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Introduction/Background Vulvar cancer is rarely seen Methodology This step by step cadaveric educational video was recorded on the left groin. Results Between the anterior superior iliac spine and pubic tubercle the skin incision is performed, 8 cm in length, and 2 cm below and parallel to the inguinal ligament. After the incision, dissection deepens to identify the Camper’s fascia over the Scarpa’s fascia. Identification and preservation of the Camper’s fascia is critical in securing the skin flap and preventing skin necrosis. To dissect the fibrofatty tissue containing the superficial inguinal lymph nodes between the Camper’s fascia and fascia lata; firstly, the fibrofatty tissue is mobilized under the Scarpa’s fascia and dissected 2 cm cephalad to the inguinal ligament where the aponeurosis of external iliac muscle is seen. Afterwards, excision of the lymphatic and fibrofatty tissue is performed from lateral (superficial circumflex iliac vein) to medial (superficial external pudendal vein) and superior to inferior (inferomedial end of inguinal ligament where it intersects with the adductor longus muscle). The fossa ovalis is encountered after resection of superficial inguinal lymph nodes. Medial to the falciform edge of fossa ovalis, dissection of the cribriform fascia will lead to the deep inguinal lymph nodes which are located medial to the femoral vein. Great saphenous vein enters the femoral vein from the opening of fossa ovalis, so a careful dissection is needed while removing the cribriform fascia. Lymphadenectomy is performed towards the apex of femoral triangle, and there is no need to dissect the femoral sheath to excise the deep inguinal nodes completely. Finally, Cloquet’s lymph node which is the most superior of deep inguinal nodes could be resected from the femoral canal under the level of inguinal ligament. Conclusion Proper anatomical knowledge of inguinofemoral anatomy, the superficial fascia structures and deep vessel structures facilitates the inguinofemoral lymphadenectomy procedure. Disclosure Nothing to disclose

Introduction/Background For all vulvar cancer patients with tumour diameter greater than 2 cm and more than 1 mm of stromal invasion, inguinofemoral lymphadenectomy is indicated. In this video we present inguinofemoral lymphadenectomy technique with a patient with vulvar squamous cell cancer. Methodology A linear incision made 1 cm above and parallel to the groin crease starting 3 cm distal and medial to the anterior superior iliac spine and ending below the superficial inguinal ring. The borders of the operation are sartorius muscle laterally, adductor longus muscle medially and inguinal ligament superiorly. The inguinofemoral lymph nodes are divided into superficial and deep. The superficial lymph nodes are above the fascia lata and the deep nodes lye below the fascia lata and within the femoral sheath. To remove the superficial nodes, incision is carried through the subcutaneous tissues to the Camper’s fascia. The dissection should not be too close to the skin flaps as flap necrosis may develop. The fascia is incised and grasped with forceps for traction, and the fatty tissue between it and the fascia lata is removed. Usually the dissection is carried from lateral to medial and superior to inferior. Care should be taken to identify and preserve the great saphenous vein, which is superficial to the fascia of the medial thigh. To access the deep nodes, an incision is made through the cribriform fascia. Lymph nodes are always situated medial to the femoral vein in the opening of fossa ovalis. The proximal deep femoral node (node of Cloquet) is removed from the femoral triangle. The incision is closed in layers. Results not applicable Conclusion not applicable Disclosure Nothing to disclose

Objective To investigate local groin recurrence and morbidity associated with fascia lata preservation during inguinal lymphadenectomy (LAD) for penile carcinoma. Methods Between January 2002 and December 2011, 201 inguinal dissections with preservation of the fascia lata were performed in 104 patients with clinical disease staged at ≤N2. The dissection boundaries were the same as those for radical inguinal LAD. All superficial inguinal nodes were removed en bloc. The cribriform fascia near the femoral canal was divided, and the deep inguinal lymph nodes were dissected. The fascia lata was completely preserved and sutured to the subcutaneous tissue. Sartorius muscle transposition was eliminated. Survival and morbidity data were retrospectively analyzed, and survival probabilities were calculated. Results The median operative time for unilateral inguinal LAD was 45 minutes (range, 40-60 minutes). Median follow-up was 36 months (range, 10-130 months). A mean number of 12.5 nodes were removed per groin. One patient (1%) had a recurrence outside the borders of the fascia lata after 7 months of follow-up. The 3-year disease-free survival rate was 92.1% (100% for pN0, 91.3% for pN1, 80% for pN2, and 33.3% for pN3 disease). A total of 59 complications (29.3%) occurred, including wound infection (2.5%), skin necrosis (5.5%), lymphedema (11.8%), seroma formation (1.5%), lymphocele (5%), paresthesia (3.5%), and deep venous thrombosis (0.5%). Conclusion Inguinal dissections with preservation of the fascia lata for penile carcinoma patients without extranodal extension is as effective as the classic dissection technique but decreases complications related to groin dissection.

