Inguinal Dissection Research Articles

Combined endoscopic and open inguinal dissection for malignant melanoma.

Positive sentinel node biopsy or clinically/radiologically demonstrable lymph node metastases in patients with malignant melanoma establishes the indication for inguinal dissection. Currently the deep (pelvic) part of the dissection is the subject of lively discussion. For the past 3 years we have been carrying out all pelvic lymph node dissections using an endoscopic extraperitoneal approach in combination with conventional superficial inguinal dissection. In analogy to endoscopic extraperitoneal hernia repair we open the extraperitoneal space with the aid of a dissection balloon and then perform a complete dissection of the para-iliac and obturator lymph nodes. The superficial part of inguinal dissection is then carried out in the conventional manner. Among a total of 31 consecutive dissections performed on 30 malignant melanoma patients between April 1999 and June 2002 neither intraoperative nor postoperative complications of the endoscopic part of the dissection were observed. While enabling better local tumor control as a result of the complete dissection, this modification entailing the use of endoscopic pelvic dissection also appreciably reduces the extent of operative trauma without compromising oncological radicalness or increasing morbidity. We recommend this approach to all surgeons with experience with endoscopic extraperitoneal procedures for use in patients requiring inguinal dissection.

Malignant gonadal mesothelioma.

Malignant mesothelioma of the gonads is a rare and highly lethal disease. Most of these tumors arise from the tunica vaginalis, which is a continuation of the mesothelium similar to the pleura and the peritoneum. However, intratesticular and ovarian mesotheliomas have also been described. Occasionally, patients with localized disease at the time of detection have been known to survive for more than 10 years; however, the majority will not live beyond 5 years, with median survival being approximately 23 months. The principle reasons for this are difficulty in making a preoperative diagnosis and advanced stage at the time of treatment. Surgery forms the mainstay of management for all stages of the tumor. Adjuvant therapy in the form of chemotherapy, immunotherapy, or radiotherapy has negligible benefit. It is essential to diagnose this rare entity at the early stages to allow complete surgical extirpation. For the management of localized disease, we suggest the following protocol: initial staging of suspected cases with computed tomographic scan of the abdomen and pelvis; radical inguinal orchiectomy or hemiscrotectomy; retroperitoneal lymph node dissection in cases with positive nodes on scan or biopsy; and inguinal node dissection in cases requiring hemiscrotectomy. For advanced or recurrent disease, we suggest local radical resection with chemotherapy, including high-dose cisplatin and doxorubicin for two cycles of 5 days each; add local radiotherapy for uncontrolled locally advanced disease.

Contemporary Morbidity From Lymphadenectomy For Penile Squamous Cell Carcinoma: The M.D. Anderson Cancer Center Experience

Inguinal lymphadenectomy can be curative in patients with small volume inguinal metastases and those with more significant adenopathy responding to combination chemotherapy. However, several series collected for 15 to 40 years attest to the significant morbidity associated with lymphadenectomy. We reviewed our recent experience with lymphadenectomy in patients with invasive penile cancer who were judged to require inguinal staging and therapeutic procedures to assess the incidence and magnitude of complications caused by this procedure, especially in those with no palpable adenopathy (prophylactic group). A total of 106 lymphadenectomy procedures were performed in 53 patients. The indications for dissection were prophylactic in 66 (62%) patients in whom a superficial dissection alone was completed on the ipsilateral side, therapeutic in 28 (26%) in whom superficial, deep and ipsilateral pelvic dissections were performed, and palliative in 12 (11%) undergoing extensive resection of inguinal and abdominal wall tissue after chemotherapy. Minor postoperative complications included those requiring local wound débridement in the clinic, mild to moderate leg edema, seroma formation not requiring aspiration and minimal skin edge necrosis requiring no therapy. Major complications included severe leg edema interfering with ambulation, skin flap necrosis requiring a skin graft, rehospitalization, deep venous thrombosis, death, or reexploration or other invasive procedures performed in the operating room. The incidence and magnitude of complications were compared with prior reports from our center and other series. A total of 41 (68%) minor and 19 (32%) major complications occurred with the 106 dissections (31 of 53 patients, 58%). Prophylactic and therapeutic dissections were associated with a lower incidence of complications compared with palliative dissections (p = 0.017 to 0.049). The incidence of major complications also trended lower in the prophylactic group compared with other indications (p = 0.05). One patient in the palliative group died of sepsis on postoperative day 15. When compared with 3 prior series, the incidence of skin edge necrosis in our series was significantly lower (8% versus 45% to 62%, p <0.0001). Similarly, the incidence and severity of edema in our series were significantly lower than in a prior report from our institution (23% versus 50%, p <0.0001). For select patients undergoing prophylactic inguinal dissection to detect the presence of microscopic metastases, the incidence and magnitude of complications appeared acceptable in our contemporary experience. Similarly the morbidity of therapeutic lymphadenectomy appeared acceptable, considering the potential therapeutic benefit. However, significant complications, including death, can be associated with palliative groin dissection. Optimal candidates are those having a significant response to systemic chemotherapy whose groins are grossly uninfected.

