Inguinofemoral, Iliac/Obturator,

and Popliteal Lymphadenectomy

for Melanoma

Keith A. Delman, Lesly A. Dossett, Clara R. Farley,

Kelly M. McMasters, and Omgo E. Nieweg

Contents
Inguinofemoral Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Modifications of the Classic Technique of Inguinofemoral Lymphadenectomy . . . . . . . . 8
Iliac/Obtuartor (Deep Pelvic) Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Modifications of the Classic Technique of Iliac/Obturator Lymphadenectomy . . . . . . . . . 14
Robotic-Assisted Transperitoneal Pelvic Lymphadenectomy . . . . . . . . . . . . . . . . . . . . . . . . 14
Postoperative Complications: Incidence and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Complications of Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Management of Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

K. A. Delman (*) · C. R. Farley

Division of Surgical Oncology, Department of Surgery,
Emory University School of Medicine, Atlanta, GA, USA
e-mail: [email protected]; [email protected]
L. A. Dossett
Division of Surgical Oncology, Department of Surgery,
University of Michigan, Ann Arbor, MI, USA
e-mail: [email protected]
K. M. McMasters
Department of Surgery, University of Louisville School of
Medicine, Louisville, KY, USA
e-mail: [email protected]
O. E. Nieweg
Melanoma Institute Australia, Department of Surgery, The
University of Sydney Central Clinical School, Royal
Prince Alfred Hospital, Department of Melanoma and
Surgical Oncology, Sydney, NSW, Australia
e-mail: [email protected]

# Springer Nature Switzerland AG 2019 1

C. Balch et al. (eds.), Cutaneous Melanoma,
https://doi.org/10.1007/978-3-319-46029-1_22-1
2 K. A. Delman et al.

Popliteal Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Abstract sentinel lymph node (SLN) to either immediate

The indications for regional lymph node dis- completion lymphadenectomy (CLND) or obser-
section for melanoma patients with micro- vation with ultrasound surveillance. Both trials
scopic disease are evolving; however, patients demonstrated no difference in melanoma-specific
with clinically evident nodal metastases iden- survival for patients undergoing immediate
tified radiographically or by physical examina- CLND versus observation, despite enhanced
tion are advised to undergo lymph node regional disease control in the immediate CLND
dissection. As the understanding and use of group. Based on the results of these two trials and
immunotherapeutic and targeted therapies in the era of effective systemic therapy, immediate
expand, the clinical indications for lymph completion lymph node dissection for micro-
node dissection will continue to evolve. scopic disease is no longer considered uniformly
These procedures provide enhanced staging indicated; however, these procedures can provide
information and may provide regional disease enhanced staging information and regional dis-
control. Additionally, due to high rates of mor- ease control. The decision to perform CLND
bidity associated with lymph node dissection should be made on a patient-to-patient basis.
in the groin, minimally invasive techniques for Two contiguous node-bearing basins comprise
inguinofemoral and iliac/obturator lymph node the draining lymph nodes of the lower trunk and
dissections have emerged; these have proven lower extremity. The first nodal basin contains the
to be safe and effective modifications to the inguinal/femoral nodes located over the lower
classic, open approach. An overview of the abdominal wall and within the femoral triangle.
anatomic and technical considerations of The second nodal basin contains the iliac and
inguinofemoral, iliac/obturator, and popliteal obturator lymph nodes. An inguinofemoral
lymph node dissection is described. lymph node dissection (sometimes referred to as
a superficial inguinal lymph node dissection or
“groin” dissection) involves removal of the node-
The indications for regional lymph node dissec- bearing tissue located over the lower external
tion for melanoma are evolving. Until recently, oblique, the inguinal ligament, and all nodes
both clinical (detected by radiographic imaging within the femoral triangle. The iliac/obturator
or physical examination) and microscopic dissection (sometimes referred to as a “deep” or
(detected via sentinel node biopsy) nodal metas- “pelvic” lymph node dissection) refers to removal
tases were considered indications for a completion of the node-bearing tissue adjacent to the internal
lymph node dissection. While patients with clini- and external iliac vessels superficial to the obtu-
cal nodal metastases should still undergo thera- rator nerve. For most surgeons, the common iliac
peutic lymph node dissection, two trials have nodal basin is not considered a routine part of
transformed the approach to patients with disease iliac/obturator lymph node dissection as involve-
identified by sentinel lymph node biopsy (SLNB). ment of these nodes is typically thought to repre-
The German Dermatologic Cooperative Oncol- sent stage IV disease. Historically, many surgeons
ogy Group Trial (Leiter et al. 2016) and the Mul- performed an inguino-pelvic (superficial and deep
ticenter Selective Lymphadenectomy Trial (Faries or “radical”) lymphadenectomy combining femo-
et al. 2017) randomized patients with a positive ral, iliac, and obturator lymph node removal in
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 3

