INGUINAL LYMPHNODE

DISSECTION
Dr.MANOJ KUMAR SISTU
 INGUINAL ANATOMY

• FEMORAL TRIANGLE
Superior- inguinal ligament
Laterally- sartorius
Medially-adductor longus
CONTENTS-
femoral nerve
femoral artery
femoral nerve
deep inguinal lymphnode
 INGUINAL LYMPHNODES

• Fascia lata of thigh

divides inguinal
lymphnodes in to two
groups
1.SUPERFICIAL
2. DEEP
 INGUINAL LYMPHNODE GROUPS

SUPERFICIAL GROUP DEEP GROUP

• NUMBER- 4-25
SITUATION- • Few in number
• Lie medial to the femoral
deep membranous layer of vein in femoral canal
superficial fascia of
thigh(CAMPER’S FASCIA) • LYMPHNODE OF
CLOQUET-
DIVISION- -Most cephalad in the
1.Central deep inguinal lymphnode
2.Superolateral group
3.Superomedial -situated between fempral
vein and lacunar ligament
4.Inferolateral
5.inferomedial
 LYMPHATIC DRAINAGE
SUPERFICIAL INGUINAL LN. DEEP INGUINAL LN.
• Scrotum • Lymphatics from glans
• Perineum penis
• Buttock • women’s clitoris
• Abdominal wall below the
level of the umbilicus • Prostatic urethra
• Back below the level of • Spongy urethra
the iliac crest
• Deep parts of lower limb
• Vulva
• Anus (below the pectinate • Superficial inguinal
line) nodes
• The thigh and the medial
side of the leg (the lateral
leg drains to the popliteal
lymph nodes first).
 PENILE LYMPHATICS
SUPERFICIAL LYMPHATIC
SYSTEM DEEP LYMPHATIC SYSTEM
GLANS
PREPUCE LARGE TRUNKS AT FRENULUM
SKIN OF PENILE SHAFT
Traverse penis through bucks
converge dorsally fascia

base of penis presymphyseal lymphatics

Rt superficial Lt. superficial deep nodes

superficial Inguinal nodes in femoral
Inguinal node inguinal triangle
node
ENLARGED INGUINAL
LYMPHNODES
 INGUINAL LYMPHNODE DISSECTION IN CA
PENIS
• Squamous cell carcinoma of penis spreads
initially to inguinal lymphnodes before
occurrence of distant metastatic disease

• RISK GROUPS FOR INGUINAL METASTASES –

low risk High risk

-Tis/Ta - T2-T3
-No vascular invasion -Vascular invasion

<10% LN mets >50% LN mets

 INGUINAL PROCEDURES

• AIM-
To define wheather metastasis exist with
minimal morbidity for the patient

• PATIENT SELECTION-
Patients with no evidence of palpable
lymphadenopathy(Node negative) but with
adverse prognostic factors with in the primary
tumour
 ….CONTD
• OPTIONS
-FINE NEEDLE ASPIRATION CYTOLOGY
- NODE BIOPSY
- SENTINEL LYMPHNODE BIOPSY
-EXTENDED SENTINEL LYMPHNODE BIOPSY
- DYNAMIC SENTINEL LYMPHNODE DISSECTION
-SUPERFICIAL DISSECTION
-MODIFIED COMPLETE DISSECTION
 FINE NEEDLE ASPIRATION
CYTOLOGY(FNAC)
• FNAC in clinicaly negative inguinal nodes
guided by lymphangiography/usg
• It doesn’t exhibit sensitivity for it to be relied on
as a staging modality
FNAC SENSITIVITY

Node negative pt. Node positive pt.

39% 93%
 SENTINEL LYMPHNODE
BIOPSY(SLNB)
• Technique to remove nodes that are first
affected by the spread of metastatic disease
• First described by CABANA(1977)
IMPRESSION

SLN –ve SLN +ve

metastasis to other inguinal Need for

nodes didn’t occur inguinal dissection
• DISADVANTAGES
False negative rate – 3/31= 10%
• 3 patients out of 31 patients died of disease
with negative sentinel lymphnode biopsy
• Mc.dougal and associates reported 50%
false negative rates
• Now a days SLNB cofined to breast
carcinoma and melanoma
 PROCEDURE OF SLNB
5cm incision parallel to inguinal crease

