Inguinofemoral, Iliac/Obturator,

and Popliteal Lymphadenectomy

for Melanoma

Keith A. Delman, Lesly A. Dossett, Clara R. Farley,

Kelly M. McMasters, and Omgo E. Nieweg

Contents
Inguinofemoral Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Modifications of the Classic Technique of Inguinofemoral Lymphadenectomy . . . . . . . . 8
Iliac/Obtuartor (Deep Pelvic) Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Modifications of the Classic Technique of Iliac/Obturator Lymphadenectomy . . . . . . . . . 14
Robotic-Assisted Transperitoneal Pelvic Lymphadenectomy . . . . . . . . . . . . . . . . . . . . . . . . 14
Postoperative Complications: Incidence and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Complications of Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Management of Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

K. A. Delman (*) · C. R. Farley

Division of Surgical Oncology, Department of Surgery,
Emory University School of Medicine, Atlanta, GA, USA
e-mail: kdelman@emory.edu; Crfarle@emory.edu
L. A. Dossett
Division of Surgical Oncology, Department of Surgery,
University of Michigan, Ann Arbor, MI, USA
e-mail: ldossett@umich.edu
K. M. McMasters
Department of Surgery, University of Louisville School of
Medicine, Louisville, KY, USA
e-mail: kelly.mcmasters@louisville.edu
O. E. Nieweg
Melanoma Institute Australia, Department of Surgery, The
University of Sydney Central Clinical School, Royal
Prince Alfred Hospital, Department of Melanoma and
Surgical Oncology, Sydney, NSW, Australia
e-mail: omgo.nieweg@melanoma.org.au

# Springer Nature Switzerland AG 2019 1

C. Balch et al. (eds.), Cutaneous Melanoma,
https://doi.org/10.1007/978-3-319-46029-1_22-1
2 K. A. Delman et al.

Popliteal Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Abstract sentinel lymph node (SLN) to either immediate