one procedure, even in the setting of sentinel node patients should not undergo lymph node dissec-
disease only; however, the routine inclusion of the tion except for palliative purposes. If a patient
iliac and obturator nodes when performing sur- with distant disease is asymptomatic or a low
gery for microscopic disease has almost uniformly volume of nodal disease is present, the
been abandoned. Most patients are now only con- lymphadenectomy may be delayed or abandoned
sidered for iliac/obturator lymphadenectomy if in lieu of systemic therapy.
there is evidence of nodal involvement by imag-
ing studies or when there is a high suspicion of
concurrent disease in the iliac/obturator basin Technique
based on the clinical features of the femoral
nodal metastases. Anesthesia and Position. A standard
Popliteal lymph node involvement is exceed- inguinofemoral dissection can be performed
ingly uncommon in patients with melanoma, even under epidural, spinal, or general anesthesia.
in those who have primary tumors of the posterior When general anesthesia is used, muscle paralysis
foot and heel (Thompson et al. 2000). In one study is avoided to help the surgeon identify and pre-
examining 4262 patients seen at the Sydney Mel- serve motor branches of the femoral nerve during
anoma Unit during a 30-year period, the incidence the dissection, though most experienced surgeons
of clinical involvement of popliteal nodes was should be familiar with the location of this nerve,
determined to be 0.3% (Thompson et al. 2000). and thus paralysis may be considered. When the
Because popliteal lymph node involvement and primary lesion is intact and located on the lower
dissection are rare, the surgeon must strive to abdomen or back, general anesthesia is required.
maintain a familiarity with the surgical anatomy The patient is placed in the supine position on
and technique required to perform popliteal the operating table, and ideally the hip is exter-
lymph node dissection. nally rotated and the knee slightly flexed. Many
patients may not have the flexibility to achieve
this optimal positioning in which case the surgeon
Inguinofemoral Dissection must be aware of the way in which the
neurovascular anatomy is altered by changes in
Indications positioning. Care is taken to protect all pressure
points, especially the heel, which is subjected to
While the indications for regional lymph node increased pressure in this position. A urinary cath-
dissection are evolving, clinically detected eter may be used, and, if used, it is nearly always
inguinofemoral nodal metastases remain an indi- removed before or on the first postoperative day.
cation for inguinofemoral dissection. Selected If iliac/obturator lymphadenectomy is to be
patients with microscopic disease may also be performed concurrently, a urinary catheter must
considered, based on shared decision-making. be placed to decompress the bladder and avoid its
Once inguinofemoral nodal metastases have intrusion into the surgical field. Sequential com-
been documented, a staging workup should be pression devices are applied to both calves unless
performed to rule out metastatic disease in the the primary melanoma precludes their use. The
iliac nodal basin or at distant sites. The workup patient is prepped and draped widely to include
should include a CT scan of the chest, abdomen, the ipsilateral abdomen, genitalia, and medial and
and pelvis or whole-body positron emission lateral thigh.
tomography (PET) combined with CT scan Incision. The traditional inguinofemoral dis-
(PET/CT) as well as a MRI of the brain to assess section involves a longitudinal “lazy-S” incision,
for stage IV disease. Additionally, a serum lactate beginning superior and medial to the anterior
dehydrogenase (LDH) level should be obtained at superior iliac spine (ASIS) and running parallel
time of diagnosis. If the staging workup identifies within the groin crease (Fig. 1a). The incision then
the presence of distant metastatic disease, most extends down to the apex of the femoral triangle.
4 K. A. Delman et al.

Fig. 1 Variations to the length and position of the incision used for open inguinofemoral lymphadenectomy. (From Keith
A. Delman, Atlanta, GA; with permission)

The incision should include excision of any exci- clinically obvious, an ellipse of the skin should
sional or sentinel node biopsy scars, and, as such, be left en bloc with the lymphadenectomy
biopsy incisions should be made with a possible specimen.
future complete dissection in mind. Because of the Flap Formation. After the incision is made,
potential wound complications of this incision, medial and lateral skin flaps are raised using either
there are many alternatives to the lazy-S incision, scalpel dissection or electrocautery. Caution
including shorter vertical incisions that cross the should be exercised if using electrocautery to
groin crease at right angles and incisions oriented minimize thermal injury to the skin flaps. Flaps
along lines of skin tension above or below the are raised at the junction of the subcutaneous
groin crease. These latter incisions may heal bet- tissue and Scarpa’s fascia, with particular care
ter, because the wound edges are not subject to the being taken to remain in this plane as the dissec-
motion of hip flexion. Ilioinguinal lymph node tion progresses. While the order of creating the
dissection, including the nodes 5 cm superior flaps is surgeon-specific, the approach to them
to the inguinal ligament, can almost always be will largely be uniform. The superior flap is
accomplished through a 6–8 cm transverse inci- extended onto the external oblique musculature
sion parallel to the groin crease, which is preferred 5–6 cm above the inguinal ligament. The lymph
by some. If an open iliac/obturator dissection is node-bearing tissue on the external oblique apo-
performed concomitantly, a separate incision neurosis is swept down into the femoral triangle
above the inguinal ligament may be performed. proper.
If necessary to achieve negative margins, particu- The medial flap is developed with extension to
larly when skin involvement is suspected or the medial aspect of the adductor longus and using
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 5