Objective The aim of this retrospective study was to assess the long-term results of stripping the insufficient great saphenous vein (GSV) with stump coagulation, closure of the cribriform fascia and some additional measures, which will be described in detail. Methods Patients treated from 1998 to 1999 for varicose veins had been invited in 2009 for follow-up colour-coded duplex sonography and had been asked to answer a quality-of-life questionnaire. In 2009, the examinations for the study were conducted at a clinic of angiology by an independent and experienced sonographer. Results From a total of 165 patients, 91 (136 limbs) had been willing to participate in the study. Duplex ultrasound after a mean follow-up of 10.7 years revealed only clinically non-relevant (Ø < 0.3 cm) neovascularizations in 1.5% of all treated legs. No clinical relevant varicosities from the groin had developed. Conclusion The crossectomy combined with stump coagulation and suture of the fossa ovalis, completed with some additional measures, is a successful method to reduce neovascularization and recurrent varicosities, even for redo-crossectomies, without increasing the risk of perioperative complications.

Background Neovascularisation at the sapheno-femoral junction (SFJ) ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. Several anatomical and prosthetic barrier techniques have been proposed to prevent this evolution. Objective A prospective study examined whether closing the cribriform fascia could reduce the incidence of postoperative neovascularisation in the groin. Patients and methods Patients with primary varicose veins and incompetence at the level of the SFJ were included. After SFJ ligation in 235 limbs of 193 patients an anatomical barrier was constructed by closing the cribriform fascia. Postoperative duplex scanning was performed after 2 and 12 months. Results were compared with historical control groups in which either a silicone patch saphenoplasty or no barrier technique had been performed. Results After one year, 10 limbs had developed recurrent thigh varicose veins and duplex scan showed neovascularisation at the SFJ ligation site in 15 of 223 re-examined limbs (6.7%). This was comparable to the group of 191 limbs with silicone patch saphenoplasty (5.2%) ( P =0.526) and superior to the group of 189 limbs without barrier (14.8%) ( P Conclusion Interposition of an anatomical barrier by closing the cribriform fascia after SFJ ligation reduced ultrasound detected neovascularisation at the SFJ after one year. In primary varicose vein operations application of an anatomical barrier technique (without prosthetic patch) is an alternative option to prevent postoperative neovascularisation.

Objective: To test the hypothesis that sapheno-femoral recurrence of varicose veins may be prevented by containment of neovascularization. Design: Prospective minimum 4-year follow-up by surgical exploration and morphological examination of recurrent vessels in all limbs with clinical or phlebographic evidence of sapheno-femoral recurrence. Setting: Varicose vein clinic of a teaching hospital. Interventions: Sapheno-femoral ligation and multiple ligation (group 1); sapheno-femoral ligation, interposition of cribriform fascia and multiple ligation (group 2); sapheno-femoral ligation, interposition of artificial implant and stripping (group 3). Main outcome measures: Incidence of sapheno-femoral recurrence. Results: The incidence of sapheno-femoral recurrence through neovascularization was lower ( p < 0.001) in groups 2 and 3 after containment of neovascularization at the sapheno-femoral junction by cribriform fascia or artificial implant than in group 1 after ligation alone (3% and 1% vs 25%, respectively). The incidence of recurrent or persistent varices distal to the groin was lower ( p < 0.001) after stripping (group 3, 57%) than after multiple ligation (group 1, 93%; group 2, 81%). Conclusions: Sapheno-femoral ligation, interposition of cribriform fascia or artificial implant at the sapheno-femoral junction, and stripping is a more effective treatment of varicose veins than sapheno-femoral ligation and multiple ligation.