Management of inguinal lymph node metastases in patients with carcinoma of the anal canal: experience in a series of 270 patients treated in Lyon and review of the literature.

The authors performed a specific analysis of the clinical significance of inguinal lymph nodes metastases in patients with anal canal carcinoma (ACC). A retrospective analysis was conducted of 270 patients who were treated in Lyon between 1980 and 1996 with radiotherapy with curative intent for ACC: No elective irradiation of clinically normal inguinal areas was performed. Patients with metastatic inguinal lymph nodes were treated with inguinal dissection and postoperative irradiation with a dose of 50 grays over 5 weeks. Concomitant chemoradiation, usually with a regimen of fluorouracil and cisplatinum, was given to 159 patients. The median follow-up for the whole series was 72 months. Synchronous inguinal metastases were observed in 10% of patients (n = 27; the rate was 16% for patients with T3--T4 lesions), and the 5-year overall survival rate was 54.4%. Metachronous inguinal metastases were seen in 19 patients (7.8%), and the 5-year overall survival rate of these patients was 41.4%. An original finding was that, when the primary tumor clearly was located on a single lateral side of the anal canal, the inguinal lymphatic metastases was always homolateral to it (36 of 36 synchronous plus metachronous tumors). The data from this series of patients and a review of the literature are in favor of a selective approach in the management of inguinal lymph node involvement for patients with ACC, depending on the disease stage and the location of the primary tumors.

Superficial Inguinal and Radical Ilioinguinal Lymph Node Dissection in Patients with Palpable Melanoma Metastases to the Groin - An Analysis of Survival and Local Recurrence

The present study addresses the question whether an extended ilioinguinal dissection as compared to an only superficial inguinal dissection improves survival and/or local tumour control after the appearance of palpable melanoma metastases to the groin. We retrospectively analysed the data of 104 patients with 69 ilioinguinal and 35 superficial inguinal dissections (median follow up 127 months). Prognostic factors of survival and groin recurrence were assessed using Kaplan-Meier estimation and Cox proportional hazards model. By multifactorial analysis, metastatic involvement of two lymph nodes or less was associated with a significantly better survival rate than involvement of >2 or pelvic nodes (p=0.0002). After radical ilioinguinal dissection, patients with extremity-located primaries had a better prognosis than patients with truncal primaries (p=0.03). Tumour infiltration of the ilio-obturator compartment was found to be an independent factor of poor prognosis (p=0.0009). The probability of recurrence in the dissected groin paralleled the number of positive nodes and significantly increased if intransits were observed (p=0.0002). The extent of surgery, Breslow thickness, epidermal ulceration, sex, age and adjuvant chemotherapy neither significantly influenced survival nor local control rates. In summary, when metastatic inguinal nodes become palpable, the presence of pelvic metastases indicates systemic disease. After therapeutic groin dissection, local recurrence and survival depend rather on regional tumour burden than on the extent of surgery.

Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva

BACKGROUND Traditional inguinal lymphadenectomy includes the removal of a portion of the saphenous vein. The authors hypothesized that preserving the saphenous vein would decrease morbidity without affecting treatment outcome. METHODS A retrospective review of 83 patients with carcinoma of the vulva who underwent inguinal lymphadenectomy between 1990–1998 was performed. Postoperative short term and long term complications were evaluated. RESULTS A total of 139 inguinal dissections were performed in 83 patients. The saphenous vein was preserved in 62 patients and ligated in 77 patients. The clinical characteristics of the patients, the operating time, and the estimated blood loss were not significantly different between the two groups. The incidence rate of short term complications including fever, seroma, phlebitis, lymphocyst, and deep venous thrombosis also was similar. Cellulitis occurred in 39% of the patients who underwent vein ligation compared with 18% of the patients who underwent a vein-sparing procedure (P = 0.006). Short term (< 6 months) lower extremity lymphedema occurred in 70% of the vein-ligated group compared with 32% of the vein-spared group (P < 0.001). Chronic edema (≥ 2 years) was present in only 3% of the patients who underwent saphenous vein preservation compared with 32% of those who underwent vein ligation (P = 0.003). Chronic lymphedema in the vein-spared group was observed in only one patient who received postoperative radiation. Overall, individuals with preservation of the saphenous vein were less likely to develop complications (56% vs. 23%; P < 0.001). There was no difference in the rate of incidence of recurrent disease between the two groups. CONCLUSIONS Preservation of the saphenous vein during inguinal lymphadenectomy reduces both the short term and long term postoperative complications without affecting treatment outcome. The saphenous vein should be preserved routinely in patients undergoing inguinal lymphadenectomy. Cancer 2000;89:1520–5. © 2000 American Cancer Society.

Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva

Traditional inguinal lymphadenectomy includes the removal of a portion of the saphenous vein. The authors hypothesized that preserving the saphenous vein would decrease morbidity without affecting treatment outcome. A retrospective review of 83 patients with carcinoma of the vulva who underwent inguinal lymphadenectomy between 1990-1998 was performed. Postoperative short term and long term complications were evaluated. A total of 139 inguinal dissections were performed in 83 patients. The saphenous vein was preserved in 62 patients and ligated in 77 patients. The clinical characteristics of the patients, the operating time, and the estimated blood loss were not significantly different between the two groups. The incidence rate of short term complications including fever, seroma, phlebitis, lymphocyst, and deep venous thrombosis also was similar. Cellulitis occurred in 39% of the patients who underwent vein ligation compared with 18% of the patients who underwent a vein-sparing procedure (P = 0.006). Short term (< 6 months) lower extremity lymphedema occurred in 70% of the vein-ligated group compared with 32% of the vein-spared group (P < 0. 001). Chronic edema (>/= 2 years) was present in only 3% of the patients who underwent saphenous vein preservation compared with 32% of those who underwent vein ligation (P = 0.003). Chronic lymphedema in the vein-spared group was observed in only one patient who received postoperative radiation. Overall, individuals with preservation of the saphenous vein were less likely to develop complications (56% vs. 23%; P < 0.001). There was no difference in the rate of incidence of recurrent disease between the two groups. Preservation of the saphenous vein during inguinal lymphadenectomy reduces both the short term and long term postoperative complications without affecting treatment outcome. The saphenous vein should be preserved routinely in patients undergoing inguinal lymphadenectomy.

