficial epigastric, and superficial external pudendal vessels, to avoid tearing their junctions with the main vessels.
- Incise the aponeurosis of the adductor longus muscle and sartorius muscle aponeurosis
- Saphenous vein
- Expose and ligate the SFJ
- Exposure of the inguinal ligament and dissection of the femoral canal
- Dissection then continue superiorly along the anterior border of vein and artery to the level of the inguinal ligament
- The femoral canal, located medial to the femoral vein below the inguinal ligament, is dissected. Cloquet’s lymph node is removed.
- Leave a suction drain - remove when <30mls/dayIliac node dissection
Illiac lymph node dissection
Operative steps
- Make a vertical incision - starting at the midpoint halfway between the umbilicus and ASIS.
- Finish at the apex of the femoral triangle (adductor longus and sartorius)
- Enter the iliac region through the inguinal ligament - by dividing the ligament over the femoral canal, or detaching it from the pubic tubercle.
- Incise the EO, IO, and transversus abdominis muscles 1-2cm above and parallel to the inguinal ligament - so the ligament can be swung laterally.
- Sweep up the peritoneum from the iliac vessels, ensuring the ureter remains attached to the peritoneum. Divide the obliterated umbilical artery.
- Sweep off the connective tissue and lymph nodes from the iliac vessels and their branches, including the obturator vessels.
- Strip out loose connective tissue from the femoral canal.
- Re-attach the inguinal ligament
- Leave a suction drain - remove when <30mls/day
- Close the skin