Annals of Surgical Oncology Cite Track
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10.1245/ASO.2005.09.022
Annals of Surgical Oncology 12:793-799 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Preventing Lymphedema and Morbidity With an Omentum Flap After Ilioinguinal Lymph Node Dissection

Laurent Benoit, MD1,2, Christophe Boichot, MD3, Nicolas Cheynel, MD1, Laurent Arnould, MD4, Bruno Chauffert, MD5, Jean Cuisenier, MD2 and Jean Fraisse, MD2

1 Service de Chirurgie Digestive, Thoracique, et Cancérologique, CHU du Bocage, B.P. 77908, 21079 Dijon Cedex, France
2 Service de Chirurgie, Centre G-F Leclerc, 1 Rue du Pr Marion, B.P. 77980, 21079 Dijon Cedex, France
3 Service de Médecine Nucléaire, Centre G-F Leclerc, 1 Rue du Pr Marion, B.P. 77980, 21079 Dijon Cedex, France
4 Laboratoire d’Anatomopathologie, Centre G-F Leclerc, 1 Rue du Pr Marion, B.P. 77980, 21079 Dijon Cedex, France
5 Service d’Oncologie Médicale, Centre G-F Leclerc, 1 Rue du Pr Marion, B.P. 77980, 21079 Dijon Cedex, France

Correspondence: Address correspondence and reprint requests to: Laurent Benoit, MD; E-mail: laurent.benoit{at}chu-dijon.fr


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Pedicled omentoplasty has been advocated to prevent the formation of lymphocysts and lymphedema after pelvic lymph node dissection, We evaluated the possible benefit of a pediculated omentoplasty placed in the groin for preventing complications after ilioinguinal lymph node dissection.

Methods: In this pilot study, we report a series of four women and three men with inguinal metastatic lymph nodes. Each was treated with a pediculated omentoplasty after groin dissection. We examined complications such as lymphedema, lymphorrhea, wound breakdown, skin necrosis, and lymphocysts.

Results: Only one wound breakdown with skin necrosis was observed, and it healed satisfactorily in 10 days without exposing the femoral vessels. No lymphocele or infectious complications occurred, even though no antibiotic prophylaxis was used. Midthigh circumference increase ranged from 1.5 to 7 cm in four cases but remained asymptomatic. Furthemaore, lymphedema of the lower limb decreased in the three remaining patients, who previously had an enlargement of the thigh. No evidence of peritoneal carcinomatosis was noted during the 4-month follow-up.

Conclusions: Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluids and resulted in less lymphedema in the lower limb even after radiotherapy. Pedicled omentoplasty reduces both short-term and long-term postoperative complications without affecting treatment outcome and could even be considered as a safe and effective therapy for lymphedema of the lower extremity.

Key Words: Radical inguinal lymphadenectomy • Lymphedema • Prevention • Omentoplasty • Complications