Objective: To survey the surgical practice of gynecologic oncologists regarding the extent of groin dissection for early vulvar cancer. Methods: A 14-item questionnaire was developed and presented to the Annual Meeting of the Felix Rutledge Society. Gynecologic oncologists were asked to describe in descriptive, categorical, and visual terms the groin procedure that they perform as part of management of early vulvar cancers. Three ink-line drawings were created by a medical illustrator for the purpose. Fifty returned surveys were evaluable. Results: The most commonly performed procedures were removal of the lymph nodes above the cribriform fascia and those medial to the femoral vein (40%), removal of lymph nodes above the cribriform fascia (34%), and removal of all nodes above and below the cribriform fascia (22%). Respondents performing the first procedure termed it "superficial inguinal lymphadenectomy" (40%), "inguinal femoral lymphadenectomy" (25%), and a variety of other names (35%). Respondents performing the second two procedures were much more consistent in the figure and name that they matched with their description of the nodes removed. When respondents were asked to match the figures with categorical definitions based on their understanding of the literature, the figure depicting Scarpa's triangle following removal of the superficial inguinal and medial femoral nodes was named superficial inguinal lymphadenectomy by 24% despite the fact that the femoral vein was clearly visible and labeled. Conclusions: We conclude that (1) among this group of gynecologic oncologists superficial inguinal and medial femoral lymphadenectomy is the most commonly performed procedure for women with early vulvar cancer and that the procedure is frequently called superficial inguinal lymphadenectomy; (2) publications and protocols on this topic must provide complete descriptions of procedures performed, and investigators must assure that individual surgeons are performing the same procedure; and (3) treatment results with superficial inguinal and medial femoral lymphadenectomy are poorly described and a fertile area for further study.

Objective: We describe early results of and potentially important anatomic findings with intraoperative lymphatic mapping in patients with vulvar cancer. Methods: Isosulfan blue was injected into the dermis at the leading edge of the vulvar lesion in 21 patients. One to five minutes later a standard groin incision was made and carried to the superficial fascia. After gentle dissection, the afferent lymphatic channel and/or sentinel lymph node was identified by its bright blue color. The sentinel node was removed and then the superficial inguinal lymphadenectomy was completed. Results: The 21 patients, ranging in age from 23 to 85 years (median, 52 years), underwent intraoperative lymphatic mapping. The clinical stages were as follows: T1in 9, T2in 10, T3in 1, and unknown in 1 patient with a prior wide local excision. Two patients had palpably suspicious nodes. Ten patients had lateral lesions, and 11 had midline tumors. Eight of the 11 patients had bilateral groin dissections, making a total of 29 groins dissected. The sentinel node was identified in 18 patients (86%) and in 19 groins (66%). Five patients had unilateral node metastases, and one patient had bilateral node metastases. A sentinel node was found in five of these seven groins. A total of 238 nodes were removed (median, 8.2 nodes per groin). In no case was a nonsentinel node positive if the sentinel node was negative. In one patient the only metastasis was microscopic tumor in the sentinel lymph node. In one case, the sentinel node was found below the cribriform fascia. The sentinel node could not be identified in either groin in one patient with a clitoral primary; however, dye was seen in lymphatic channels passing under the symphysis pubis. The sentinel node was identified in various sites within the superficial compartment including lateral to the femoral artery and at the extreme medial border of the dissection. No complication related to the injection of isosulfan blue was seen. Conclusion: Intraoperative lymphatic mapping is safe and simple to perform and may help identify the sentinel node, define the extent of superficial inguinal lymphadenectomy, and identify uncommon anatomic variations.

