Sartorius transposition during inguinal lymphadenectomy for melanoma

Current Controversies in Melanoma Treatment

LEARNING OBJECTIVES

After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management.

SUMMARY

Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.

A Novel Fascial Flap Technique After Inguinal Complete Lymph Node Dissection for Melanoma

INTRODUCTION

Inguinal complete lymph node dissection (CLND) for metastatic melanoma exposes the femoral vein and artery. To protect femoral vessels while preserving the sartorius muscle, we developed a novel sartorius and adductor fascial flap (SAFF) technique for coverage.

METHODS

The SAFF technique includes dissection of fascia off sartorius and/or adductor muscles, rotation over femoral vasculature, and suturing into place. Patients who underwent inguinal CLND with SAFF for melanoma at our institution were identified retrospectively from a prospectively-collected database. Patient characteristics and post-operative outcomes were obtained. Multivariate logistic regression assessed associations of palpable and non-palpable disease with wound complications.

RESULTS

From 2008 to 2019, 51 patients underwent CLND with SAFF. Median age was 62 years, and 59% were female. Thirty-one (61%) patients were presented with palpable disease and 20 (39%) had non-palpable disease. Fifty-five percent (95% confidence interval CI: 40%-69%) experienced at least one wound complication: wound infection was most common (45%; 95% CI: 31%-60%), while bleeding was the least (2%; 95% CI: 0.05%-11%). Complications were similar, with and without palpable disease.

CONCLUSIONS

The SAFF procedure covers femoral vessels, minimizes bleeding, preserves the sartorius muscle, and uses standard surgical techniques easily adoptable by surgeons who perform inguinal CLND.

Comparison of different surgical methods and strategies for inguinal lymph node dissection in patients with penile cancer

To compare the clinical feasibility and oncological outcome of different surgical techniques for inguinal lymphadenectomy (ILND) in patients suffering from penile cancer. This study included data from 109 cN_0-2 patients diagnosed with penile cancer who received ILND. 80 laparoscopic ILND were performed on 40 patients, while 138 open surgeries were performed on 69 patients. Perioperative complications and prognosis were compared between different surgical techniques. Compared with the open surgery group, the laparoscopy group had a shorter hospital stay (8.88 ± 7.86 days vs. 13.94 ± 10.09 days, P = 0.004), and a lower wound healing delay rate (8.75% vs. 22.46%, P = 0.017), but also had longer drainage time (10.91 ± 9.66 vs. 8.70 ± 4.62, P = 0.002). There were no significant differences in terms of other intraoperative parameters, complications, and survival between open and laparoscopic group. Compared with saphenous vein ligated subgroup, preserved subgroup showed no significant reducing of complication rate. There was no significant difference among complication between different open surgery subgroup. Immediate ILND showed no prognostic advantage over delayed ILND regardless of clinical lymph node status. Compared with open surgery, the minimally invasive ILND technique has similar oncological efficiency and a lower complication rate. Saphenous vein preservation has limited value in reducing complications. Delayed lymphadenectomy might be a more reasonable option for ILND.

Minimally invasive inguinal lymph node dissection: initial experience and reproducibility in a limited resource setting-with technique video

BACKGROUND

Conventional inguinal lymph node dissection comes with a high wound complication rate which increases hospital stay and may delay adjuvant treatment. Minimally invasive lymph node dissection (MILND) is a novel endoscopic technique which aims to minimize complications of lymphadenectomy. Herein we present our technique and experience with MILND to examine safety, feasibility and reproducibility in a setting of limited resources.

METHODS

All patients undergoing MILND in the National Cancer Institute, Cairo were prospectively included following informed consent, IRB and ethical committee approval. Demographics, clinical, pathological data and postoperative complications according to Clavien-Dindo classification were recorded. Footage collected was used to create a step-by-step video demonstrating the technique.