its tendinous insertion as a medial marker at the sartorius muscle is reached. The main trunk of
pubic tubercle (just medial to the femoral canal). the femoral nerve should be identified at this
As the dissection proceeds inferiorly, the tissue point, because it emerges below the inguinal lig-
overlying the fascia of the adductor longus muscle ament and is located deep to the fascia iliaca.
is mobilized to the apex of the femoral triangle Beginning inferiorly, the artery is skeletonized
where it meets the sartorius muscle. Some sur- beneath the adventitia. The anterior half of the
geons choose to mobilize the adductor fascia, femoral artery is then skeletonized. Branches
but this is not routinely necessary. In some coursing anteriorly are divided and ligated. The
approaches (such as in the context of the mini- sheath overlying the femoral artery is incised
mally invasive lymphadenectomy), mobilizing along its entire length from the apex of the femoral
the fascia aids the dissection and may be routinely triangle inferiorly to the inguinal ligament superi-
performed. At the inferior aspect of the medial orly. Importantly, as the upper aspect of the arte-
flap, the saphenous vein is visualized and can be rial dissection is completed and the surgeon
ligated and divided. Many surgeons prefer to pre- approaches the level of the saphenofemoral
serve the saphenous vein as some studies have junction, a branch of the common femoral artery
implied a reduction in morbidity with this is routinely present and should be expected by
approach (Ozturk et al. 2014; Abbas and Seitz the surgeon. Division of this vessel is safe and
2011). facilitates the ongoing soft tissue dissection. The
The lateral flap is created in the same plane, lateral aspect of the femoral vein sheath is
extending to the lateral border of the sartorius also incised during the arterial dissection. By
muscle up to the level of the anterior superior dissecting superiorly along the femoral artery,
iliac spine (ASIS). The surgeon should take care the surgeon stays in a plane that avoids injury to
to preserve the lateral femoral cutaneous nerve, the adjacent femoral nerve and its branches.
which exits just inferior to the ASIS. Several The medial soft tissue dissection is then
cutaneous branches of the femoral nerve may performed in a subfascial plane over the adductor
also be encountered crossing distally over the longus and pectineus muscles (Fig. 2). The over-
muscle and at the apex of the femoral triangle, lying fascia must again be incised adjacent to the
which marks the inferior extent of the lateral femoral vein. At this point the specimen is dis-
flap as well. For most surgeons, the fascia of sected off the femoral vein in a subadventitial
the sartorius muscle (unlike the adductor) is rou- plane, working from the inferior-most aspect of
tinely incised, as a muscle transposition may be this vein upward toward the inguinal ligament. As
included as the final aspect of an open inguinal the saphenofemoral junction is approached, care
lymphadenectomy. A common mistake among must be taken to dissect off investing connective
inexperienced surgeons is to raise flaps medially tissue around the proximal saphenous vein at the
and laterally further than necessary; the flaps fossa ovalis. If not already done, a clamp is placed
should be raised only to the adductor longus medi- across the saphenous vein, leaving enough dis-
ally and the sartorius laterally. tance for the stump to be ligated without imping-
Soft Tissue Dissection. Importantly, the tech- ing on the lumen of the femoral vein. The
nical approach to this dissection is variable, saphenous vein is then transected and the stump
but the key elements are the identification and doubly ligated. Alternatively, the surgeon may
removal of the appropriate tissue. To begin, the choose to preserve the saphenous vein and dissect
fibrofatty node-bearing tissue located 5–6 cm around it (as noted above).
superior to the inguinal ligament is dissected off From here, the only remaining attachments
the external oblique aponeurosis to a point just should be the soft tissue superior and medial to
below the inguinal ligament. Next, the specimen the proximal femoral vein (the tissue entering the
is dissected off the sartorius muscle in a subfascial femoral canal). At this point in the operation, the
plane, working toward the femoral nerve. The surgeon must decide whether or not to biopsy
fascia is again incised as the medial border of the Cloquet’s node. If a biopsy is intended, the
6 K. A. Delman et al.

Fig. 2 Medial dissection of

the fatty and lymphatic
tissue overlying the femoral
triangle. This has been
excised off the adductor
longus muscle until the
femoral vein is exposed.
The dissection then
proceeds superiorly along
the femoral vein. The
saphenous vein is
transected at the confluence
of the femoral vein.
Dissection then continues
beneath the inguinal
ligament to remove
Cloquet’s node. (From
Keith A. Delman, Atlanta,
GA; with permission)

dissection then continues superiorly beneath the to hold sutures more securely to the inguinal lig-
inguinal ligament in order to incise the lacunar ament when transposed. The lateral edge of the
ligament. There is considerable variability in how sartorius muscle is dissected free with the medial
Cloquet’s node is defined, but traditionally the edge left intact to provide blood supply to the
node can be found slightly posterior and medial muscle flap. The blood supply to this muscle
to the external iliac vein (Fig. 3) as the first node in arises from its medial aspect and is segmental,
the pelvis. After the node is identified, a hemostat allowing preservation with this approach. The
can be clamped across the fatty tissue just above muscle flap is then rotated from lateral to medial,
the node. Cloquet’s node is generally submitted with the transected end of the sartorius muscle
for frozen section analysis, whereas the main brought underneath the lateral femoral cutaneous
specimen is marked for orientation and sent for nerve and vessels without damaging them.
routine pathologic examination. The sartorius muscle is held upward, while
Transposition of the Sartorius Muscle. At the dissection proceeds inferiorly, sacrificing the
this point the surgeon may transpose the sartorius upper branches of the vessels and nerves. The
muscle to cover the femoral vessels. This provides muscle should be appropriately mobilized to
well-vascularized muscle tissue to protect the allow transposition over the femoral vessels with-
femoral vessels in case wound breakdown occurs. out undue tension and to avoid devascularization.
The upper part of the sartorius muscle is dissected Additionally, because the blood supply is segmen-
from its surrounding connective tissue and is freed tal, the muscle should not be dissected more than
from its origin on the ASIS (Fig. 4). It is then halfway into the femoral triangle inferiorly. Any
divided sharply through the fascia at its origin, tenting of the muscle should be avoided as this
preserving the fascia, which will provide strength
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 7

