Radical inguinal orchiectomy and high ligation of the cord is the standard primary surgical procedure 92324. The extent of surrounding soft tissue excision and the margins required, however, remains controversial. Simple excision is clearly inadequate for paratesticular sarcomas as repeat wide excision has revealed microscopic residual disease in 27% of completely excised cases 23. Aggressive surgical strategies are therefore recommended in the management of spermatic cord LMS and a decrease in local recurrence has been observed in patients who underwent re-operative wide excision after a prior incomplete resection 25.

Malignant mesenchymal tumours such as LMS have a "pseudocapsule" 26 and, as such, there may be infiltration of tumour cells into the adjacent tissues; therefore, it might be difficult to precisely estimate the tumour margins. Due to this 'irregular' pattern of tumour growth and the anatomical constraints in the inguinal region, wide circumferential resection margins may be difficult to achieve 112. Nevertheless, due to the tumours' high propensity for local recurrence, if negative histological margins are not achieved during primary surgery, re-excision should be considered mandatory, even if this involves sacrificing some areas of adjacent normal anatomy. Advances in microsurgery have made it possible to reconstruct significant anatomical defects in this region (discussed later).

The role of prophylactic lymph node dissection remains unclear. Although performed in some centres, the true incidence of para-aortic and pelvic nodal metastasis has never been documented 12, and hence there is insufficient evidence at present to suggest that prophylactic para-aortic and pelvic nodal dissection prevents relapse or improves the prognosis of patients with spermatic cord LMS 8. It, however, has a role in other types of para-testicular sarcomas such as rhabdomyosarcomas, fibrosarcomas, and intermediate or high-grade malignant fibrous histiocytomas 7.

The inguinal region lies at the junction of the lower abdomen and the anterior thigh. The lower abdominal wall below skin and subcutaneous tissue is composed of three layers of muscle (external oblique, internal oblique and transversus abdominis) and their aponeurosis anterolaterally, and vertical rectus muscle covered in an aponeurotic sleeve medially (Figure 1). The rectus sheath differs in composition above and below the arcuate line, which lies one-third of the way from the umbilicus to the symphysis pubis (Figure 2).

The inguinal canal allows the passage of the spermatic cord or round ligament (in females) without vascular compromise and without obstructing ductus deferens in the male. Below the inguinal ligament lies the femoral triangle. The boundaries of the femoral triangle are the inguinal ligament superiorly, the medial border of sartorius laterally, and the medial border of adductor longus medially. The femoral triangle contains the femoral vessels and nerve, sapheno-femoral junction and the deep inguinal lymph nodes.

After wide excision of soft tissues, it is important to repair the defect in the inguinal region and the lower anterior abdominal wall (Figure 3). The structures that may require covering include the spermatic cord, femoral neurovascular bundle, abdominal wall muscles and sometimes-exposed bone. If the surgical resection involves removal of abdominal wall muscles, then reconstruction using mesh in addition to tissue coverage may be necessary. The principle of soft tissue reconstruction is based on the reconstructive ladder (Figure 4). Various reconstructive surgical options are available in the plastic surgeon's armoury to repair defects in this region (Table 1).

Local flaps to cover the inguinal region and the lower anterior abdominal wall include the muscle or musculo-cutaneous flaps such as rectus abdominis (transverse rectus abdominis muscle (TRAM) or vertical rectus abdominis muscle (VRAM) flaps, gracillis flap, tensor fasciae latae flap (Figure 5), rectus femoris flap and vastus lateralis flap. The tensor fasciae latae (TFL) flap is a frequently employed flap because it is very resilient and has a reliable vascular pedicle from the lateral femoral circumflex branch of the profunda femoris artery 27 (Figure 5). In addition, the division of TFL from its normal anatomical insertion does not have a significant effect on the function of the limb; for this reason, the rectus femoris and vastus lateralis flaps are not the first choice since their loss may lead to some limitation of movements at the hip or knee joints, and thus functional loss.

If the resection is not deep (no muscle loss), fascio-cutaneous flaps such as the groin flap and the antero-lateral thigh flap, or an abdominal wall skin and fat flap based on perforating vessels – deep inferior epigastric perforator (DIEP) flap – could be used. The use of a groin flap, however, may be limited in situations where the vessels, which originate in the femoral triangle, may be ligated as part of the resection. If femoral dissection is required leading to soft tissue loss, a sartorius muscle switch or an omental flap 28 could be used to cover exposed vessels in the femoral triangle.

In the event of no local flap options being available (very rare), a free flap may be used to achieve cover. This involves raising a distant flap, usually the latissimus dorsi muscle, disconnecting the blood supply and transferring the tissue to the groin and anastomosing the thoraco-dorsal vessels to recipient vessels in the inguinal region.

The use of well vascularised tissue to cover exposed femoral vessels is important as it minimises local vascular complications when adjuvant RT is instituted to the groin region.

The various reconstructive options discussed above are useful in different clinical (or operative) scenarios. With adequate planning and proper choice, satisfactory short- and long-term results can be obtained with all the above reconstructive procedures. The choice of one particular flap for reconstruction depends on various factors: (i) the anatomical location of the cover required; (ii) the extent and type of soft tissue loss (e.g., skin, muscle, etc.); (iii) tumour type – primary or recurrent; (iv) the ease of donor site coverage; (v) flap availability; and (vi) the experience of the surgeon in the usage of a particular flap. In primary tumours, the skin might not be involved and hence a muscle flap might be adequate. However, in recurrence, the overlying skin might be damaged due to RT. This may necessitate excision of the skin (along with underlying tissues) and coverage using a musculo-cutaneous or a fascio-cutanoeus flap (alternatively a muscle flap with split skin grafting can be used).

Adjuvant RT has become an established method in the management of LMS of the spermatic cord 891213. Some authors recommend adjuvant RT only for high-grade LMS or to those patients believed to be at a high risk of local recurrence. However, due to the tumour's high propensity (approximately 50%) 89 of local recurrence following surgery alone 612, there is increasing consensus that LMS of all grades and histology should receive adjuvant RT 12. Several studies have reported better results with combined modality treatment and the recurrence could be reduced to 10 – 20% by using adjuvant RT 29. It needs to be emphasised at this point that adjuvant RT should supplement rather than substitute radical surgical excision and should be instituted only after complete clearance of the tumour is achieved surgically. The field for RT should include the inguinal canal, ipsilateral pelvic tissue 12, and the scrotum 8. The role of pre-operative RT has not been clearly established, and, as such, there is no evidence to suggest that radiotherapy before surgical excision reduces the rate of recurrence or improves the overall prognosis.

There are no controlled studies at present that specifically addresses the role of adjuvant systemic chemotherapy in adult spermatic cord LMS 11, although they have a well-defined role in childhood rhabdomyosarcomas 30. Adjuvant chemotherapy is currently not used routinely in the management of spermatic cord LMS though it has been suggested that it might have a role in abrogating the haematogenous metastatic potential in high grade sarcomas 12 and in patients with metastatic disease.