Judging the therapeutic value of lymph node dissections for melanoma>

Background: The management of the regional lymph nodes remains controversial for early-stage melanoma and for those patients with lymph node metastases; American Joint Committee on Cancer stage III. This study examines the importance of quality of the surgical resection measured by the extent of lymph node dissection (quartile of the total number of lymph nodes removed) to determine if this factor is an important prognostic factor for survival. Study Design: We reviewed our computer-assisted database of more than 8,700 melanoma patients prospectively collected from 1971 through the present to identify patients who underwent lymph node dissection for stage III melanoma. We included only patients who had their nodal dissections performed at our institute. Patients who underwent sentinel lymph node dissection were excluded. These patients were then analyzed as a group and by individual lymphatic basins: cervical, axillary, and inguinal basins. Univariate and multivariate analyses were used to examine the model that included tumor burden, thickness of the primary melanoma, gender, age, clinical status of the lymph nodes (palpable versus not palpable), and the primary site. The survival and recurrence rates were analyzed using the Cox proportional hazards model. Results: Five hundred forty-eight patients underwent regional lymph node dissections. Of these patients, 214 underwent axillary dissections, 181 inguinal dissections, and 153 cervical dissections. The extent of the nodal dissections was based on the quartile of nodes excised, ranging from 1 to 98 (mean ± SD = 25.8 ± 15.8). Patients were stratified by tumor burden and quartile of number of lymph nodes removed. The overall 5-year survival of patients with four or more lymph nodes having tumor and the highest quartile of lymph nodes removed was 44% and was 23% for the lowest quartile of total lymph nodes excised (p = 0.05). By univariate analysis, tumor burden (p = 0.0001), quartile of total lymph nodes removed (p = 0.043), and primary site (p = 0.047) were statistically significant for predicting overall survival. Gender, clinical status of the nodes, primary tumor thickness, age, and dissected basin were not significant (p > 0.05). By multivariate analysis only the tumor burden (p = 0.0001) and quartile of lymph nodes resected (p = 0.044) were statistically significant. Conclusions: The extent of lymph node dissection for melanoma when analyzed by quartiles is an independent factor in overall survival. This factor appears to be more important with increasing tumor burden in the lymphatic basin. The extent of lymph node dissection should be considered as a prognostic factor in the design of clinical trials that involve stage III melanoma.

Primary Nodal Gastrinomas An Immunohistochemical Study in Support of a Theory

○ Background.-The term primary lymph node gastrinoma was first used to describe a group of patients with gastrin-producing tumors present in lymph nodes located in a well-defined anatomic region. The patients had no known primary tumors in the pancreas or gastrointestinal tract and had disease-free survival for up to 18 years. The anatomic region in question has a triangular shape that extends from the cystic and common bile ducts to the second and third portion of the duodenum and the neck and body of the pancreas. The term gastrinoma triangle was coined to identify the area; in addition, it was postulated that lymph nodes located in the gastrinoma triangle normally contained neuroendocrine cells capable of secreting gastrin and other neuropeptides. From its inception, the postulate became the subject of controversy. Design.-To extend previous observations, we examined the lymph nodes located in the gastrinoma triangle of 20 autopsy cases for the presence of neuroendocrine cells, as determined by immunohistochemistry, using antibodies to a panneuroendocrine substance (eg, synaptophysin) and a specific neuropeptide (eg, gastrin). Scanning for positive cells was performed by 2 observers (M.E.H. and M.C.C.). We compared the findings in these lymph nodes with lymph nodes obtained from axillary and inguinal dissections during surgical procedures. Results.-In all, 417 lymph nodes were studied. Five of the 20 gastrinoma triangle cases contained synaptophysin reactive cells, whereas 3 had gastrin reactive cells. None of the axillary and inguinal lymph nodes contained neuroendocrine cells. Conclusion.-Our findings support the hypothesis of entrapment of neuroendocrine cells during development and the presence of primary nodal gastrinomas.

Primary nodal gastrinomas.