During the last decade, endovascular abdominal aortic repair (EVAR) has emerged as the preferred treatment in a selected group of patients with suitable aortic anatomy for endografting. In order to both minimise its invasiveness and reduce complications related to groin dissections, Harrison and coworkers studied a fascial closure technique of the puncture site without the need to touch the femoral artery itself. In 1997, Diethrich was the first to describe closure of the cribriform fascia where it covers the common femoral artery access. Larzon and colleagues published the largest series so far and analysed 131 sutured fascial cases during EVAR. In their hands, complication rate was 13.7% (89%

Purpose To evaluate a technique for closure of a femoral artery access in which the cribriform fascia covering the common femoral artery is sutured. Methods A consecutive series of 127 patients (103 men; median age 74 years, range 45- 89) underwent endovascular aortic aneurysm repair between August 2001 and September 2004. Twelve patients underwent a secondary intervention for a total of 139 procedures in the group. Sixty-one (43.9%) of the 139 operations were acute. Among the 257 femoral arteries used for access, a fascia suturing technique was performed in 131 (51.0%). Data were collected for analysis of access site complications, bleeding, thrombosis, pseudoaneurysm, and stenosis. A subgroup of 72 patients had ankle-brachial indexes (ABI) recorded; another subgroup of 50 patients were also investigated by duplex ultrasonography. Results Complications occurred in 18 (13.7%) of the 131 sutured cases. The majority (n = 16) arose within 24 hours: 8 cases of perioperative bleeding or thrombosis required open surgery and 8 cases were reoperated within 24 hours for bleeding (n = 4), thrombosis (n = 3), and 1 intimal dissection. The acute failure rate was 12.2%. Two patients had late complications: 1 case of neuralgia and 1 pseudoaneurysm that required acute surgery 28 months postoperatively. The ABI did not change significantly from pre- to postoperatively in the 72 patients examined. Five patients with stenoses did not have a reduction in ABI. In the 66 sites examined with ultrasound in 50 patients, 3 minor pseudoaneurysms were detected. Conclusion The fascia suturing technique for closure of a femoral artery access during endovascular repair of aortic diseases is feasible, even in acute situations. Failures can be managed easily. Late complications requiring additional procedures are rare.

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.

Objectives: to investigate whether a silicone implant at the sapheno-femoral ligation site could prevent recurrent varicosities. Materials and methods: two non-randomised groups of patients were studied prospectively. In group A 173 patients and 212 limbs had sapheno-femoral ligation, while 172 patients and 210 limbs additionally had a piece (2×3 cm) of silicone sheet sutured to the saphenous stump to cover the anterior half of the common femoral vein. The implant was fixed in apposition to the deep vein by carefully closing the cribriform fascia. Colour duplex scanning was performed after 2 and 12 months. Results: in the no implant group neovascularisation was observed in 35 (17%) after 12 months, but only in 13 (6%) limbs treated with a silicone implant ( p Conclusions: interposition of a partition of silicone implant seems to lower the incidence of neovascularisation one year after saphenofemoral ligation. This technique may constitute an efficient method to prevent recurrence at the correctly ligated saphenous stump.

Objective. The goal of this study was to assess the local groin recurrence of vulvar carcinoma in patients treated by complete groin node dissection with preservation of the fascia lata (GNDPFL). Methods. This study is a retrospective chart review of 60 patients with Stage I–IV vulvar carcinoma who underwent radical vulvectomy and GNDPFL between 1990 and 1998. All superficial inguinal nodes and the deep femoral nodes on the anterior and medial surfaces of the femoral vein within the fossa ovalis were removed en bloc while sparing the fascia lata and the cribriform fascia over the femoral artery. Results. Of the 60 study patients, 14 patients had Stage I disease, 20 Stage II, 21 Stage III, and 5 Stage IV. The mean number of nodes removed was 10 per groin. Thirty-nine patients had benign nodes on groin dissection. None of these 39 patients developed cancer recurrence in the dissected groins. Twenty-one of the sixty study patients (34%) had malignant nodes on groin dissection. Of these 21 patients, 2 experienced cancer recurrence in the groins. Our study describes a groin recurrence rate of 7.6% in patients with fewer than three malignant unilateral groin nodes. Postoperatively, 13% of patients developed lymphedema and 15% formed lymphoceles. Conclusions. The zero groin recurrence rate in patients with negative nodes and the low rate of recurrence in patients with positive nodes indicate that groin lymphadenectomy with preservation of fascia lata is complete, therapeutic, and comparable to radical techniques of lymphadenectomy involving skeletonization of femoral vessels, resection of fascia lata, and muscle transposition.

