Modified inguinal lymphadenectomy

Modified inguinal lymph node dissection for surgical treatment of vulvar and vestibular large adenocarcinoma. Modern modified inguinal lymph node dissection is designed according to the lymph node metastasis rate of different clinical stages of vulvar cancer, and selective unilateral or bilateral inguinal lymph node resection: 1. In stage Ia of vulvar cancer, the rate of inguinal lymph node metastasis is low, so the inguinal lymph node dissection is omitted. 2. Ia's vulvar cancer, lateral vulvar cancer and bilateral inguinal lymph node status are the basis for the determination of inguinal lymph node resection. 1 vulvar centrality (2 cm in the vulva midline) or large cancerous lesion (diameter > 2 cm), using uniform or separate resection. Extensive vulvar resection and bilateral inguinal lymphadenectomy. 2 lateral vulvar cancer, only the affected side (half side) vulvectomy plus ipsilateral inguinal lymph node resection. If the rapid pathology confirms lymph node metastasis, the contralateral inguinal lymph node should be removed. 3. Microscopic superficial cancer, local excision, but not inguinal lymph node resection. 4. Inguinal lymph nodes can be accessed, regardless of the primary tumor, inguinal lymph node resection, or under the guidance of lymph node angiography to quantitatively remove all suspicious metastatic lymph nodes. Treatment of diseases: vulvar cancer Indication 1. Indications for bilateral inguinal lymphadenectomy (1) vulvar squamous cell carcinoma>T1b. (2) Vulvar adenocarcinoma. (3) Melanoma or cancerous lesions suspected of having lymph node metastasis > 0.75 mm. (4) malignant melanoma. (5) Central vulvar cancer (> 2cm in diameter) tumor infiltrated to the distal vaginal wall 1 ~ 2cm and the urethra and anus. (6) Patients with endometrial adenocarcinoma and ovarian cancer with inguinal lymph node metastasis. Pelvic lymph node clearance is also required during the same period. 2. Indications for unilateral inguinal lymph node resection (1) Small lesions on the outside of the vulva (diameter < 2 cm). (2) No signs of bilateral inguinal lymph node metastasis and pathological examination of the affected inguinal lymph node biopsy confirmed no metastasis. (3) Only one or two clinically positive lymph nodes in the inguinal region should undergo inguinal lymph node resection before radiotherapy. Surgical procedure 1. Conventional application of knee to umbilical skin disinfection. 2. Incision can be performed in a uniform or separate unified incision for vulvar and bilateral inguinal lymph node resection. There are two separate incisions: 1 longitudinal incision, 3 cm inside the anterior superior iliac spine, and longitudinal incision from the anterior superior iliac spine down to the top of the femoral triangle. The length is about 15 cm and the depth is 3 to 4 mm. 2 transverse incision parallel to the inguinal fold incision, length 8 ~ 10cm, depth 3 ~ 4mm. Then, the adductor tendon expands to the anterior superior iliac spine, and the lower fat of the flap contains the superficial lymph nodes on the upper edge of the femoral triangle and on both sides of the incision. The distal incision of the inguinal region terminates in the deep fascia of the abdominal wall, the Scarpa fascia. 3. Resection range No matter the longitudinal incision or transverse incision, in order to maintain the blood supply of the skin, when the flap is free along the skin margin, the upper side, the left and right sides, part of the subcutaneous tissue is properly preserved as much as possible. The incision skin was separated inward from the pubic symphysis, separated to the lateral anterior superior iliac spine, the inguinal ligament was separated downward, and the external oblique muscle was exposed to the deep subcutaneous tissue. The extent of the inferior inguinal lymph nodes was removed: the fatty lymph nodes in the femoral triangle, with the superficial fascia above the inguinal superficial lymph nodes, and below the femoral sheath and the striate fascia, the lymph nodes around the femoral vessels in the fossa ovalis are deep inguinal lymph nodes. Excision begins at the lower edge of the inguinal region and exposes the fascia along the medial lateral edge of the incision. It is collected from the top, the outer, and the inner directions. 4. Check to determine the medial muscle fascia and fascia of the adductor, the sartorius fascia, and define the boundaries of the femoral triangle. Use the index finger to separate the long muscle and the sartorius muscle, and separate the subcutaneous shallow fat tunnel along the upper and lower edges of the incision, and extend down to the top of the femoral triangle to merge and return at the top of the broad ligament. At this time, the lower part of the femoral triangle is fully exposed. The flaps are used to lift the fatty lymph nodes, clamp the ligation, and expose the adductor longus and the proximal myofascial fascia. Care should be taken to prevent damage to the great saphenous vein. 5. The large saphenous vein branch encountered by ligation is separated by fingers to determine the outer edge skin tunnel, the fat pad of the upper flap is freed, and the superficial tissue covering the inguinal ligament is removed. Then, the shallow layer (Scarpa fascia) of the deep fascia of the abdominal wall is separated downward, and the superficial branch of the lower vascular wall of the abdominal wall is ligated. Pull the thigh down and separate the fat pad from the deep fascia to the lower edge of the inguinal ligament. Generally, it can be gently separated and removed. The pedicle tissue between the upper and lower inner and outer corners of the fat pad is clamped and ligated. Note in this step: 1 The separated tissue gap is correct, the fat pad is easy to tear off the aponeurosis, and the inguinal outer ring and the bulge containing the round ligament are visible on the inner edge of the incision. 