Fig. 3 Location of
Cloquet’s node (inset) and
superficial inguinal lymph
nodes resected en bloc off
the underlying femoral
vessels. The saphenous vein
has been ligated at the level
of the saphenofemoral
junction. (From Keith
A. Delman, Atlanta, GA;
with permission)

will create dead space, thereby negating any least one closed suction drain (some surgeons
advantage that may be gained by its transposition. routinely use two) brought out through an inferior
The stump of the sartorius muscle is then or superior stab wound and sutured to the skin.
sutured to the external oblique aponeurosis with The wound is closed in layers with interrupted
horizontal mattress sutures (Fig. 5). The muscle is absorbable sutures placed to close Scarpa’s fascia.
also loosely approximated to the adductor longus The skin may be closed with skin staples or with a
muscle medially and the quadriceps fascia later- subcuticular suture. The dressing applied to the
ally with interrupted sutures. Surgeons may also wound and drainage site is occlusive.
perform a modification of a Cooper’s ligament Postoperative Care. Patients are generally
closure of the femoral triangle, especially if a kept on bed rest overnight, particularly in the
biopsy of Cloquet’s node is performed in order setting of a muscle transposition, but are then
to reduce the possibility of a femoral hernia. encouraged to resume ambulation the following
Closure of the Incision. After appropriate day. Most patients are discharged on the first
assessment and sharp debridement of any non- postoperative morning if they have appropriate
viable flap edges, the wound is closed over at assistance at home. Drains are kept in place until
8 K. A. Delman et al.

Fig. 4 Right view of the

incision. Transection of the
Sartorius muscle at its
origin on the anterior
superior iliac spine. It is
important to incise the
muscle directly off the bone
to preserve the fascial end,
which holds sutures better.
The muscle is then
dissected free of
surrounding tissue and
transposed over the femoral
vessels and nerves. (From
Keith A. Delman, Atlanta,
GA; with permission)

the 24-h output is less than 30–50 mL. This may incision (Fig. 1). Additionally, a minimally inva-
take 2–3 weeks or longer. However, some sur- sive approach, referred to as videoscopic inguinal
geons will elect to remove the drain at or prior to lymphadenectomy, has emerged as a promising
the 3-week mark even if this target is not met. alternative to traditional open surgery with
A 20–30-mmHg pressure gradient, thigh-high comparable oncological control and reduced mor-
compression stocking may be prescribed and bidity (Postlewait et al. 2017; Delman et al. 2010,
fitted preoperatively so that it will be available 2011; Martin et al. 2013).
for the patient to wear postoperatively as soon as Videoscopic Inguinal Lymphadenectomy.
the drain is removed. Before beginning the procedure, the patient is
placed in the supine position on a split leg table
with the legs externally rotated and abducted.
Modifications of the Classic Technique The boundaries of the femoral triangle are
of Inguinofemoral Lymphadenectomy mapped out and marked with a surgical pen. The
patient is widely prepped to include the supra-
The preceding section describes the classic tech- pubic region to monitor for crepitus. The surgeon
nique of inguinofemoral lymphadenectomy. In an is positioned between the patient’s legs and the
effort to minimize short- and long-term morbidity assistant stands to the outside of the operative
associated with the procedure, several modifica- limb (Fig. 6). To begin, an incision is made
tions have been proposed, including (as noted) approximately 3 cm inferior to the apex of the
preservation of the adductor magnus and sartorius femoral triangle and carried down to Scarpa’s
fascia, preservation of the saphenous vein, and fascia. Using blunt dissection, a space is devel-
modifications to the length and position of the oped on either side of the incision to allow
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 9

Fig. 5 Completed inguinal

node dissection showing the
transposed Sartorius
muscles in place. It is
sutured to the external
oblique aponeurosis with
interrupted nonabsorbable
horizontal mattress sutures.
Suction catheters are then
placed in the lateral and
medial aspects of the wound
and the incision is closed.
(From Keith A. Delman,
Atlanta, GA; with
permission)

Fig. 6 Surgeon and patient

positioning for video-
assisted lymphadenectomy.
(From Keith A. Delman,
Atlanta, GA; with
permission)
10 K. A. Delman et al.

Fig. 7 The anterior

working space is created
using blunt dissection.
(From Keith A. Delman,
Atlanta, GA; with
permission) Anterior working space
(avascular layer)
created superficial to
the Scarpa fascia

Dermis (cutis)

Hypodermis/Superficial
fascia of the thigh

Fascia lata

Muscle

insertion of two 10-mm trocars (Fig. 7). A 12-mm nodal packet is then dissected free from its ingui-
trocar is then placed in the original incision site, nal ligament attachments by inferior retraction or
and the surgical site is insufflated to 15 mm using an ultrasonic dissecting scalpel (Fig. 8). The
Hg. Dissection is carried 5 cm above the inguinal specimen is then withdrawn in an endoscopic
ligament along the abdominal wall with an endo- retrieval bag. To conclude, the wound is irrigated,
scopic dissecting stick and ultrasonic shears. The the ports are removed, and a drain is placed
medial and lateral boundaries of the dissection through the lateral port site.
should consist of the adductor longus and The patient is encouraged to ambulate on the
sartorius muscle fascia. day of surgery, and discharge is routinely planned
Once the working space is created, the node- for the same day. The fluted drain remains in place
bearing tissue may be rolled inward on both sides until output is less than 30–50 mL per day.
using an endoscopic sponge or Kittner, continuing
superiorly and inferiorly as much as possible to
define the posterior wall of the nodal packet. The Iliac/Obtuartor (Deep Pelvic) Lymph
saphenous vein should be identifiable within the Node Dissection
apex of the femoral triangle and can be ligated
using an endoscopic linear stapler. The femoral Benefits
artery and vein are then identified, and the over-
lying nodal packet is dissected from an inferior to Patients with iliac/obturator nodal metastases
superior direction as both vessels are skeleton- should not be dismissed as having incurable or
ized. Once the vascular dissection is complete, disseminated disease as the presence of iliac/obtu-
the saphenofemoral junction is exposed, and rator nodal metastases still represents a potentially
the saphenous vein is then transected at this curable circumstance. Several reports demon-
level using an endoscopic linear cutting stapler. strate 5-year survival rates for patients with iliac/
Inferomedial dissection is continued along the obturator nodal metastases ranging from 24%
femoral vein to enable resection of the deep ingui- to 43%, rates that are comparable to patients
nal nodes. Dissection should continue to the with a similar burden of inguinal nodal metastases
level of femoral canal to ensure complete nodal (Badgwell et al. 2007; Strobbe et al. 1999;
retrieval. Assessment for and possible biopsy of Mann and Coit 1999). In a 2007 study from MD
Cloquet’s node can be performed at this step. The Anderson, 97 patients underwent a combined
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 11

