Pravin Narkhede

Inguinal Anatomy
superficial and deep groups,
anatomically separated by the fascia lata of the
thigh.
Superficial Group
composed of 4 to 25 lymph nodes that are
situated in the deep membranous layer of the
superficial fascia of the thigh (Camper's
fascia).
• Divided into five anatomic groups
(1) central nodes around the saphenofemoral
junction,
(2) superolateral nodes around the superficial
circumflex vein,
(3) inferolateral nodes around the lateral femoral
cutaneous and superficial circumflex veins,
(4) superomedial nodes around the superficial
external pudendal and superficial epigastric
veins, and
(5) inferomedial nodes around the greater
saphenous vein
• Deep Group
• fewer and lie primarily medial to the femoral
vein in the femoral canal.
• The node of Cloquet is the most cephalad of
this deep group and is situated between the
femoral vein and the lacunar ligament
• The external iliac lymph nodes receive drainage
from the deep inguinal, obturator, and
hypogastric groups. In turn, drainage progresses
to the common iliac and para-aortic nodes
Indications
Penile carcinoma
Vulval carcinoma
Melanoma with involvement of inguinal lymph nodes
Carcinoma affecting lower limb
Incisions for inguinal
lymphadenopathy
 Modified Inguinal
Lymphadenectomy ( Catalona)
Key aspects of the procedure are
(1) shorter skin incision,
(2) limitation of the dissection by excluding the
area lateral to the femoral artery and caudal to
the fossa ovalis,
(3) preservation of the saphenous vein, and
(4) elimination of the need to transpose the
sartorius muscle
 Modified Inguinal
Lymphadenectomy
Position of patient :- frog-legged position.
A foley catheter is placed to straight drainage.
The scrotum and penis are then retracted out of
the field and draped off
A pillow is placed beneath the knees for support.
A 6 to 8-cm incision is then made 3 to 4-cm
below the inguinal ligament and parallel to it
• The incision is carried down to Scarpa's fascia.
Gentle sponge traction is used to separate the
skin edges
• subcutaneous tissue in Camper's layer is carefully
preserved, and meticulous handling of these
tissues and the skin edges must be observed
throughout
• The saphenous vein and its tributaries are
identified, and the superficial areolar and node-
bearing tissue is gently dissected off the vein
downward to the fascia lata
• The venous branches emptying into the
saphenous vein are carefully ligated and divided.
The saphenous vein is preserved
• Particular attention is paid in area of the sentinel
node tissue.
• Large lymphatics and small venous branches
must be carefully and meticulously ligated or
fulgerated.
• The dissection is carried superiorly to
approximately 2-cm cephalad to the inguinal
ligament where it is carried down to the fascia of
the external oblique muscle.
• Dissection is next carried inferiorly to about 4-cm
below the incision
• In the Catalona operation, the lower limit of
dissection is the lower border of the fossa ovalis .
• Puras and associates, carry our dissections
slightly lower, although there is not much
superficial nodal tissue in this area.
• sent for frozen section evaluation ,
• If the nodes are negative, the wound is thoroughly
irrigated with sterile water and closed in layers,
taking care to eliminate any potential spaces.
• A closed suction drainage system is placed and
remains for 5 to 7 days during which time the
patient is maintained at complete bed rest.
 Classic Inguinal
Lymphadenectomy ( Daseler)
• An incision of 6 to 8-cm is made parallel to the
inguinal ligament and about 3 to 4-cm inferior to it.
• The incision is carried down to Scarpa's fascia, and
the saphenous vein is identified. This is ligated with
2-0 silk sutures and divided.
• The superficial nodal tissue is systematically
mobilized, beginning in the superomedial quadrant,
freeing the tissue towards the junction of the
saphenous vein with the femoral vein at the fossa
ovalis.
• The sentinel node tissue is identified and tagged with
a suture.
This dissection is extended above the inguinal
ligament 2-cm, and the limits of the standard
dissection,
• meticulously ligated and divided as well as any
large lymphatics.
• The saphenous vein carefully dissected down to
the fossa ovalis and the junction with the femoral
vein is identified, clamped, divided and ligated.
• venous tributaries of the saphenous vein are The
fascia lata is opened and excised with all the
nodal tissue superficial to it.
• This exposes the femoral sheath and Scarpa's
triangle.
• The lateral aspect of this dissection is the medial
border of the sartorious, and the medial border
