|Year : 2006 | Volume
| Issue : 4 | Page : 355-359
Groin reconstruction after inguinal block dissection
Ashish Kumar Gupta, Paul M Kingsly, Isaac Jacob Jeeth, Prema Dhanraj
Department of Plastic Surgery, Christian Medical College, Vellore, Tamilnadu, India
Paul M Kingsly
Department of Plastic Surgery, Christian Medical College, Vellore - 632 004, Tamilnadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Inguinal block dissection is a necessary component in the treatment of certain cancers. Cancer of the penis is not an uncommon malignancy in the Indian subcontinent and while no one questions the treatment of the primary lesion, the need to remove the inguinal lymph glands concurrently, remains a matter of great controversy. Never the less, the survival of patients with penile cancer depends solely on the presence or absence of metastasis to the inguinal lymph nodes. The hesitation in offering inguinal lymph node dissection in every case is significantly related to the morbidity of the procedure in an attempt to reduce these complications, skin flaps can be used to cover the groin. This article looks at various flaps that can be used in groin reconstruction.
Keywords: Flap, groin reconstruction
|How to cite this article:|
Gupta AK, Kingsly PM, Jeeth IJ, Dhanraj P. Groin reconstruction after inguinal block dissection. Indian J Urol 2006;22:355-9
Inguinal block dissection is a necessary component in the treatment of certain cancers. Cancer of the penis is not an uncommon malignancy in the Indian subcontinent and while no one questions the treatment of the primary lesion, the need to remove the inguinal lymph glands concurrently, remains a matter of great controversy. Nevertheless, the survival of patients with penile cancer depends solely on the presence or absence of metastasis to the inguinal lymph nodes. The hesitation in offering inguinal lymph node dissection in every case, is significantly related to the morbidity of the procedure. In an attempt to reduce these complications, skin flaps can be used to cover the groin. This article looks at various flaps that can be used in groin reconstruction.
Groin dissection is an essential component in the treatment of penile and distal urethral cancers. Unfortunately, the procedure has been associated with significant complications such as wound infection, seroma and skin necrosis leading to wound dehiscence and lymphedema.
The most common complication is skin edge necrosis (7.5-62% of dissections).,,,,,,,,, The most common cause for poor healing following groin dissection, is poor vascularity of the lower flap. The vascular supply of the skin of the groin is from the superficial epigastric, superficial circumflex and superficial pudendal arteries and these are all divided during groin dissection [Figure - 1]. Other contributing causes are large dead spaces in the femoral triangle, thin skin flaps and the presence of bacteria within the lymph nodes. Various inguinal block techniques are described to reduce the incidence of skin edge necrosis. Ornellas et al and Ravi have compared the morbidity of groin dissection, in relation to different types of incisions used. Byron et al , Whitmore and Vagawala and Vordemark et al excised two to four cm of wide ellipse of skin prior to closure. Flap reconstruction of the groin is required after block dissection of fixed and fungating lymph nodes, especially in postradiotherapy patients. Flaps are also used in wound dehiscence following groin dissection, as attempts to close the defect primarily fail very often. Flap closure of the groin has the following advantages: (1) The flap brings well-vascularized tissue from a distant area to the groin (2) It covers the dead space in the femoral triangle and decreases seroma formation (3) It helps in wound closure without tension (4) Pre and postoperative radiotherapy can be safely given (5) It shortens the hospital stay.
Commonly used flaps for groin reconstruction are the sartorius, tensor fascia lata, rectus abdominis, rectus femoris, gracilis, anterolateral thigh flap and abdominal flaps. Our policy is to use elective flap coverage, rather than closing the groin defect under tension. Early debridement and flap coverage in wound breakdown after inguinal block dissection is generally preferred. Local mobilization of the skin and positioning of the hip in acute flexion for 10-15 days can help in primary healing, but the results are not gratifying. Use of flaps improves results and allows early ambulation.
| Approach to flap selection|| |
Skin grafts can be used for coverage, provided vital structures are not exposed, but usually the "take" is not good and cannot be used in postradiotherapy cases. Random pattern flaps can be used, but again, they cannot be used following radiotherapy. Muscle or musculocutaneous flaps are better in this situation because of the following advantages:
- A blood supply that is based out of the field of resection or radiation [Figure - 2].
- A blood supply precisely known, as is the exact location of the vascular pedicle.
- A single-stage procedure.
- Sartorius muscle flap for routine coverage of femoral vessels, even when primary closure of groin skin is possible.
- TFL flap is the flap of choice for groin defects.
- Rectus femoris, gracilis, anterolateral thigh flap are all alternative back-up flaps.