The indications for regional lymph node dis-
section for melanoma patients with micro-
scopic disease are evolving; however, patients
with clinically evident nodal metastases iden-
tified radiographically or by physical examina-
tion are advised to undergo lymph node
dissection. As the understanding and use of
immunotherapeutic and targeted therapies
expand, the clinical indications for lymph
node dissection will continue to evolve.
These procedures provide enhanced staging
information and may provide regional disease
control. Additionally, due to high rates of mor-
bidity associated with lymph node dissection
in the groin, minimally invasive techniques for
inguinofemoral and iliac/obturator lymph node
dissections have emerged; these have proven
to be safe and effective modifications to the
classic, open approach. An overview of the
anatomic and technical considerations of
inguinofemoral, iliac/obturator, and popliteal
lymph node dissection is described.
The indications for regional lymph node dissec-
tion for melanoma are evolving. Until recently,
both clinical (detected by radiographic imaging
or physical examination) and microscopic
(detected via sentinel node biopsy) nodal metas-
tases were considered indications for a completion
lymph node dissection. While patients with clini-
cal nodal metastases should still undergo thera-
peutic lymph node dissection, two trials have
transformed the approach to patients with disease
identified by sentinel lymph node biopsy (SLNB).
The German Dermatologic Cooperative Oncol-
ogy Group Trial (Leiter et al. 2016) and the Mul-
ticenter Selective Lymphadenectomy Trial (Faries
et al. 2017) randomized patients with a positive
completion lymphadenectomy (CLND) or obser-
vation with ultrasound surveillance. Both trials
demonstrated no difference in melanoma-specific
survival for patients undergoing immediate
CLND versus observation, despite enhanced
regional disease control in the immediate CLND
group. Based on the results of these two trials and
in the era of effective systemic therapy, immediate
completion lymph node dissection for micro-
scopic disease is no longer considered uniformly
indicated; however, these procedures can provide
enhanced staging information and regional dis-
ease control. The decision to perform CLND
should be made on a patient-to-patient basis.
Two contiguous node-bearing basins comprise
the draining lymph nodes of the lower trunk and
lower extremity. The first nodal basin contains the
inguinal/femoral nodes located over the lower
abdominal wall and within the femoral triangle.
The second nodal basin contains the iliac and
obturator lymph nodes. An inguinofemoral
lymph node dissection (sometimes referred to as
a superficial inguinal lymph node dissection or
“groin” dissection) involves removal of the node-
bearing tissue located over the lower external
oblique, the inguinal ligament, and all nodes
within the femoral triangle. The iliac/obturator
dissection (sometimes referred to as a “deep” or
“pelvic” lymph node dissection) refers to removal
of the node-bearing tissue adjacent to the internal
and external iliac vessels superficial to the obtu-
rator nerve. For most surgeons, the common iliac
nodal basin is not considered a routine part of
iliac/obturator lymph node dissection as involve-
ment of these nodes is typically thought to repre-
sent stage IV disease. Historically, many surgeons
performed an inguino-pelvic (superficial and deep
or “radical”) lymphadenectomy combining femo-
ral, iliac, and obturator lymph node removal in
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma
one procedure, even in the setting of sentinel node
disease only; however, the routine inclusion of the
iliac and obturator nodes when performing sur-
gery for microscopic disease has almost uniformly
been abandoned. Most patients are now only con-
sidered for iliac/obturator lymphadenectomy if
there is evidence of nodal involvement by imag-
ing studies or when there is a high suspicion of
concurrent disease in the iliac/obturator basin
based on the clinical features of the femoral
nodal metastases.
Popliteal lymph node involvement is exceed-
ingly uncommon in patients with melanoma, even
in those who have primary tumors of the posterior
foot and heel (Thompson et al. 2000). In one study
examining 4262 patients seen at the Sydney Mel-
anoma Unit during a 30-year period, the incidence
of clinical involvement of popliteal nodes was
determined to be 0.3% (Thompson et al. 2000).
Because popliteal lymph node involvement and
dissection are rare, the surgeon must strive to
maintain a familiarity with the surgical anatomy
and technique required to perform popliteal
lymph node dissection.
Inguinofemoral Dissection
Indications
While the indications for regional lymph node
dissection are evolving, clinically detected
inguinofemoral nodal metastases remain an indi-
cation for inguinofemoral dissection. Selected
patients with microscopic disease may also be
considered, based on shared decision-making.
Once inguinofemoral nodal metastases have
been documented, a staging workup should be
performed to rule out metastatic disease in the
iliac nodal basin or at distant sites. The workup
should include a CT scan of the chest, abdomen,
and pelvis or whole-body positron emission
tomography (PET) combined with CT scan
(PET/CT) as well as a MRI of the brain to assess
for stage IV disease. Additionally, a serum lactate
dehydrogenase (LDH) level should be obtained at
time of diagnosis. If the staging workup identifies
the presence of distant metastatic disease, most
3
patients should not undergo lymph node dissec-
tion except for palliative purposes. If a patient
with distant disease is asymptomatic or a low
volume of nodal disease is present, the
lymphadenectomy may be delayed or abandoned
in lieu of systemic therapy.
Technique
Anesthesia and Position. A standard
inguinofemoral dissection can be performed
under epidural, spinal, or general anesthesia.
When general anesthesia is used, muscle paralysis
is avoided to help the surgeon identify and pre-
serve motor branches of the femoral nerve during
the dissection, though most experienced surgeons
should be familiar with the location of this nerve,
and thus paralysis may be considered. When the
primary lesion is intact and located on the lower
abdomen or back, general anesthesia is required.
The patient is placed in the supine position on
the operating table, and ideally the hip is exter-
nally rotated and the knee slightly flexed. Many
patients may not have the flexibility to achieve
this optimal positioning in which case the surgeon
must be aware of the way in which the
neurovascular anatomy is altered by changes in
positioning. Care is taken to protect all pressure
points, especially the heel, which is subjected to
increased pressure in this position. A urinary cath-
eter may be used, and, if used, it is nearly always
removed before or on the first postoperative day.
If iliac/obturator lymphadenectomy is to be
performed concurrently, a urinary catheter must
be placed to decompress the bladder and avoid its
intrusion into the surgical field. Sequential com-
pression devices are applied to both calves unless
the primary melanoma precludes their use. The
patient is prepped and draped widely to include
the ipsilateral abdomen, genitalia, and medial and
lateral thigh.
Incision. The traditional inguinofemoral dis-
section involves a longitudinal “lazy-S” incision,
beginning superior and medial to the anterior
superior iliac spine (ASIS) and running parallel
within the groin crease (Fig. 1a). The incision then
extends down to the apex of the femoral triangle.
4 K. A. Delman et al.
Fig. 1 Variations to the length and position of the incision used for open inguinofemoral lymphadenectomy. (From Keith
A. Delman, Atlanta, GA; with permission)
The incision should include excision of any exci-
sional or sentinel node biopsy scars, and, as such,
biopsy incisions should be made with a possible
future complete dissection in mind. Because of the
potential wound complications of this incision,
there are many alternatives to the lazy-S incision,
including shorter vertical incisions that cross the
groin crease at right angles and incisions oriented
along lines of skin tension above or below the
groin crease. These latter incisions may heal bet-
ter, because the wound edges are not subject to the
motion of hip flexion. Ilioinguinal lymph node
dissection, including the nodes 5 cm superior
to the inguinal ligament, can almost always be
accomplished through a 6–8 cm transverse inci-
sion parallel to the groin crease, which is preferred
by some. If an open iliac/obturator dissection is
performed concomitantly, a separate incision
above the inguinal ligament may be performed.
If necessary to achieve negative margins, particu-
larly when skin involvement is suspected or
clinically obvious, an ellipse of the skin should
be left en bloc with the lymphadenectomy
specimen.
Flap Formation. After the incision is made,
medial and lateral skin flaps are raised using either
scalpel dissection or electrocautery. Caution
should be exercised if using electrocautery to
minimize thermal injury to the skin flaps. Flaps
are raised at the junction of the subcutaneous
tissue and Scarpa’s fascia, with particular care
being taken to remain in this plane as the dissec-
tion progresses. While the order of creating the
flaps is surgeon-specific, the approach to them
will largely be uniform. The superior flap is
extended onto the external oblique musculature
5–6 cm above the inguinal ligament. The lymph
node-bearing tissue on the external oblique apo-
neurosis is swept down into the femoral triangle
proper.
The medial flap is developed with extension to
the medial aspect of the adductor longus and using
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma
its tendinous insertion as a medial marker at the
pubic tubercle (just medial to the femoral canal).
As the dissection proceeds inferiorly, the tissue
overlying the fascia of the adductor longus muscle
is mobilized to the apex of the femoral triangle
where it meets the sartorius muscle. Some sur-
geons choose to mobilize the adductor fascia,
but this is not routinely necessary. In some
approaches (such as in the context of the mini-
mally invasive lymphadenectomy), mobilizing
the fascia aids the dissection and may be routinely
performed. At the inferior aspect of the medial
flap, the saphenous vein is visualized and can be
ligated and divided. Many surgeons prefer to pre-
serve the saphenous vein as some studies have
implied a reduction in morbidity with this
approach (Ozturk et al. 2014; Abbas and Seitz
2011).
The lateral flap is created in the same plane,
extending to the lateral border of the sartorius
muscle up to the level of the anterior superior
iliac spine (ASIS). The surgeon should take care
to preserve the lateral femoral cutaneous nerve,
which exits just inferior to the ASIS. Several
cutaneous branches of the femoral nerve may
also be encountered crossing distally over the
muscle and at the apex of the femoral triangle,
which marks the inferior extent of the lateral
flap as well. For most surgeons, the fascia of
the sartorius muscle (unlike the adductor) is rou-
tinely incised, as a muscle transposition may be
included as the final aspect of an open inguinal
lymphadenectomy. A common mistake among
inexperienced surgeons is to raise flaps medially
and laterally further than necessary; the flaps
should be raised only to the adductor longus medi-
ally and the sartorius laterally.
Soft Tissue Dissection. Importantly, the tech-
nical approach to this dissection is variable,
but the key elements are the identification and
removal of the appropriate tissue. To begin, the
fibrofatty node-bearing tissue located 5–6 cm
superior to the inguinal ligament is dissected off
the external oblique aponeurosis to a point just
below the inguinal ligament. Next, the specimen
is dissected off the sartorius muscle in a subfascial
plane, working toward the femoral nerve. The
fascia is again incised as the medial border of the
5
sartorius muscle is reached. The main trunk of
the femoral nerve should be identified at this
point, because it emerges below the inguinal lig-
ament and is located deep to the fascia iliaca.
Beginning inferiorly, the artery is skeletonized
beneath the adventitia. The anterior half of the
femoral artery is then skeletonized. Branches
coursing anteriorly are divided and ligated. The
sheath overlying the femoral artery is incised
along its entire length from the apex of the femoral
triangle inferiorly to the inguinal ligament superi-
orly. Importantly, as the upper aspect of the arte-
rial dissection is completed and the surgeon
approaches the level of the saphenofemoral
junction, a branch of the common femoral artery
is routinely present and should be expected by
the surgeon. Division of this vessel is safe and
facilitates the ongoing soft tissue dissection. The
lateral aspect of the femoral vein sheath is
also incised during the arterial dissection. By
dissecting superiorly along the femoral artery,
the surgeon stays in a plane that avoids injury to
the adjacent femoral nerve and its branches.
The medial soft tissue dissection is then
performed in a subfascial plane over the adductor
longus and pectineus muscles (Fig. 2). The over-
lying fascia must again be incised adjacent to the
femoral vein. At this point the specimen is dis-
sected off the femoral vein in a subadventitial
plane, working from the inferior-most aspect of
this vein upward toward the inguinal ligament. As
the saphenofemoral junction is approached, care
must be taken to dissect off investing connective
tissue around the proximal saphenous vein at the
fossa ovalis. If not already done, a clamp is placed
across the saphenous vein, leaving enough dis-
tance for the stump to be ligated without imping-
ing on the lumen of the femoral vein. The
saphenous vein is then transected and the stump
doubly ligated. Alternatively, the surgeon may
choose to preserve the saphenous vein and dissect
around it (as noted above).
From here, the only remaining attachments
should be the soft tissue superior and medial to
the proximal femoral vein (the tissue entering the
femoral canal). At this point in the operation, the
surgeon must decide whether or not to biopsy
Cloquet’s node. If a biopsy is intended, the
6 K. A. Delman et al.

