The Second Surgery – Total Dissection of the Left Inquinal Lymph Node Basin

Above is a photo to try to depict the extent of this type of surgery.  It is major surgery and an informed decision should be made before deciding what is right for you.

Above is a photo to try to depict the extent of this type of surgery. It is major surgery and an informed decision should be made before deciding what is right for you.

As I said in my article about my first surgery for melanoma, my surgeon told me that I would need a second surgery – one to remove the rest of the lymph nodes in that particular area of my body.

Since the melanoma was in my upper left thigh and the sentinel nodes drained into the left inguinal basin, the recommended procedure was a total dissection of all the lymph nodes in that basin.  At the end of this post, I have added a copy of an article that reviews in simple language the pros and cons of such surgery.  I made the decision to have this surgery because of two things:

(1) Two sentinel nodes were positive for microscopic malignant metastatic melanoma, and

(2) Removing all nodes in this basin would provide more and better information for the proper staging of my disease, future treatment planning and would result in the highest survival rate and disease-free time period.

While my surgeon provided me a lot of information and explained that this procedure was major surgery, I still was not totally prepared for the extent of the surgery, the amount of pain or the time it would take to recover.

Time Out Before Surgery

In between the two surgeries, my wife and I took a trip to visit Charleston, SC.  I needed some time to relax and reflect on my decision.  I also wanted to have some time to just have fun.  We ate at some great restaurants, went to cooking school and saw some great attractions.  I recommend taking time out when you face major crossroads in your life so that you can relieve anxiety and be certain that you are making the right choices as you move forward.

The Surgery

On the day of surgery, I once again arrived at the hospital in the early morning and was taken to the pre-surgical prep area.  My wife was with me and all the usual questions were asked about what you did or did not eat, your medication list, etc.  While there, the surgeon came and went over one more time the risks of the procedure and the nurse had me sign the hospital’s informed consent document.  After all of this and changing into the hospital gown, it was time to move to the surgical holding area.

In surgical holding, a nurse talks with you about the procedure you are having and what they will do in the holding area to get you ready to go the operating room.  An IV is established.  The anesthesiologist visits and asks many of the same old questions and checks recent medical history for any possible complications of anesthesia.  The surgeon also visits briefly to mark the site of surgery with a marking pen.  You are then given the medicine to start getting you ready for anesthesia.

Suddenly it’s time and you are rolled in the operating room.  The light was bright and once again after an introduction and some light-hearted remarks, all consciousness fades away and you remember no more.

The procedure lasted about two hours and afterward I was moved from the OR to recovery.  My next memory was again hearing my name called as I was aroused from the deep sleep.  This time I didn’t feel quite as awake as I did after the first surgery.  As I would discover, this procedure would be a lot harder to deal with post surgery.  My wife was brought in to be with me as I continued to recover from the anesthesia.  After I had sufficiently recovered, I was taken to my hospital room for what would be at least an overnight stay.

In this surgical procedure, all the nodes and some surrounding tissue that is closely connected with the nodes are removed through a long cut (incision) in the groin. The length of the scar is usually between 6cm and 10cm.  Mine was at least 10 cm long! 

The  wound is closed with one or two drains (plastic tubes). One end is put in the wound under the skin and the other end is attached to a plastic bag or container. This drains away any blood or lymph fluid from inside the wound.

Once awake, the nurse comes and provides education on the care of the wound and the drains.  The dressings in the groin and the drains have to be regularly checked.  You are shown how to care for the dressings and how to empty the container and measure the fluid after discharge from the hospital.  The drains are usually removed in 5 to 10 days when the drainage becomes less. Sometimes the amount of drainage may remain high and, as a result, the drains may have to be kept for longer.  My drainage remained high for a long time and the drains stayed in for an extended period. 

I was told that I needed to use a bed urinal and bedpan and that I would not be getting up until the next morning.  I hate bedpans and I find urinals hard to use when lying down.  So, that night I insisted that I be allowed to get up and be escorted to the bathroom.  Permission was granted and oh my that first step will be remembered for eternity.  Such pain I had never experienced before.   It was like an electric bolt shooting both up and down from the incision site.  But I was determined and I made it to the bathroom and actually had a bowel movement and made sure the nurse documented it in the chart.  I knew that bowel movements are important to show that the body is as back to normal as possible post surgery and to have a chance at an early discharge home.

