Joseph J Skitzki, MD, Sydney Lillard, MD, John M Kane III, MD. Roswell Park Cancer Institute
Objective: The potentially curative treatment for nodal metastatic melanoma is lymphadenectomy. In the sentinel lymph node (SLN) biopsy era, a superficial (inguinal) lymph node dissection is usually sufficient to address the microscopic nodal metastatic disease. As the majority of the surgical morbidity is due to the flaps/incision, we investigated a “gas-less” minimally invasive inguinal lymphadenectomy using standard laparoscopic equipment while still maintaining appropriate oncologic principles.
Methods: A 60 yo obese female (BMI=36.7) underwent wide excision for a clinical stage IIC perineal melanoma as well as a right groin SLN biopsy. A 0.2 mm focus of micrometastatic disease was indentified within one SLN and the patient consented to a minimally invasive right inguinal lymphadenectomy. A 0° laparoscope, basic laparoscopic tools, and retraction system were utilized through 3 separate skin incisions; each <4 cm in length (superior, inferior, and scar excision of prior SLN biopsy site). The specimen was removed en bloc to include all lymphatic tissue as defined by the classic open lymphadenectomy landmarks. Cloquet’s node was evaluated intraoperatively.
Results: Separation of the superficial (Scarpa’s) fascia and the overlying subcutaneous tissue was possible without the use of CO2 insufflation as mechanical retraction created ample working space. All anatomic landmarks were clearly visualized as dissection progressed in a proximal to distal fashion using a harmonic scalpel. A vascular load endostapling device divided the saphenofemoral junction flush with the femoral vein. Final endoscopic views demonstrated the completeness of the lymphadenectomy. Total operative time was 240 minutes and estimated blood loss was 30 ml. The intact surgical specimen fulfilled criteria of adequacy (14 lymph nodes removed) with a negative Cloquet’s node. Additional metastases were noted in 2/14 nodes. Postoperatively, there were no wound healing issues.
Conclusions: Minimally invasive inguinal lymphadenectomy is technically feasible with standard laparoscopic equipment and does not require CO2 insufflation with its attendant shortcomings. It also obviates the need for a sartorius rotation flap to cover the femoral vessels. Our described method warrants further investigation as an oncologically appropriate, less morbid alternative to traditional inguinal lymphadenectomy for nodal micrometastatic melanoma.
Program Number: V075