Fig. 2 Medial dissection of

the fatty and lymphatic
tissue overlying the femoral
triangle. This has been
excised off the adductor
longus muscle until the
femoral vein is exposed.
The dissection then
proceeds superiorly along
the femoral vein. The
saphenous vein is
transected at the confluence
of the femoral vein.
Dissection then continues
beneath the inguinal
ligament to remove
Cloquet’s node. (From
Keith A. Delman, Atlanta,
GA; with permission)

dissection then continues superiorly beneath the
inguinal ligament in order to incise the lacunar
ligament. There is considerable variability in how
Cloquet’s node is defined, but traditionally the
node can be found slightly posterior and medial
to the external iliac vein (Fig. 3) as the first node in
the pelvis. After the node is identified, a hemostat
can be clamped across the fatty tissue just above
the node. Cloquet’s node is generally submitted
for frozen section analysis, whereas the main
specimen is marked for orientation and sent for
routine pathologic examination.
Transposition of the Sartorius Muscle. At
this point the surgeon may transpose the sartorius
muscle to cover the femoral vessels. This provides
well-vascularized muscle tissue to protect the
femoral vessels in case wound breakdown occurs.
The upper part of the sartorius muscle is dissected
from its surrounding connective tissue and is freed
from its origin on the ASIS (Fig. 4). It is then
divided sharply through the fascia at its origin,
preserving the fascia, which will provide strength
to hold sutures more securely to the inguinal lig-
ament when transposed. The lateral edge of the
sartorius muscle is dissected free with the medial
edge left intact to provide blood supply to the
muscle flap. The blood supply to this muscle
arises from its medial aspect and is segmental,
allowing preservation with this approach. The
muscle flap is then rotated from lateral to medial,
with the transected end of the sartorius muscle
brought underneath the lateral femoral cutaneous
nerve and vessels without damaging them.
The sartorius muscle is held upward, while
the dissection proceeds inferiorly, sacrificing the
upper branches of the vessels and nerves. The
muscle should be appropriately mobilized to
allow transposition over the femoral vessels with-
out undue tension and to avoid devascularization.
Additionally, because the blood supply is segmen-
tal, the muscle should not be dissected more than
halfway into the femoral triangle inferiorly. Any
tenting of the muscle should be avoided as this
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 7

Fig. 3 Location of
Cloquet’s node (inset) and
superficial inguinal lymph
nodes resected en bloc off
the underlying femoral
vessels. The saphenous vein
has been ligated at the level
of the saphenofemoral
junction. (From Keith
A. Delman, Atlanta, GA;
with permission)

will create dead space, thereby negating any
advantage that may be gained by its transposition.
The stump of the sartorius muscle is then
sutured to the external oblique aponeurosis with
horizontal mattress sutures (Fig. 5). The muscle is
also loosely approximated to the adductor longus
muscle medially and the quadriceps fascia later-
ally with interrupted sutures. Surgeons may also
perform a modification of a Cooper’s ligament
closure of the femoral triangle, especially if a
biopsy of Cloquet’s node is performed in order
to reduce the possibility of a femoral hernia.
Closure of the Incision. After appropriate
assessment and sharp debridement of any non-
viable flap edges, the wound is closed over at
least one closed suction drain (some surgeons
routinely use two) brought out through an inferior
or superior stab wound and sutured to the skin.
The wound is closed in layers with interrupted
absorbable sutures placed to close Scarpa’s fascia.
The skin may be closed with skin staples or with a
subcuticular suture. The dressing applied to the
wound and drainage site is occlusive.
Postoperative Care. Patients are generally
kept on bed rest overnight, particularly in the
setting of a muscle transposition, but are then
encouraged to resume ambulation the following
day. Most patients are discharged on the first
postoperative morning if they have appropriate
assistance at home. Drains are kept in place until
8 K. A. Delman et al.