Objective. To clarify some anatomical controversies of the fascial structures and lymph node development of the inguinal region through an embryological study in relation to the surgical techniques of groin lymphadenectomy. Methods. Sections of the femoral triangle belonging to four fetuses whose crown–rump (CR) length ranged from 70 to 310 mm, corresponding to a developmental age of 11 and 35 weeks, were studied. Results. The femoral fascia is formed of one layer and is not divided into superficial and deep layers. The cribriform fascia has a morphogenetic origin different from that of the femoral fascia and it is defined by the thickening of the connective tissue filling the fossa ovalis and therefore would be more correctly named lamina cribrosa. The deep inguinal lymph nodes originate directly from the superficial lymphatic tissue located in the fossa ovalis. This last observation supports the fact that no lymph nodes are present beneath the femoral fascia distal to the lower margin of the fossa ovalis. Conclusions. The results of this study, from a surgical point of view, support the technique of total or radical inguinal–femoral lymphadenectomy with preservation of the femoral fascia and, from an anatomical point of view, resolve some of the contradictory statements reported in the anatomical literature regarding morphogenesis and terminology of the structures of the Scarpa's triangle. In addition, the present study provides useful anatomic and terminological landmarks to those surgical oncologists (gynecologist, urologist, dermatologist, etc.) dealing with malignant diseases requiring groin dissection practices. In addition, it could represent a useful background for a future more precise surgical terminology which represents a vital issue for institutional studies with multiple surgeons as well as for large multi-institutional studies.

Great saphenous vein is one of the longest vein in the body. As other venous channels this is also known to have different types of variation in its course and numbers. During the routine cadaveric dissection of undergraduate students in S.I.M.S. &R.C. Shimoga we found that the great saphenous vein was duplicated on the right side along with the presence of accessory tributaries joining it at various levels. In our case great saphenous vein was duplicated from its origin near medial malleolus and continued till the knee joint where it was joined by a tributary and later in the lower one third of the thigh it branched like a mesh and formed three trunks which ascended in the thigh and in the upper one third of the thigh two trunks joined to form anterior accessory saphenous vein and great saphenous vein proper which received the terminal tributaries later emptied into the femoral vein by piercing the cribriform fascia. The duplication of the great saphenous vein can explain the recurrent incompetence of the great saphenous vein. Also presence of such accessory trunks can be used for vascular grafting in cases of ischaemia and arterial blocks. The knowledge of such type of variation is important for surgeons, orthopaedicians and interventional radiologists who operate in this region.

Axial T1-weighted magnetic resonance (MR) images and exactly corresponding sections obtained with freezing microtomy of cadaveric lumbosacral spinal columns were compared to describe the MR appearance of the cribriform fascia within the neural foramen. On anatomic sections, the cribriform fascia was identified as a thin sheet of tissue in the lateral neural foramen. On MR images, the cribriform fascia appeared as a thin band of low signal intensity, which contrasted with the high-signal-intensity epidural fat. The cribriform fascia is another landmark in the neural foramen that can be identified with MR imaging.

Publisher Summary This chapter describes the reversed saphenous vein for femoropopliteal bypass grafting. A good-caliber long saphenous vein remains the conduit of first choice for bypassing the atherosclerotic obstruction of the femoropopliteal segment. The confirmation of an adequate saphenous vein and avoidance of vein damage are the first two steps of the operation. The preference is to find the upper end of the vein by a vertical incision placed over the saphenofemoral junction, which is then extended up across the front of inguinal ligament. This incision also allows adequate access to the common femoral artery. Using a combination of blunt and sharp dissection, the vein should be found in the subcutaneous fat as it dips down through the cribriform fascia. The junction of the saphenous with the common femoral vein must be confirmed. If this step is omitted, it is possible to trace a large anteromedial or posterolateral thigh vein instead of the main saphenous trunk. Once the vein has been found and exposed to its termination, the initial short incision may be extended along the course of the vein by sliding a finger along the perisaphenous space superficial to the vein and carefully incising the skin overlying the surface of the finger with a scalpel.