How to Dissect Lymphatics under Loupes for Line Production System for Multiple Lymphaticovenular Anastomosis

Abstract

Background A surgical line production system using loupes to dissect lymphatics and veins is a cost-effective way of performing multiple lymphaticovenular anastomoses. There is an art to successful dissection of lymphatics under loupes, and selection of the correct loupe magnification is important. Therefore, the aim of this study was to provide a detailed description of how to dissect lymphatics under loupes.

Patients and Methods Dissection of lymphatics under loupes was performed for a series of 13 patients. Lymphatics are transparent threadlike structures that are arranged longitudinally and may be oriented with feeding capillary vessels. At the start of dissection, it is helpful to have a reference scale in the field of vision when operating to appreciate the size of the structures seen under loupes. It is also helpful to be able to separate lymphatics from fat tissue in the background.

Results Mean time for exploration under loupes was 25 ± 7 minutes; lymphatics were successfully found in 27 sites (90%) of the 30 attempted with failure to identify lymphatics in three sites (10%) and failure to identify veins in three sites (10%); the average size of the lymphatics was found to be 0.5 ± 0.2 mm. No lymphatics could be found by the microscopes after loupes exploration in two sites.

Discussion Even a novice surgeon can identify lymphatics based on knowledge of the visual characteristics of these structures. However, a higher magnification is likely necessary for accurate discrimination.

Keywords

lymphatics - dissection - loupes

• References

• 1 Mihara M, Hara H, Tange S. , et al. Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases. Plast Reconstr Surg 2016; 138 (01) 262-272
• 2 Yamamoto T, Koshima I, Yoshimatsu H, Narushima M, Miahara M, Iida T. Simultaneous multi-site lymphaticovenular anastomoses for primary lower extremity and genital lymphoedema complicated with severe lymphorrhea. J Plast Reconstr Aesthet Surg 2011; 64 (06) 812-815
• 3 Yoshida S, Koshima I, Imai H. , et al. Line production system for multiple lymphaticovenular anastomoses. J Plast Reconstr Aesthet Surg 2019; 72 (08) 1334-1339
• 4 Campisi C, Boccardo F. Microsurgical techniques for lymphedema treatment: derivative lymphatic-venous microsurgery. World J Surg 2004; 28 (06) 609-613
• 5 Yamamoto T, Matsuda N, Doi K. , et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128 (04) 314e-321e
• 6 Chen WF, Eid A, Yamamoto T, Keith J, Nimmons GL, Lawrence WT. A novel supermicrosurgery training model: the chicken thigh. J Plast Reconstr Aesthet Surg 2014; 67 (07) 973-978
• 7 Mihara M, Hara H, Hayashi Y. , et al. Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy. PLoS One 2012; 7 (07) e41126
• 8 Ayestaray B, Bekara F, Andreoletti JB. Patent blue-enhanced lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2013; 66 (03) 382-389