Fig. 4 Right view of the

incision. Transection of the
Sartorius muscle at its
origin on the anterior
superior iliac spine. It is
important to incise the
muscle directly off the bone
to preserve the fascial end,
which holds sutures better.
The muscle is then
dissected free of
surrounding tissue and
transposed over the femoral
vessels and nerves. (From
Keith A. Delman, Atlanta,
GA; with permission)

the 24-h output is less than 30–50 mL. This may
take 2–3 weeks or longer. However, some sur-
geons will elect to remove the drain at or prior to
the 3-week mark even if this target is not met.
A 20–30-mmHg pressure gradient, thigh-high
compression stocking may be prescribed and
fitted preoperatively so that it will be available
for the patient to wear postoperatively as soon as
the drain is removed.
Modifications of the Classic Technique
of Inguinofemoral Lymphadenectomy
The preceding section describes the classic tech-
nique of inguinofemoral lymphadenectomy. In an
effort to minimize short- and long-term morbidity
associated with the procedure, several modifica-
tions have been proposed, including (as noted)
preservation of the adductor magnus and sartorius
fascia, preservation of the saphenous vein, and
modifications to the length and position of the
incision (Fig. 1). Additionally, a minimally inva-
sive approach, referred to as videoscopic inguinal
lymphadenectomy, has emerged as a promising
alternative to traditional open surgery with
comparable oncological control and reduced mor-
bidity (Postlewait et al. 2017; Delman et al. 2010,
2011; Martin et al. 2013).
Videoscopic Inguinal Lymphadenectomy.
Before beginning the procedure, the patient is
placed in the supine position on a split leg table
with the legs externally rotated and abducted.
The boundaries of the femoral triangle are
mapped out and marked with a surgical pen. The
patient is widely prepped to include the supra-
pubic region to monitor for crepitus. The surgeon
is positioned between the patient’s legs and the
assistant stands to the outside of the operative
limb (Fig. 6). To begin, an incision is made
approximately 3 cm inferior to the apex of the
femoral triangle and carried down to Scarpa’s
fascia. Using blunt dissection, a space is devel-
oped on either side of the incision to allow
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 9

Fig. 5 Completed inguinal

node dissection showing the
transposed Sartorius
muscles in place. It is
sutured to the external
oblique aponeurosis with
interrupted nonabsorbable
horizontal mattress sutures.
Suction catheters are then
placed in the lateral and
medial aspects of the wound
and the incision is closed.
(From Keith A. Delman,
Atlanta, GA; with
permission)