The term primary lymph node gastrinoma was first used to describe a group of patients with gastrin-producing tumors present in lymph nodes located in a well-defined anatomic region. The patients had no known primary tumors in the pancreas or gastrointestinal tract and had disease-free survival for up to 18 years. The anatomic region in question has a triangular shape that extends from the cystic and common bile ducts to the second and third portion of the duodenum and the neck and body of the pancreas. The term gastrinoma triangle was coined to identify the area; in addition, it was postulated that lymph nodes located in the gastrinoma triangle normally contained neuroendocrine cells capable of secreting gastrin and other neuropeptides. From its inception, the postulate became the subject of controversy. To extend previous observations, we examined the lymph nodes located in the gastrinoma triangle of 20 autopsy cases for the presence of neuroendocrine cells, as determined by immunohistochemistry, using antibodies to a panneuroendocrine substance (eg, synaptophysin) and a specific neuropeptide (eg, gastrin). Scanning for positive cells was performed by 2 observers (M.E.H. and M.C.C.). We compared the findings in these lymph nodes with lymph nodes obtained from axillary and inguinal dissections during surgical procedures. In all, 417 lymph nodes were studied. Five of the 20 gastrinoma triangle cases contained synaptophysin reactive cells, whereas 3 had gastrin reactive cells. None of the axillary and inguinal lymph nodes contained neuroendocrine cells. Our findings support the hypothesis of entrapment of neuroendocrine cells during development and the presence of primary nodal gastrinomas.

The pedicled anterolateral thigh island flap for inguinal defects

The interpolated anterolateral thigh flap islanded on its vascular pedicle, is a durable local flap option for large skin and soft tissue defects caused by inguinal block dissections. So far, this flap has not been described for resurfacing such defects. Two cases are presented to highlight the technique.

Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma of the lower extremity.

Lymphatic mapping and sentinel lymph node biopsy is a new technique used in the surgical treatment of patients with malignant melanoma. The purpose of this study was to evaluate the results of this approach for patients with melanoma of the lower extremity. Between May of 1994 and June of 1997 at the H. Lee Moffitt Cancer Center and Research Institute, 85 consecutive patients with clinical stage I and II melanoma of the lower extremity underwent lymphatic mapping and sentinel lymph node biopsy. These nodes were identified in all 85 patients by intraoperative lymphatic mapping with both radiolymphoscintigraphy and a vital blue dye injection. Eleven patients (12.9 percent) had histologically positive sentinel lymph nodes, and 10 patients underwent inguinal complete lymph node dissections. All 10 patients had no further histologically positive lymph nodes confirmed by subsequent complete dissection. Among 74 patients with histologically negative sentinel lymph nodes, only 2 patients (2.7 percent) developed inguinal nodal metastases during a mean follow-up period of 21.8 months (range, 13.5 to 58.3 months). The sensitivity of lymphatic mapping and sentinel lymph node biopsy in this series was 100 percent and the specificity was 97.3 percent. Therefore, we conclude that the use of lymphatic mapping and sentinel lymph node biopsy can accurately stage patients with melanoma of the lower extremity and provide a rational surgical approach for these patients.

Laparoscopic lymph node dissection

ObjectiveLaparoscopic lymph node dissection in the treatment of endometrial, cervical and ovarian cancer, endoscopic axillary dissection in breast cancer and endoscopic inguinal dissection in vulval cancer are surgical techniques that have been developed over the last 10 years. The careful investigation of this endoscopic field in selected cases of gynaecological malignancy was attempted in a combined study. It is the aim of the present paper to assess the endoscopic possibilities of lymphadenectomy while observing the same oncological principles as the laparotomy approach. Endoscopic surgical techniques may give patients a better quality of life within the treatment of their malignant condition.DesignClinical retrospective evaluation.SettingThe study was carried out at the Department of Obstetrics and Gynaecology, University of Kiel, Germany and at the Oncological Centre in Warsaw, Poland.Subjects60 patients were treated by endoscopic lymphadenectomy, and 38 of these were treated for endometrial cancer stages I and II according to the FIGO (International Federation of Obstetricians and Gynaecologists) classification.InterventionsEndoscopic pelvic lymphadenectomies and laparoscopic‐assisted vaginal hysterectomies (LAVH) were performed.Main outcome measuresEase of performance of pelvic lymphadenectomies, and number of lymph nodes obtained compared with laparotomy.ResultsAn average of 14 nodes per patient was removed. There were no complications.ConclusionsThe surgical approach to patients with endometrial cancer has changed. After laparoscopic surgical staging of endometrial cancer, the combined laparoscopic and vaginal surgical approach to treatment is possible, in properly selected patients by well‐trained surgeons. Lymphadenectomy and LAVH seem to be optimal surgical techniques for the treatment of endometrial cancer.

