Inguinofemoral Lymphnode Dissection

Author

Mr Moiad Alazzam 

Preparation & setup
  • Positioning
    • Patient in modified lithotomy position
  • Draping
    • Upper: 2 cm above ASIS and across the abdomen
    • Lower: 5-10 cm from the knee
    • Under buttocks
    • Foleys catheter
  • Instruments
    • Monopolar needle
      • Colorado needle for skin, usual needle to other
      • Energy set up: cut 35-pure, coagulation 35-spray
    • Short bipolar scissors
    • Advanced bipolar device
    • Skin retractors; Kilner (Cat-Paw), Langenbecks (medium and large)
  • Drain
    • Redivac drain size 10

Patient position and incision planning
 
 
 
  •  Patient is placed in supine position with gluteal fold at the end of the table.
  • The patient is in modified lithotomy position with legs slightly abducted.
  • Draw a line between the anterior superior iliac spine (ASIS) and pubic tubercle
  • Measure 3 cm, medial to ASIS to mark your lateral dissection border (By doing this step you minimise injury to the lateral cutaneous nerve of the thigh).
  • Draw a 90-degree line, 6-7 cm down towards the thigh (The end point is about 1-2 cm below the groin crease).
  • Repeat the same step from the pubic tubercle.
  • Join the two-end point; this would represent your incision for the groin nodes.

Access and identification of dissection plans
 

 

  • Skin incision is carried out using Colorado monopolar needle (pure cut).
  • Once in the subcutaneous, use bipolar energy and gently until you reach to superficial fascia (Campers fascia).
  • Incise the fascia gently and using the Cat-Paw retractors left the fascia and dissect parallel to the lower border of the fascia to separate the superficial inguinal nodes from the subcutaneous tissue.
    • Ensure Campers fascia remains intact to obtain primary wound healing and avoid skin break down.
  • Continue with the dissection until the inguinal ligament is reached.

Dissection Superficial inguino-femoral lymph nodes

 

  • Upper border: Dissect the superficial inguinal lymph nodes off the inguinal ligament starting from the upper edge of the ligament down to the femoral triangle.
    • Be aware of
      • Lateral circumflex vessels laterally
      • Superficial epigastric vessels central & cranial
    • Lateral border: Dissect the lymph-nodes off the sartorius muscle fascia starting from upper down to the lower border of the triangle.
    • Medial border: Dissect the lymph nodes off the adductor longus muscle
      • Be aware of the superficial external pudendal vessels
    • Once the borders identified proceed with separating/dissecting the groin nodes off the femoral triangle floor proceeding from lateral to medial.
    • Identify the great saphenous vein and dissect carefully until the point of insertion with the femoral vein.
    • Complete the dissection and retrieval of the superficial lymph nodes.
Dissection deep femoral lymph nodes
 
 
  • Usually these are 1-3 lymph nodes present in fossa ovalis
  • Gently dissect the fatty tissue starting from the point of junction between great saphenous vein and femoral vein. Follow the femoral vein through the length of fossa ovalis (usually 3 cm)
  • Retract the inguinal ligament cephalad to check for Cloquet’s node.
 
 

Drain & closure

 

 
  • Place the drain on the pelvic floor (fenestrated tip away from vessels)
  • Use silk suture to fix the drain
    • This step is used to reduce risk of drain detaching prematurely
  • Close Campers fascia with interrupted sutures vicryl 2/0
  • Close skin subcut with continuous suture
  • Steristerips to skin
  • Chloramphenicol