1. Ray’s ‘River Flow Incision’ Technique for Ilio-Inguinal Dissection
to minimize morbidity, specially flap necrosis
M D Ray*, A R Singh, S Kumar, N K Shukla, SVS Deo, D Pandey
Dept of Surgical Oncology, DR BRA IRCH
All India Institute of Medical Sciences, New Delhi, India
Introduction
Technique of the Iliac dissection
Ilio-inguinal block dissection (IIBD)
Indications
Both male & female genital and anorectal cancers
Skin cancers of lower limbs, perineal, groin, skin adnexal tumour, SCC, melanoma, STS etc.
Incisions described:
Lazy S, T-incision, B incision, Horizontal incision etc
Flaps described:
TFL Flap/ VRAM Flap/ Anterior Scrotal Flap ,Bi pedicle Flap etc.
Complications
Flap necrosis, seen in up to 65% of all cases in literature, average 30%-40% in a standard centre.
A modified Technique:
We like to share our initial experience of a new surgical approach for IIBD, i.e. Ray’s ‘River Flow’ incision technique – a modified horizontal incision technique
The external oblique muscle is divided along the skin incision. The internal oblique and transverses abdominis muscle are split along the muscle fibres. Then we enter into the retro peritoneal space. Lymph nodes dissection in the iliac territories is performed with standard technique.
Boundary of Standard Iliac Dissection
Above-up to common iliac bifurcation
Below-pelvic diaphragm i.e. upto levator ani and obturator inernus muscles
Laterally – genital branch of genetofemoral nerve.
Medially up to bladder wall and
Obturator nerve posteriorly
Results
Aim of the Study
A total of 34 patients under went 55 IIBDs.
Bilateral IIBD: 21 patients and Unilateral IIBD: 13 patients
Primary Diagnosis:
Carcinoma penis : 12 patients
Carcinoma Vulva : 7 patients
Inguinal mets of unknown origin : 4 patients
Urethral carcinoma : 2 patients
Carcinoma cervix : 2 patients
Melanoma lower limb : 3 patients
SCC Lower Limb : 2 patient
STS lower limb : 2 Patient
An observational clinical study was designed aiming to minimize the rate of groin skin flap necrosis.
Materials and Methods
All patients who underwent unilateral / bilateral ilio-inguinal block dissection from July 2012 till Oct 2014 were included in the study.
The ‘Ray’s ‘River Flow’ incision’ was made and standard ilio-inguinal block dissection done.
Flap viability, seroma formation, lymphorea, lymphedema, infection etc. were observed during hospitalisation and followed up.
Intra-operative monitoring:
There should be good bleeding at the flap margins. Still we freshen both the margins routinely
Post-operative monitoring(First 30 days) :
No operative mortality
No Flap necrosis
Seroma: 4 patients
Wound infection and Dehiscence: 3 patients
The position of the patient
Ray’s ‘River Flow’ incision
Ray’s ‘River Flow’ incision (Two-parallel curvilinear incisions- inguinal & iliac)
Inguinal Incision:
Approx 5-7cm curvilinear incision is made 4 cm below and parallel to inguinal ligament
Iliac Incision:
Approx 5-7cm curvilinear incision is made 4 cm above and parallel to inguinal ligament
The curves of each incision indicate medial and lateral limit of both the dissections
During follow-up(After30 days)
Three had lymphedema
Two had DVT
Oncological Outcome
Recurrence: One patient with primary unknown, the disease recurred in multiple sites i.e. in lungs and mediastinum, rectroperitoneal, supraclavicular area including the inguinal region, and one patient of a Urethral carcinoma had local recurrence.
The hip and thigh are on external rotation and abduction. Knee is on flexion position.
Ray’s ‘River Flow’ Incision
Flap is raised just below the fascia scarpa
On follow-up: Both the Incision wounds are well healed.
Conclusion
The Boundary of Inguinal Dissection
Ray’s ‘River Flow’ incision technique for ilioinguinal block dissection is an effective method to minimize flap necrosis without compromising adequate dissection.
Upper limit: 3 cm above the inguinal ligament i.e. external oblique aponeurosis and spermatic cord / round ligament.
The lateral limit of dissection is kept up to the medial border of Sartorius, not beyond.
The medial limit is kept up to the lateral border of adductor longus, not beyond.
Lower Limit: Apex of the femoral triangle.
REFERENCES
Groin recurrence in patients with early vulvar cancer following superficial inguinal node dissection Ahmad El Afandy, Hussein Soliman, , Magdy El Sherbiny, Hatem Abo Elkasem DOI: /j.jnci
Hegarty PK, Dinney CP, Pettaway CA. Controversies in ilioinguinal lymphadenectomy. Urol Clin North Am. 2010;37:
Ravi R. Morbidity following groin dissection for penile ca. Br J Urol. 1993;72:941-5
Pandey D, Mahajan V, Kannan RR. Prognostic factors in node-positive carcinoma of the penis. J Surg Oncol. 2006;93:133-8.
Spratt J. Groin dissection. J Surg Oncol. 2000;73:
Conflict of interest - none.
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