Videoscopic Inguinal Lymphadenectomy for Metastatic Melanoma
Videoscopic Inguinal Lymphadenectomy for Metastatic Melanoma
The oncological application of endoscopic and laparoscopic techniques has expanded in the wake of the Clinical Outcomes of Surgical Therapy trial, which favorably compared laparoscopically assisted colectomy with open colectomy for colon cancer. Extending these techniques to complication-prone procedures represents a logical evolution toward reducing associated morbidities. This is especially true for procedures in which the majority of complications are related to the wound. Multiple studies have demonstrated a 50% or greater rate of wound-related complications following open inguinal lymphadenectomy for metastatic melanoma, including dehiscence, infection, seroma formation, and skin flap necrosis (Table). This high morbidity may be a potential explanation for the poor rate of compliance with complete lymphadenectomy in these patients.
In combination with our reported experience with VIL and the recently published work of Abbott et al, we have shown a reduction in woundrelated complications in patients undergoing VIL, equivalent or greater lymph node retrieval, and decreased length of hospital stay when compared with open lymphadenectomy. Despite the apparent advantages of VIL, barriers remain to its widespread implementation. Increases in operative time and the associated learning curve may make some surgeons reticent to adopt this approach. For many, lymph node retrieval may not be an adequate surrogate for oncological outcomes data that demonstrate equivalent or improved long-term regional control following VIL. A randomized controlled trial comparing open lymphadenectomy to VIL would be ideal and is ongoing (NCT01526486). However, despite our institutional study, many consider the application of an established technology (videoscopy or laparoscopy) to inguinal lymphadenectomy insufficient to warrant a randomized controlled trial that would deny patients access to this technique and incur significant trial-related costs.
Furthermore, a recent survey revealed that more than 30% of melanoma surgeons routinely perform ilioinguinal (superficial groin and deep pelvic) dissection for melanoma metastatic to the groin. This likely impacts surgical decision-making about the specific approach to a procedure. It is important to note that the decision to pursue pelvic lymphadenectomy need not preclude the use of VIL in which the superficial groin dissection can be videoscopically performed and the deep pelvic nodes removed via either an open approach or through a laparoscopic retroperitoneal approach. Moreover, we routinely perform deep pelvic lymphadenectomy in patients with bulky adenopathy in the groin. In the 4 patients who underwent groin dissection for bulky adenopathy in the groin, we performed open pelvic lymphadenectomy because our complication rate of the incision used for that procedure was low.
Discussion
The oncological application of endoscopic and laparoscopic techniques has expanded in the wake of the Clinical Outcomes of Surgical Therapy trial, which favorably compared laparoscopically assisted colectomy with open colectomy for colon cancer. Extending these techniques to complication-prone procedures represents a logical evolution toward reducing associated morbidities. This is especially true for procedures in which the majority of complications are related to the wound. Multiple studies have demonstrated a 50% or greater rate of wound-related complications following open inguinal lymphadenectomy for metastatic melanoma, including dehiscence, infection, seroma formation, and skin flap necrosis (Table). This high morbidity may be a potential explanation for the poor rate of compliance with complete lymphadenectomy in these patients.
In combination with our reported experience with VIL and the recently published work of Abbott et al, we have shown a reduction in woundrelated complications in patients undergoing VIL, equivalent or greater lymph node retrieval, and decreased length of hospital stay when compared with open lymphadenectomy. Despite the apparent advantages of VIL, barriers remain to its widespread implementation. Increases in operative time and the associated learning curve may make some surgeons reticent to adopt this approach. For many, lymph node retrieval may not be an adequate surrogate for oncological outcomes data that demonstrate equivalent or improved long-term regional control following VIL. A randomized controlled trial comparing open lymphadenectomy to VIL would be ideal and is ongoing (NCT01526486). However, despite our institutional study, many consider the application of an established technology (videoscopy or laparoscopy) to inguinal lymphadenectomy insufficient to warrant a randomized controlled trial that would deny patients access to this technique and incur significant trial-related costs.
Furthermore, a recent survey revealed that more than 30% of melanoma surgeons routinely perform ilioinguinal (superficial groin and deep pelvic) dissection for melanoma metastatic to the groin. This likely impacts surgical decision-making about the specific approach to a procedure. It is important to note that the decision to pursue pelvic lymphadenectomy need not preclude the use of VIL in which the superficial groin dissection can be videoscopically performed and the deep pelvic nodes removed via either an open approach or through a laparoscopic retroperitoneal approach. Moreover, we routinely perform deep pelvic lymphadenectomy in patients with bulky adenopathy in the groin. In the 4 patients who underwent groin dissection for bulky adenopathy in the groin, we performed open pelvic lymphadenectomy because our complication rate of the incision used for that procedure was low.