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Cancers of the lower and lumbar extremities, the perineum, or even the bladder or prostate can all metastasize to the inguinal lymph nodes.1 Consequently, the indications for ilioinguinal lymphadenectomy are numerous and potentially expose the patients to a high morbidity rate.2 Since the first description of the inguinal lymphadenectomy by Basset3 in 1912, lymphedemas, lymphorrheas, wound breakdown, cellulitis, and cutaneous necrosis have always been feared by even the most experienced surgeons. If less invasive techniques could reduce this morbidity, most groin lymphadenectomies could lead to major parietal damage with devascularization of the skin flaps and interruption of the collateral lymphatic channels.4,5 Even with various reconstruction possibilities after ilioinguinal lymphadenectomy, the treatment and prevention of lymphedema remains a true therapeutic challenge, especially for obese elderly patients in poor medical condition (diabetes and hypertension).5 In the following study, immediate pediculated omentoplasty covering the femoral vessels was realized after complete groin dissection. We report a pilot study of seven patients requiring such an approach that tested the feasibility and efficiency of a pediculated omentoplasty, especially on lymphedema prevention.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
From January 1, 2002, to January 1, 2003, we performed radical lymphadenectomies combined with inguinal omentoplasties in seven patients with inguinal lymph node metastases, The average age of these two men and five women was 71 years (range, 56–80 years), Four of them had excess weight (with body mass indexes between 25.5 and 36.6 Kg/m2)6. Four patients had histories of cardiogenic abnormalities or hypertension, but none had oedemas of the inferior limbs from a cardiac origin. The other clinical and iconographic characteristics are listed in (Table 1Go). The original tumor was malignant melanoma in four cases. The three remaining patients had vulvar (n = 2) and lumbar (n = 1) epidermoid carcinomas. None had any additional history of cancer. In all cases, the clinical examination revealed suspicious inguinal adenopathies whose size had been measured by ultrasonography. For one patient (patient 4), the groin lymph nodes seemed to be fixed to the femoral vessels, whereas for three other patients (1, 2, and 3), they seemed to infiltrate the skin. Concomitant operation of the groin and of the primitive tumor was performed twice: once at neoplasm discovery (case 4) and once after a local recurrence (case 1). They were vulva neoplasms; one of them (case 1) had been treated 8 months earlier by a total vulvectomy. In one case (case 7), lower limb lymphoscintigraphy was performed to visualize the effectiveness of the technique.


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  		TABLE 1. Preoperative characteristics of patients treated by lymphadenectomy and omentoplasty
 
In all cases, the circumferences at mid thigh (half the distance between the anterior superior iliac spine and the lower extremity of the patella), at mid calf (half the distance between the lower extremity of the patella and the external malleolus), and at the malleoli of each of the two limbs were measured before each surgical procedure and then regularly at each follow-up visit. These measurements were made on patients in the dorsal decubitus position, with the inferior limbs in complete extension. Pre operative chemotherapy was given twice (Table 1Go). In one case (case 2), three regimens of carboplatin, eldisine, and dacarbazine had no antitumoral effect. In another case (case 4), a regression of the primary tumor was noticed after three regimens of 5-fluorouracil and cisplatin, but without any effect on the inguinal adenopathies. The lymphadenectomy technique subsequently used was the one described by Basset3 with a vertical cutaneous approach. The saphenous vein was constantly ligated at the distal and proximal ends and removed with the nodes. The omentoplasty presented no particular characteristics and corresponded to Kiricuta’s description.7 For its mobilization beneath the inguinal ligament, we used a combined incision — first inguinal and abdominal — and made a digital passage situated in the femoral canal, medial to the femoral vein. The omentum flap, once down in the groin, was fixed by 3–0 polyglycolic acid sutures (Figs. 1GoGo–3Go). The wound was closed with No. 2 polypropylene sutures. All operations were performed by the same surgeon. All patients received thromboembolism prophylaxis. Suction drains were placed against the omentum flap in the groin. These were removed once the output was < 20 mL over a 24-hour period.



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  		FIG. 1. Groin site after ilioinguinal lymphadenectomy along with the omentum flap.

 


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  		FIG. 2. Digital passage between the abdomen and Scarpa triangle, materialized by scissors, situated in the femoral canal.

 


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  		FIG. 3. Omentum flap, once down in the groin, fixed by 3–0 polyglycolic acid sutures.

 

