Selçuk et al.

Inguinofemoral lymphadenectomy J Turk Ger Gynecol Assoc 2021; 22: 155-7

Video Article 155

Inguinofemoral lymphadenectomy and femoral

dissection: cadaveric educational video
İlker Selcuk1, Hilal Aktaş Akdemir2, Burak Ersak1, İlkan Tatar2, Mustafa Fevzi Sargon3, Tayfun Güngör4
1Department of Gynecologic Oncology, Ankara City Hospital, Women’s Health Education and Research Hospital, Ankara, Turkey
2Hacettepe University Faculty of Medicine, Department of Anatomy, Ankara, Turkey
3Lokman Hekim University Faculty of Medicine, Department of Anatomy, Ankara, Turkey
4Private Clinic, Ankara, Turkey

Abstract
Vulvar cancer is rare. The complex inguinofemoral anatomy and the limited number of surgical procedures per year per gynecological oncologist
tends to decrease the competency level. This step-by-step, cadaveric educational video was produced to increase understanding of the anatomy
and technique of inguinofemoral lymphadenectomy.
Keywords: Inguinofemoral, lymphadenectomy, vulvar cancer, dissection, groin

Received: 04 February, 2019 Accepted: 26 March, 2019

Introduction demonstrate a step-by-step technique and we believe one of

the strong points of this study is that, whether the cadaver is
Since vulvar cancer is a rarely seen gynecological malignancy, fresh frozen or not, if used properly this type of study still has an
every year only a limited number of surgeries are likely to be important place in medical and post-graduate education.
performed by each gynecological oncologist. Van der Zee et al.
(1) suggested that at least 5 to 10 patients should be managed Inguinal anatomy
per year by each surgeon to ensure the competency level.
The groin is the anatomical region between the anterolateral
Additionally, adoption of a sentinel lymph node approach has
abdominal wall and lower extremity. The inguinal ligament,
led to a less radical surgical concept that further reduces the
which is one edge of the femoral (Scarpa’s) triangle, lies
number of cases with full inguinofemoral lymphadenectomy.
between the anterior superior iliac spine and pubic tubercle.
The current situation has motivated gynecological oncology
The inguinal ligament is formed by the aponeurosis of the
fellows and young surgeons to gain education and practice
external oblique muscle. Under the skin the superficial fascia
by cadaveric dissections. This cadaveric surgical educational
may be observed and it is composed of a fatty superficial
video demonstrates the technique of inguinofemoral lymph
layer (Camper’s fascia) and a deeper membranous layer
node dissection in a step-by-step process.
(Scarpa’s fascia). Superficial vessels, which supply the lateral,
middle and medial sites are the superficial circumflex iliac,
Material and Methods
superficial epigastric and superficial external pudendal
This cadaveric educational dissection video was recorded vessels, respectively. Scarpa’s fascia fuses with the fascia lata,
at Hacettepe University Faculty of Medicine, Department of the deep fascia of the thigh. Under the fascia lata the femoral
Anatomy. One limitation of this study was that a fresh frozen vessels and nerve can be dissected. They lie as nerve-artery-
cadaver was not used. However, the video was recorded to vein-lymphatics formation from lateral to medial. The femoral

Address for Correspondence: İlker Selçuk

e.mail: ilkerselcukmd@hotmail.com ORCID: orcid.org/0000-0003-0499-5722
©Copyright 2021 by the Turkish-German Gynecological Education and Research Foundation - Available online at www.jtgga.org
Journal of the Turkish-German Gynecological Association published by Galenos Publishing House.
DOI: 10.4274/jtgga.galenos.2019.2019.0026
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Inguinofemoral lymphadenectomy J Turk Ger Gynecol Assoc 2021; 22: 155-7
156

