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.
Armando E. Giuliano. Extraperitoneal Laparoscopically Assisted Ilioinguinal Lymphadenectomy for Treatment of Malignant Melanoma—Invited Commentary. Arch Surg. 1998;133(3):275. doi:10.1001/archsurg.133.3.275