I was given pain medicine by injection into the IV at first but was switched to pills before discharge.  I stayed an extra two days in the hospital because of the pain and to be certain that I could be safe at home.  I was given physical therapy including training on how to use a rolling walker.  Every step was painful and the stupid container for the lymph fluid kept dropping down which made walking even that much more difficult.

The Recovery

Knowing that it would take time until I could climb stairs at home, we had made preparations for a sleeping area for me downstairs in the living room.  Even after getting home, the pain continued at what seemed to be an unbearable level.  I took the pain medication willingly even though I wanted to avoid it.

I had also made arrangements for a sitting and working area in the den.  A high speed connection had been installed at home so that I could get on the network and access business e-mail and files through my laptop.  In retrospect, I am not so sure that this was a wise decision.  However, it made me feel better to still be involved in what was happening at work and at least knowing about any problems or need for information.

My follow-up appointment was about five days post discharge.  I knew from emptying the containers that a lot of fluid was still draining from the wound.  I walked into the doctor’s office using my walker which actually surprised him.  He told me that most of his patients came to their first appointment post surgery in a wheelchair.  He looked at the wound, said it was healing nicely but also said that the drains needed to stay in longer because of the amount of fluid that was coming out.  We set the next appointment for one week later but he gave me instructions that if the amount of fluid went down, I should call so that he could remove the drains.  He also explained how important it was to leave them in for as long as possible to help prevent the possibility of lymphedema or to at least reduce its severity.  As it turned out, I did indeed avoid lymphedema although I did have to suffer quite a bit before I could enjoy the benefits of this outcome.

The fluid kept pouring out.  We kept following directions to keep the site clean and to empty the drain container using the proper protocol.  At the next appointment, the doctor recommended keeping the drain in for even longer.  I asked him if I could return to work.  He told me that I really shouldn’t but if I insisted that I should keep it half days and to keep my leg elevated.  Well, I went to work the next day and it wasn’t too many days before the half days had stretched well into the afternoon.  Now remember, this is only about two weeks or so post surgery.  Again, I probably did not make the wisest choice.  I was also back to climbing the stairs at home so that I could sleep in my own bed and be more comfortable.  I do think getting good sleep is important to getting better and staying better.

One week later I returned to the doctor and nothing had really changed.  A lot of fluid was still draining out and he wanted to try to keep the drain in longer.  He advised me to continue to properly care for the site and to watch for signs of infection.

The Infection

A couple of days later, I noticed some changes.   The site was a little bit red and was noticeably swollen.  Also, the seal of the container had seemed to come loose and was floating in the fluid.  I scheduled an appointment for the next day, but my doctor was off.  Instead, I saw another doctor in the practice.  He looked at the wound, fixed the drain and advised me to continue to watch it until the first of the week when my doctor was back.  This was Friday so I thought waiting over the weekend wouldn’t be too bad.

That Saturday night was my daughter’s birthday.  I had been feeling a little sick all day and the pain in my groin was increasing but we had made plans to go to a really great restaurant and didn’t want to miss out on a great night out.  Unfortunately, I only got sicker.  I was barely able to maintain a conversation although I did manage to eat most of the food I ordered.

By the time I got home, I was very sick and I had a high fever.  I called the doctor on call who phoned in a prescription for antibiotics.  He told me that if I got worse or if the fever would not come down, that I should call back and come to the emergency room.  Well, I lasted out the night in pain with a fever that went up and down in response to the Tylenol and ibuprofen I was taking.  Sunday morning, I asked my wife to call the doctor.  He called back and we headed to the ER.

At the ER I was taken to an exam room to wait for the surgeon on call to take a look.  While there, I experienced severe chills and my fever shot way up.  By this time, the site was extremely swollen and the pain was excruciating.  When the doctor arrived, he examined me and then, with a needle, tried to drain the infection.  Not much came out.  He then admitted me and soon after I was taken upstairs to a room.

That first night in the hospital was a nightmare.  I told my wife to go home.  My fever was high and the nurses were trying to bring it down with ice packs.  I was hurting and it was a tremendous effort just to sit on the side of the bed to use a urinal.  Finally, morning came.

My surgeon was there to see me early that morning.  A CT scan had been taken which showed the extent of the infection.  He told me that he had scheduled a procedure in surgery to drain the site of the infection.

I had been placed on IV antibiotics when I got to the hospital room from the ER.  When the culture came back, it was changed to vancomycin.   Early in the afternoon, I was taken to surgery, given anesthesia and the infected wound was drained.

