Video-endoscopic Inguinal Lymphadenectomy
Comparison of VEIL with the open procedure in this preliminary study showed a reduced overall complication rate (20 and 70%, respectively), especially related to skin events. The same number of nodes was removed with each approach.
A second study was designed to test whether VEIL could promote the advantages related to minimally invasive procedures.23
The results of
this study suggested that a reduced hospital stay and a faster recovery could be achieved in more than six patients when bilateral VEIL was applied. The feasibility of VEIL in N1 patients was additionally proved. There was no recurrence over a mean follow-up of 36 months.
Technical Aspects
Conventional Video-endoscopic Inguinal Lymphadenectomy (Superficial and Deep Inguinal Dissection)17,21
Patient Positioning and Inferior Member Preparation The patient was positioned in supine position with thigh abduction. The video system was placed on the opposite side to the abducted thigh, next to the patient’s waist.
Initial Access and Surgical Team Positioning
A 1.5cm incision was made 2cm distally to the lower vertex of the femoral triangle. Scissors and digital manoeuvres were used to develop a plane of dissection deep into Scarpa’s fascia. A second 1.0cm incision was made 6cm medially to the apex of the triangle, after digital elevation of the skin through the first incision, to place a 10mm trocar. The last 5mm port was placed 6cm laterally to the apex of the triangle in an analogous manner. A 10mm Hasson trocar was inserted in the first incision. The first port accommodates 0º optics. The medial port accepts the harmonic scalpel or the clip applier and the lateral port may accept the grasper, scissors or a dissection device (see Figure 1). Surgeons were positioned laterally to the patient’s leg and the surgery can be performed ergonomically.
Gas Insufflation
The working space was insufflated with CO2 at 15mmHg with quick space distention, and CO2 pressure could be be kept as low as 5mmHg for the duration of the procedure. Transillumination allows
good orientation and monitoring of the progression of the dissection area towards the cavity.
Retrograde Dissection and Identification of Anatomical Limits It is imperative that the dissection be carried out with a harmonic scalpel in a correct plane deep to Scarpa’s fascia until the external obliquous fascia is achieved, so that all lymphatic superficial tissue can be removed (see Figure 2). The main landmarks – the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly – are clearly visualised (see Figure 3).
At this point we identify the saphenous vein medially and the spermatic cord and the external inguinal ring superomedially. The femoral nerve branches, which can be preserved, present laterally.
Identification and Dissection of the Saphenous Vein The saphenous vein is dissected cranially up to the fossa ovalis.
Femoral Artery Identification at the Femoral Triangle This is the lateral edge of the dissection limit. At this point it is recommended to open the muscular fascia in all its extension.
EUROPEAN ONCOLOGY
Pentagons represent 10mm trocars; circle represents 5mm trocar. Figure 2: Dissection of the Correctly Plane
Figure 1: Disposition of Trocars in Right Thigh for Video-endoscopic Inguinal Lymphadenectomy
Dissection of the correctly plane is made with a harmonic scapel, and maintained scarpa’s fascia is adhered to the skin to prevent ischaemia.
Distal Lymphatic Tissue Ligation at the Femoral Triangle Vertex The tissue is dissected with a harmonic scalpel and final control is obtained using clips.
The following steps are then undertaken:
• Lymphatic tissue dissection reaches the femoral vessels above the femoral ring.
• •
• Distal saphenous ligation with metallic or polymeric clips.
Control of saphenous branches with a harmonic scalpel or clips and proximal ligation of the saphenous vein at the femoral vein with metallic or polymeric clips.
End of dissection, liberating the specimen after ligation of the proximal portion of the lymphatic tissue at the deep portion of the femoral channel (see Figure 4).
• Specimen removal through the first 15mm incision. If the specimen is larger, the incision can be enlarged, usually by 20–25mm. Suction drainage at the 5mm port incision.
•
• Suture of incisions (10–20mm). • Peri-operative care and follow-up.
Prophylactic intravenous cefalotin was administered routinely. In the post-operative period, patients were stimulated to early ambulation and none received anticoagulants. Oral intake was started 12 hours after the procedure. The suction drain was removed when output less than 50ml.
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