   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
We did not observe any lymphocele, lymphorrhea, wound infection, or general complications. Evolution of perimeters at mid thigh, mid calf, and malleoli is reported in (Fig. 4Go). For two patients who had no preexisting lymphedema, the difference in circumference measured at day 90 (for patient 2) and day 120 (for patient 6) after surgery was, respectively, 1.5 and 2 cm. This increase in circumference of the ipsilateral lower limb was not symptomatic in either case. In case 2, the omentoplasty was associated with an autoplasty for an umbilical hernia. The abdominal exploration of this patient revealed numerous hepatic metastases and iliac lymphadenopathies that were considered not removable. The patient died 100 days after the procedure as a result of metastasis. She had no evidence of local tumor recurrence, wound problems, or symptomatic lymphedema at the time of death. For patient 7 the difference in circumference at mid thigh showed an increase of 1 cm during the 4-month study but was still not symptomatic. Patient 1 experienced tumor progression in both the vulva and groin 2 months after surgery. This tumor progression was associated with an increase in lymphedema, with a 7-cm maximum difference of the circumference at mid thigh; previously this measurement had shown, during the last two checkup visits, an increase of 2 and 3 cm. An abdominal computed tomographic scan and a plain chest roentgenograph were considered normal. The patient was subsequently treated by a vulva and groin tumor resection. Pathologic analysis of the resected tissue demonstrated tumor neoplasm in each sites, but there were no lymph nodes in the sample. This operation was followed by a lymphedema regression of approximately 30%; the patient died with cachexia a few weeks later. For cases 5, 4, and 3, we observed a decrease of, respectively, 25%, 50%, and 55% of the previous circumference measured at mid thigh. In this last case (case 3), surgery was complicated by a cutaneous necrosis of approximately 2 cm2. It was localized on the middle part of the scar. It appeared on the eighth day after surgery and was treated medically within 10 days by daily local care. This patient died of pulmonary and hepatic metastatic disease on day 90.



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  		FIG. 4. Evolution of perimeter difference at mid thigh, mid calf, and malleoli. Cas, case.

 
Three patients received postoperative radiotherapy during the study period as follows: 50 Gy on the resected field and 46 Gy as a prophylactic measure on the controlateral groin in case 1, 30 Gy on the resected field in case 2, and 40 Gy on the pelvic and groin area followed by an additional 10 Gy on the inguinal level in case 3. We observed no abdominal complications and an average of 3 days of postoperative ileus. The main postoperative characteristics of the presented cases are listed in Table 2Go. The omentoplasty increased the length of the operation by an average of 30 minutes. The average length of drainage was approximately 13 days (range 5–19 days), and the mean duration of postoperative hospitalization was 17 days (range, 13–20 days). Lower limb lymphoscintigraphy (Fig. 5Go) showed major omentoplasty radiotracer fixation and progression for patient 7.


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  		TABLE 2. Surgical characteristics and follow-up of patients treated by lymphadenectomy and omentoplasty
 


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  		FIG. 5. Lower limb lymphoscintigraphies performed 30 minutes (A), 60 minutes (B), and 90 minutes (C) after injection of 99mTc colloid into the first interdigital spaces (*) for patient 7, showing a symmetrical diffusion of the tracer along the lymphatic pathways (arrowheads) up to the right lymph nodes (thin arrows) and the omentum graft in the left groin (large arrow). The bladder is also visible (white cross).

 
All patients were able to return home, even though the average survival time for three of them was <168 days. Up to this point, patients 4, 5, 6, and 7 have not demonstrated any sign of recurrence, tumor progression, or incapacitating lymphedema.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The complication rate of the inguinal dissection, including complications such as skin edge necrosis, wound breakdown, cellulitis, lymphedemas, or lymphocysts, can reach 85%.2 Some of these complications can be reduced by preservation of the saphenous vein when possible.7 In our series, all patients were particularly exposed to a high rate of morbidity, considering the systematic nonsparing of the saphenous vein, the massive metastatic disease in the lymph nodes, and the possibility of adjuvant radiotherapy.8–10 In clinically similar circumstances of preexisting or potential lymphedema, authors such as Orefice et al.11 would have first attempted a lymphovenous anastomosis (LVA). On the basis of their experience, LVA seems to be able to reduce the incidence of locoregional complications and of lymphedema of the lower limb to 38% (vs. 66% without LVA) and 30% (vs. 75%), respectively. Egorov et al.,12 after a previous study of lymph nodal venous shunt in rabbits and microvascular autotransplantation of omentum in dogs, published a study of microtransplantation of omentum in 21 patients with chronic lymphedema. In 19 of the 21 patients observed from 3 months to 2 years after operation, remission of lymphedema was good (reduction in swelling 50%) in 14 patients and satisfactory in 5 (approximately a 25%–50% reduction in swelling), and improvement gradually increased with time.12,13 This study confirmed the same experience with dogs published by O’Brien et al.,14 which showed a significant reduction of experimental lymphedema after microvascular insertion of a free omental flap graft in the groin.