Multi-disciplinary operative management of vulval metastasis from rectal adenocarcinoma

A 61-year-old female developed vulval metastasis five months after a metastatic rectal carcinoma was treated by abdomino-perineal resection (APR) and pelvic exenteration, chemotherapy and radiotherapy. In view of her previous management and the anticipated defect a joint operative management was performed by the oncological and plastic surgical teams. She had bilateral en bloc inguinal node dissection and posterior vulvo-vaginectomy. Immediate reconstruction using bilateral gracilis myocutaneous flaps was complicated only by minor skin necrosis. The selection of flaps for reconstruction was limited by previous and current operative management.

Conservative trends in the surgical management of vulvar cancer: a University of Miami patient care evaluation study

The objective of this study was to determine the impact of conservative surgical trends in vulvar cancer related to morbidity, adequacy of surgical resection, recurrence rates and survival. A retrospective analyses of 160 patients treated surgically for vulvar cancer at the University of Miami/Jackson Memorial Medical Center from January 1, 1973 to December 31, 1991 was performed. Patients were divided into two groups based on the date of surgery. Group 1 patients (82) had surgery between January 1, 1973 to December 31, 1982. Group 2 patients (78) had surgery between January 1, 1983 and December 31, 1991. Patient demographics, stage, T N M classification and grade were not statistically different between groups. There was a significant trend away from curvilinear en bloc resection toward the use of a separate triple incision (P = 0.0001). Decreases in exenterative surgery and radical vulvectomy and concurrent increases in radical local excision and hemivulvectomy occurred (P = 0.014). In addition, deep pelvic node dissection was abandoned and an increase in unilateral vs bilateral inguinal node dissection also occurred, yet this did not reach significance (P = 0.09). No difference in the mean number of total nodes, number of groin nodes obtained and percentage of patients with positive nodes or positive margins was found. With the trend toward more conservative surgery, statistically significant decreases in mean estimated blood loss (1 334 ml to 834 ml; P = 0.009), length of days hospitalized (31.5 to 19.7; P = 0.001) and operative times (5.3 h to 4.1 h; P = 0.002) occurred. No difference was noted in minor wound breakdown rates; however, there were significantly fewer major wound breakdowns in the conservatively treated group (43.2% vs 16.6%) (P = 0.0003). Major wound breakdowns occurred more frequently in the abdomen/groin region in group 1 vs 2 (24.7% vs 7.7%; P = 0.004). Frequencies of wound breakdown in relation to the number of clinical risk factors (smoking, hypertension, diabetes, obesity, other) for all patients was found to be highly statistically significant (P = 0.006). When evaluating patients with squamous carcinoma only, recurrence rates and 5-year survivals were not statistically different (P = 0.45). The trend toward conservative surgical management of vulvar carcinoma significantly reduced morbidity with no impact on recurrence rates or 5-year survival.

Accurate Staging of Carcinoma of the Penis in Men with Nonpalpable Inguinal Lymph Nodes by Modified Inguinal Lymphadenectomy

Purpose The accuracy and safety of a modified inguinal lymphadenectomy in the staging of penile cancer cases with nonpalpable groin nodes were assessed. Materials and Methods A modified inguinal lymph node dissection in which the saphenous vein is preserved together with reduction of the lateral, distal and proximal margins of dissection was performed on 12 consecutive men with invasive squamous carcinoma of the penis and negative inguinal nodes. Results Five patients were identified with nodal metastasis. The sites of inguinal node involvement were localized within the boundaries of the dissection in all patients. No major complications occurred, and no permanent lymphedema or flap necrosis was encountered. With a followup of 14 to 72 months no patient has had recurrent disease. Conclusions The modified inguinal dissection is a reliable staging technique that also provides therapeutic benefit to patients with penile cancer and clinically negative nodes.

