Surgical Technique Video Endoscopic Inguinal Lymphadenectomy

International Braz J Urol Vol. 32 (3): 316-321, May - June, 2006

Video Endoscopic Inguinal Lymphadenectomy (VEIL):

Minimally Invasive Resection of Inguinal Lymph Nodes
M. Tobias-Machado, Alessandro Tavares, Wilson R. Molina Jr, Pedro H. Forseto Jr, Roberto
V. Juliano, Eric R. Wroclawski

Section of Urology, ABC Medical School, Santo Andre, Sao Paulo, Brazil

ABSTRACT

Objectives: Describe and illustrate a new minimally invasive approach for the radical resection of inguinal lymph nodes.
Surgical Technique: From the experience acquired in 7 operated cases, the video endoscopic inguinal lymphadenectomy
(VEIL) technique was standardized in the following surgical steps: 1) Positioning of the inferior member extended in
abduction, 2) Introduction of 3 work ports distal to the femoral triangle, 3) Expansion of the working space with gas, 4)
Retrograde separation of the skin flap with a harmonic scalpel, 5) Identification and dissection of the long saphenous vein
until the oval fossa, 6) Identification of the femoral artery, 7) Distal ligature of the lymph node block at the femoral triangle
vertex, 8) Liberation of the lymph node tissue up to the great vessels above the femoral floor, 9) Distal ligature of the long
saphenous vein, 10) Control of the saphenofemoral junction, 11) Final liberation of the surgical specimen and endoscopic
view showing that all the tissue of the region was resected, 12) Removal of the surgical specimen through the initial orifice,
13) Vacuum drainage and synthesis of the incisions.
Comments: The VEIL technique is feasible and allows the radical removal of inguinal lymph nodes in the same limits of
conventional surgery dissection. The main anatomic repairs of open surgery can be identified by the endoscopic view,
confirming the complete removal of the lymphatic tissue within the pre-established limits. Preliminary results suggest that
this technique can potentially reduce surgical morbidity. Oncologic follow-up is yet premature to demonstrate equivalence
on the oncologic point of view.

Key words: penile cancer; groin; lymphadenectomy; video-assisted surgery

Int Braz J Urol. 2006; 32: 316-21

INTRODUCTION performed through a bilateral inguinal incision from

the iliac crest until the pubic tubercle. There is,
Inguinal lymphadenectomy is indicated in however, a high morbidity regarding the dissected skin
patients presenting penile and urethral cancer, after flap to access the inguinal lymph nodes, as well as
local treatment, when there is a lymph node mass that skin necrosis and local infection, and depending on
does not disappear with antibiotic therapy, or when the extension of the lymphadenectomy, higher
palpable lymph nodes appear in the postoperative frequency of edema in inferior members, lymphocele,
follow-up or when there are risk factors for the lymphedema and lymphorea (1).
development of inguinal metastasis (prophylactic Trying to reduce the morbidity of this radical
lymphadenectomy). This operation is frequently operation the literature shows surgical alternatives

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that aim at restricting the inguinal dissection area. Video Endoscopic Inguinal
However, all techniques present different local Lymphadenectomy (VEIL)
recurrence rates, probably due to false negative results 1 – Positioning and preparation of the inferior
(2). member - The leg is folded over the thigh in a way to
Video-assisted surgery has been employed put in evidence the femoral triangle that is marked
in the iliac and retroperitoneal lymph nodes with ink over the skin. After the marking, the leg is
approach, reducing postoperative discomfort, extended and fixed to the table with abduction and
minimizing anatomic sequels and allowing a faster light external rotation of the thigh. The video monitor
recuperation of patients, keeping the functional is positioned at the contralateral side to the operated
results of conventional surgery for the majority of one at the patient’s pelvic waist.
indications. 2 – Introduction of the ports - At 2 cm of the
We aimed at describing and illustrating the femoral triangle vertex in a distal sense an incision
technical details of a minimally invasive procedure of 1.5 cm in the skin and in the subcutaneous tissue
for inguinal lymphadenectomy recently described in until the Scarpa’s fascia is performed, being devel-
the clinical scenario (3). This technique duplicates oped a subcutaneous plan with scissors and later with
the principles of conventional technique, promoting a digital maneuver in the largest possible extension.
a radical resection of inguinal lymph nodes, with A second incision of 1 cm, at around 2 cm above and
encouraging preliminary results regarding the 6 cm medially to the first incision, to the introduction
reduction of surgical morbidity. of a 10 mm port. It is possible to identify the trajec-
tory of the saphenous vein through this access. A lat-
erally symmetric position 5 mm port is introduced
SURGICAL TECHNIQUE for graspers, dissection tweezers and scissors. At the
initial access, a 10 mm Hasson trocar is preferably
The technique described was developed in a introduced. All the ports are fixed to the skin through
prospective protocol that includes up to now 7 patients a purse-string suture with cotton 0. At the initial port,
presenting penile spinocellular carcinoma, without we introduce a 0-degree optic, and at the medial port,
palpable lymph nodes or that had a regression after a we introduce the tweezers of the harmonic scalpel
6-week-antibiotic therapy. All patients had an and the clipper. The surgeon and the camera operator
indication of bilateral lymphadenectomy due to the are positioned laterally to the operated member.
presence of risk factors for lymph node dissemination 3 – Expansion with gas of the working space
such as: clinical stage > T1 or information regarding – The creation of a working space is completed
the initial biopsy such as histological grade > 1, through the initial insufflation of CO2 with a 15-
lymphatic or vascular invasion. mmHg pressure, with its fast diffusion, being able to
After signature of the informed consent the keep the pressure at 5-10 mmHg during the procedure
patients were submitted to classic open surgery in one (Figure-1). Transillumination allows a good
of the members (control group) and a video-assisted orientation regarding the progression of the dissection
surgery, named video endoscopic inguinal area.
lymphadenectomy (VEIL) in the other member (group 4 – Retrograde separation of the skin flap –
of the technique to be assessed). This time is fundamental to the success of the
procedure and is performed with a harmonic scalpel.
Control Member Initially we perform the separation between the skin
For the open conventional surgery, we have and the fibroareolar tissue that contains the superficial
used the superficial inguinal lymphadenectomy lymph nodes until the external oblique muscle fascia
technique and deep in the Dressler triangle, medial on the superior part (Figure-2). Afterwards we proceed
to the femoral artery, without the preservation of the to the dissection of the fundamental parameters,
long saphenous vein through a large inguinotomy. having as a limit the long adductor muscle and its

