Groin Defect Reconstruction After Inguinal Lymphadenectomy
Groin defect reconstruction addresses the skin, soft-tissue and femoral-vessel coverage problem left after inguinal (ilioinguinal) lymph node dissection for penile, vulvar, anal or cutaneous (melanoma) cancer, independent of the oncologic indications and nodal boundaries for the dissection itself.[1][2] The reconstructive problem is shared across these cancers: a groin incision through often-irradiated or lymphedematous skin, with the femoral vessels left superficial once the overlying fat and nodal tissue are removed.
The Reconstructive Problem
Wound complications after inguinal lymphadenectomy are common. In a 163-patient, 237-dissection cohort from a single center, one or more wound complications occurred after 58% of procedures (10% of these graded severe), with wound infection in 43%, seroma in 24% and skin-flap problems in 16%.[3] In a more recent 421-patient, 660-dissection series using a fascial-sparing technique that preserves Scarpa's and Camper's fascia and the subcutaneous veins, overall complications fell to 36.1%, with wound infection in 11.9%, deep wound dehiscence in 5.0% and lymphedema in 24.7%.[4] Reconstructive options are considered when skin and soft-tissue loss, wound breakdown or exposed femoral vessels exceed what local wound care and primary closure can manage.
A sartorius muscle flap is often used specifically to interpose muscle over exposed femoral vessels, but its use has itself been associated with a higher rate of moderate-to-severe wound complications in the same 163-patient cohort cited above (odds ratio 2.64, p = 0.04 on univariable analysis; 2.12, p = 0.06 after multivariable adjustment). This is an observational association in a cohort where sartorius transposition was presumably used preferentially in more extensive or higher-risk dissections, not evidence that the flap itself causes complications, but it is a reason not to treat sartorius coverage as uniformly protective.[3]
Sartorius Muscle Flap
The sartorius is supplied by six to eight segmental vascular pedicles along its length, grouped by a cadaveric angiographic study into a proximal major-pedicle cluster located 18 to 25 cm from the anterior superior iliac spine (ASIS), perfusing about 80% of the muscle, and a distal major-pedicle cluster 35 to 44 cm from the ASIS, perfusing about 90%; either cluster can serve as a pivot point for a local transposition flap.[5]
For femoral-vessel coverage after inguinal lymphadenectomy, division of the muscle near its proximal origin at the ASIS, with limited mobilization that preserves its segmental blood supply along the thigh, allows the muscle to be rotated medially over the exposed vessels like a hinged door; the proximal 10 to 12 cm of muscle is typically sufficient for this coverage. Dissection carried medially beyond the first preserved segmental pedicle risks muscle necrosis.[1] This technique has been combined, in a small case series, with an abdominal cutaneous advancement flap (below) to achieve primary closure of large groin defects, including bilateral defects, with primary wound healing and preserved graft survival despite postoperative radiotherapy to the flap site in one of the three reported patients.[2]
Skin and Soft-Tissue Coverage
| Defect pattern | Reported option | Notes |
|---|---|---|
| Large anterior groin skin defect | Abdominal cutaneous advancement flap | Described for primary closure of large, including bilateral, groin defects after extensive dissection with skin excision; reported advantages are technical simplicity, lower morbidity and favorable cosmesis compared with the other flaps used for this purpose, in a small series of 3 patients[2] |
| Medial groin / genitocrural skin defect | Scrotal advancement flap | Used in men when adjacent scrotal skin laxity allows advancement to cover a medial defect; attributed operative description, not a comparative series[1] |
| Composite defect with exposed vessels and soft-tissue deficit | Sartorius transposition plus regional flap (anterolateral thigh, tensor fasciae latae or gracilis) | For wounds too large or too deep for local skin advancement alone; flap choice depends on pedicle availability, defect size and depth, and whether the groin field itself was part of the dissection or radiation field |
No comparative trial establishes superiority among these options for groin coverage; selection depends on defect size, depth, prior radiation and the vascular territory left intact by the dissection.[1][2]
Lymphatic Complications
Lymphocele, lymphorrhea and chronic lower-extremity lymphedema are common after inguinal lymphadenectomy and are a separate problem from the acute wound-coverage issues above; lymphedema was reported in 24.7% of groins in the fascial-sparing series cited above.[4] Evaluation and management of established lower-extremity or genital lymphedema, including compression, complex decongestive therapy and lymphatic microsurgery, are covered on Genital Lymphedema and on the lymphedema-specific reconstructive pages in this atlas.
See Also
- Genital Lymphedema
- Anterolateral Thigh Flap
- Tensor Fasciae Latae (TFL) Flap
- Gracilis Flap
- Pelvic and Perineal Flap Postoperative Care
- Vulvar Reconstruction
- Penile Reconstruction
References
1. Brandes SB, Eswara JR. Penile and Inguinal Reconstruction and Tissue Preservation for Penile Cancer. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:655-673.
2. Tabatabaei S, McDougal WS. Primary skin closure of large groin defects after inguinal lymphadenectomy for penile cancer using an abdominal cutaneous advancement flap. J Urol. 2003;169(1):118-120. doi:10.1016/S0022-5347(05)64049-9
3. Stuiver MM, Djajadiningrat RS, Graafland NM, Vincent AD, Lucas C, Horenblas S. Early wound complications after inguinal lymphadenectomy in penile cancer: a historical cohort study and risk-factor analysis. Eur Urol. 2013;64(3):486-492. doi:10.1016/j.eururo.2013.02.037
4. Schifano N, Fallara G, Rezvani S, et al. Outcomes following radical inguinal lymphadenectomy for penile cancer using a fascial-sparing surgical technique. World J Urol. 2023;41(6):1581-1588. doi:10.1007/s00345-023-04396-x
5. Mojallal A, Wong C, Shipkov C, et al. Redefining the vascular anatomy and clinical applications of the sartorius muscle and myocutaneous flap. Plast Reconstr Surg. 2011;127(5):1946-1957. doi:10.1097/PRS.0b013e31820cf44a