Technical pearls in lymphatic supermicrosurgery

Abstract

Lymphedema is becoming a major public issue with improvement of cancer survival rate, as the disease is incurable and progressive in nature, and the number of cancer survivor with lymphedema is increasing over time. Surgical treatment is recommended for progressive lymphedema, especially when conservative therapies are ineffective. Among various lymphedema surgeries, supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular with its effectiveness and least invasiveness. There are many technical knacks and pitfalls in LVA surgery. In preoperative evaluation, indocyanine green lymphography is recommended for considering indication and incision sites. Intraoperatively, intravascular stenting method, temporary lymphatic expansion maneuver, fieldrotating retraction, and several navigation methods are useful. The most important postoperative care is immediate compression after LVA surgery. Compression is critical to keep lymphatic pressure higher than venous pressure, allowing continuous lymph-to-venous bypass flow. These technical pearls should be shared with lymphedema surgeons for better lymphedema management.

A Case-control Analysis of the Knight’s Move Technique in a Chicken Wing Microsurgery Model: Video Article

“…However, as alluded to by Miyamoto et al in a rat superficial epigastric artery model, IVaS takes a significantly longer time to perform compared with the open guide suture technique 16 or similar techniques like the knight’s move. As alluded to by Yamamoto et al 2 , any supermicrosurgery technique ultimately depends on fine motor skills to precisely control the needle point. This comes with experience.…”

Free superficial circumflex iliac artery perforator fascial flap for reconstruction of upper abdominal wall with extensive infected herniation: A case report

“…First, supermicrosurgery is necessary to perform perforator‐to‐perforator anastomosis (Yamamoto, 2019; Yamamoto et al, 2020a). Specialized training for and clinical experience of supermicrosurgery is required to perform the supermicrosurgical dissection and anastomosis (Yamamoto, 2019; Yamamoto et al, 2011; Yamamoto et al, 2014b; Yamamoto et al, 2014a; Yamamoto et al, 2017; Yamamoto et al, 2020b). Second, it is difficult to estimate the area with good perfusion, as there is no comprehensive study on SCIP perfusion to the lateral thigh fascia.…”

Injection sites for indocyanine green lymphography to enhance minor forearm lymphatic pathways

“…Most previous studies and textbooks describe main lymphatic pathways of upper extremity; start from the wrist crease to the axillary lymph nodes through medial part of the cubital fossa. [2][3][4][5] However, there are few studies showing other lymphatic pathways of upper extremity, and especially those in the dorsal aspect of the cubital area is not clarified at all.…”

“…Descriptions of upper extremity lymphatic pathways in most studies and textbooks focus on the main pathway starting from the wrist crease or the interdigital spaces to the axillary lymph nodes through medial part of the cubital fossa. [2][3][4][5] It is doubtless that main lymphatic pathway of upper extremity is the first choice for LVA or manual lymph drainage for upper extremity lymphedema. However, upper extremity lymphedema patients after LVA of main pathway sometimes suffer from cubital area of edematous symptoms.…”