Repair after radical groin dissection

Successful laparoscopic trans-peritoneal repair of an incisional inguinal hernia, resulting from deep lymph node dissection for melanoma: A case report

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Groin incisional hernia may result like late complication of deep pelvic dissection.

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When this type of inguinal ventral hernia develops, the surgeon is facing some problems different to the common ventral hernia repair.

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Most of these difficulties may be overcome using laparoscopic approach.

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We present a case of successful laparoscopic repair of a giant ventral hernia developed like late complication of deep pelvic dissection for melanoma.

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To our knowledge, no other laparoscopic repair of this type of ventral hernia has been previously reported.

Introduction

Deep pelvic lymph node dissection for cancer may result in incisional inguinal hernias. We present a case report of successful laparoscopic trans-peritoneal repair of a large ventral inguinal hernia that developed following ileo-inguinal lymph node dissection (CLND) for melanoma.

Case presentation

A successful 3 port laparoscopic trans-peritoneal procedure was performed on a 56-year-old female for the repair of a left inguinal hernia, developed 13 months following CLND for melanoma. The large oval 18 × 14 cm inguinal defect, with superior margins bordering the conjoint tendon and inferior margins bordering the ileo-psoas muscle, femoral vessels and nerve, was not closed in order to avoid excessive tension and was repaired by fixing a 25 × 20 cm intra-peritoneal mesh to abdominal borders at superior and lateral margins with permanent fasteners and at the inferior margin by a cyanoacrylate-glued overlap to protect femoral vessels and nerves from damage. No hernia recurrence was observed 8 months following this procedure.

Discussion

Incisional inguinal hernias, following CLND, are rare but present a challenge to surgeons due to the difficulty in identifying both anatomical plains and safe sites for stable repair.

Conclusions

We report a laparoscopic trans-peritoneal approach for the safe, reproducible and efficacious repair of incisional inguinal hernias that result from CLND. In our opinion prevention of hernia recurrence can be achieved by a intraperitoneal large mesh fixed at superior and lateral margin borders with permanent fasteners and using cyanoacrylate glue to overlap inferior margin borders in order to prevent vessels and/or nerve injury.

Femoral hernia, a rare complication following deep inguinal lymph node dissection

A 72-year-old woman underwent complete deep inguinal lymph node dissection on her right side subsequent to metastasis from malignant melanoma. On the second postoperative day, the patient reported of nausea and vomiting. She presented with a mass in the resected area that gradually increased in size to approximately 15×20 cm. The wound was opened a few hours after onset of symptoms and a large femoral hernia with 40 cm of small intestine was immediately revealed protruding in the groin. Prophylactic suturing of the inguinal ligament and Coopers ligament can reduce the risk of postoperative femoral hernia. Further, the authors argue that drainage for seroma and haematoma should be performed with utmost care, considering other possible causes and, if necessary, guided by ultrasonography.

Surgical considerations in anal cancer

SCC of the anus is rare; however, the surgeon is bound to encounter some of these patients during his or her career. It is important that the anatomic location and the histology be defined because the initial treatment may initially differ. Multimodality therapy is the treatment of choice in SCC of the anal canal, with surgery reserved for persistent or recurrent tumors. Multimodality therapy can be used selectively in SCC of the perianal skin, especially in large bulky tumors, followed by definitive surgery. Nevertheless, the initial treatment of perianal neoplasms is surgical therapy. In general, inguinal node metastases are treated with chemoradiation. In highly selected patients, groin dissections are performed, but this procedure is not routine.

Management of iatrogenic lower limb ischaemia in children

An acutely ischaemic lower limb following femoral artery cannulation in children is a problem infrequently encountered by plastic surgeons in the UK. When such a case presented to us, we performed a search of published literature to guide us to the optimum treatment. This included methods for extraperitoneal exposure of the common iliac artery and vein. We describe the surgical technique that we used to salvage an acutely ischaemic lower limb following femoral puncture and a review of the literature.

Lymph node dissection for clinically evident lymph node metastases of malignant melanoma

AIMS

A considerable number of melanoma patients present with clinically evident regional lymph node metastases. Factors influencing prognosis following therapeutic lymph node dissection (TLND) were evaluated.

METHODS

In total 140 patients (68 women, 72 men, median age 53 years) with established regional lymph node metastases, but without clinically detectable distant metastases, received cervical, axillary or ilioinguinal TLND between 1978 and 1997 and were retrospectively reviewed. Uni- and multivariate survival analysis was performed.

RESULTS

Median survival for all 140 patients was 25 months; the observed overall 5 year survival rate was 30%. Age greater than 50 years, primary tumour site on the trunk, more than three lymph node metastases and extracapsular spread were associated with a poor prognosis. In multivariate analysis age (< or =50 years vs >50 years, P=0.02), location of the primary tumour (non-truncal vs truncal, P=0.005), number of lymph nodes involved ( n< or =3 vsn >3, P=0.01) and extracapsular spread (none vs present, P=0.04) proved to be independent prognostic factors.

CONCLUSIONS

TLND is worthwhile and offers a potential chance of cure in about one-third of melanoma patients with established regional lymph node metastases. There are subgroups with a particularly poor prognosis in whom the benefit of radical surgery alone is limited.