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Cervelo Gonzalo*, Quildrian Sergio, Daffinoti Anabella, Chapela Jorge, Calnico Nstor.
Departamento de Ciruga de Tumores de Partes Blandas. Instituto de Oncologa ngel H. Roffo. Buenos Aires, Argentina.
* Mdico Concurrente
Mdico de Planta (MAAC)
Mdico de Planta
Jefe de Servicio de Partes Blandas (MAAC)
RESEA ANATOMICA
La regin inguino-crural corresponde a la
parte medial de la cara anterior de la raz del muslo.
Tiene una forma triangular con su pice en el extremo inferior. El lado superior corresponde al ligamento inguinal, el lado externo al musculo sartorio y el
medial al musculo aductor mediano del muslo. El
vrtice, inferior, esta formado por la interseccin de
los haces del msculo sartorio con los del aductor
mediano del muslo. Este tringulo as formado corresponde al tringulo de Scarpa (Figura 1).
Planos superficiales: Piel y tejido celular
subcutneo. En este plano se encuentra la estacin
linfoganglionar inguinal superficial, conformada por
un grupo variable de 10 a 20 ganglios distribuidos a
lo largo del tronco de la safena interna. En el plano
subcutneo existen adems formaciones vasculares
y nerviosas de escasa importancia prctica en el curso de la intervencin. El nico elemento nervioso de
cierta importancia esta representado por el nervio
cutneo lateral del muslo, proveniente del plexo lumbar, que aparece en esta regin a nivel del ligamento
inguinal, por dentro de la espina iliaca anterosuperior, descendiendo verticalmente. Se lo encuentra
durante la preparacin del colgajo lateral.
Plano profundo: Este plano se encuentra
separado del anterior por la presencia de una estructura fascial que se continua hacia abajo y por fuera
con la fascia lata y que asciende hasta el ligamento inguinal, fijndose a l. Esta estructura fascial
Inguinal lymphadenectomy includes the removal of lymph nodes and lymph tissue associated
with the femoral vessels' path.
The main indication for this intervention are
metastatic melanomas of the lower extremity, genital region, perineal and abdominal wall skin, whether
they are palpable nodes with a positive Fine Needle
Aspiration (FNA) biopsy or occult metastases detected by sentinel positive node. Another indication
of this procedure includes the inguinal lymph node
metastases from carcinoma of the penis, vulva and
anus.
Local control of the underlying disease and
the absence of distant metastases are prerequisites
for performing this surgery.
ANATOMICAL OVERVIEW
The inguinal-femoral region corresponds to
the medial part of the anterior aspect of the upper
thigh.It has a triangular shape with its apex at the
lower end.The upper side corresponds to the inguinal ligament, the external side to the sartorius and
the medial side to the adductor longus muscle of the
thigh.The vertex, bottom, is formed by the intersection of the muscles fascicles of the sartorius muscle
with the adductor longus of the thigh.This triangle
thus formed corresponds to the Scarpa triangle (Figure 1).
Superficial levels: Skin and subcutaneous
tissue.At this level it is find the superficial inguinal
lymph node station, consisting of a variable group of
10 to 20 nodes distributed along the inner saphenous
trunk. In the subcutaneous plane there are other vascular and nervous formations which have little prac-
Pag. 19
Tcnica Quirrgica /
Surgical Technique
El vaciamiento ganglionar inguinal contempla la extirpacin de los ganglios linfticos y del tejido
linftico asociado con el recorrido de los vasos femorales.
La principal indicacin de esta intervencin
son los melanomas metastsicos de la extremidad
inferior, regin genital, perineal y piel de la pared abdominal; ya sean estos ganglios palpables con PAAF
positiva, o metstasis ocultas detectadas por ganglio
centinela positivo. Otra indicacin de este tipo de
procedimiento incluye las metstasis ganglionares
inguinales de los carcinomas de pene, vulva y ano.
