Right gastroepiploic lymph node flap

Abstract

Vascularized lymph node flap transfer (VLNFT) is a tissue transfer procedure of high interest for the treatment of lymphedema. VLNFT is a new approach for treating lymphedema and during the last few years it is becoming more popular. 1 Different donor sites for VLNFT including groin, supraclavicular, submental, thoracodorsal artery have been described.Herein, we present the results of the successful surgical management of six patients suffering from upper (2) and lower (4) limb lymphedema using a novel vascularized lymph node flap based on the right gastroepiploic (R-GE) vessels. To our knowledge, this is the first report using an intra-abdominal lymph node flap to treat lymphedema.The flap was based on the R-GE artery and vein. Harvest of the flap was performed through an upper midline laparotomy incision. The first step was to identify the right gastroepiploic vessels, then omentum was carefully dissected off the transverse colon with great care not to injure the mesocolon. The left gastroepiploic vessels were then divided and dissection of the short segmental gastric branches allowed the release of the flap from the stomach and permitted complete visualization of the R-GE vessels. Dissection was carried to the level of the right epiploic vessels. The lymph nodes within the flap cannot always be visualized but they often can be palpable. Indocyanine green lymphatic imaging could be performed to confirm the vascularity of the lymph nodes included within the flap.All patients underwent preoperative assessment, including photographs, circumference measurement, lymphoscin-tigraphy, and skin tonicity measurement. Microsurgical anastomoses were performed using the medial plantar vessels end-to-end and the radial artery for end-to-side anastomosis of lower and upper limb lymphedema respectively (Fig. 1). A suction drain was left in situ at the donor-site for 6 days. Patients were discharged on the tenth postoperative day. Post-operative follow-up was performed every 3 months during the first year.After 1 year follow-up all patients exhibited significant improvement and were satisfied with the functional and aesthetic results. Lymphoscintigraphy was performed and improvement was seen in all cases. No postoperative episodes of cellulitis or other complications were observed during the follow-up period.This flap has two mechanisms of function: one is the physiological lymphatic drainage from the interstitium to the vascularized lymph node flap and then into the pedicle vein, 2 and the second is through its ability to absorb the lymphatic fluid by the omentum tissue adjacent to the vascular pedicle. 3 Advantages of the use of this flap include the large diameter of the gastroepipolic vessels, minimal donor-site morbidity, no concern of causing iatrogenic lymphedema, and allowing a two-team approach. This flap contains omentum tissue around the pedicle that will also help in the absorption of lymphatic fluid by the affected limb. The use of laparoscopy to harvest the flap could offer a minimal insult to the abdominal wall ...

Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema

“…During the last decade, our unit has explored different surgical techniques in VLNT surgery . We have searched for the least invasive technique that minimizes donor site morbidity, avoids iatrogenic lymphedema, reduces the number of complications, and maximizes the efficacy of the procedure.…”

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report

“…Even though VLN transfer has been shown to be effective in reducing limb volumes, decreasing the number of infectious episodes and improving quality of life (Raju & Chang, ; Ciudad et al, ), donor‐site morbidity has been a source of concern for surgeons. Patients can develop complications such as iatrogenic lymphedema and lymphorrhea among others secondary to flap harvest (Massey & Gupta, ; Pons, Masia, Loschi, Nardulli, & Duch, ; Scaglioni et al, ; Sulo et al, ; Vignes, Blanchard, Yannoutsos, & Arrault, ).…”

“…Multiple donor sites for VLN harvest have been proposed in search of the optimal one (Scaglioni et al, ). Our group has first reported the right GE‐VLN transfer (Ciudad et al, ) for the treatment of extremity lymphedema. Based on our surgical experience with the use of various VLN flaps (Ciudad et al, ), we prefer to use the laparoscopically harvested right GE‐VLN flap.…”

“…In this regard, recently described intra‐abdominal lymph node flaps have demonstrated promising results without evidence of iatrogenic lymphedema (Ciudad et al, ; Coriddi et al, ) or major donor site morbidity, particularly when harvested laparoscopically (Ciudad et al, ) or with robotic techniques (Ciudad et al, ). We present the clinical outcomes of a novel intra‐abdominal VLN flap option based on the ileocolic artery and vein, the ileocecal vascularized lymph node (IC‐VLN) flap.…”

Lymphatic‐venous anastomosis in a rat model: A novel exercise for microsurgical training

“…Surgical operations are performed only in severe cases refractory to conservative therapies. Advances in microsurgical techniques have revolutionized surgical options for treating lymphedema . Physiologic surgical procedures such as lymphaticovenular anastomosis and vascularized lymph node transfer have demonstrated promising results …”