Fig. 8 The inguinal lymph

node packet is mobilized
and dissected free from its
inguinal ligament
attachments. (From Keith Inguinal
A. Delman, Atlanta, GA; ligament
with permission) Nodal packet held up
to transect last
remaining attachments

Artery Vein

LATERAL MEDIAL

Pectineus muscle
visible below posterior
femoral sheath
Femoral Sheath

Sartorious m. Adductor longus m.

inguinofemoral and iliac/obturator node dissec- Indications

tion. In 54 patients with positive iliac/obturator
nodes, 5-year overall survival was 42%, and over- While the indication for iliac/obturator lymph
all survival of patients with three or fewer tumor- node dissection in the setting of biopsy-proven
positive iliac/obturator nodes was comparable to disease and no distant disease is clear, the role of
patients with negative iliac/obturator nodes iliac/obturator lymph node dissection in other
(Badgwell et al. 2007). These data support the clinical scenarios is controversial. In the setting
classification of iliac/obturator disease as stage of clinically palpable inguinal disease, the
III rather than stage IV disease. It is also important estimated prevalence of positive iliac/obturator
to note that this data was prior to the use of nodes is 30%, suggesting that the majority of
targeted and immunotherapy, making it likely patients would not benefit from routine combined
that overall survival would be further improved inguinofemoral and iliac/obturator dissection. In
today. It is incumbent on the multidisciplinary an effort to determine which patients may benefit
team to identify patients for whom an iliac/obtu- from iliac/obturator dissection, studies have
rator lymphadenectomy might be of benefit. As explored the risk factors for pelvic nodal disease
our understanding and use of immunotherapeutic and have resulted in several relative indications
and targeted therapies expand, it is expected that for iliac/obturator node dissection. Based on these
the clinical indications for iliac/obturator nodal data, relative indications include (Oude Ophuis
dissection will further evolve. et al. 2015):

• Radiographic suspicion of pelvic disease, typ-

ically either by CT or PET/CT (Fig. 9)
• Involvement of three or more inguinal nodes
12 K. A. Delman et al.

Fig. 9 Melanoma patient

with clinically positive
iliac/obturator node on PET
scan (large arrow). (From
Lesly A. Dossett, Ann
Arbor, Michigan; with
permission)

• Extracapsular tumor extension of inguinal investigators at the John Wayne Cancer Institute
nodes have concluded that it is possible to predict
positive iliac/obturator nodes by assessment of
Historically, a large (>3 cm) positive Cloquet’s node (Shen et al. 2000; Essner et al.
inguinofemoral node or a positive Cloquet’s 2006). With routine histology of Cloquet’s node,
node has been considered relative indications for the investigators were able to achieve a sensitivity
iliac/obturator lymph node dissection, but limited of 82%, a positive predictive value of 70%, and a
data exist to support these factors as accurate pre- negative predictive value of 84%. They concluded
dictors of pelvic nodal disease. Additionally, that Cloquet’s node assumes the role of a SLN for
patients meeting these criteria generally already the iliac/obturator nodes in patients with positive
have an indication for iliac/obturator dissection inguinofemoral nodes (Shen et al. 2000; Essner
based on the criteria above. et al. 2006). Routine biopsy of Cloquet’s node in
The majority of the data on Cloquet’s node as a SLNB patients is of low value and not
predictor of pelvic nodal disease was in the era recommended(Chu et al. 2010).
prior to SLNB. In the absence of SLNB, the Although likely of limited value in the current
sensitivity and specificity of Cloquet’s node in era, in the setting of microscopic inguinofemoral
predicting pelvic disease are highly variable. In a disease, there are two generally accepted indica-
series from the Netherlands Cancer Institute, tions for iliac/obturator node dissection: (1) a pos-
Cloquet’s node and the number of positive nodes itive iliac/obturator SLN and (2) an iliac/obturator
were evaluated as possible factors to predict pos- SLN identified on preoperative lymphoscin-
itive deep nodes. The sensitivity and negative tigraphy, but not sampled/removed, in the setting
predictive value of a positive Cloquet’s node of a positive inguinofemoral SLN. Of note, in one
were 55% and 78%, respectively. Use of more study assessing the true frequency of synchronous
than three positive nodes in the inguinofemoral iliac/obturator nodal metastases with microscopic
dissection as a predictor revealed a sensitivity of inguinofemoral disease, the authors found the
41% and a negative predictive value of 78%. prevalence of synchronous disease to be 11.9%.
Combining the two variables resulted in a sensi- Patients with iliac/obturator disease were more
tivity of 56% and a negative predictive value of likely to have a ratio of total positive inguinal
82% (Strobbe et al. 2001). The authors concluded nodes to total retrieved inguinal nodes greater
that the sensitivity of Cloquet’s node is too low to than 0.20 or 3 total involved inguinal nodes
recommend routine sampling as a predictor of (Chu et al. 2011). Iliac/obturator dissection is
iliac/obturator nodal involvement. In contrast, also performed in patients who have recurrent
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 13