Omentum and Rectus abdominis flaps are rarely indicated. All these flaps are reliable; however, the ones most commonly used are based on the sartorius and tensor fascia lata. We will discuss these two flaps in detail.
| Sartorius|| |
Baronofosky was the first to describe the transposition of the sartorius muscle to decrease the dead space and to prevent the exposure of vessels in case of wound breakdown. The sartorius muscle is an expendable muscle and is present near the defect.
It is a long, thin, flat, superficial muscle extending from the anterior superior iliac spine (ASIS) diagonally across the thigh to the medial tibial condyle.
It has a (segmental) Type IV pattern of circulation. Its vascular supply is significant in that, it has six to seven segmental branches from the superficial femoral artery and vein, entering the muscle on its medial border.
Flap elevation technique
- Identify the muscle.
- Divide origin from anterior superior iliac spine [Figure - 3].
- Mobilize muscle from above downward and turn muscle medially.
- If required, the upper one to two segmental pedicles can be divided to allow transposition. The first segmental vessel is 6.5 cm below the anterior superior iliac spine [Figure - 4].
- Suture muscle to the inguinal ligament, adductor and psoas muscles over the femoral vessels [Figure - 5][Figure - 6].
| Tensor Fascia Lata|| |
Tensor fascia lata (TFL),, is the most commonly used flap for groin defects. The TFL is a small thin flat muscle that takes its origin from the anterior 5 cm of the iliac crest and inserts into the iliotibial tract of the fascia lata over the lateral aspect of the knee. Its size is 5 x 15 inches.It has a single dominant vascular pedicle (Type I). The main vascular supply is from the ascending branch of the lateral circumflex artery, which is a branch of the profunda femoris artery [Figure - 7]. The ascending branch of the profunda femoris artery enters the muscle deep on the medial aspect, at a point approximately 8-10 cm below the anterior superior iliac spine.
The flap may be raised as standard or extended flap.
Standard flap dimensions -10 x 20 cm.
Extended flap dimensions -15 x 40 cm.
Flap elevation technique:
- Anterior border of the flap is marked by drawing a line from the anterior superior iliac spine to the lateral condyle of tibia.
- Greater trochanter marks the posterior boundary.
- Mark the length as required [Figure - 8].
- Raise the flap from the distal border to the pivot point.
- Skin and subcutaneous tissue is incised, tensor fascia is identified and incised, fascia is temporarily sutured to skin edges.
- Flap is then elevated off the vastus lateralis in a relatively avascular plane.
- Vascular pedicle is identified approximately 8-10 cm below the anterior superior iliac spine, as it enters from the medial aspect.
- Flap is ready for transposition [Figure - 9][Figure - 10].
It is a very simple and reliable flap. It is available next to the defect and the vascular pedicle is out of the zone of radiation.
The donor site closure almost always requires a skin graft and forms a big dog ear (standing cone deformity) at the pivot point. Dog ear deformity can be avoided if the flap is raised as an island flap.
| Gracilis|| |
The gracilis muscle is a long, thin, muscle situated on the medial side of the thigh, extending from the pubis to the medial aspect of the thigh.
It has a Type II (dominant vascular pedicle and minor vascular pedicles) as its blood supply.
The dominant pedicle is the ascending branch of the medial circumflex femoral artery and vena comitantes. It enters the muscle's deep surface, approximately 8-10 cm below the pubic symphysis.
The minor pedicle is from one or two branches of the superficial femoral artery and vena comitantes.
The flap is raised as a myocutaneous flap with a skin paddle over the middle one-third of the muscle. The key to successful elevation is precise marking of the skin paddle.
The gracilis muscle is not commonly used for groin reconstruction because it is unreliable and has a small skin paddle in comparison to other flaps.
| Rectus Femoris|| |
The rectus femoris muscle is a superficial large fusiform muscle located at the middle of the anterior aspect of thigh. It is the central muscle of the quadriceps muscle group. It has a Type II pattern of vasculature. The dominant pedicle is from the descending branch of the lateral circumflex artery and vena comitantes.
The minor pedicles are from the ascending branch of the lateral circumflex artery and muscular branches of the superficial femoral artery and vena comitantes.
The flap is raised as a myocutaneous flap with a skin paddle over the middle third of the muscle. The rectus femoris muscle flap is rarely used, because it is not an entirely expendable muscle and use of this muscle may cause weakness of knee extension.
| Rectus Abdominis Flap|| |
Only the contralateral muscle can be used, because the inferior epigastric vessels on the ipsilateral side are divided during inguinal block dissection.
It is a vertically oriented muscle which extends from the costal margins to the pubic ramus.
It has a Type III (two dominant pedicles) pattern of vasculature.
Its main vascular supply is from:
- Superior epigastric artery and vein.