2 The superficial branch of the external genital artery and the superficial iliac crest were transversely passed through the subcutaneous tissue covering the inguinal ligament at the medial and lateral sides of the upper flap, respectively, and were clamped and ligated. 6. Pull and cut the fascia of the sartorius and adductor muscles, pull the sartorius muscle cutting edge upwards, and remove the lymph node fat pad containing the shallow, deep and femoral groin from the outside to the inside. In the removal, the fascia tissue should be preserved to cover the femoral nerve and extend to the lateral edge of the femoral artery. The tissue covering the femoral artery and vein is excised. Note that the deep external pudendal artery is confirmed and ligated, and the boundary of the great saphenous vein and the distal part of the femoral vein are tracked and the saphenous vein is sutured. Continue to separate across the pubis muscle, through the femoral canal to the adductor fascia cutting edge, the surgical specimen was removed. 7. After the completion of lymph node dissection, the outside of the inguinal region should be routinely examined to see if there is any external mouth looseness or hernia sac. It was found that the slender was repaired by suture reinforcement. If necessary, suture the femoral condyle between the inguinal ligament and the crypt ligament, but pay attention to avoid squeezing the femoral vein. 8. Warm the saline to wash the wound, completely stop the bleeding and place the closed negative pressure drainage, and suture the incision. The drainage tube is placed in the groin area (can be placed through the upper abdominal wall or the lower thigh). Pay attention to the tension suture when the incision is sutured (ie, the first needle thread passes through the skin into the adductor fascia and re-penetrates the skin, and then passes through the incision through the skin and the external oblique fascia to wear the skin. The second needle is embedding The line traverses the first line, passes through the skin and the sartorius to the inguinal incision, and passes through the skin and the anterior rectal sheath to the inguinal incision, and the suture is ligated to the wound dressing). If the surgical incision is tension-free, the incision skin edge can be closed with a skin stapler or a 3-0 prolene gut suture. 9. According to the rapid pathology report, the contralateral inguinal lymph node resection and ipsilateral pelvic lymph node resection were performed. All patients with inguinal lymph node metastasis are indications for bilateral lymph node resection. Patients with increased positive lymph nodes or multiple positive inguinal lymph node metastases were all indications for pelvic lymphadenectomy. Some people also determined the pelvic lymphadenectomy based on the pathological results of the Cloquet lymph nodes. complication 1. Wound infection and necrosis of necrosis occur mostly in the central part of the proximal end of the incision. After the examination of the necrosis of the flap, the sharp debridement and debridement are beneficial to promote healing. The local granulation tissue is wet and dry after dressing. Bandaging. If there is no radiotherapy, if necessary, use a muscular flap to cover the wound. 2. The incidence of lymphocysts is 28%. If there is a lymphatic cyst, the cystic fluid can be taken every day. For those who are stubborn and unhealed, a sclerosing agent (such as absolute ethanol) can be injected into the capsule. It has also been reported that intracapsular injection of sterilized iodine solution is beneficial. But pay attention to avoid secondary infection or cause subcutaneous necrosis. 3. Cellulitis and lymphangitis are mostly caused by -hemolytic streptococcal infection, acute onset, high fever and chill, skin redness and heat pain, and more dramatic reactions to antibiotic treatment. Cellulitis can also cause lymphatic reflux disorders and aggravate lower extremity edema. 4. Nerve damage is mostly caused by cutaneous lesions of the femoral and femoral nerves of the femoral triangle and chronic edema of the thigh. The anterior part of the anterior part often has a paresthesia that naturally resolves or disappears within a few months. Occasional sensory abnormal pain. 5. Lymphedema, temporarily appears. But often because of radiotherapy, obesity, deep vein thrombosis and varicose veins, the symptoms are more serious. The principle of treatment is to bed and raise the affected limb, wear elastic stockings, intermittent use of diuretics, etc., generally curable. Patients with ineffective treatment were treated with a lymphedema pump.

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