When I recovered and returned to the room, I was still very sick.  My head hurt, the pain in my groin was almost overwhelming and I was getting anxious.  I knew that what had grown in the culture must have been resistant because of the antibiotic change.  It would be another painful, restless night in the hospital.

The next morning, my surgeon came by, examined me and told me that he had asked for a consult from the infectious disease specialist.  A little while later, the infection doctor arrived.  He told me that I had a difficult infection and that he was changing the antibiotic to Cubicin and that it might be possible when I got a little better to discharge me home on IV antibiotics because I would need to take them for quite some time.

To make it easier to administer the home antibiotic a PICC line was inserted.  A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is a long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart in order to obtain intravenous access.  PICC insertions are less invasive, have decreased complication risk associated with them, and remain for a much longer duration than other central or periphery access devices.  While I didn’t realize it yet, the PICC line would be very much a saving grace in the coming months.

Well, I did get better.  After a couple of more days in the hospital, I did go home with an order for IV cubicin.  Either my wife or I were able to administer the antibiotic as prescribed and per the home health instructions.  I went to the infectious disease doctor for about a month for weekly follow-ups until the infection had finally cleared.

What Next?

In my next blog, I will write about Interferon Therapy, the next chapter in my journey fighting cancer.

____________________________________________________________

Following is a brief article that in simple terms reviews why you might or might not want this type of surgery to treat your specific melanoma.  Talk with your doctor.  Ask questions.  Read more about the topic.  Make an informed decision.

This About.com page has been optimized for print. To view this page in its original form, please visit: http://skincancer.about.com/od/treatmentoptions/a/lymph_node_dissection.htm
©2014 About.com, Inc. All rights reserved.

Pros and Cons of Lymph Node Dissection for Treating Melanoma

Updated August 03, 2009

When melanoma is on the skin, it can be effectively and permanently removed in most cases. Sometimes, however, it spreads (metastasizes) to other areas of the body, usually traveling first to the nearest lymph nodes in your armpit, neck, or groin. If your doctor suspects that this has happened, a test called a sentinel node biopsy will be performed to identify and remove the lymph node to which the cancer is likely to have spread from the primary tumor.

If your sentinel node biopsy is positive (that is, contains cancerous cells), then it’s decision time. Should you have all the other lymph nodes in this area removed, in a surgical procedure called completion lymph node dissection (CLND, or lymphadenectomy)? The idea is that a CLND ensures that the melanoma cells in all the other lymph nodes are removed, which then may prevent the disease from spreading farther.

Unfortunately, the evidence is inconclusive, so this decision is not straightforward, even for doctors. Here are some pros and cons to consider.

Pros

  • A CLND helps to accurately determine the stage of the melanoma, which assists the doctor in making recommendations for post-surgery (adjuvant)
    treatment.
  • The overall number of nodes containing melanoma cells is a predictor of survival for patients who have stage III disease, and only a CLND can provide this information.
    Some studies show that 20% of patients who undergo a CLND immediately after finding out they have a positive sentinel lymph node experience improved survival. This is especially true for patients who had intermediate-thickness tumors on their skin (1.2 to 3.5 mm).
  • By stopping the spread of melanoma at the lymph nodes, a CLND optimizes the chance for a cure. Even microscopic amounts of melanoma in lymph nodes can eventually progress over time to be significant and dangerous.

Cons

  • Complications of a CLND are significant and occur in up to 67% of patients, especially in those over 60.  Although swelling after surgery can be prevented or controlled by use of antibiotics, elastic stockings, massage, and diuretics, it can be a debilitating
    complication.
  • The effectiveness of a CLND may depend on the size of the melanoma tumor. Small tumors (0.1 mm or less in diameter) in the sentinel lymph node may not ever lead to metastasis at all, so performing a CLND may not be necessary. A 2009 study showed that the survival and relapse rates of patients with these small tumors was the same as those who had no melanoma in their sentinel lymph node. Thus, these “low-risk” patients may be able to avoid a CLND and have the same outcome.

The Bottom Line

Electing to undergo a major surgical procedure like a CLND is not a decision you should take lightly, especially if your biopsy shows only a small amount of melanoma in your lymph nodes. Many factors are involved, including the size and location of your primary melanoma, the results of the sentinel lymph node biopsy and other tests, and your age. You may find it helpful to seek out a second opinion.

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About mcreyscope

Retired / disabled survivor of Stage IV melanoma and paraneoplastic syndrome.
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