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7 – Distal ligature of the lymph node block at

the femoral triangle vertex – the fibroareolar tissue is
dissected with a harmonic scalpel and the control of
the final section at the femoral triangle vertex is
obtained with clips.
8 – Liberation of the lymph nodes until the
great vessels above the femoral floor. During this
operative time, the use of the harmonic scalpel and a
careful manipulation of the specimen in areas near
the veins are necessary to avoid vascular lesion. As
in the conventional technique, the aim is to skeletonize
the femoral veins, resecting all local lymphatic tissue
Figure 1 – Trocar disposition for a right member (Figure-4).
lymphadenectomy. The work space was almost all filled up by
the diffusion of gas.

Figure 3 – Dissection of the long saphenous vein in a cranial

Figure 2 – Separation of the skin and the fibroareolar tissue
aspect.
that contains the lymph nodes, with the aid of a harmonic scalpel.

fascia medially, the sartorius muscle and its fascia

laterally, and the inguinal ligament superiorly. It is
possible to identify branches of the femoral nerve that
should be preserved.
5 – Identification and cranial dissection of
long saphenous vein until the oval fossa (Figure-3).
6 – Identification of the femoral artery – After
the identification of the femoral artery and the opening
of the femoral vein sheath we define the lateral limit
of the dissection, allowing the access to the deep
cervical lymph nodes (Figure-4). At this moment it
can be necessary to control with 1 or 2 branch clips Figure 4 – Exposition of femoral artery and vein after the control
coming from the femoral artery that run anteriorly to of 3 small branches of the femoral artery that course anteriorly
the femoral vein. to the femoral vein.

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9 – Distal ligature of the long saphenous vein

with clips
10 – Control of the branches and the long
saphenofemoral junction with a harmonic scalpel and
metallic clips - most part of the branches of the long
saphenous vein are controlled only by the harmonic
scalpel. Branches larger than 4 mm need clips for the
ligature. The entrance of the long saphenous vein in
the femoral vein should be well dissected and
controlled preferably with polymer clips (Figure-5).
11 – Final liberation of the specimen medially
to the long saphenous vein, ligating the proximal
portion of the lymph nodes at the deep region of the Figure 6 – Endoscopic view at the end of the lymph node
femoral channel with clips. After completing the dissection. The limits of the lymphadenectomy are viewed and
liberation of the specimen, the endoscope view attests all the lymphatic tissue was removed.
that all the tissue of the region was completely
resected (Figure-6).
12 – Removal of the surgical specimen by
the 15 mm incision. In case the specimen is of large
dimensions, it can be put inside a bag and latter
removed.
13 – Vacuum drainage through the 5 mm
orifice and suture of the larger incisions (Figure-7).

