What are the guidelines for laparoscopic excision of an inguinal lymph node?

Laparoscopic Excision of Inguinal Lymph Node

Video endoscopic inguinal lymphadenectomy (VEIL) or robotic-assisted laparoscopy for inguinal lymph node excision shows promise with reduced complication rates compared to open procedures, but the open surgical approach should still be considered the standard until laparoscopic approaches are validated in larger surgical series with longer follow-up. 1

Patient Selection Criteria

• VEIL is appropriate for patients who would otherwise warrant an open procedure, specifically: 1

  • Patients with palpable lymphadenopathy
  • Patients with nonpalpable nodes and a T2 or greater primary tumor with high-grade features and/or vascular invasion

• Bulky or fixed lymph nodes (≥4 cm) are generally not considered amenable to laparoscopic excision 1

Surgical Technique

• The lymph node template for VEIL follows the modified inguinal lymphadenectomy approach with the following boundaries: 1

  • Sartorius muscle laterally
  • Adductor longus muscle medially
  • Inguinal ligament and spermatic cord superiorly

• Unlike the open procedure, VEIL does not always preserve the saphenous vein 1

• Robotic-assisted VEIL (RA-VEIL) can be performed using ports positioned at the apex of the femoral triangle or the hypogastrium 1

Outcomes and Complications

• Comparative studies show significant reduction in wound-related complications with VEIL/RA-VEIL compared to open procedures: 1

  • 20% complication rate with VEIL vs. 70% with open procedure in one comparative study
  • Significantly lower rates of wound infection and skin necrosis (OR 0.229 and 0.16, respectively)

• Lymphatic-related complications (lymphedema, lymphocele) appear similar between laparoscopic and open approaches 1

• Oncologic outcomes in limited studies show promising results: 1

  • No recurrences at median follow-up of 33 months in one comparative study
  • Similar nodal yield between VEIL and open procedures, suggesting comparable oncologic adequacy

Postoperative Management

• Drains should be removed when drainage is less than 30 to 50 mL/day, typically 3 to 17 days postoperatively 1

• Consider prophylactic oral cephalosporin (or other gram-positive covering broad-spectrum antibiotic) for several weeks postoperatively to decrease wound-related complications 1

Current Guideline Recommendations

• The National Comprehensive Cancer Network (NCCN) and European Association of Urology (EAU) guidelines still consider open inguinal lymph node dissection (ILND) as the standard approach (level of evidence: 2a; strength of recommendation: strong) 1

• Minimally invasive techniques (VEIL/RA-VEIL) are recommended only in clinical trial settings due to limited evidence and uncertain long-term oncological safety 1

Special Considerations

• For patients with bulky disease (lymph nodes ≥4 cm), consider neoadjuvant chemotherapy prior to surgical excision 1

• For patients with confirmed pelvic nodal metastasis or those with 2 or more positive inguinal nodes, consider pelvic lymph node dissection (PLND) 1

• The learning curve for minimally invasive inguinal lymphadenectomy is steep, even for surgeons experienced in laparoscopic techniques 2

Limitations and Caveats

• While minimally invasive approaches show promise in reducing morbidity, they require validation in larger surgical series with longer follow-up 1, 3

• Most studies on RA-VEIL have been limited to clinically node-negative (cN0) cases, with limited data on confirmed node-positive disease 1

• Consider referral to tertiary centers with substantial experience in these techniques 1, 4