melanoma of the extremity and are offered limb and they are frequently ligated and divided at their
perfusion after they have already undergone an origin. The vas deferens will be seen at this stage
inguinofemoral lymphadenectomy. and should be preserved, as should the testicular
vessels that lift off the iliac fossa with the perito-
neum. The round ligament can be sacrificed in
Operative Technique women.
The use of an in-continuity dissection,
Skin Incision. Usually an iliac/obturator described by Karakousis and Driscoll(Karakousis
dissection is performed simultaneously with an and Driscoll 1994), provides for an en bloc resec-
inguinofemoral dissection, as described earlier. tion and can offer superior exposure, especially to
Under these circumstances, the incision can be the most distal external iliac nodes. This approach
made by extending the inguinofemoral incision involves the division of the external oblique apo-
cephalad, raising the superior flap to reveal neurosis in a nearly vertical fashion approxi-
the lower abdominal musculature. When using a mately 4 cm medial to the ASIS. Inferiorly, the
transverse infrainguinal incision for inguinofemoral inguinal ligament is divided just medial to the
dissection, a separate incision may be performed femoral artery. This line of dissection courses
for the iliac/obturator dissection in a similar fash- through the internal oblique and transversalis fas-
ion to the retroperitoneal incision used for kidney cia and allows for a more straightforward fascia-
transplantation. Another alternative is a lower to-fascia closure compared with performing the
midline incision from the umbilicus to the pubic incision precisely at the ASIS. Division of the
symphysis to access the iliac/obturator nodes via inguinal ligament is associated with remarkable
an extraperitoneal approach. morbidity, particularly postoperative pain, and
Abdominal Wall Incision. Access to the iliac should not be undertaken lightly. The utility
fossa is gained via a transverse incision through of an en bloc resection is questionable, but, if
the external oblique aponeurosis approximately strongly desired as an alternative to the division
5–6 cm above the inguinal ligament (i.e., above of the inguinal ligament, some surgeons favor a
the inguinal canal). The internal oblique and separate obliquely oriented incision in the groin
the transversus abdominis muscle are then split crease. This allows for the inguinal ligament to be
in the direction of their fibers. The incision is left intact, which may lower the incidence of
continued to include the lateral sheath of the rec- postoperative abdominal wall weakness or hernia
tus abdominis muscle. The deep circumflex artery formation.
and vein are identified and ligated where they lie Iliac/Obturator Node Dissection. Dissection
between the internal oblique and transversus around the external iliac vessels is usually
abdominis muscles. performed with sharp instruments up to the level
The preperitoneum is entered and freed from of the ureter, crossing the bifurcation of the com-
the abdominal wall in the distal direction. As the mon iliac artery, or higher if clinically detectable
retroperitoneum is entered, the peritoneum is nodes are involved along the iliac vessels. Though
bluntly lifted up out of the iliac fossa, and the as noted, common iliac nodes are generally con-
inferior epigastric vessels are identified, passing sidered stage IV disease. The ureter is identified
upward and medially from the point where the and preserved as it courses over the iliac artery.
femoral arterial pulsations can be felt. Once The lymphatic contents are dissected medially off
encountered, the retroperitoneal space is devel- the bladder wall and superiorly off the posterior
oped by bluntly dissecting and retracting the rectus sheath.
peritoneum in a superior and medial direction. Beginning at the inguinal ligament inferiorly,
A self-retaining retractor can be used to hold the the lymph nodes are dissected off the artery and
peritoneal contents off the pelvic brim. The infe- vein, working within the vessel sheath. Small
rior epigastric vessels are identified as they come vessels and lymphatics at the perimeter of the
off the distal aspect of the external iliac vessels, excision should be ligated, cauterized, or clipped
14 K. A. Delman et al.

