We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Invited Commentary |

Extraperitoneal Laparoscopically Assisted Ilioinguinal Lymphadenectomy for Treatment of Malignant Melanoma—Invited Commentary

Armando E. Giuliano, MD
Arch Surg. 1998;133(3):275. doi:10.1001/archsurg.133.3.275.
Text Size: A A A
Published online


The authors should be commended for their diligence in refining the technique of a laparoscopically assisted ilioinguinal node dissection for patients with American Joint Commission on Cancer stages I or II melanoma. They have managed to excise a statistically similar number of lymph nodes using the laparoscopically assisted approach as with the open approach (approximately 10 nodes in each ilioinguinal node dissection). However, does the technical ability to perform this procedure justify its practice? Does this technique really benefit the patient? During the standard approach for an open deep ilioinguinal node dissection, described by Karakousis1 and to which the authors refer, the inguinal ligament is transected. Laparoscopic IIL was developed to avoid this transection, thus decreasing pain and morbidity. However, in the text of his description of the standard operation, Karakousis also mentions an effective modification of his technique that preserves the inguinal ligament, by making a transverse incision parallel and cephalad to the ilioinguinal ligament and going through the external and internal oblique muscles to obtain entrance to the retroperitonial space. With this technique, the ilioinguinal ligament remains intact and the potential postoperative complication of hernia is avoided. This modification has become a common practice. While not transecting the ilioinguinal ligament may diminish the likelihood of a hernia, the closed laparoscopically assisted dissection is indeed likely to be associated with less pain. For this reason, the laparoscopically assisted technique may be worth pursuing. In malignant melanoma, however, the possibility of implanting disrupted melanoma cells from a crushed lymph node is significant and is a potential problem more likely to occur with the closed procedure than with the open procedure. While the differences were not statistically significant, it is notable that half of the patients treated with open ilioinguinal dissection had clinical adenopathy compared with only 2 of the 12 treated with the laparoscopic technique. The differences in pain and lymphatic drainage may be due, at least in part, to the differences in extent of disease. While the authors state that patients had a mean hospital stay of 7 days in the laparoscopically assisted group, we have been able to discharge the majority of our patients within 48 to 72 hours using Karakousis modified approach to the deep ilioinguinal nodes. As advances in minimal-access surgery continue to occur, more and more operations are being identified that can be done with a laparoscope. Many of these have obvious advantages; however, the advantages of laparoscopically assisted ilioinguinal node dissection is not clear. Whether the benefits of this advanced laparoscopic procedure justify the prolonged operating room time and potential risk of wound implantation by melanoma is not so evident. I think this study is an important contribution, identifying a new area of minimally invasive cancer surgery; however, more experience and more follow-up is needed before we are able to judge the efficacy of lap IIL.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles