Surgical management of metastatic inguinal lymphadenopathy
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《英国医生杂志》
EDITOR—Swan et al present an interesting review,1 but their technical recommendations are inconsistent with our experience of groin dissection over 20 years. Evidence for preferential use of straight oblique incisions is minimal.
Tonouchi et al studied only 25 procedures, with eight S-shaped incisions and 17 "straight obliques."2 The learning curve and lack of information on the case mix make it difficult to draw conclusions. Our 95 groin dissections using a "lazy S" incision caused one case of wound ischaemia, one case of wound dehiscence, and five postoperative infections. These results compare favourably with studies in which straight oblique incisions were used. An appropriately placed lazy S incision allows excellent access to the apex of the femoral triangle without compromising healing.
Swan et al say that preservation of the long saphenous vein reduces lymphoedema. Zhang et al showed reduced complications in such patients.3 However, a 70% incidence of lymphoedema in the group receiving vein ligation is surprisingly high. Baas et al performed 151 groin dissections sacrificing saphenous vein and noted a 20% incidence of lymphoedema.4
Support for sartorius transposition was also disappointing. There was no reduction in wound morbidity by this approach in a prospective randomised study.5 We never use sartorius transposition. The technique dates from times when inguinal lymphadenectomy was performed as a "wide excision," requiring split skin grafting.
Anatomists and surgeons who perform inguinal node clearance dispute the presence of deep inguinal nodes. We believe that skeletonisation of the femoral vessels clears the femoral triangle completely. The term "deep inguinal nodes" should be abandoned.
Simon C Gibson, senior house officer in general and vascular surgery
simoncgibson@hotmail.com, Department of General and Vascular Surgery, Gartnavel General Hospital, Glasgow G12 OYN
Stephen Kettlewell, specialist registrar in general and vascular surgery, Dominique S Byrne, consultant general and vascular surgeon, Alan J McKay, consultant general and vascular surgeon
Department of General and Vascular Surgery, Gartnavel General Hospital, Glasgow G12 OYN
Competing interests: None declared.
References
Swan MC, Furniss D, Cassell OD. Surgical management of metastatic inguinal lymphadenopathy. BMJ 2004;329: 1272-6. (27 November.)
Tonouchi H, Ohmori Y, Kobayashi M, Konishi N, Tanaka K, Mohri Y, et al. Operative morbidity associated with groin dissections. Surg Today 2004;34: 413-8.
Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 2000;89: 1520-5
Baas PC, Koops HS, Hoekstra HJ, van Bruggen JJ, van der Weele LT, Oldhoff J. Groin dissection in the treatment of lower-extremity melanoma. Arch Surg 1992;127: 281-6.
Judson PL, Jonson AL, Paley PJ, Bliss RL, Murray KP, Downs Jr LS, et al. A prospective, randomized study analyzing sartorius transposition following inguinalfemoral lymphadenectomy. Gynecol Oncol 2004;95: 226-30.
Tonouchi et al studied only 25 procedures, with eight S-shaped incisions and 17 "straight obliques."2 The learning curve and lack of information on the case mix make it difficult to draw conclusions. Our 95 groin dissections using a "lazy S" incision caused one case of wound ischaemia, one case of wound dehiscence, and five postoperative infections. These results compare favourably with studies in which straight oblique incisions were used. An appropriately placed lazy S incision allows excellent access to the apex of the femoral triangle without compromising healing.
Swan et al say that preservation of the long saphenous vein reduces lymphoedema. Zhang et al showed reduced complications in such patients.3 However, a 70% incidence of lymphoedema in the group receiving vein ligation is surprisingly high. Baas et al performed 151 groin dissections sacrificing saphenous vein and noted a 20% incidence of lymphoedema.4
Support for sartorius transposition was also disappointing. There was no reduction in wound morbidity by this approach in a prospective randomised study.5 We never use sartorius transposition. The technique dates from times when inguinal lymphadenectomy was performed as a "wide excision," requiring split skin grafting.
Anatomists and surgeons who perform inguinal node clearance dispute the presence of deep inguinal nodes. We believe that skeletonisation of the femoral vessels clears the femoral triangle completely. The term "deep inguinal nodes" should be abandoned.
Simon C Gibson, senior house officer in general and vascular surgery
simoncgibson@hotmail.com, Department of General and Vascular Surgery, Gartnavel General Hospital, Glasgow G12 OYN
Stephen Kettlewell, specialist registrar in general and vascular surgery, Dominique S Byrne, consultant general and vascular surgeon, Alan J McKay, consultant general and vascular surgeon
Department of General and Vascular Surgery, Gartnavel General Hospital, Glasgow G12 OYN
Competing interests: None declared.
References
Swan MC, Furniss D, Cassell OD. Surgical management of metastatic inguinal lymphadenopathy. BMJ 2004;329: 1272-6. (27 November.)
Tonouchi H, Ohmori Y, Kobayashi M, Konishi N, Tanaka K, Mohri Y, et al. Operative morbidity associated with groin dissections. Surg Today 2004;34: 413-8.
Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 2000;89: 1520-5
Baas PC, Koops HS, Hoekstra HJ, van Bruggen JJ, van der Weele LT, Oldhoff J. Groin dissection in the treatment of lower-extremity melanoma. Arch Surg 1992;127: 281-6.
Judson PL, Jonson AL, Paley PJ, Bliss RL, Murray KP, Downs Jr LS, et al. A prospective, randomized study analyzing sartorius transposition following inguinalfemoral lymphadenectomy. Gynecol Oncol 2004;95: 226-30.