to avoid hemorrhage or lymphoceles. The dissec- Postoperative Care. Patients are kept on bed
tion then continues superiorly up to the common rest with the operated extremity elevated over-
iliac vessels. night. If placed intraoperatively, the urinary cath-
The deeper portion of the dissection is made eter is removed on the first postoperative morning,
possible by reflecting the peritoneum medially and the patient is allowed to ambulate with assis-
with a broad self-retaining retractor and then tance as needed. Most patients are discharged on
working downward, using fingers or sponge sticks the first postoperative morning, similar to those
as blunt dissectors. The advantage of this method undergoing inguinofemoral dissection. Patients
is that the obturator nerve, which is very close to are instructed to keep the operated extremity ele-
the major lymph nodes, can be felt as a taut cord vated when they are not ambulating. Drains in the
that moves away from the sidewall of the pelvis. If pelvis should be removed when draining less than
this part of the dissection is performed with a 30 mL per day for two consecutive days.
sharp instrument, there is some risk of damaging
the nerve. The medial dissection (to remove the
iliac nodes) and deep dissection (to remove the Modifications of the Classic Technique
obturator nodes) are completed when the obtura- of Iliac/Obturator Lymphadenectomy
tor nerve is identified and preserved as it courses
from the lateral aspect of the internal iliac artery As with inguinofemoral lymphadenectomy,
toward the obturator foramen. The obturator a minimally invasive technique, referred to
nodes are carefully resected from this area, and as the robotic-assisted transperitoneal pelvic
the specimen is removed. Interestingly, most sur- lymphadenectomy (rPLD), has emerged as a
geons dissect the deep aspect of this procedure safe and effective technique for iliac/obturator
along the obturator nerve using digital dissection, lymphadenectomy. The advantages of minimally
as a finger will prevent significant damage and is invasive rPLD are well-described in the literature
sensitive enough to alert the surgeon to structures where it is routinely used for staging and treat-
that should be avoided. ment of urologic and gynecologic malignancies.
As the specimen containing the lymph nodes is rPLD has been shown to improve visualization of
lifted upward in one unit with the external iliac the iliac and obturator nodes and provide equiva-
nodes, abdominal packs are placed firmly in the lent nodal yield and shorter length of stay when
pelvis and left until the operation is complete, by compared to the classic technique of iliac/obtura-
which time minor venous bleeding will have tor lymphadenectomy (Dossett et al. 2016).
stopped. After the wound is irrigated and meticu-
lous hemostasis is achieved, the transversalis and
internal oblique muscles are approximated with Robotic-Assisted Transperitoneal
nonabsorbable sutures, and the external oblique Pelvic Lymphadenectomy
aponeurosis is then approximated with non-
absorbable sutures. To obliterate the enlarged When utilizing the minimally invasive approach,
femoral canal defect, the inguinal ligament is preparation for conversion to open and for
approximated to the lacunar ligament with a inguinofemoral dissection if being performed in
figure-of-eight suture of nonabsorbable material a combined procedure should be made as
(unless this has been closed as previously described above. The patient is placed in steep
described during the inguinal part of a combined Trendelenburg position, and the robot is docked
procedure). A closed suction drain may be placed between the legs of the patient. A 12-mm midline
in the retroperitoneal space through a separate stab port is typically placed 18–20 cm above the pubic
wound, although this is optional. Skin closure is symphysis. Two 8-mm robotic ports are placed
accomplished and the dressings applied in the laterally on the contralateral side of the abdomen
manner described for inguinofemoral dissection. from the site of pelvic dissection, at least 14 cm
from the pubic symphysis, and at least 6 cm away
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 15

without the costs associated with robotic technol-

ogy. The robotic approach, however, has the
advantage of three-dimensional visualization;
ergonomic, intuitive control; and wristed instru-
ments that approximate the motion of the human
hand, which are all advantageous, given the exten-
sive dissection in close proximity to iliac vessels
and the obturator nerve.

Postoperative Complications:
Incidence and Risk Factors

Complications of Lymph Node

Dissection

The morbidity after an inguinofemoral lymph

Fig. 10 Port placement for a left robotic assisted trans- node dissection is greater than that associated
peritoneal pelvic lymphadenectomy. There are three 8 mm with axillary or cervical lymphadenectomy,
robotic ports seen at the lateral aspects of the abdomen, a
12 mm camera port in the center of the abdomen and a
particularly in the older population and in
12 mm assistant port in the left abdomen. (From Dossett patients who are obese (Beitsch and Balch
et al. 2016) 1992). The rate of postoperative complications
following inguinofemoral lymph node dissection
from other ports. A 12-mm assistant port is placed has been estimated as high as 75% (Chang
in the midclavicular line on the affected side of the et al. 2010; Stuiver et al. 2014). Early perio-
abdomen. A third 8-mm robotic port is placed on perative complications include infection, hemor-
the affected side of the abdomen at least 8 cm rhage, seroma formation, skin edge necrosis,
lateral to the assistant port and at least 2 cm medial wound dehiscence, and lymphocele. Long-term
to the anterior superior iliac spine (Fig. 10). complications include paresthesias and chronic
In the retroperitoneum, the psoas muscle, ure- lymphedema. One explanation for the short-term
ter, and common iliac bifurcation are identified. morbidity associated with inguinal lymph-
The lymph node packet overlying and between adenectomy is that the main blood supply to the
the external iliac artery and vein is dissected from skin overlying the femoral triangle comes from a
underneath the inguinal ligament to the iliac bifur- series of small anterior branches of the femoral
cation or higher if indicated. After removal of the artery. These small arteries pass directly through
iliac nodal packet, resection of the obturator the cluster of femoral lymph nodes. Any complete
lymph nodes is performed. The iliac vein is excision of these nodes divides most, if not all, of
retracted laterally, and the obturator nodes are these vessels. It follows that the vitality of the skin
carefully dissected free of their attachments, iden- close to the incision and for a distance of up
tifying and preserving the obturator vessels and to 10 cm below the inguinal ligament may
nerve. Each lymph node packet is placed in an be impaired regardless of where the incision for
endoscopic retrieval bag and removed through the lymphadenectomy is placed. The reduced blood
midline port. For cases where rPLD is combined supply to the skin may result in either slow wound
with a superficial inguinal lymphadenectomy, the healing or complete breakdown of this part of the
rPLD precedes the inguinal lymphadenectomy to wound, particularly in older and/or obese patients,
avoid leakage of CO2 out of the operative field. though some of these wound complications can be
Of note, it is possible to achieve similar out- minimized by excising the skin over the femoral
comes with a strictly laparoscopic approach triangle.
16 K. A. Delman et al.

