Videoscopic Iliac-Obturator and Inguinal Lymph Node Dissection

Abstract

Introduction:

An extended iliac-obturator–inguinal lymph node dissection is required for positive inguinal sentinel lymph nodes to rule out regional metastases. This surgery may result in lower limb lymphedema, infections, or cutaneous necrosis. A minimally invasive technique to dissect the iliac-obturator–inguinal nodes reduces the complications associated with an open procedure. This video shows a minimally invasive technique for the iliac-obturator and inguinal dissection.

Materials and Methods:

A 33-year-old man presented status post a resection for a right foot malignant melanoma. Histologic examination revealed a pT2a melanoma, a Breslow depth of 1.34 mm with 2 mitoses/mm², and a Clark's level II of invasion with a positive right inguinal sentinel node. Total body CT scan was negative. A minimally invasive iliac-obturator–inguinal dissection was performed as shown in the video.

Results:

Histologic evaluation revealed 15 iliac-obturator lymph nodes that were negative for metastatic disease. A drain was left only in the inguinal surgical site for 5 days. Hospital stay was 3 days, convalescence about 15 days, and with a full return to activities at 40 days. After a 6-month follow-up, the patient had no functional limitations of the lower limb with an increase of only 0.79 inch of the right thigh circumference. Overall, in our case series (25 open vs 10 minimally invasive patients), no statistical significant differences were observed in lymph node retrieval between the traditional open and minimally invasive group (17.5 vs 14.6, p = 0.2), whereas the minimally invasive approach showed a slightly increased operative length (161′ vs 221′, p = 0.5). Follow-up time was shorter for the minimally invasive group (31 vs 20 months, p = 0.01). Hospital stay was decreased for the minimally invasive group (6 vs 3 days, p = 0.001) and the inguinal drainage was shorter (15 vs 5 days, p = 0.005). Patients resumed full activities faster (60 vs 40 days, p = 0.02). Postoperative complications were significantly higher in the open group (16% vs 0%, p = 0.03), with a higher incidence of lymphedema, although reoperation was not required. Six recurrences were observed in the open group: one local, three hepatic, and two pulmonary at a mean interval of 18 months. All recurrent patients had malignant melanoma. The recurrence rate was higher in the open group (24% vs 0%, p = 0.006), but this could have been secondary to the longer mean follow-up period.

Conclusions:

A minimally invasive lymphadenectomy is associated with similar and adequate oncologic outcomes and markedly reduced surgical complications when compared with open lymphadenectomy. Minimally invasive approach is a safe approach that should be considered to assess the iliac-obturator–inguinal lymph node basins.

No competing financial interests exist.

Runtime of video: 10 mins 11 secs