Fig. 6 Surgeon and patient

positioning for video-
assisted lymphadenectomy.
(From Keith A. Delman,
Atlanta, GA; with
permission)
10
Fig. 7 The anterior
working space is created
using blunt dissection.
(From Keith A. Delman,
Atlanta, GA; with
permission)
insertion of two 10-mm trocars (Fig. 7). A 12-mm
trocar is then placed in the original incision site,
and the surgical site is insufflated to 15 mm
Hg. Dissection is carried 5 cm above the inguinal
ligament along the abdominal wall with an endo-
scopic dissecting stick and ultrasonic shears. The
medial and lateral boundaries of the dissection
should consist of the adductor longus and
sartorius muscle fascia.
Once the working space is created, the node-
bearing tissue may be rolled inward on both sides
using an endoscopic sponge or Kittner, continuing
superiorly and inferiorly as much as possible to
define the posterior wall of the nodal packet. The
saphenous vein should be identifiable within the
apex of the femoral triangle and can be ligated
using an endoscopic linear stapler. The femoral
artery and vein are then identified, and the over-
lying nodal packet is dissected from an inferior to
superior direction as both vessels are skeleton-
ized. Once the vascular dissection is complete,
the saphenofemoral junction is exposed, and
the saphenous vein is then transected at this
level using an endoscopic linear cutting stapler.
Inferomedial dissection is continued along the
femoral vein to enable resection of the deep ingui-
nal nodes. Dissection should continue to the
level of femoral canal to ensure complete nodal
retrieval. Assessment for and possible biopsy of
Cloquet’s node can be performed at this step. The
K. A. Delman et al.
Anterior working space
(avascular layer)
created superficial to
the Scarpa fascia
Dermis (cutis)
Hypodermis/Superficial
fascia of the thigh
Fascia lata
Muscle
nodal packet is then dissected free from its ingui-
nal ligament attachments by inferior retraction or
using an ultrasonic dissecting scalpel (Fig. 8). The
specimen is then withdrawn in an endoscopic
retrieval bag. To conclude, the wound is irrigated,
the ports are removed, and a drain is placed
through the lateral port site.
The patient is encouraged to ambulate on the
day of surgery, and discharge is routinely planned
for the same day. The fluted drain remains in place
until output is less than 30–50 mL per day.
Iliac/Obtuartor (Deep Pelvic) Lymph
Node Dissection
Benefits
Patients with iliac/obturator nodal metastases
should not be dismissed as having incurable or
disseminated disease as the presence of iliac/obtu-
rator nodal metastases still represents a potentially
curable circumstance. Several reports demon-
strate 5-year survival rates for patients with iliac/
obturator nodal metastases ranging from 24%
to 43%, rates that are comparable to patients
with a similar burden of inguinal nodal metastases
(Badgwell et al. 2007; Strobbe et al. 1999;
Mann and Coit 1999). In a 2007 study from MD
Anderson, 97 patients underwent a combined
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma
Fig. 8 The inguinal lymph
node packet is mobilized
and dissected free from its
inguinal ligament
attachments. (From Keith Inguinal
A. Delman, Atlanta, GA; ligament
with permission)
LATERAL
Sartorious m.
inguinofemoral and iliac/obturator node dissec-
tion. In 54 patients with positive iliac/obturator
nodes, 5-year overall survival was 42%, and over-
all survival of patients with three or fewer tumor-
positive iliac/obturator nodes was comparable to
patients with negative iliac/obturator nodes
(Badgwell et al. 2007). These data support the
classification of iliac/obturator disease as stage
III rather than stage IV disease. It is also important
to note that this data was prior to the use of
targeted and immunotherapy, making it likely
that overall survival would be further improved
today. It is incumbent on the multidisciplinary
team to identify patients for whom an iliac/obtu-
rator lymphadenectomy might be of benefit. As
our understanding and use of immunotherapeutic
and targeted therapies expand, it is expected that
the clinical indications for iliac/obturator nodal
dissection will further evolve.
11
Nodal packet held up
to transect last
remaining attachments
Artery Vein
MEDIAL
Pectineus muscle
visible below posterior
femoral sheath
Femoral Sheath
Adductor longus m.
Indications
While the indication for iliac/obturator lymph
node dissection in the setting of biopsy-proven
disease and no distant disease is clear, the role of
iliac/obturator lymph node dissection in other
clinical scenarios is controversial. In the setting
of clinically palpable inguinal disease, the
estimated prevalence of positive iliac/obturator
nodes is 30%, suggesting that the majority of
patients would not benefit from routine combined
inguinofemoral and iliac/obturator dissection. In
an effort to determine which patients may benefit
from iliac/obturator dissection, studies have
explored the risk factors for pelvic nodal disease
and have resulted in several relative indications
for iliac/obturator node dissection. Based on these
data, relative indications include (Oude Ophuis
et al. 2015):
• Radiographic suspicion of pelvic disease, typ-
ically either by CT or PET/CT (Fig. 9)
• Involvement of three or more inguinal nodes
12
Fig. 9 Melanoma patient
with clinically positive
iliac/obturator node on PET
scan (large arrow). (From
Lesly A. Dossett, Ann
Arbor, Michigan; with
permission)
• Extracapsular tumor extension of inguinal
nodes
Historically, a large (>3 cm) positive
inguinofemoral node or a positive Cloquet’s
node has been considered relative indications for
iliac/obturator lymph node dissection, but limited
data exist to support these factors as accurate pre-
dictors of pelvic nodal disease. Additionally,
patients meeting these criteria generally already
have an indication for iliac/obturator dissection
based on the criteria above.
The majority of the data on Cloquet’s node as a
predictor of pelvic nodal disease was in the era
prior to SLNB. In the absence of SLNB, the
sensitivity and specificity of Cloquet’s node in
predicting pelvic disease are highly variable. In a
series from the Netherlands Cancer Institute,
Cloquet’s node and the number of positive nodes
were evaluated as possible factors to predict pos-
itive deep nodes. The sensitivity and negative
predictive value of a positive Cloquet’s node
were 55% and 78%, respectively. Use of more
than three positive nodes in the inguinofemoral
dissection as a predictor revealed a sensitivity of
41% and a negative predictive value of 78%.
Combining the two variables resulted in a sensi-
tivity of 56% and a negative predictive value of
82% (Strobbe et al. 2001). The authors concluded
that the sensitivity of Cloquet’s node is too low to
recommend routine sampling as a predictor of
iliac/obturator nodal involvement. In contrast,
K. A. Delman et al.
investigators at the John Wayne Cancer Institute
have concluded that it is possible to predict
positive iliac/obturator nodes by assessment of
Cloquet’s node (Shen et al. 2000; Essner et al.
2006). With routine histology of Cloquet’s node,
the investigators were able to achieve a sensitivity
of 82%, a positive predictive value of 70%, and a
negative predictive value of 84%. They concluded
that Cloquet’s node assumes the role of a SLN for
the iliac/obturator nodes in patients with positive
inguinofemoral nodes (Shen et al. 2000; Essner
et al. 2006). Routine biopsy of Cloquet’s node in
SLNB patients is of low value and not
recommended(Chu et al. 2010).
Although likely of limited value in the current
era, in the setting of microscopic inguinofemoral
disease, there are two generally accepted indica-
tions for iliac/obturator node dissection: (1) a pos-
itive iliac/obturator SLN and (2) an iliac/obturator
SLN identified on preoperative lymphoscin-
tigraphy, but not sampled/removed, in the setting
of a positive inguinofemoral SLN. Of note, in one
study assessing the true frequency of synchronous
iliac/obturator nodal metastases with microscopic
inguinofemoral disease, the authors found the
prevalence of synchronous disease to be 11.9%.
Patients with iliac/obturator disease were more
likely to have a ratio of total positive inguinal
nodes to total retrieved inguinal nodes greater