Surgical management of malignant melanoma.

Wide and mutilating surgical excision is contraindicated for primary malignant melanoma. Tumours less than 1 mm thick require only 1 cm excision margins while those 1-4 mm thick need only 2 cm margins. Primary closure without skin grafting should always be attempted. Axillary and inguinal block dissection remain standard treatment for established lymphatic metastases but elective block dissection is still controversial and should only be performed in the context of a clinical trial. Selective lymphadenectomy based on intraoperative lymphatic mapping is being evaluated. Isolated limb perfusion plays an important role in palliation, and perfusion with a combination of cytotoxic agents and cytokines is an exciting therapeutic advance. Laser vapourization under local or general anaesthesia is an alternative way of treating multiple small cutaneous and subcutaneous lesions and is much better tolerated.

Transperitoneal closure of the internal ring in incarcerated infantile inguinal hernias

Over a 6-year period, 14 infants with a total of 16 inguinal hernias (IH) underwent transperitoneal closure of the internal ring (TPIR). This was performed through a minilaparotomy, using a purse-string suture placed around the internal ring from within. A difficult inguinal dissection of an edematous and friable spermatic cord was avoided. TPIR was performed for incarceration in 13 of the infants and for recurrence of the hernia within 24 hours of herniotomy in one. There were no intraoperative problems, and during follow-up there was no evidence of testicular atrophy or recurrence of the hernia. This suggests that TPIR is a reliable and safe operation in babies for whom the alternative inguinal approach would be difficult. These situations include hernias that are irreducible and early recurrence in which dissection of the cord would risk damage to the vas deferens or testicular vessels.

Malignant melanoma of the vulva and vagina: a report of 23 cases presenting in a 10-year period.

In the 10-year period ending December 1991, 14 patients with primary melanoma of the vulva and nine with primary melanoma of the vagina were diagnosed and treated. Of the patients with vulval melanoma, three were treated surgically with wide local excision of the tumor alone, six had wide local excision with inguinal node dissection, and five had radical vulvectomy with inguinal node dissection. Four of the patients with vaginal melanoma had wide local excision; two had wide local excision with inguinal and or pelvic node dissection; and three had surgery that was more radical than this. Two years after diagnosis, all of the patients whose tumors were 2 mm thick or more had died, or were alive but had distant metastases. This was independent of the apparent surgical success of local excision of the disease. We consider that conservative procedures in the management of invasive melanoma of the lower female genital tract should be the rule, and that radical procedures should be reserved for palliation rather than cure.

Intraoperative laparoscopy in unilateral hernia repair to detect a contralateral patent processus vaginalis

The controversy over the need to explore the asymptomatic contralateral groin for the existence of a hernia sac in children who undergo inguinal hernia repair is not easy to resolve. To detect the patency of the contralateral processus vaginalis, we used intraoperative nonpuncture laparoscopy. By insufflating carbon dioxide and inserting a laparoscope through the open hernia sac, the opening of the contralateral processus vaginalis was clearly seen. A patent processus vaginalis on the opposite side is considered to be a potential hernia. A total of 74 children, 56 boys and 18 girls, were involved in the study. All of them had inguinal dissection on the symptomatic side and laparoscopy was performed through the opened hernial sac. A contralateral patent processus vaginalis was found in 22 children, 14 boys and 8 girls, by laparoscopy. The results were confirmed by surgical exploration of the opposite groin. There were no false-positive and no false-negative results. Intraoperative non-puncture laparoscopy is a simple, safe, and accurate method of detecting patency of a contralateral processus vaginalis. When used instead of routine bilateral exploration, this procedure can avoid many unnecessary surgical operations.