2 finger breadth lateral and inferior to pubic tubercle

upper and lower flaps raised

By inserting finger under upper flap towards pubic

tubercle sentinel lymphnode encountered

excise lymphnode
EXTENDED SENTINEL LYMPHNODE BIOPSY

• Pettaway and collegues

• Removed additional nodes around sentinel
node area i.e nodes between inguinal
ligament andsuperficial external pudental
vein
• Revealed false negative rate of 18-25%
 DYNAMIC SENTINEL LYMPHNODE BIOPSY

• AIM-
To define where the sentinel lymphnode reside in
the inguinal lymphnode group by using gamma
emission probe and visual dyes
• This technique studied in patients with
- malignant melanoma
-breast carcinoma
-vulval carcinoma
• It remains a diagnostic procedure allowing some
men to avoid a therapeutic inguino femoral
lymphnode dissection
• ROLE IN PENILE CARCINOMA-

As a staging tool with false negative rate of

1%
LIMITATIONS-
-Performed only at high volume centres
- Needs to follow standard protocols
- Needs experienced surgeons
- Nuclear medicine specialist undervsion
 FOLLOW UP
• Strict followup is necessary to identify recurrences
that can be treated surgically
Negative usg
Negative DSNB

clinical evluation of inguinal nodes

(best is self examination by the patient)

examination of inguinal nodes

1st yr- every 3months
2nd yr- every 4months
3rd yr and after- every 6 months
SUPERFICIAL INGUINAL NODE DISSECTION

• It is used as a staging tool for patients

without palpable inguinal lymphnodes
• It includes removal of nodes
-superficial to fascia lata
-fossa ovalis
- saphenofemoral junction
• Peripheral boundaries of dissection are
similar to modified complete inguinal node
dissection
 MODIFIED COMPLETE INGUINAL
LYMPHNODE DISSECTION
• CATALONA(1988) proposed this technique
• KEY ASPECTS-
-Shorter skin incision
- preservation of saphenous vein
- limitation of dissection by
excluding area lateral to femoral artery
and caudal to fossa ovalis
- elimination of the need to
transpose sartorius muscle
 Contd..

• All superficial inguinal

lymphnodes
+
• Deep inguinal nodes
that are located
primarly medial to the
femoral vein to th
level of inguinnal
ligament
 SURGICAL PROCEDURE

• Patient position-
FROG LEG POSITION
• Incision-
10cm incision 1.5-2.0cm
below inguinal crease
• Flaps-
developed in the plane
just beneathe the scarpas
fascia
• Extent of flaps-
Superior-
8cms superiorly up to external oblique fascia
with exposure of spermatic cord
Inferior-
up to 6cms inferiorly
• Extent of dissection-
Medially- Adductor longus muscle
Laterally- Femoral Artery

• Structures to be preserved-
saphenous vein
 DISSECTION PROCEDURE

A funiculus of lymphofatty tissue extending

from base of penis to superomedial portion of
lymphnode packet is ligated and divided

dissection commences in caudal direction

till inferior skin flap

lymphatics carefully ligated

specimen delivered and sent for biopsy

 ADVANTAGES

• False negative rate is less approximately

(0-5.5%)
• Morbidity less in terms of
-Seroma/lymphocele formation
- Lymphorrhea
-Wound infection/skin necrosis
• Lower extremity edema occurs in 0-36% of
patients but clinically significant persistent
edema uncommon
 ENDOSCOPIC AND ROBOTIC INGUINAL
LYMPHADENECTOMY
• Patient position-
positioned on split leg table/Low
lithotomy
Reason- This position allow bilateral groin
dissection without repositioning of robot
Surgeons position-
Assistant-
-lateral to right leg for for right sided
dissection
- between the legs for left sided
dissection
• LOCATION OF ROBOT
-45 degrees contralateral to the patient
on
right sided dissection
- Lateral to the patient in left sided
dissection
Instruments-
Left robotic arm- Bipolar maryland
Right robotic arm- monopolar scissors
• LANDMARKS FOR
TROCARS-
• Mark bony and soft tissue
land marks creating an
invrted traingle
Base-line joinging ASIS to
pubic tubercle
Lateral- sartorius muscle
Medial – adductor longus
 PORT PLACEMENT
• Robotic port
placement- 12-mm
camera port placed 25
cm from midpoint of
inguinal ligament,
• 2 robotic parts (8 mm)
placed 8 cm apart
making isosceles
triangle,
• 10-mm assistant port
between the camera
port and lateral robotic
port
 PROCEDURE OF TROCAR PLACEMENT
2cm incision at 3cm below inferior aspect
of femoral triangle