than 0.20 or 3 total involved inguinal nodes
(Chu et al. 2011). Iliac/obturator dissection is
also performed in patients who have recurrent
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma
melanoma of the extremity and are offered limb
perfusion after they have already undergone an
inguinofemoral lymphadenectomy.
Operative Technique
Skin Incision. Usually an iliac/obturator
dissection is performed simultaneously with an
inguinofemoral dissection, as described earlier.
Under these circumstances, the incision can be
made by extending the inguinofemoral incision
cephalad, raising the superior flap to reveal
the lower abdominal musculature. When using a
transverse infrainguinal incision for inguinofemoral
dissection, a separate incision may be performed
for the iliac/obturator dissection in a similar fash-
ion to the retroperitoneal incision used for kidney
transplantation. Another alternative is a lower
midline incision from the umbilicus to the pubic
symphysis to access the iliac/obturator nodes via
an extraperitoneal approach.
Abdominal Wall Incision. Access to the iliac
fossa is gained via a transverse incision through
the external oblique aponeurosis approximately
5–6 cm above the inguinal ligament (i.e., above
the inguinal canal). The internal oblique and
the transversus abdominis muscle are then split
in the direction of their fibers. The incision is
continued to include the lateral sheath of the rec-
tus abdominis muscle. The deep circumflex artery
and vein are identified and ligated where they lie
between the internal oblique and transversus
abdominis muscles.
The preperitoneum is entered and freed from
the abdominal wall in the distal direction. As the
retroperitoneum is entered, the peritoneum is
bluntly lifted up out of the iliac fossa, and the
inferior epigastric vessels are identified, passing
upward and medially from the point where the
femoral arterial pulsations can be felt. Once
encountered, the retroperitoneal space is devel-
oped by bluntly dissecting and retracting the
peritoneum in a superior and medial direction.
A self-retaining retractor can be used to hold the
peritoneal contents off the pelvic brim. The infe-
rior epigastric vessels are identified as they come
off the distal aspect of the external iliac vessels,
13
and they are frequently ligated and divided at their
origin. The vas deferens will be seen at this stage
and should be preserved, as should the testicular
vessels that lift off the iliac fossa with the perito-
neum. The round ligament can be sacrificed in
women.
The use of an in-continuity dissection,
described by Karakousis and Driscoll(Karakousis
and Driscoll 1994), provides for an en bloc resec-
tion and can offer superior exposure, especially to
the most distal external iliac nodes. This approach
involves the division of the external oblique apo-
neurosis in a nearly vertical fashion approxi-
mately 4 cm medial to the ASIS. Inferiorly, the
inguinal ligament is divided just medial to the
femoral artery. This line of dissection courses
through the internal oblique and transversalis fas-
cia and allows for a more straightforward fascia-
to-fascia closure compared with performing the
incision precisely at the ASIS. Division of the
inguinal ligament is associated with remarkable
morbidity, particularly postoperative pain, and
should not be undertaken lightly. The utility
of an en bloc resection is questionable, but, if
strongly desired as an alternative to the division
of the inguinal ligament, some surgeons favor a
separate obliquely oriented incision in the groin
crease. This allows for the inguinal ligament to be
left intact, which may lower the incidence of
postoperative abdominal wall weakness or hernia
formation.
Iliac/Obturator Node Dissection. Dissection
around the external iliac vessels is usually
performed with sharp instruments up to the level
of the ureter, crossing the bifurcation of the com-
mon iliac artery, or higher if clinically detectable
nodes are involved along the iliac vessels. Though
as noted, common iliac nodes are generally con-
sidered stage IV disease. The ureter is identified
and preserved as it courses over the iliac artery.
The lymphatic contents are dissected medially off
the bladder wall and superiorly off the posterior
rectus sheath.
Beginning at the inguinal ligament inferiorly,
the lymph nodes are dissected off the artery and
vein, working within the vessel sheath. Small
vessels and lymphatics at the perimeter of the
excision should be ligated, cauterized, or clipped
14
to avoid hemorrhage or lymphoceles. The dissec-
tion then continues superiorly up to the common
iliac vessels.
The deeper portion of the dissection is made
possible by reflecting the peritoneum medially
with a broad self-retaining retractor and then
working downward, using fingers or sponge sticks
as blunt dissectors. The advantage of this method
is that the obturator nerve, which is very close to
the major lymph nodes, can be felt as a taut cord
that moves away from the sidewall of the pelvis. If
this part of the dissection is performed with a
sharp instrument, there is some risk of damaging
the nerve. The medial dissection (to remove the
iliac nodes) and deep dissection (to remove the
obturator nodes) are completed when the obtura-
tor nerve is identified and preserved as it courses
from the lateral aspect of the internal iliac artery
toward the obturator foramen. The obturator
nodes are carefully resected from this area, and
the specimen is removed. Interestingly, most sur-
geons dissect the deep aspect of this procedure
along the obturator nerve using digital dissection,
as a finger will prevent significant damage and is
sensitive enough to alert the surgeon to structures
that should be avoided.
As the specimen containing the lymph nodes is
lifted upward in one unit with the external iliac
nodes, abdominal packs are placed firmly in the
pelvis and left until the operation is complete, by
which time minor venous bleeding will have
stopped. After the wound is irrigated and meticu-
lous hemostasis is achieved, the transversalis and
internal oblique muscles are approximated with
nonabsorbable sutures, and the external oblique
aponeurosis is then approximated with non-
absorbable sutures. To obliterate the enlarged
femoral canal defect, the inguinal ligament is
approximated to the lacunar ligament with a
figure-of-eight suture of nonabsorbable material
(unless this has been closed as previously
described during the inguinal part of a combined
procedure). A closed suction drain may be placed
in the retroperitoneal space through a separate stab
wound, although this is optional. Skin closure is
accomplished and the dressings applied in the
manner described for inguinofemoral dissection.
K. A. Delman et al.
Postoperative Care. Patients are kept on bed
rest with the operated extremity elevated over-
night. If placed intraoperatively, the urinary cath-
eter is removed on the first postoperative morning,
and the patient is allowed to ambulate with assis-
tance as needed. Most patients are discharged on
the first postoperative morning, similar to those
undergoing inguinofemoral dissection. Patients
are instructed to keep the operated extremity ele-
vated when they are not ambulating. Drains in the
pelvis should be removed when draining less than
30 mL per day for two consecutive days.
Modifications of the Classic Technique
of Iliac/Obturator Lymphadenectomy
As with inguinofemoral lymphadenectomy,
a minimally invasive technique, referred to
as the robotic-assisted transperitoneal pelvic
lymphadenectomy (rPLD), has emerged as a
safe and effective technique for iliac/obturator
lymphadenectomy. The advantages of minimally
invasive rPLD are well-described in the literature
where it is routinely used for staging and treat-
ment of urologic and gynecologic malignancies.
rPLD has been shown to improve visualization of
the iliac and obturator nodes and provide equiva-
lent nodal yield and shorter length of stay when
compared to the classic technique of iliac/obtura-
tor lymphadenectomy (Dossett et al. 2016).
Robotic-Assisted Transperitoneal
Pelvic Lymphadenectomy
When utilizing the minimally invasive approach,
preparation for conversion to open and for
inguinofemoral dissection if being performed in
