04 Malignant Skin Lesions

The specimen is then dissected free from the femoral

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Unformatted text preview: rting medially at the lateral edge of the adductor longus and proceeding laterally [see Figures 6 and 7].The femoral vessels are left undisturbed.The saphenous vein is ligated and divided at the fossa ovalis [see Figure 8]; it is also ligated and divided as it exits the femoral triangle distally.The specimen is then dissected free from the femoral nerve.This step usually entails sacrificing branches of the lateral femoral cutaneous nerve, thereby resulting in numbness of the anterolateral thigh. Cloquet’s lymph nodes are located medial to the femoral vein under the inguinal ligament.These nodes are dissected out and submitted as a separate specimen. If Cloquet’s nodes contain melanoma, the risk that iliac nodes will harbor melanoma is high, and a deep groin dissection should be performed (see below). Figure 7 Superficial groin dissection. The groin dissection is continued on the lateral side. Fat and Lymphatics Great Saphenous Vein Femoral Sheath Femoral Vein Femoral Artery Figure 8 Superficial groin dissection. The great saphenous vein is ligated and divided. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE 4 Malignant Skin Lesions — 11 DEEP GROIN DISSECTION The inguinal ligament is divided, and the inguinal canal is further exposed by releasing the internal oblique abdominal muscle, the transversus abdominis, and the fascia transversalis and dissecting into the retroperitoneal space.The deep circumflex iliac vessels are ligated, and the peritoneum is separated from the preperitoneal fat and nodes by means of blunt finger dissection. Alternatively, rather than dividing the inguinal ligament, one may make a separate incision in the external oblique fascia parallel to and above the inguinal ligament. Retractors are inserted to widen the retroperitoneal space, and the peritoneum and the abdominal viscera are retracted medially. The chain of lymph nodes, areolar tissue, and adventitial tissues along the external iliac vessels is dissected; the dissection proceeds proximally to the origins of the internal iliac vessels (avoiding the ureter) and incorporates the nodes overlying the obturator foramen while carefully avoiding injury to the obturator nerve.The deep epigastric vessels are usually ligated at their origins from the external iliac artery and vein. The lymph node–bearing specimen is then removed as a unit, oriented, and marked with sutures for orientation and identification. The inguinal canal is reconstructed to prevent a hernia. Any defect medial to the femoral vessels under the ligament is sutured closed with Cooper’s ligament.The sartorius is detached from the anterior superior iliac spine and is sutured to the midportion of the inguinal ligament to cover the femoral vessels.The skin and the subcutaneous tissues are then closed in layers over a soft suction drain. References 1. Miller DL, Weinstock MA: Nonmelanoma skin cancer in the United States: incidence. J Am Acad Dermatol 30:774....
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