El control local de la enfermedad primaria o
de base y la ausencia de metstasis a distancia son
requisitos indispensables para la realizacin de esta
ciruga.
Se rasura al paciente desde la regin infraumbilical hasta el pubis y despus a lo largo del
muslo hasta la rodilla. Se lava la piel con soluciones
antispticas.
La intervencin de realiza bajo anestesia
Pag. 20
Incisin
El plano cutneo se secciona con dos incisiones ligeramente curvas que convergen en los
extremos. El losange cutneo delimitado de esta
manera esta centrado en una lnea moderadamente
oblicua desde arriba hacia abajo y desde afuera ha-
SURGICAL TECHNIQUE
Patient Preparation
The patient is shaved
from the infraumbilical region
to the pubis and then along the
thigh to the knee. The skin is
washed with antiseptic solutions.
The intervention is performed under general anesthesia
or, if the patient's condition required under epidural anesthesia.
The patient is placed supine on the operating table with
Fig 2. Posicin del Paciente
Patient Position
the limb to be operated with the
knee moderately flexed and rotated outward over the hip joint (Figure 2).This position
is extremely important because it exposes the femoral triangle and makes its content more accessible to
the surgeon.
In male patients, the scrotum and genitals
are covered with a gauze and moved to the opposite
side or can be sutured with a sitch to the contralateral
thigh.
The surgeon position himself on the same
side as the limb in which he will perform the
surgery.
Incision
Pag. 21
Tcnica Quirrgica /
Surgical Technique
Diseccin inguino-crural
Se procede a preparar los colgajos cutneos. Para este fin mientras el ayudante estira hacia
arriba y al lado opuesto el borde cutneo, se extirpa
todo el tejido adiposo subcutneo hasta el plano fascial subyacente. En la preparacin de los dos colgajos el lmite lateral est representado por el borde
del musculo sartorio (Figura 4); el lmite medial por
el borde del musculo aductor mediano del muslo (Figura 5); arriba y abajo los extremos de la incisin cu-
Inguinal-femoral Dissection
Skin flaps are prepared. To this end the
assistant stretches upward and to the opposite side
the skin flap, and all the subcutaneous fat to the underlying fascial plane is removed.In the preparation
of t he two lateral flaps, the limit is represented by the
sartorius muscle edge (Figure 4); the medial limit of
the edge of the thigh adductor longus muscle (Figure
5); above and below the ends of the skin incision represent the boundaries of the dissection. Upward dissection should continue to expose the inguinal arch
and major oblique (Figure 6).
The incision should be made on the inside
above the thigh adductor longus muscle and laterally
to the sartorius from the inguinal ligament to Scarpa's
triangle vertex .
At this point by the lower end of the operative field, the trunk of the saphenous vein can be
isolated in the adipose tissue thickness above the
Fig 5: Colgajo medial hasta el Aductor Mediano Fig 6: Exposicin de Oblicuo Mayor y Arcada Inguinal
Pag. 22
muscles levels. It
should be sectioned
between ligatures
(Figure 7).
Now the surgeon
laterally stretches
the fascial plane
Fig 7: Safena Interna en vrtice del tringulo de
Scarpa. Saphenous in Scarpas triangle vertex and all the tissue
that surrounds it and
that contains the inguinal lymph nodes, as well as the
trunk of the saphenous vein, and undertakes a delicate subfascial tissue dissection until near the wall of
the femoral vein whose adventitia is sectioned and
dissected.
This maneuver allows us to correctly visualized the saphenous vein outfall into the femoral vein,
so that is isolated and sectioned.
All arterial and venous branches should be
desprende.
Esta maniobra permite evidenciar la desembocadura de la safena en la femoral, de modo que
se asla y se secciona entre ligaduras de lino.
Se deben ligar las diversas ramas colaterales arteriales y venosas que van apareciendo.
La diseccin continua hacia afuera con el
aislamiento y esqueletizacin de la arteria femoral,
Completed Lymphadenectomy
sectioned.