a combined procedure should be made as
described above. The patient is placed in steep
Trendelenburg position, and the robot is docked
between the legs of the patient. A 12-mm midline
port is typically placed 18–20 cm above the pubic
symphysis. Two 8-mm robotic ports are placed
laterally on the contralateral side of the abdomen
from the site of pelvic dissection, at least 14 cm
from the pubic symphysis, and at least 6 cm away
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma
Fig. 10 Port placement for a left robotic assisted trans-
peritoneal pelvic lymphadenectomy. There are three 8 mm
robotic ports seen at the lateral aspects of the abdomen, a
12 mm camera port in the center of the abdomen and a
12 mm assistant port in the left abdomen. (From Dossett
et al. 2016)
from other ports. A 12-mm assistant port is placed
in the midclavicular line on the affected side of the
abdomen. A third 8-mm robotic port is placed on
the affected side of the abdomen at least 8 cm
lateral to the assistant port and at least 2 cm medial
to the anterior superior iliac spine (Fig. 10).
In the retroperitoneum, the psoas muscle, ure-
ter, and common iliac bifurcation are identified.
The lymph node packet overlying and between
the external iliac artery and vein is dissected from
underneath the inguinal ligament to the iliac bifur-
cation or higher if indicated. After removal of the
iliac nodal packet, resection of the obturator
lymph nodes is performed. The iliac vein is
retracted laterally, and the obturator nodes are
carefully dissected free of their attachments, iden-
tifying and preserving the obturator vessels and
nerve. Each lymph node packet is placed in an
endoscopic retrieval bag and removed through the
midline port. For cases where rPLD is combined
with a superficial inguinal lymphadenectomy, the
rPLD precedes the inguinal lymphadenectomy to
avoid leakage of CO2 out of the operative field.
Of note, it is possible to achieve similar out-
comes with a strictly laparoscopic approach
15
without the costs associated with robotic technol-
ogy. The robotic approach, however, has the
advantage of three-dimensional visualization;
ergonomic, intuitive control; and wristed instru-
ments that approximate the motion of the human
hand, which are all advantageous, given the exten-
sive dissection in close proximity to iliac vessels
and the obturator nerve.
Postoperative Complications:
Incidence and Risk Factors
Complications of Lymph Node
Dissection
The morbidity after an inguinofemoral lymph
node dissection is greater than that associated
with axillary or cervical lymphadenectomy,
particularly in the older population and in
patients who are obese (Beitsch and Balch
1992). The rate of postoperative complications
following inguinofemoral lymph node dissection
has been estimated as high as 75% (Chang
et al. 2010; Stuiver et al. 2014). Early perio-
perative complications include infection, hemor-
rhage, seroma formation, skin edge necrosis,
wound dehiscence, and lymphocele. Long-term
complications include paresthesias and chronic
lymphedema. One explanation for the short-term
morbidity associated with inguinal lymph-
adenectomy is that the main blood supply to the
skin overlying the femoral triangle comes from a
series of small anterior branches of the femoral
artery. These small arteries pass directly through
the cluster of femoral lymph nodes. Any complete
excision of these nodes divides most, if not all, of
these vessels. It follows that the vitality of the skin
close to the incision and for a distance of up
to 10 cm below the inguinal ligament may
be impaired regardless of where the incision for
lymphadenectomy is placed. The reduced blood
supply to the skin may result in either slow wound
healing or complete breakdown of this part of the
wound, particularly in older and/or obese patients,
though some of these wound complications can be
minimized by excising the skin over the femoral
triangle.
16
Lymphedema is the most significant long-term
complication following lower extremity node dis-
section. Clinical rates of lower extremity swelling
following inguinofemoral dissection are reported
to range from 20% to 64% in most series (Chang
et al. 2010). Lymphedema is generally reported as
being mild, although criteria for the definition of
lymphedema vary among authors. It is possible
that a significant percentage of patients actively
complying with a regimen of long-term elastic
support stockings and/or sequential compression
pump therapy have lymphedema but are success-
fully treated as opposed to patients who are truly
free of lymphedema. Importantly, the addition of
an iliac/obturator lymph node dissection with an
inguinofemoral dissection has historically been
associated with an increased risk of lymphedema;
however, more recent data suggests the addition
of an iliac/obturator lymph node dissection does
not significantly increase this risk (Chang et al.
2010).
Management of Postoperative
Complications
Meticulous attention to surgical technique and
hemostasis should help prevent a significant num-
ber of postoperative complications. Avoiding the
creation of nonviable skin flaps or intraoperative
wound contamination will contribute significantly
to the prevention of postoperative wound edge
necrosis, dehiscence, and infection. When these
complications do occur, they are best managed
with appropriate local wound care.
Debridement should be performed aggres-
sively to remove any and all nonviable tissue.
Tissues of questioned viability, however, should
be observed while they are treated with topical
antibiotics. Systemic antibiotics should be
reserved only for evidence of invasive soft tissue
infection or cellulitis. The open wound should be
packed and the dressing changed two to three
times per day until there is healthy granulation
tissue in the defect.
Lymphocele with seroma formation is a com-
mon complication, with incidence ranging from
5% to 27% (Badgwell et al. 2007). Lymphoceles
K. A. Delman et al.
large enough to cause the overlying skin flaps to
become firm or tense should be treated by prompt
aspiration under sterile conditions. Aspiration
attempts should be made as far away from the
incision as possible. A lymph collection that rap-
idly re-accumulates after repeated aspirations
should be considered for percutaneous suction
catheter drainage rather than continuing to per-
form repeated serial aspirations, each of which
incurs the risk of infecting the lymphocele
(Hoffman et al. 1995).
Lymphedema clearly represents the most
serious nonmalignant long-term complication
resulting from lower extremity node dissection.
Prevention of lymphedema begins in the operat-
ing room by taking steps to prevent perioperative
wound infection. Wound infection results in
increased fibrosis of the soft tissues of the femoral
area and thereby likely results in the obliteration
of microscopic lymphatic vessels. Lymphedema
itself predisposes patients to infection of the
extremity, particularly cellulitis. A vicious cycle
of infection resulting in worsening of lymph-
edema followed by further infections can thereby
be initiated. Thus, prevention of lymphedema and
perioperative infection goes hand in hand.
While lymphedema surveillance and preven-
tion protocols vary on an institutional level,
all patients should receive education emphasizing
the importance of early detection. At many
institutions, patients are measured preoperati-
vely for custom-fitted, medium compression
(20–30 mmHg) elastic garments, so that they can
be worn as soon as possible and for up to 6 months
postoperatively. At other institutions, a compres-
sion garment is only used in the treatment of
established lymphedema. Additionally, sequential
compression devices have become an important
part of the treatment armamentarium in combating
significant established lymphedema. Devices are
custom fit for each patient with lymphedema and
are typically worn for periods of up to 1–4 h daily
while the patient is at home. Sequential compres-
sion devices function by mimicking the natural
pumping action of the lower extremity muscula-
ture during ambulation, which propels the protein-
rich edema fluid out of the soft tissues in a
cephalad direction.
Inguinofemoral, Iliac/Obturator, and Popliteal Lymphadenectomy for Melanoma 17