the of the adductor longus is the medial side.
• femoral sheath is opened from the inguinal ligament
to the apex of the femoral triangle. Within the sheath
are the femoral vein, the femoral artery lateral to it,
and fatty areolar tissue containing the deep inguinal
nodes medially
• The femoral nerve is lateral to the artery and is not
encountered in the usual dissection
• The vein is gently retracted laterally to allow
dissection of tissue from the lateral and anterolateral
aspect of the vein, and nodal and areolar tissue is
dissected from the anterior artery and between the
artery and vein.
• The nodes are dissected to below the inguinal
ligament, to the node of Cloquet (or
Rosenmuller), the most proximal of the deep
inguinal chain.
• One to 5 nodes are usually encountered.
• About 5 to 8-cm below the inguinal ligament, the
profunda femoris artery arises on the lateral
aspect of the femoral artery. This must be
carefully dissected and preserved, especially if
myocutaneous flap coverage may later be
required.
• The wound is then irrigated carefully and careful
attention is given to all bleeders and lymphatics.
• The sartorious muscle is separated sharply from
its origin on the anterior superior iliac spine and
mobilized medially to cover the now exposed
femoral vessels
• Drainage using a closed suction catheter
apparatus is placed, and the wound is carefully
closed in layers.
• Several sutures are used to secure Camper's
fascia to the anterior aspect of the muscles to
close potential space and discourage
lymphocoele formation
The skin edges are carefully assessed, using
intravenous fluorescein and the Woods' lamp if
necessary, and any questionably viable skin
excised. The wound is then meticulously closed
in layers
Enlarged or Ulcerated Nodes and
Femoral Vessel Involvement
• Induration of the skin is suggestive of such local
invasion. In this setting, the tumor is excised
leaving a 2-cm margin of normal skin around the
indurated or ulcerated area.
• involvement of the femoral vessels, particularly
the vein. Resection of the anterior wall of the
vein with reconstruction using a saphenous vein
graft or Gore-tex patch may be required.
• involvement of the femoral vessels, particularly
the vein. Resection of the anterior wall of the
vein with reconstruction using a saphenous vein
graft or Gore-tex patch may be required.
• In some instances of severe involvement, the
vein may be ligated and excised.
• Large skin defects may be closed with a tensor
fascia lata or gracilis myocutaneous graft
Complications from Inguinal
Lymphadenectomy
• Skin flap necrosis
• can be minimized by selecting the appropriate
incision, by careful tissue handling,
• by careful attention to skin flap thickness with
excision of ischemic flap margins, and
• by transposing the head of the sartorius muscle to
cover the defect left over the femoral vessels.
• Use of intravenous fluorescein dye and a Woods'
lamp intraoperatively to assess viability of wound
edges is a useful adjunct
• Lower limb lymphedema
• can be reduced by careful attention to
intraoperative ligation of lymphatics,
• by immobilization of the limb or limbs in the
postoperative period, and
• by suction drainage of the lymphadenectomy
site
• Elastic support hose should be used in the
immediate postoperative period and may be
required long term in many patients.
• Wound infection
• can be minimized by intensive preoperative
antibiotic therapy to reduce infection and
inflammation from the primary, and by the use
of prophylactic antibiotics.
• Thrombotic problems
• may be avoided through the use of
subcutaneous heparin in the perioperative
period, particularly when the classical inguinal
and pelvic dissection is combined with
prolonged bed rest postoperatively.
Nodes not Primary Palpable
palpable surgery nodes

Primary lesion Primary lesion

B/L
observe Sup LND
Node
+ ve Nodes Nodes
Examination
- ve - ve + ve

Deep LND &

Node not Antibiotics for Nodes

Ipsilateral
total LND + Unilateral
Contralateral B/L nodes
nodes
sup LND

C/L nodes C/L nodes

B/L total
Deep LND &
observe LND
Pelvic LND
Sentinel Node
of nodesBiopsy
proposed by Cabanas, and postulates that there is
a node or group - lying between the
superficial external pudendal vein and the
superficial epigastric vein - where the earliest
metastasis from a penile tumor will occur
consistently
Although Cabanas reported 90% survival in
patients with normal findings on sentinel node
biopsy, subsequent authors found the results to be
less satisfactory, with reports of development of
extensive regional metastases after a biopsy with
normal findings