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Radical lymphadenectomy for malignant melanoma


Medical editor Truls Ryder MD
Plastic Surgeon

Oslo University Hospital
Norway

General

In a lymphadenectomy, all of the lymph node-containing tissue is removed from the region. Limited dissection does not guarantee adequate removal of positive nodes, therefore, a "node-picking" operation should not be performed. Adequate dissection reduces the chance for recurrence in dissected lymph node stations. Such recurrence are difficult to treat.

Extranodal growth, extensive tumor involvement, or tumor spillage during an operation, should often be treated with radiation to prevent local recurrence.

Lymphadenectomy is performed in the:

  • groin
  • axilla
  • neck 
  • pelvis 

Indications

  • Malignant melanoma with regional lymph node metastasis

Goal

  • Cure the disease

Equipment

  • Plastic surgery instruments

Preparation

  • Removal of hair in the area.
  • Clyx the preoperative evening if the patient is to be bedridden postoperatively.
  • Thrombosis prophylaxis the preoperative evening.
  • Measure for long antithrombotic stocking.
  • The operation is performed under general anaestesia.

Positioning

  • Groin: Supine position: The leg on the involved side is bended at the knee ("tailor position").
  • Axilla: Supine position. The arm on the involved side in 70-90 degrees angle to the body.
  • Neck: Supine position. The head turned laterally on a cushion to stretch the neck.

Implementation

Inguinal dissection  

The superficial nodes are localized at least 5 cm above the inguinal ligament in the entire femoral triangle and spread on both sides of the great saphenous vein. Except for in very thin people, these lymph nodes are located under scarpa's fascia.

A vertical lazy-S incision is made starting 10 cm above the inguinal ligament, crosses the midpoint, and continues about 15 cm below the inguinal ligament . Alternatively, an incision is made a few centimeters below and parallel to the inguinal ligament and curved medially down in the femoral triangle.

  • The skin flaps are dissected and the specimen is removed en bloc. The great saphenous vein is included in the specimen from the tip of the femoral triangle to the origin into the femoral vein. If metastatic lymph nodes are confirmed in the pelvis, the operation is extended to an ilio-inguinal dissection including iliac and obtural nodes.
  • The wound is washed and a drain is installed. 
  • The wound is closed in two layers. 

Axillary dissection

The incision is often made horizontally, lazy-S, or zig-zag, and extends from the lateral edge of the major pectoral muscle to the edge of the latissimus dorsi. An upper and lower skin flap is created. All 6 node groups are situated under the clavipectoral fascia, and an en bloc removal is performed. The axilla dissection should include levels 1, 2, and 3 .

To obtain sufficient access to the top of the axilla, it may be necessary to split the minor pectoral muscle by the coracoid process or remove it. It is rarely necessary to split the major pectoral muscle. The axillary vein can, if absolutely necessary, be removed since intact blood supply around the scapula prevents permanent stasis in the arm. The dissection continues down to the 6th rib while trying to conserve the large nerves in the area (the thoracodorsal and long thoracic nerves).

Neck dissection

Neck dissections for malignant melanoma have changed in character in recent years. Selective and modified radical neck dissections are now performed more frequently. Which levels are dissected depend on the location of the primary tumor.

A neck dissection is a technically difficult operation with a high risk of complications and high relapse frequency. This type of operation should be centralized.


Follow-up

Groin dissection:

  • The day of operation and 1. postoperative day the patient stays in bed (toilet leave prohibited).
  • 2. postoperative day the patient may move by wheel-chair and careful walking to the toilet. Gradually mobilization till normal within a week.
  • Thigh-long "white" stocking continuously during the hospital stay and every night for 3 months.
  • Thigh-long "brown" stocking every day for 6 months.

Axillary dissection:

  • The day of operation the patient stays in bed.
  • Mobilisation with mitella from 1. postoperative day.

The vacuum-drain (active) should be kept for 5-10 days or until the volume of fluid is reduced to 40-50 ml per 24 hours. The vacuum is neutralized and remains passive. At home the drain is shortened 1 cm daily by the nurse. This is to ensure that the wound heals from the inside- outwards.

Complications

  • Postoperative seromas – these are drained aseptically
  • Nerve pain and dysfunctions – often temporary
  • Edge necrosis, lymphedema, and incision infections – more frequent for inguinal dissection
  • Deep vein thrombosis in the leg

Lymphedema is a serious and persistent complication. Lymphedema after axilla dissection is rarely observed, but occurs in approximately 20% of patients after a groin dissection. 

After an inguinal dissection, it is recommended that for the first three months after the operation, the patient elevates their feet while lying and sitting. In the same period, it is recommended to use elastic stockings day and night. Gradual decrease in the use of stockings should take place during the next three months. After an axillary dissection, it is not necessary to routinely use elastic stockings.

Physiotherapy

Physiotherapy after the operation is important for the patient to achieve an adequate rehabilitation process. Many do not need to go to sessions of physiotherapy, but rather, information and guidance will be adequate.


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