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The discourse regarding the balance of oncologic benefit and complication profile for lymphadenectomy has been front and center in both breast cancer and melanoma for well over a decade. arguably, inguinal lymphadenectomy has been a lightning rod for this debate because of the high morbidity that has repeatedly been reported from this procedure. The authors of this editorial admittedly have contributed to the ongoing rhetoric by developing and reporting a novel approach to inguinal lymphadenectomy. Combined with ongoing investigation into the role and utility of completion lymphadenectomy, this has led the melanoma community aggressively to revisit groin dissection in the therapeutic armamentarium of the melanoma surgeon. In this issue of Annals of Surgical Oncology, Faut et al. analyze the impact of changes in perioperative care on the outcomes from inguinal lymphadenectomy. They grouped their analysis by three major changes related to mobility, splinting, and duration of hospitalization. Importantly, they meticulously analyzed the data for incidence of complications and included patients who underwent both superficial and combined superficial and deep lymphadenectomies. One could argue that these two populations are not the same and so inclusion of both in this manuscript weakens its conclusions, but nonetheless, the authors draw our attention to the challenge of surgery in this area of the body. While this group is trained and does use minimally invasive lymphadenectomy, the present report does not investigate the impact of that procedure on outcomes; all patients in the study underwent open inguinal lymphadenectomy. Recent series (including the Faut series in this issue) estimating the morbidity from inguinal lymphadenectomy have been more comprehensive in reporting adverse outcomes than historical series. Modern data report complication rates ranging from 19–77 %, with the majority observing an estimated 50 % of patients with a wound complication. This type of meticulous analysis has led to considerable discussion in the melanoma community about the true accuracy of reported complication rates after inguinal lymphadenectomy. While this debate may never be put to rest, it can be argued that it is irrelevant, because there is no debate that the rate of complications is significant. If one is to accept that the complication rate from this procedure is simply ‘‘too high’’ (whether that number is 20 or 50 %), then the discussion about reducing morbidity is valid and the call to arms of the group from Groningen is worthy of acknowledgement. Including the current article, a number of modifications to surgical technique have been advocated to reduce morbidity from inguinal lymphadenectomy, and while minimally invasive surgery may be the most impactful, there are still significant complications even with this approach. Arguably, the optimal way to reduce complications is to avoid surgery altogether. Two trials, the Multicenter Selective Lymphadenectomy Trial-II and the EORTC’s MiniTub registry trial, prospectively are analyzing the outcome of patients who do not undergo completion lymphadenectomy after a positive sentinel lymph node biopsy (SLNB). The melanoma community eagerly awaits the results of these trials, especially as recent data imply that some patients may avoid completion lymphadenectomy without adversely impacting overall Society of Surgical Oncology 2016

Revisiting the Strait of Messina: The Balance Between Optimal Oncologic Outcomes and Complications From Surgery