Because of these encouraging results, we chose to perform an omentoplasty, which seemed much easier to perform than a microvascular approach. Not only is the great omentum an eNcient drainage agent of the abdomen and the pelvis, but it may also be an active coverage tissue, provide an alternative blood supply, and, therefor, shorten wound healing.11,15,16 Until now, we have used it to promote healing after perineal wounds or in cases of thoracic empyemas.17,18 In a pilot study, Ruckley et al.18 and Longmans et al.19 demonstrated that an omentoplasty allows satisfactory lymph drainage in the pelvis after an iliac lymphadenectomy by reducing both the number and the importance of lymphedemas and lymphorrheas. In this 22-subject comparative study, postoperative lymphedema could be clinically detected in 4 control subjects and in 1 patient in the omentoplasty group. By magnetic resonance imaging, lymphedema could be visualized in 7 of the 22 patients: 5 in the control group and 2 in the omentoplasty group.

Moreover, this rule in preventing radiotherapeutic injuries has been clearly established.20 To our knowledge, no articles have been published on the prophylactic use of this technique in lymphedema of the lower limb after ilioinguinal dissection. Although our initial aim was to control it, we noticed a decrease in the circumference at mid thigh—up to 50% in three cases. According to those results, pediculated omentoplasty in the groin could be a surgical solution to lymphedema of the lower limb. In the attempt to reduce complications due to lymphatic stasis, surgery is actually performed in <10% of lymphedema cases and would be suitable only after the failure of physical treatment.21 The most common techniques are "orange slice" resection, liposuction, and Thompson’s operation.22 In our opinion, the groin omental transposition is more attractive because it is simpler, faster, and without major complications. In our series, no omentum necrosis, parietal defects, or occlusions were observed.

With regard to the size of laparotomy, the laparoscopic approach could be an interesting alternative. The laparotomy can also provide an opportunity for abdominal exploration. In one case, it confirmed the presence of hepatic metastases (case 2) and could even be combined with parietal repair. Our omental transposition indications first concerned patients with palliative treatment. Encouraging results, such as no evidence of abdominal metastasis 3 months after surgery despite a local recurrence for our first patient, led us to enlarge our indications. We then applied this method to patient 4, considered to be in complete remission after surgery, chemotherapy, and radiotherapy for a vulva cancer classified as T2N1. Nevertheless, the cell function of the great omentum and its involvement in neoplastic diseases such as ovarian carcinomatosis could limit its indication.23 Preventing lymphedema is not the only potential advantage of this procedure. We observed no infectious complications, even without antibiotic prophylaxis. Our results on wound breakdown substantiate the use of this procedure in those particular cases. Initial treatment of patient 2 required a large cutaneous resection whose closing, under tension, was possible only after a large cutaneous debridement. In this case, omentoplasty probably allowed us to reduce both the size of and the healing time for cutaneous necrosis and wound breakdown that could have exposed the femoral triangle region. The myocutaneous flaps, such as the rectus abdominis, the latissimus dorsi, the tensor fascia lata, the vastus lateralis, and the sartorius flaps, are another solution to the problem of parietal defects.24–27 However, they consist in aggressive operations with exposure to serious complications.28 Other solutions, such as the use of the testis, dura mater, or polytetrafluoroethylene prostheses to provide adequate coverage over the femoral vessels, have also been considered.28–31

Although prospective, our work will remain limited in the number of patients and will present omentoplasty as a solution reserved for extreme situations. The average overall survival of three of our patients was relatively short (168 days), but this technique allowed them to return home with acceptable living conditions and without major functional handicaps. We believe that these patients may benefit from wide surgical excision and omentoplasty for wound closure, and we recognize that such eQorts may be only palliative. Our work has been limited to palliative procedures reserved for extreme situations. These positive results incite us to propose omentoplasty systematically after radical inguinal lymphadenectomy performed with curative intent, especially when the saphene vein cross must be removed.

Received for publication September 29, 2004. Accepted for publication April 4, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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