RESULTS

Twenty-seven procedures were included in the study. The most common indications were vulval cancer (44%) and skin melanoma (19%). There were 5 (18%) conversions to open procedure, all of them in the first 10 cases of the learning curve. The median (range) operative time was 120 (45-240) min and there was a trend towards shorter operative time after the first 5 cases. Wound dehiscence occurred in 4 cases (15%). Three of them (11%) required reoperation (grade III). Grade I/II complications in the form of seroma and wound infection occurred in 34%. The median (range) postoperative hospital stay was 2 (1-14). The median (range) number of retrieved lymph nodes was 12 (3-19). No grade III/IV lymphedema was recorded at 90 days after surgery.

CONCLUSION

MILND is a safe, feasible technique associated with relatively low postoperative wound complications even when performed in a centre with relatively limited resources.

Definition and severity grading of postoperative lymphatic leakage following inguinal lymph node dissection

Purpose

Lymphatic complications occur frequently after radical inguinal lymph node dissection (RILND). The incidence of lymphatic leakage varies considerably among different studies due to the lack of a consistent definition. The aim of the present study is to propose a standardized definition and grading of different types of lymphatic leakage after groin dissection.

Methods

A bicentric retrospective analysis of 82 patients who had undergone RILND was conducted. A classification of postoperative lymphatic leakage was developed on the basis of the daily drainage output, any necessary postoperative interventions and reoperations, and any delay in adjuvant treatment.

Results

In the majority of cases, RILND was performed in patients with inguinal metastases of malignant melanoma (n = 71). Reinterventions were necessary in 15% of the patients and reoperations in 32%. A new classification of postoperative lymphatic leakage was developed. According to this definition, grade A lymphatic leakage (continued secretion of lymphatic fluid from the surgical drains without further complications) occurred in 13% of the patients, grade B lymphatic leakage (persistent drainage for more than 10 postoperative days or the occurrence of a seroma after the initial removal of the drain that requires an intervention) in 28%, and grade C lymphatic leakage (causing a reoperation or a subsequent conflict with medical measures) in 33%. The drainage volume on the second postoperative day was a suitable predictor for a complicated lymphatic leakage (grades B and C) with a cutoff of 110 ml.

Conclusion

The proposed definition is clinically relevant, is easy to employ, and may serve as the definition of a standardized endpoint for the assessment of lymphatic morbidity after RILND in future studies.

Evaluation of the videoscopic inguinal lymphadenectomy in melanoma patients

INTRODUCTION

A completion or therapeutic inguinal lymph node dissection is a procedure accompanied with a high rate of postoperative complications. A novel, minimally invasive alternative has been developed; the videoscopic inguinal lymphadenectomy. The aim of this study is to present our first experience with the videoscopic inguinal lymphadenectomy among melanoma patients with inguinal metastases.

METHODS

Melanoma patients with a histologically confirmed inguinal metastases who underwent a videoscopic inguinal lymphadenectomy between November 2015 and January 2018 were included. Outcome measures were operation time, nodal yield, and postoperative complications. Furthermore, lymphedema measurements were performed both subjectively and objectively.

RESULTS

A total of 20 patients (3 males and 17 females) underwent a videoscopic inguinal lymphadenectomy. In 75% of patients the procedure was combined with an open iliac lymphadenectomy. Median operation time of the videoscopic procedure was 110 min (range, 79-165). There were no perioperative complications or conversions. In 12 patients (60%) there was ≥1 postoperative complication. The most frequent complications were seroma and wound infection. All complications were treated conservatively without the need for a surgical re-intervention. The median nodal yield of the videoscopic procedure was 9 (range, 1-19). Lymphedema was present in nine patients (45%) after three months of follow-up.

CONCLUSION

Our initial results show that the videoscopic inguinal lymphadenectomy is an attractive alternative to the conventional open technique. The number of complications is comparable with the complication rate reported for the conventional open procedure, but they are less severe and there is no need for a surgical re-intervention.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

Background

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

Methods

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

Results

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

Conclusion

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Tissue sealants for the prevention of lymphoceles after radical inguinal lymph node dissection in patients with melanoma: A systematic review and individual patient data meta-analysis

BACKGROUND AND OBJECTIVES

Postoperative lymphoceles and further wound complications occur frequently after radical inguinal lymph node dissection (ILND). In various studies, tissue sealants have shown to reduce the incidence of postoperative morbidity.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of tissue sealants in reducing the incidence of postoperative lymphoceles following ILND in patients with melanoma was conducted. Individual patient data was requested to pool the data for meta-analysis appropriately.