Lymphedema is the most significant long-term large enough to cause the overlying skin flaps to
complication following lower extremity node dis- become firm or tense should be treated by prompt
section. Clinical rates of lower extremity swelling aspiration under sterile conditions. Aspiration
following inguinofemoral dissection are reported attempts should be made as far away from the
to range from 20% to 64% in most series (Chang incision as possible. A lymph collection that rap-
et al. 2010). Lymphedema is generally reported as idly re-accumulates after repeated aspirations
being mild, although criteria for the definition of should be considered for percutaneous suction
lymphedema vary among authors. It is possible catheter drainage rather than continuing to per-
that a significant percentage of patients actively form repeated serial aspirations, each of which
complying with a regimen of long-term elastic incurs the risk of infecting the lymphocele
support stockings and/or sequential compression (Hoffman et al. 1995).
pump therapy have lymphedema but are success- Lymphedema clearly represents the most
fully treated as opposed to patients who are truly serious nonmalignant long-term complication
free of lymphedema. Importantly, the addition of resulting from lower extremity node dissection.
an iliac/obturator lymph node dissection with an Prevention of lymphedema begins in the operat-
inguinofemoral dissection has historically been ing room by taking steps to prevent perioperative
associated with an increased risk of lymphedema; wound infection. Wound infection results in
however, more recent data suggests the addition increased fibrosis of the soft tissues of the femoral
of an iliac/obturator lymph node dissection does area and thereby likely results in the obliteration
not significantly increase this risk (Chang et al. of microscopic lymphatic vessels. Lymphedema
2010). itself predisposes patients to infection of the
extremity, particularly cellulitis. A vicious cycle
of infection resulting in worsening of lymph-
Management of Postoperative edema followed by further infections can thereby
Complications be initiated. Thus, prevention of lymphedema and
perioperative infection goes hand in hand.
Meticulous attention to surgical technique and While lymphedema surveillance and preven-
hemostasis should help prevent a significant num- tion protocols vary on an institutional level,
ber of postoperative complications. Avoiding the all patients should receive education emphasizing
creation of nonviable skin flaps or intraoperative the importance of early detection. At many
wound contamination will contribute significantly institutions, patients are measured preoperati-
to the prevention of postoperative wound edge vely for custom-fitted, medium compression
necrosis, dehiscence, and infection. When these (20–30 mmHg) elastic garments, so that they can
complications do occur, they are best managed be worn as soon as possible and for up to 6 months
with appropriate local wound care. postoperatively. At other institutions, a compres-
Debridement should be performed aggres- sion garment is only used in the treatment of
sively to remove any and all nonviable tissue. established lymphedema. Additionally, sequential
Tissues of questioned viability, however, should compression devices have become an important
be observed while they are treated with topical part of the treatment armamentarium in combating
antibiotics. Systemic antibiotics should be significant established lymphedema. Devices are
reserved only for evidence of invasive soft tissue custom fit for each patient with lymphedema and
infection or cellulitis. The open wound should be are typically worn for periods of up to 1–4 h daily
packed and the dressing changed two to three while the patient is at home. Sequential compres-
times per day until there is healthy granulation sion devices function by mimicking the natural
tissue in the defect. pumping action of the lower extremity muscula-
Lymphocele with seroma formation is a com- ture during ambulation, which propels the protein-
mon complication, with incidence ranging from rich edema fluid out of the soft tissues in a
5% to 27% (Badgwell et al. 2007). Lymphoceles cephalad direction.
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 17

Fig. 11 Technique of
popliteal node dissection
incision and exposure of
superficial structures. (From
Advanced Therapy in
Surgical Oncology, Pollock
RE, Curley SA, Ross MI,
eds.; used with permission
from PMPH USA, Ltd.,
Raleigh, NC)

are raised, while traction is maintained with skin

Popliteal Dissection
hooks. As the fascia is exposed, the most superfi-
cial structures that come into view are the lesser
Indications
saphenous vein and some small cutaneous nerve
terminal branches (Fig. 11). At this point the lesser
Because the incidence of popliteal lymph node
saphenous vein must be ligated and divided.
involvement is exceedingly rare in patients with
Next the deep fascia is incised vertically, tak-
melanoma, Thompson et al. (2000) recommends
ing care to avoid damaging structures below the
popliteal lymph node dissection only for clinical
fascia, because the nerves are quite superficial
evidence of metastatic disease in a popliteal node.
(Fig. 12). If the medial sural nerve can be retracted
out of the way, it should be. However, if neces-
sary, it can be divided to gain better access to
Operative Technique
deeper structures; this will result in cutaneous
anesthesia. The tibial nerve is the most superficial
To prepare for dissection, the patient is placed in
midline structure. This is very gently retracted
the prone position with the operative leg slightly
laterally with a vessel loop. Similarly, the peroneal
flexed at the knee. The patient is prepped from the
nerve courses along the biceps femoris and semi-
mid-thigh to the inferior aspect of the gastrocne-
membranosus muscles. Inferiorly the two heads of
mius muscle. A lazy-S incision is made over the
the gastrocnemius muscle can be further retracted
flexor crease to (1) allow optimal exposure and
as well to enhance distal exposure. The node-
(2) heal in a manner that does not cause a
bearing tissue is swept from around the nerves
deforming joint contracture (Sholar et al. 2005).
and moved distally to expose the popliteal artery
The incision should begin approximately 10 cm
and vein. Nodal tissue surrounding these vessels
above the joint crease of the lateral thigh and then
should be dissected free, making sure to include
move transversely across the joint. From there, it
any tissue lying on the far side of the vessels as
extends longitudinally along the medial aspect of
well (Fig. 12). The dissection is continued until
the leg for approximately 10 cm (Fig. 11). After
these vessels dive behind the gastrocnemius mus-
the incision is created and carried down through
cle. Once the specimen is removed, a drain is
the subcutaneous tissue, lateral and medial flaps
placed and the wound is closed in layers.
18 K. A. Delman et al.

Fig. 12 Technique of
popliteal node dissection
exposure of vessels and
deeper structures. (From
Advanced Therapy in
Surgical Oncology, Pollock
RE, Curley SA, Ross MI,
eds.; used with permission
from PMPH USA, Ltd.,
Raleigh, NC)

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