vessels are covered by the femoral sheath, which is the node, the nexus between the deep inguinal and iliac/obturator
continuation of transversalis and iliac fascia, below the inguinal lymph nodes (6).
ligament. Additionally, the femoral triangle is detected under
the fascia lata. The lateral border is the sartorius muscle and Surgical procedure
the medial border is the adductor longus muscle. The fossa This surgical procedure is performed in the low lithotomy
ovalis is approximately 3 cm inferolateral to the pubic tubercle position, at the left groin. Between the anterior superior iliac
and it is an opening through the fascia lata where the great spine and pubic tubercle the skin incision is performed, 8 cm
saphenous vein enters to the femoral vein. This part is covered in length, and 2 cm below and parallel to the inguinal ligament.
by a thin, multi-perforated fascia called the fascia cribrosa, After the incision, the dissection deepens to identify Camper’s
and many lymphatics and venous structures pass through this fascia lying over Scarpa’s fascia. Identification and preservation
region (Figure 1) (2,3). of Camper’s fascia is critical in live patients to secure the skin
flap and prevent skin necrosis. To dissect the fibrofatty tissue
Inguinal lymph nodes containing the superficial inguinal lymph nodes between the
The inguinal lymph nodes are categorized into the superficial Scarpa’s fascia and the fascia lata, the first step should be to
and the deep group, separated by the fascia lata. The mobilize the fibrofatty tissue under Scarpa’s fascia and then
superficial lymph nodes are located under Scarpa’s fascia and dissect 2 cm cephalad, to the inguinal ligament where the
divided into five groups, depending on the termination point aponeurosis of the external oblique muscle is seen. Afterwards,
of the great saphenous vein; superomedial, superolateral, excision of the lymphatic and fibrofatty tissue is performed from
inferomedial, inferolateral and central (4). The deep inguinal lateral (superficial circumflex iliac vein) to medial (superficial
lymph nodes are located beneath the fascia lata, medial to the external pudendal vein) and superior to inferior, identified by
femoral vein (5). The lymph node found at the femoral canal, the inferomedial end of inguinal ligament where it intersects
anterosuperior to the femoral vein, is known as Cloquet’s with the adductor longus muscle.

Figure 1. Inguinal anatomy with regard to superficial and deep inguinal lymph nodes (the figure was illustrated from the
book “Atlas of Human Anatomy, Pelvis and Perineum, Plate 389, 7th Edition, 2019 Elsevier, Netter Frank H.” by Sedef Yasin
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J Turk Ger Gynecol Assoc 2021; 22: 155-7 Inguinofemoral lymphadenectomy
157

The fossa ovalis is encountered after resection of superficial after inguinofemoral lymphadenectomy. The most serious
inguinal lymph nodes (Figure 2). Medial to the falciform edge complication is lymphedema and the great saphenous vein
of the fossa ovalis, dissection of the cribriform fascia will lead should be secured during dissection to decrease the risk of
to the deep inguinal lymph nodes, which are located medial lymphedema (8).
to the femoral vein. The great saphenous vein enters the
femoral vein from the opening of the fossa ovalis, so careful Video 1.
dissection is essential while removing the cribriform fascia.
Lymphadenectomy is performed towards the apex of the
femoral triangle, and there is no need to dissect the femoral
sheath to excise the deep inguinal nodes completely (Figure
3). Finally, Cloquet’s lymph node, the most superior of the deep https://www.doi.org/10.4274/jtgga.galenos.2019.2019.0026.video1
inguinal nodes, may be resected from the femoral canal under
the level of the inguinal ligament (7). Acknowledgement: Special thanks to medical illustrator Sedef
Yasin. We would like to thank Hacettepe University Faculty of
Complications Medicine, Department of Anatomy, where the dissection was
Hematoma, seroma, wound breakdown, wound infection performed.
and lymphedema are the most probable complications
Conflict of Interest: No conflict of interest was declared by the
authors.

Financial Disclosure: The authors declared that this study

received no financial support.

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Figure 3. Femoral nerve, artery, vein and great saphenous

vein after dissection of the femoral sheath