RESULTS

Thousand seven hundred twenty-nine manuscripts were screened for eligibility. Six RCTs published between 1986 and 2012 were identified including 194 patients for ILND. Only four RCTs were included in the meta-analysis. No study properly defined the term "lymphocele." Tissue sealants failed to influence the duration of drain placement (mean difference [MD] = -3.05 days; z = 1.18; P = 0.24), total drainage volume (MD = 598.39 mL; z = 1.49; P = 0.14), the incidence of postoperative seroma, wound infection and skin necrosis.

CONCLUSIONS

No improvement was identified with the use of tissue sealants, however, a valid comparison of the results of included trials was difficult owing to the lack of a definition of the term "lymphocele." Other surgical techniques and trials using validated endpoint definitions are required to reevaluate these findings.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction

BACKGROUND

The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure.

METHODS

A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014.

RESULTS

A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459).

CONCLUSIONS

Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.

Morbidity After Inguinal Lymph Node Dissections: It Is Time for a Change

BACKGROUND

Inguinal lymph node dissection (ILND) for stage 3 melanoma is accompanied by high wound complication rates. During the past decades, several changes in perioperative care have been instituted to decrease the incidence of these complications. This study aimed to evaluate the effect of these different care protocols on wound complications after ILND.

METHODS

A retrospective analysis of prospectively collected data was performed with 240 patients who underwent an ILND in the University Medical Center Groningen between 1989 and 2014. Four groups with different treatment protocols were analyzed: A (≥10 days of bed rest with a Bohler Braun splint), B (10 days of bed rest without a splint), C (5 days of bed rest), and D (1 day of bed rest). The effect of early mobilization, abolishment of the Bohler Braun splint and postural restrictions, and the introduction of prophylactic antibiotics were analyzed.

RESULTS

One or more wound complications occurred in 51.2 % of the patients including wound infection (29.8 %), seroma (21.5 %), wound necrosis (13.6 %), and hematoma (5 %). In consecutive periods, respectively 44.4, 60.3, 44.9 and 55.2 % of the patients experienced wound complications. None of the instituted changes in protocols led to a decrease in wound complications.

CONCLUSION

Changes in perioperative care protocols did not affect the rate of wound complications. Perhaps a change in the surgical procedure itself can lead to the necessary reduction of wound complications after ILND.

Video endoscopic inguinal lymphadenectomy for lymph node metastasis from solid tumors

AIM

Inguinal lymphadenectomy (IL) is the standard treatment for inguinal lymph node (LN) metastases from genitourinary neoplasm and other cutaneous malignancies. Video endoscopic inguinal lymphadenectomy (VEIL) is emerging as a new modality for treating inguinal LN metastasis, with the aim of reducing post-operative complications. However, the safety and effectiveness of this new approach is still unclear.

METHOD

A systematic literature review was performed. Patient characteristics, selection criteria, intra-operative data, number of excised LNs and post-operative outcomes were extracted and described for each study.

RESULTS

Ten series that encompassed data of 236 procedures performed in 168 patients were reviewed. The conversion to traditional IL rates ranged between 0 and 7.7%. Median/mean operation time varied between 60 and 245 min. Wound-related complications and lymphatic collection/seroma ranged between 0 and 13.3% and 4 and 38.4%, respectively. The median/mean number of excised inguinal LNs ranged between 7 and 16. Although only four studies reported a follow-up time longer then 2 years, local recurrence rate was up to 6.6%.

CONCLUSIONS

VEIL is safe and feasible for experienced surgeons with advanced laparoscopic skills and familiarity with groin anatomy. The post-operative morbidity appears lower compared to the open procedure, mainly for wound/skin related complications. The number of harvested LN and the regional recurrence rate is comparable to that of conventional groin dissection. Before VEIL technique can be considered suitable for routine clinical practice, comparable oncological outcomes and lower post-operative morbidity should be assessed in a randomized controlled trial.