Fig. 11 Technique of
popliteal node dissection
incision and exposure of
superficial structures. (From
Advanced Therapy in
Surgical Oncology, Pollock
RE, Curley SA, Ross MI,
eds.; used with permission
from PMPH USA, Ltd.,
Raleigh, NC)

are raised, while traction is maintained with skin

Popliteal Dissection
hooks. As the fascia is exposed, the most superfi-
cial structures that come into view are the lesser
Indications
saphenous vein and some small cutaneous nerve
terminal branches (Fig. 11). At this point the lesser
Because the incidence of popliteal lymph node
saphenous vein must be ligated and divided.
involvement is exceedingly rare in patients with
Next the deep fascia is incised vertically, tak-
melanoma, Thompson et al. (2000) recommends
ing care to avoid damaging structures below the
popliteal lymph node dissection only for clinical
fascia, because the nerves are quite superficial
evidence of metastatic disease in a popliteal node.
(Fig. 12). If the medial sural nerve can be retracted
out of the way, it should be. However, if neces-
sary, it can be divided to gain better access to
Operative Technique
deeper structures; this will result in cutaneous
anesthesia. The tibial nerve is the most superficial
To prepare for dissection, the patient is placed in
midline structure. This is very gently retracted
the prone position with the operative leg slightly
laterally with a vessel loop. Similarly, the peroneal
flexed at the knee. The patient is prepped from the
nerve courses along the biceps femoris and semi-
mid-thigh to the inferior aspect of the gastrocne-
membranosus muscles. Inferiorly the two heads of
mius muscle. A lazy-S incision is made over the
the gastrocnemius muscle can be further retracted
flexor crease to (1) allow optimal exposure and
as well to enhance distal exposure. The node-
(2) heal in a manner that does not cause a
bearing tissue is swept from around the nerves
deforming joint contracture (Sholar et al. 2005).
and moved distally to expose the popliteal artery
The incision should begin approximately 10 cm
and vein. Nodal tissue surrounding these vessels
above the joint crease of the lateral thigh and then
should be dissected free, making sure to include
move transversely across the joint. From there, it
any tissue lying on the far side of the vessels as
extends longitudinally along the medial aspect of
well (Fig. 12). The dissection is continued until
the leg for approximately 10 cm (Fig. 11). After
these vessels dive behind the gastrocnemius mus-
the incision is created and carried down through
cle. Once the specimen is removed, a drain is
the subcutaneous tissue, lateral and medial flaps
placed and the wound is closed in layers.
18 K. A. Delman et al.

Fig. 12 Technique of
popliteal node dissection
exposure of vessels and
deeper structures. (From
Advanced Therapy in
Surgical Oncology, Pollock
RE, Curley SA, Ross MI,
eds.; used with permission
from PMPH USA, Ltd.,
Raleigh, NC)

Generally, the patient remains hospitalized at
least overnight and longer if additional nodal dis-
sections were performed. The drain is left in place
until drainage is less than 30 mL/day.
Cross-References
▶ Biopsy of the Sentinel Lymph Node
▶ Hyperthermic Regional Perfusion for Mela-
noma of the Limbs
▶ Lymphoscintigaphy in Patients with Melanoma
▶ Molecularly Targeted Therapy for Patients with
BRAF Wild-type Melanoma
▶ Novel Immunotherapies and Novel Combina-
tions of Immunotherapy
▶ Targeted Therapies for BRAF Mutant Meta-
static Melanoma
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