“Double Barrel” Lymphaticovenous Anastomosis: A Useful Addition to a Supermicrosurgeon’s Repertoire

Abstract

Background: Microsurgical amelioration of lymphedema has gained much traction in recent years and is now an established modality of treatment for this condition. Despite the development of many newer techniques, lymphaticovenous anastomosis still remains the most frequently carried out microsurgical procedure for lymphedema. One of the most common hurdles faced by lymphatic surgeons while carrying out a lymphaticovenous anastomosis is a mismatch in sizes of the vein and the lymphatic vessels. Method: This article describes a novel but simple “double barrel” technique, developed by the authors for carrying out lymphaticovenous anastomosis in cases of such lymphaticovenous mismatch. Seventeen double barrel anastomoses were carried out in 12 lymphedema patients, over a 4-year period from 2017 to 2021. Results: The overall success rate was 100%, as measured by clinical observation (venous washout, lymphatic backflow), the Acland vessel strip test, and by means of intraoperative ICG lymphography. Mild leakage was observed in four cases after release of the venous clamp and was corrected by application of additional sutures. Conclusions: The double barrel technique is a safe and effective tool that can be employed to deal with the bane of size mismatch, a persistent problem faced by lymphedema surgeons universally. Although we do not advocate it as a total replacement for other techniques, it can be a worthy addition to the present set of available options. In specific scenarios of mismatch with additional challenges, the double barrel technique has the potential to be considered as primus inter pares.

Lymphovenous Coupler-Assisted Bypass for Immediate Lymphatic Reconstruction

“…A technique for performing 2:1 LVB with I-I anastomosis has been described using a “double-barrel” approach, but its use is limited due to the technical challenge of the procedure. 39 By contrast, lymphatic implantation methods achieve LVB:vein ratios greater than 2:1 through the insertion, intussusception, or telescoping of lymphatic adventitia to venous intima. These approaches are instrumental when multiple neighboring lymphatics require LVB as they circumvent issues of a size mismatch, decrease the need for venous sacrifice, and are cited to be technically easier than traditional I-I.…”

Imaging Modalities for Evaluating Lymphedema

“…Objective measurements (circumference, volume, bioimpedance, dielectric constant), imaging (ultrasound-US; indocyanine green lymphography-ICG-L; lymphoscintigraphy-LS; magnetic resonance imaging-MRI; photoacoustic imaging-PAI; optical coherence tomography-OCT), and self-reporting (lymphedema life impact scale-LLFI; lower limb functional index-LEFS; disabilities of the arm, shoulder, and hand-DASH; international classification of functioning, disabilities and health-ICF; quality of life-QoL) assist in choosing the best therapy for the patient. The preoperative use of US [33], ICG-L [74], MRL [60], LS [39] solely and the combined use of US and ICG-L [27], ICGL and LS [41,75], MRL and ICG-L [55], and ICG-L and LS and MRI and CT [56] has been reported. ICG-L and MRI are superior in diagnosing lymphedema compared to LS or CT [56,57], and the US is applicable as a standalone imaging modality in the localization of LVA-candidate vessels [33].…”

“…Sonographic localization of fluid and solid predominant regions in the lymphedematous limb is crucial since we expect the most volume reduction by positioning physiologic procedures (such as LVA surgeries and lymphatic tissue transfers) in the regions of excessive fluid accumulation. Preoperatively identifying adjacent superficial comparable-diameter venules [24] and ectasis-type lymph vessels-according to normal, ectasis, contraction, sclerosis type (NECST) classification [25]-significantly increases the success rate of LVA operations [24][25][26][27].…”