The surgery of 'inguino-femoral' lymph nodes: is it adequate or excessive?

In the management of women with any but the earliest vulval carcinoma, the received surgical dogma is that there should be complete removal of all potentially involved lymph nodes in the groin (distal to the inguinal ligament). Traditionally, this has included stripping bare the femoral vessels after unroofing the deep fascia in the proximal thigh (Hunter's canal), although currently a number of surgeons carrying out block dissection of the groin would be less radical. The morbidity of the more extensive block dissection is important, and the need for a procedure of this magnitude has been challenged on the basis that a deep node chain does not extend more distally than the sapheno-femoral junction. This study examined possible reasons for this important difference of opinion. In 20 targeted anatomical groin dissections from cadavers, no nodes were identified deep to the deep fascia distal to saphenous opening. However, in the cribriform fascia covering the saphenous opening, some nodes of the superficial group were found within fenestrations of this fascia, which might account for the historic descriptions of deep femoral nodes distal to the sapheno-femoral junction. This finding also suggested that an inguinal lymphadenectomy confined to the superficial fascia may fail to include all those nodes normally regarded as being in the superficial inguinal group. Together, these findings also lend support to the contention that neither the removal of deep fascia in the femoral triangle nor its incision, with consequent stripping of the femoral vessels in the thigh, is normally necessary in a radical groin node dissection.