Surgical intervention is a Machiavellian endeavor: the ends justify the means. This obligates the clinician to minimize the risk of a procedure to justify the gains obtained from an intervention. Progress in medical knowledge and technology, improvements in anesthesia, and an increased understanding of the biology of disease have all led to better selection of patients, better intraoperative management, and concomitant reductions in morbidity.

These considerations come into sharp focus for clinicians who treat patients with melanoma. Despite significant advances in recent years, melanoma still lags well behind many other cancers in the options for systemic therapy for advanced disease. As a result, surgery remains an important component in the armamentarium of tools for treating patients with this malignancy.

With the completion of accrual of the Multicenter Selective Lymphadenectomy Trial- II, surgical intervention is left as the only standard therapy for patients with lymph node metastases. Despite this, as many as 50% of patients who should receive surgical lymphadenectomy do not undergo this procedure.

 A suggested motivation behind the failure to refer patients for appropriately indicated surgery is the concern about morbidity from the procedure. This is especially true for inguinal lymphadenectomy, which has reported rates of wound complications above 50% in most studies.

During the past 25 years, a number of methods have been implemented to reduce morbidity from the surgical management of regionally metastatic disease. These have included: (1) the use of sentinel node biopsy to reduce the number of patients undergoing regional lymphadenectomy; (2) novel applications of minimally invasive surgical techniques; and (3) improvement in the selection of patients for surgery. Here we highlight a novel minimally invasive approach to inguinal lymphadenectomy that, in early data, has shown reduced morbidity, oncologic outcomes similar to standard procedures, and improved patient results.

Videoscopic inguinal lymphadenectomy (VIL) has been developed as a minimally invasive approach to superficial groin dissection. In brief, the approach utilizes standard laparoscopic instrumentation and techniques to remove the inguinal nodal packet under videoscopic guidance. (The standard three-incision VIL technique has been described in detail elsewhere.

The technique was first used by Bishoff in patients with penile cancer,

 and subsequent experience has shown reductions in wound-related morbidity.

 On the basis of this description, a research group at the Winship Cancer Institute of Emory University extended and modified the procedure to meet the requirements for a complete melanoma dissection, allowing it to be applied to all malignancies that may need groin dissection, inclusive of anal, vulvar, urethral, penile, and scrotal cancers. Since initiallydescribing the approach, we have performed more than 100 videoscopic lymphadenectomies. In October 2014, we reported the outcomes of the the procedure at the American College of Surgeons Clinical Congress (Squires et al, American College of Surgeons Surgical Forum, unpublished data).

This report included patients with both melanoma and genitourinary malignancies. The teamat Emory previously reviewed the subset of patients undergoing the procedure for melanoma only, and these data were reported at the Southern Surgical Association meeting in December 2013 and were published in the Journal of the American College Surgeons shortly thereafter.15 The oncologic outcomes for patientsundergoing VIL for melanoma are comparable to those experienced by a similar cohort of patients receiving the traditional open approach for the malignancy (

In a separate study, Abbott et al reported similar lymph node yields after VIL in patients with melanoma.

 When lymph node yield is used as an indirect measure of adequate oncologic resection,this report appears to confirm that VIL delivers similar results to those obtained with open superficial inguinal lymphadenectomy.

		Table: Comparative Outcomes in Patients Undergoing VIL Versus Open Lymphadenectomy for Metastatic Melanoma

Perhaps most importantly, fewer complications occur after VIL than after open superficial inguinal lymphadenectomy. In a comprehensive analysisof 29 procedures, using a very strict descripti of ”complications,” 42% of patients who underwent VIL had complications; however, the majority were classified as minor.

 This analysis used a broad definition of complication; seroma and lymphocele were included as significant complications, and a subjective definition of lymphedema was used. A follow-up to this study reviewing 108 procedures and comparing them with open lymphadenectomy revealed marked reductions in complications and was a component of the presentation at the American College of Surgeons. Reduced complication rates translate into decreased length of hospitalization and hopefully will lead to more appropriate adherence to therapeutic guidelines.

Reducing morbidity from surgical intervention remains a primary focus for all individuals involved in the care of patients. Recent progress in minimally invasive techniques has led to a transformation in risk and markedly better outcomes for patients. VIL is one approach that appears to provide equal oncologic outcomes with reduced morbidity for patients with melanoma metastatic to regional nodes.

			Bilimoria KY, Balch CM, Bentrem DJ, et al. Complete lymph node dissection for sentinel node-positive melanoma: assessment of practice patterns in the United States [published online April 15, 2008]. 

			Coit DG, Peters M, Brennan MF. A prospective randomized trial of perioperative cefazolin treatment in axillary and groin dissection. 

			Beitsch P, Balch C. Operative morbidity and risk factor assessment in melanoma patients undergoing inguinal lymph node dissection. 

			Sabel MS, Griffith KA, Arora A, et al. Inguinal node dissection for melanoma in the era of sentinel lymph node biopsy. 

			Chang SB, Askew RL, Xing Y, et al. Prospective assessment of postoperative complications and associated costs following inguinal lymph node dissection (ILND) in melanoma patients [published online March 25, 2010]. 

			de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity after inguinal sentinel lymph node biopsy and completion lymph node dissection in patients with cutaneous melanoma [published online June 27, 2006]. 

			van Akkooi AC, Bouwhuis MG, van Geel AN, et al. Morbidity and prognosis after therapeutic lymph node dissections for malignant melanoma [published online December 11, 2006].

			Guggenheim MM, Hug U, Jung FJ, et al. Morbidity and recurrence after completion lymph node dissection following sentinel lymph node biopsy in cutaneous malignant melanoma. 

			Poos HP, Kruijff S, Bastiaannet E, et al. Therapeutic groin dissection for melanoma: risk factors for short term morbidity [published online December 2, 2008]. 

			Delman KA, Kooby DA, Ogan K, et al. Feasibility of a novel approach to inguinal lymphadenectomy: minimally invasive groin dissection for melanoma. 

			Bishoff JT, Basler JW, Teichman JM, Thompson IM. Endoscopic subcutaneous modified inguinal lymph node dissection for squamous cell carcinoma of the penis. 

			Delman KA, Kooby DA, Rizzo M, et al. Initial experience with videoscopic inguinal lymphadenectomy [published online december 24, 2010]. Ann Surg Oncol. 2011;18(4):977-982.

			Abbott AM, Grotz TE, Rueth NM, et al. Minimally invasive inguinal lymph node dissection (MILND) for melanoma: experience from two academic centers [published online August 9, 2012]. 

			Master VA, Jafri SM, Moses KA, et al. Minimally invasive inguinal lymphadenectomy via endoscopic groin dissection: comprehensive assessment of immediate and long-term complications [published online August 15, 2012]. 

			Martin BM, Etra JW, Russell MC, et al. Oncologic outcomes of patients undergoing videoscopic inguinal lymphadenectomy for metastatic melanoma [published online December 24, 2013]. 

Articles

Surgical intervention is a Machiavellian endeavor: the ends justify the means. This obligates the clinician to minimize the risk of a procedure to justify the gains obtained from an intervention.

By Keith A. Delman, MD

Articles

Novel VIL Approach Reduces Complications From Regional Lymphadenectomy in Melanoma