COMMENTS

Approximately 30% of the patients with

penile spinocellular carcinoma present lymph node
metastasis at the time of the diagnosis. Bilateral
Figure 7 – Final aspect of the incisions and vacuum drainage.

inguinal lymphadenectomy is a procedure accepted

as a prognostic and therapeutic value in cases of penile
and urethral spinocellular carcinoma with high risk
of developing metastasis (1). However, morbidity
associated to this surgery is high, being questioned
its need mainly when the intention is prophylactic. In
the past, due to the data presented, some centers
adopted a conservative conduct through a rigid clinic
follow-up.
Figure 5 – Aspect of the long saphenous vein in its entrance into Contemporary works have demonstrated that
the femoral vein. prophylactic lymphadenectomy offers better survival

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results than salvage lymphadenectomy performed in no skin complications. The presence of infraumbilical
those patients where we have initially opted for a subcutaneous emphysema of spontaneous resolution
rigorous observation. Besides that, they have also is the rule, being uncommon the clinical
showed that the non-controlled lymph node disease manifestation. Hypercarbia can occur intraoperatively,
was an important cause for morbidity and mortality being completely reversible with hyperventilation,
in patients with penile cancer. without the need for conversion. In a subjective
Before the dilemma of offering radical analysis, all patients preferred endoscopic surgery.
surgery with a significant morbidity to 70% of the Pathological exam of surgical specimens showed that
patients in an unnecessary way or harm the survival the medium number of lymph nodes excised did not
of 30% of the patients submitted to the surveillance differ from that obtained with conventional surgery.
regimen, new alternatives were reported in literature. We attribute this preliminary result to the
The techniques described in the last 20 years to reduce following technical principles: 1) Non use of electrical
the morbidity are based on the reduction of inguinal current and mechanical retraction with subcutaneous
dissection templates. Even though the evident retractors. The retraction is performed atraumatically
reduction of operation complications described both by the gas, minimizing cutaneous lesions, 2) Short
with simplified lymphadenectomy and with the incisions outside the area of the great vessels allow a
employment of sentinel lymph node with shorter area of lesion of the separated flap and
radioisotopes, some authors believe that its higher probably less chance of infection, besides making
morbidity could be related to a rate of 15% of late unnecessary the rotation of the sartorius muscle flap
recurrence of the disease with possible involvement to recover femoral veins, 3) Control of the lymph
of these individual’s survival (2). nodes, visualized by magnification, with harmonic
The present work was motivated by the attempt scalpel and clips. The proximal and distal ligature of
to reduce the complications of inguinal major channels is fundamental to avoid important
lymphadenectomy, based on the initial works of video- lymphoceles or lymphorea.
assisted saphenous vein resection, subcutaneous The presence of skin adherences or palpable
endoscopic procedures used in plastic surgery and video mass of lymph nodes, predictive factors for technical
endoscopic resection of axillary lymph nodes. (4-6). difficulty, were excluded from this initial study which
Recently, Bishoff et al. described the objectives were to assess the possibility and technical
possibility of modified dissection of inguinal lymph equivalence to classical lymph nodes resection.
nodes through endoscopic subcutaneous access
performed in 2 human cadavers and in 1 patient with
penile cancer stage T3N1M0. Dissection was possible CONCLUSIONS
on the human cadavers but it was however not possible
in the patient due to the adherence of the enlarged The VEIL technique is feasible and allows
lymph nodes to the femoral veins (7). After some the radical removal of inguinal lymph nodes at the
technical changes we have performed, to this date, same dissection template as conventional surgery. The
the surgery in a safe and efficient way in 7 patients main anatomic repairs of open surgery can be
with indication of prophylactic lymphadenectomy. identified in an endoscopic view, confirming the
The idealized technique allows a complete complete removal of the lymphatic tissue within the
excision of inguinal lymph nodes, the way it is done pre-established limits.
in conventional surgery, allowing an initial impression Preliminary results with this new endoscopic
of benefit regarding the lower postoperative morbidity approach for inguinal lymphadenectomy are
when compared to the conventional technique. The promising, with potential to reduce morbidity. It seems
medium 120 minutes operative time is still superior not to change expected oncologic results with the
to the open technique; however, we should consider conventional technique, but the follow-up is still short
the learning curve. Surprisingly enough, there were for definite conclusions.

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Future studies and validation by other authors 3. Machado MT, Tavares A, Molina Jr WR, Zambon JP,
will determine the real role of this procedure in the Forsetto Jr P, Juliano RV, Wroclawski ER: Comparative
staging and treatment of patients with penile and study between videoendoscopic radical inguinal
urethral spinocellular carcinoma. lymphadenectomy(VEIL) and standard open
lymphadenectomy for penile cancer: preliminary
surgical and oncological results. J Urol. 2005; 173:
226, Abst 834.
CONFLICT OF INTEREST 4. Folliguet TA, Le Bret E, Moneta A, Musumeci S,
Laborde F: Endoscopic saphenous vein harvesting
None declared. versus ‘open’ technique. A prospective study. Eur J
Cardiothorac Surg. 1998; 13: 662-6.
5. Dardour JC, Ktorza T: Endoscopic deep periorbital
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Accepted after revision:

January 15, 2006

Correspondence address:
Dr. Marcos Tobias-Machado
Rua Graúna, 104/131
São Paulo, SP, 04514-000, Brazil
Fax: + 55 11 3288-1003
E-mail: tobias-machado@uol.com.br

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