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DISSECTION
Dr.MANOJ KUMAR SISTU
INGUINAL ANATOMY
• FEMORAL TRIANGLE
Superior- inguinal ligament
Laterally- sartorius
Medially-adductor longus
CONTENTS-
femoral nerve
femoral artery
femoral nerve
deep inguinal lymphnode
INGUINAL LYMPHNODES
-Tis/Ta - T2-T3
-No vascular invasion -Vascular invasion
• AIM-
To define wheather metastasis exist with
minimal morbidity for the patient
• PATIENT SELECTION-
Patients with no evidence of palpable
lymphadenopathy(Node negative) but with
adverse prognostic factors with in the primary
tumour
….CONTD
• OPTIONS
-FINE NEEDLE ASPIRATION CYTOLOGY
- NODE BIOPSY
- SENTINEL LYMPHNODE BIOPSY
-EXTENDED SENTINEL LYMPHNODE BIOPSY
- DYNAMIC SENTINEL LYMPHNODE DISSECTION
-SUPERFICIAL DISSECTION
-MODIFIED COMPLETE DISSECTION
FINE NEEDLE ASPIRATION
CYTOLOGY(FNAC)
• FNAC in clinicaly negative inguinal nodes
guided by lymphangiography/usg
• It doesn’t exhibit sensitivity for it to be relied on
as a staging modality
FNAC SENSITIVITY
39% 93%
SENTINEL LYMPHNODE
BIOPSY(SLNB)
• Technique to remove nodes that are first
affected by the spread of metastatic disease
• First described by CABANA(1977)
IMPRESSION
excise lymphnode
EXTENDED SENTINEL LYMPHNODE BIOPSY
• AIM-
To define where the sentinel lymphnode reside in
the inguinal lymphnode group by using gamma
emission probe and visual dyes
• This technique studied in patients with
- malignant melanoma
-breast carcinoma
-vulval carcinoma
• It remains a diagnostic procedure allowing some
men to avoid a therapeutic inguino femoral
lymphnode dissection
• ROLE IN PENILE CARCINOMA-
• Patient position-
FROG LEG POSITION
• Incision-
10cm incision 1.5-2.0cm
below inguinal crease
• Flaps-
developed in the plane
just beneathe the scarpas
fascia
• Extent of flaps-
Superior-
8cms superiorly up to external oblique fascia
with exposure of spermatic cord
Inferior-
up to 6cms inferiorly
• Extent of dissection-
Medially- Adductor longus muscle
Laterally- Femoral Artery
• Structures to be preserved-
saphenous vein
DISSECTION PROCEDURE
contd…
Subcutaneous work space extended with
endoscope by sweeping with lens itself
or
12mm baloon port trocar used
(25mmHg pressure for 10 mins)
• Superiorly- Inguinal
ligament
• laterally- Sartorius
muscle
• Medially- Adductor
longus
DISSECTION PROCEDURE
With blunt dissection
the nodal tissue rolled
inwards on both sides
Continue dissection
inferiorly till apex
Positive Negative
Compressive elastic
girdle to provide
bilateral
compression of
groins
+
Elastic compression
stockings for
3months after
surgery
PALPABLE INGUINAL LYMPHADENOPATHY/
POSITIVE INGUINAL NODES
• RADICAL INGUINOFEMORAL
LYMPHNODE DISSECTION
• LANDMARKS-
Superiorly-
Line drawn from superior margin
of external ring to ASIS
Laterally-
Line from ASIS to 20cm inferiorly
Medially-
Pubic tubercle to 15cm down the
medial thigh
INCISIONS
PROCEDURE
• Oblique incision (most common)