Editing Inguinal Node Dissection (section)

=== Modified complete inguinal lymphadenectomy ===
'''Advantage'''
*'''Less morbidity than standard radical inguinal lymphadenectomy'''

==== Key aspects of the procedure (5): ====
# '''<span style="color:#ff0000">Shorter skin incision</span>'''
# '''<span style="color:#ff0000">Limiting dissection by excluding the areas (2)</span>'''
##'''<span style="color:#ff0000">Lateral to the femoral artery[https://link.springer.com/content/pdf/10.1007/978-1-62703-367-1.pdf]</span>'''
##* Lateral limit of dissection is femoral artery modified dissection, compared to sartorius muscle in standard inguinal lymphadenectomy
##'''<span style="color:#ff0000">Caudal to the fossa ovalis[https://pubmed.ncbi.nlm.nih.gov/30730389/]</span>'''
###Also known as the saphenous opening[https://en.wikipedia.org/wiki/Saphenous_opening]
###An oval opening in the upper mid part of the fascia lata of the thigh
###Allow the passage of the great saphenous vein
###Lies 3–4 cm below and lateral to the pubic tubercle and is about 3 cm long and 1.5 cm wide.
# '''<span style="color:#ff0000">Preservation of the saphenous vein[https://pubmed.ncbi.nlm.nih.gov/30730389/]</span>''' and lateral accessory saphenous vein[https://www.youtube.com/watch?v=5HdhCDdDnP0]
##Superficial epigastric and superficial circumflex veins are ligated at the superior boundaries of dissection[https://www.youtube.com/watch?v=5HdhCDdDnP0]
##Superficial epigastric, superficial circumflex veins, external pudendal veins are ligated at the superior boundaries of dissection[https://www.youtube.com/watch?v=5HdhCDdDnP0]
# '''<span style="color:#ff0000">Elimination of the need to transpose the sartorius muscle[https://pubmed.ncbi.nlm.nih.gov/30730389/]</span>'''
# '''<span style="color:#ff0000">Thicker skin flaps</span>'''

==== Indications ====
*'''<span style="color:#ff0000">Clinically node-negative disease (not palpable on physical exam) but increased risk for inguinal metastasis based on primary tumor characteristics (pT ≥2, presence of vascular or lymphatic invasion, or grade ≥3).</span>'''

==== Boundaries of Dissection[https://pubmed.ncbi.nlm.nih.gov/16643509/ §] ====
* '''<span style="color:#ff0000">Superior: inguinal ligament/superior boundary of the external oblique aponeurosis and the spermatic cord</span>'''
**'''<span style="color:#ff0000">Inguinal ligament is the portion of the external oblique aponeurosis which extends between the anterior superior iliac spine and the pubic tubercle as a thick band, folded inward[https://en.wikipedia.org/wiki/Aponeurosis_of_the_abdominal_external_oblique_muscle]</span>'''
* '''<span style="color:#ff0000">Medial: anterolateral border of adductor longus muscle</span>'''
* '''<span style="color:#ff0000">Lateral: saphenous vein and femoral vein</span>[https://pubmed.ncbi.nlm.nih.gov/16643509/]'''
* '''<span style="color:#ff0000">Inferior: fossa ovalis (where the saphenous penetrates the fascia lata to drain into the common femoral vein)[https://www.youtube.com/watch?v=5HdhCDdDnP0]</span>'''
*'''<span style="color:#ff0000">Floor: pectineus muscle for deep dissection (fascia lata for superficial)</span>'''
**Note that adductor longus and sartorious are posterior to fascia lata and are therefore not the relevant medial and lateral boundaries for superficial dissection.
*'''Contemporary modified ILND should include the central and superior zones of the inguinal region[https://pubmed.ncbi.nlm.nih.gov/21481617/] and the deep inguinal nodes'''
==== Step by step ====

*'''Similar to standard inguinal lymph node dissection with the following adjustments'''
** '''Incision: 10-cm skin incision is made ≈1.5-2 cm below the inguinal crease extending from just lateral to the femoral artery to the area of the adductor longus muscle[https://pubmed.ncbi.nlm.nih.gov/30730389/][https://pubmed.ncbi.nlm.nih.gov/21481617/]'''
* The saphenous vein is identified and preserved, although a number of branches draining into it will need to be sacrificed.
*'''Modified dissection should be converted to a radical inguinal lymphadenectomy if positive inguinal lymph nodes are present on frozen section[https://link.springer.com/book/10.1007/978-3-319-60858-7]'''