white subcutaneous layer (scarpa’s fascia)

identified

Create potential space beneathe the scarpa’s

fascia by sweeping finger dissection

develop skin flaps for two 8mm robotic ports

at the apex of triangle

contd…
Subcutaneous work space extended with
endoscope by sweeping with lens itself
or
12mm baloon port trocar used
(25mmHg pressure for 10 mins)

work space expanded with CO2 insufflation

at pressure 15mmHg

10 mm assistant port placed between

primary robotic port and camera port

Robotic docking performed

 LIMIT OF DISSECTION

• Superiorly- Inguinal
ligament
• laterally- Sartorius
muscle
• Medially- Adductor
longus
 DISSECTION PROCEDURE
With blunt dissection
the nodal tissue rolled
inwards on both sides

Continue dissection
inferiorly till apex

identify saphenous vein

follow saphenous vein

till saphaenofemoral
junction at fossa ovalis
 After fossa ovalis continue dissection
supero laterally and supero medially

Pull nodal tissue from inguinal ligament

(superficial and deep plane of dissection
join here)

separate lymphatic packet from ingunal

ligament
if possible- spare
Saphenous vein-
if not –ligate with clips /
endovascular stappler

Remove Specimen and sent for frozen section

• FROZEN SECTION

Positive Negative

Deep inguinal node dissection

Fascia lata medial to saphenous

arch opened to expose SF
junction

inferomedial dissection aound

femoral vein enables resection
of deep inguinal nodes

Limit – Till pectineus muscle is

seen
to ensure complete node
retrieval
• Insufflation pressure reduced to 5mm to
confirm hemostasis to reduce risk of
formation of lymphocele/haematoma
• Closed suction drain placed in dependant
position
• Ambulate on the day of surgery
• Keep drains till output <50ml/24hrs
• DVT prophylaxis
 .
• POST OP-

Compressive elastic
girdle to provide
bilateral
compression of
groins
+
Elastic compression
stockings for
3months after
surgery
 PALPABLE INGUINAL LYMPHADENOPATHY/
POSITIVE INGUINAL NODES
• RADICAL INGUINOFEMORAL
LYMPHNODE DISSECTION
• LANDMARKS-
Superiorly-
Line drawn from superior margin
of external ring to ASIS
Laterally-
Line from ASIS to 20cm inferiorly
Medially-
Pubic tubercle to 15cm down the
medial thigh
INCISIONS
 PROCEDURE
• Oblique incision (most common)

3cm below and parallel to inguinal

ligament extending from lateral to
medial limit of dissection

superficial and deep flaps developed

just below scarpa’s fascia

Superior-4cm above inguinal ligament

Flaps-
Inferior- up to lower limit
Fat and aereolar tissue dissected from
external oblique aponeurosis and spermatic
cord to inferior border of inguinal ligament

inferiorly expose at femoral triangle

long saphenous vein identified and divided

dissection from femoral triangle done

 .
After dissection of femoral triangle

sartorius muscle mobilised from ASIS and

transposed /rolled 180 degrees medially
to cover femoral vessels

muscle sutured to inguinal ligament

superiorly

margins sutured to muscles of thigh

adjacent
to femoral vessels
 CLOSURE
• Closure possible without any skin
mobilization
• If large area of inguinal soft tissue
sacrificed then primary closure by
-scrotal skin rotational flap
- abdominal wall advancement flaps
- myocutaneous flaps based on rectus
abdominus or tensor fascia lata
• Suction drain under subcutaneous space
• Skin flaps are sutured to surface of
exposed muscles to reduce dead space
 Complications
• Skin flap necrosis
minimized by-
-appropriate incision
- careful attention to skin flap thickness
with excision of ischemic flap margins
-transposing sartorius to cover defect
left
over the femoral vessels
• Lower limb lymphedema
Minimized by-
-careful intraoperative ligation of
lymphatics
-suction drain at lymphadenectomy site
-elastic support
• Wound infection-use of prophylactic antibiotics
• Thrombotic problems- avoided by use of
subcutaneous heparin in perioperative period
THANK YOU