Dissection of the Iliac and Obturator Nodes in Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • General:
    • I generally perform a deep groin dissection (dissection of the iliac and obturator nodes) for the following indications:
      • Known involvement of the nodes revealed by preoperative imaging studies
      • More than three grossly positive nodes in the superficial lymph node dissection specimen
      • Metastatic disease in Cloquet node:
        • If performed
  • Incision:
    • To gain access to the deep nodes, we extend the skin incision superiorly if performed concomitantly with a superficial groin dissection
    • If a deep groin dissection only is to be performed:
      • I generally use a dedicated right lower quadrant incision
  • Lymph Node Dissection:
    • The external oblique muscle:
      • Is split from a point superomedial to the anterior superior iliac spine to the lateral border of the rectus sheath
    • The internal oblique and transversus abdominis muscles:
      • Are divided, and the peritoneum is retracted superiorly
    • An alternative approach:
      • Sometimes used when extensive disease populates this region:
        • Is to split the inguinal ligament vertically:
          • Medial to the femoral vein
    • The ureter is exposed:
      • As it courses over the iliac artery
    • The inferior epigastric artery and vein are divided, if necessary
    • The bifurcation of the common iliac artery marks the cephalad extent of the dissection:
      • All nodes are taken along the external iliac artery to the inguinal ligament caudally
    • Nodes overlying the external iliac vein:
      • Are dissected to the point at which the internal iliac vein courses under the internal iliac artery
    • The plane of the peritoneum is traced along the wall of the bladder:
      • The fatty tissues and lymph nodes are dissected off the perivesical fat starting at the internal iliac artery
    • Dissection is completed on the medial wall of the external iliac vein, and the nodal chain is further separated from the pelvic fascia until the obturator nerve is seen
    • Obturator nodes:
      • Are located in the space between the external iliac vein and the obturator nerve (in an anteroposterior direction) and between the internal iliac artery and the obturator foramen (in a cephalad–caudad direction)
    • The obturator artery and vein usually need not be disturbed
  • Wound Closure:
    • The transversus abdominis, internal oblique, and external oblique muscles:
      • May be closed with running sutures
    • The inguinal ligament, if previously divided:
      • Is approximated with interrupted nonabsorbable sutures to Cooper ligament medially and to the iliac fascia lateral to the femoral vessels
    • A closed suction drain is placed in the deep pelvic space exiting through a separate small incision
  • Postoperative Management:
    • Suction drainage is continued until output is less than 20 mL to 30 mL per day for 2 consecutive days
    • The pelvic drain is usually removed prior to hospital discharge
    • Ambulation is encouraged the day after surgery
    • Patients are hospitalized postoperatively for expectant management of potential ileus after deep pelvic surgery and for pain control, usually for a duration of 2 to 3 days
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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