Dissection continues laterally with isolation
and skeletonization of the femoral artery, which is recognized by gently moving outward the surgical specimen in orden to put tension into the surrounding
tissues (Figure 8).
Once liberated the femoral artery as described, the femoral nerve and the sartorius muscle are
shown.
The last thing to do at this time is to detach
fatty tissue above the inguinal ligament from
the oblique aponeurosis.
This gives the specimen represented above the fascia lata by the adipose tissue in the
groin, superficial inguinal lymph nodes and
trunk of the saphenous vein and underneath
the fascia by the surrounding connective tissue, the adventitia of femoral vessels and the
deep inguinal lymph nodes.
After finishing the dissection it should be
displayed in the surgery field the femoral artery and
vein and the femoral nerve outside the artery, which
divides into its terminal branches just below the inguinal ligament (Figure 9).
Closure
The inguinal ligament can be fixed with one
or two stiches to Cooper's ligament, aiming to prevent and to to limit the occurrence of femoral hernias.
To complete reconstruction in 1948 Baronofsky proposed a technique which consisted in rotating the sartorius muscle above the femoral vessels.
For this purpose, the muscle should be isolated at
its insertion into the anterior superior iliac spine and
sectioned (Figure 10).The muscular body is released
taking care not to damage its the vascular pedicle
reaching the muscle in its middle portion.Onceprepared, the sartorius muscleit is rotated inwards and its
proximal end secured with resorbable stitches to the
Cierre
Se puede fijar el ligamento inguinal con uno
o dos puntos al ligamento de Cooper, a los efectos
de limitar la aparicin de hernias crurales en este sitio.
Para completar la reconstruccin, en 1948
Baronofsky propuso una tcnica que consiste en rotar el musculo sartorio encima de los vasos femorales. Para ello, se asla al msculo en su insercin en
la espina ilaca anterosuperior y se lo secciona (figura 10). El cuerpo muscular se libera tomando precaucin de no interrumpir el pedculo vascular que
llega al msculo en su tercio medio. Preparado as,
se rota al msculo sartorio hacia adentro y su extremo proximal se fija con puntos de sutura de material
Sartorius transection
Sartorio
Pag. 23
Tcnica Quirrgica /
Surgical Technique
Control postoperatorio
Postoperative Control
No retirar el drenaje antes de los 5 a 7 das
y nunca antes de que la secrecin sea menor a 50
60 ml diarios.
No indicar la deambulacin antes del tercer da postoperatorio para favorecer la creacin de
suficientes adherencias entre el plano drmico y el
muscular. Indicar medidas de trombo profilaxis, preferiblemente HBPM.
Utilizar vendaje elstico de la extremidad
operada durante el postoperatorio inmediato, as
como tambin cuando se inicia la deambulacin, con
el fin de reducir la incidencia de linfedema postoperatorio.
La antibioticoterapia slo es til en presencia de signos clnicos de infeccin, y en caso de ser
necesario utilizamos cefalosporinas de primera generacin.
Drainage removal should be done within 5
to 7 days and never before the discharge is less than
50-60 ml daily.
Deambulation should not be indicated before the third postoperative day to help create sufficient
adhesion between the dermal and muscular planes.
Thrombus prophylaxis measures, preferably LMWH
should be indicated.
In order to reduce the incidence of postoperative lymphedema it is recommended thte use
of an elastic bandage on the operated limb during
the immediate postoperative period, as well as when
walking is started.
Antibiotic therapy is only usefwhen clinical
signs of infection are present, and if necessary firstgeneration cephalosporins should be used.
Bibliografa
1.Groshong LE. A technique for radical groin dissection. Surg Gynecol Obstet. 1973; 136:986-90.
2.Veronesi U. 1991. Ciruga Oncologica. Tumores Cutneos. 1ra Edicin. Editorial Medica Panamericana. 779-784
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