- Inferior epigastric artery and vein.
The flap is raised as an inferiorly based flap with vertical or oblique skin paddle.
| Anterolateral Thigh Flap|| |
Anterolateral thigh flap is a perforator flap based on the branches from the lateral circumflex artery. The skin territory of this flap is very wide and can be raised as a very thin flap, but is technically more demanding.
| Abdominal Flaps|| |
The anterior abdominal skin has a rich blood supply from branches of the internal mammary, intercostals and superior epigastric arteries. They are not destroyed after ilio-inguinal lymphadenectomy. These arteries ensure a reliable blood supply to medially or laterally based abdominal rotation and advancement flaps. These flaps are not indicated in postradiotherapy block dissections and are associated with more complications in comparison to the TFL and rectus abdominis flap.
| Conclusion|| |
In cases with gross skin involvement, primary flap reconstruction is indicated, thereby helping in an uneventful primary healing.
| References|| |
|1.||Peck GT, Reckers P. The management of malignant tumours in the groin: A report of 122 groin dissections. Am J Surg 1942;38:321. |
|2.||Byron RL, Lamb EJ, Yonemoto RH, Kase S. Radical inguinal node dissection in the treatment of cancer. Surg Gynecol Obstet 1962;114:401. |
|3.||Fortner JG, Booher RJ, Pack GT. Results of groin dissection for malignant melanoma in 220 patients. Surgery 1964;55:485-94. [PUBMED] |
|4.||Johnson DE, Lo RK. Management of regional lymph nodes in penile carcinoma. Five-year results following therapeutic groin dissections. Urology 1984:24:308-11. |
|5.||Ravi R. Morbidity following groin dissection for penile carcinoma. Br J Urol 1993;72:941-5. [PUBMED] |
|6.||Bevan-Thomas R, Slaton JW, Pettaway CA. Contemporary morbidity from lymphadenectomy for penile squamous cell carcinoma: The M.D. Anderson cancer center experience. J Urol 2002;167:1638-42. |
|7.||Ornellas AA, Seixas AL, Moraes JR. Analyses of 200 lymphadenectomies in patients with penile carcinoma. J Urol 1991;146:330-2. [PUBMED] |
|8.||Nelson BA, Cookson MS, Smith JA Jr, Chang SS. Complications of inguinal and pelvic lymphadenectomy for squamous cell carcinoma of the penis: A contemporary series. J Urol 2004;172:494-7. [PUBMED] |
|9.||Whitmore WF Jr, Vagawala MR. A technique of ilioinguinal dissection for carcinoma of the penis. Surg Gynecol Obstet 1984;159:573-8. |
|10.||Vordemark JS, Jones BM, Harrison DH. Surgical approaches to block dissection of the inguinal lymph nodes. Br J Plast Surg 1985;38:321-5. |
|11.||Mathes SJ, Foad N. A systemic approach to flap selection: Groin and perineum, The C V Mobsy Company: Sartorius; 1982. p. 402-21. |
|12.||Baronofsky ID. Technique of inguinal node dissection. Surgery 1948;24:555-65. |
|13.||Wu LC, Djohan RS, Liu TS, Chao AH, Lohman RF, Song DH. Proximal vascular pedicle preservation for sartorius muscle flap transposition. Plast Reconstr Surg 2006;117:253-8. [PUBMED] [FULLTEXT]|
|14.||Hill HL, Hester R, Nahai F. Covering large groin defects with tensor fascia lata musculocutaneous flap. Br J Plast Surg 1979;32:12-4. [PUBMED] |
|15.||Gopinath KS, Chandrasekhar M, Kumar MV, Srikant KC. Tensor fascisae latae musculocutaneous flap to reconstruct skin defect after radical inguinal lymphadenectomy. Br J Plast Surg 1988;41:366-8. |
|16.||Airhart RA, deKernion JB, Guillermo EO. Tensor fascia lata flap for coverage of skin defect after radical groin dissection for metastatic penile carcinoma. J Urol 1982;128:599-601. [PUBMED] |
|17.||Ahmad QG, Reddy M, Shetty KP, Prasad R, Hosi JS, Bhathena M. Groin reconstruction by anterlateral thigh flap: A review of 16 cases. Indian J Plast Surg 2004;37:34-9. |
|18.||Rayment R, Evans M. Use of an abdominal rotation flap for inguinal node dissection. Br J Plast Surg 1987;40:485-7. |
|19.||Tabatabaei S, McDougal WS. Primary skin closure of large groin defects after inguinal lymphadenectomy forpenile cancer using abdominal cutaneous advancement flap. J Urol 2003;169:118-20. [PUBMED] |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]
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