J Reconstr Microsurg 2021; 37(05): 427-435
DOI: 10.1055/s-0040-1718549
Original Article

Intraoperative Real-Time Visualization of the Lymphatic Vessels Using Microscope-Integrated Laser Tomography

Akitatsu Hayashi*
1   Department of Lymphedema Center, Kameda General Hospital, Chiba, Japan
Hidehiko Yoshimatsu*
2   Department of Plastic Surgery, Cancer Institute Hospital of the JFCR, Tokyo, Japan
3   Department of Plastic and Reconstructive Surgery, University Hospital “A. Gemelli,” Università Cattolica del “Sacro Cuore,” Rome, Italy
Sasithorn Sujarittanakarn
4   Department of Surgery, Faculty of Medicine, Thammasat University, Bangkok, Thailand
Guido Giacalone
5   Department of Lymphatic Surgery, AZ Sint-Maarten Hospital, Duffel, Belgium
Nobuko Hayashi
6   Department of Plastic Surgery, Taiyo-kai Social Welfare Awachiiki Iryo Center, Chiba, Japan
Takumi Yamamoto
7   Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
Johnson Chia-Shen Yang
8   Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
9   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
› Author Affiliations


Background Detection and selection of the lymphatic vessels are important for maximizing therapeutic efficacy of lymphaticovenular anastomosis (LVA). Some imaging modalities have been reported to be useful for intraoperative identification of the lymphatic vessels, but they have limitations. In this article, we present new capabilities of intraoperative laser tomography, which was used to evaluate the lumen of the lymphatic vessel and to validate the patency of anastomosis.

Methods Fifty-two patients with upper extremity lymphedema secondary to breast cancer treatment underwent indocyanine green (ICG) lymphography and real-time laser tomography imaging of ICG-enhanced lymphatic vessels intraoperatively before transecting the vessels during LVA. The imaging findings of the lymphatic vessels in laser tomography were investigated. Time required for scanning of the lymphatic vessels was compared between laser tomography and ultrasonography. The correlation between the thickness of the lymphatic vessel wall measured with laser tomographic imaging and the histologically measured thickness of the lymphatic vessel wall was examined. The patency of anastomosis sites was determined based on the image using laser tomography immediately after establishment of LVA.

Results A total of 132 ICG-enhanced lymphatic vessels were scanned with laser tomography showing clear lumen with surrounding vessel wall. The required time for lymphatic vessel scanning was significantly shorter with laser tomography than with ultrasonography (1.6 ± 0.3 vs. 4.8 ± 1.2 minutes; p = 0.016). Strong correlation was seen between the thickness of the lymphatic vessels wall measured using laser tomography and the histologically measured thickness of the lymphatic vessel wall (r = 0.977, 95% confidence interval: 0.897–0.992, p < 0.001). The quality of patency was evaluated immediately after anastomosis, which assisted in deciding whether reanastomosis was needed.

Conclusion Microscope-integrated laser tomography provides real-time images of the lymphatic vessels in extremely high resolution and enables evaluation of lymphatic lumen condition and objective post-LVA anastomosis status.

Authors' Contributions

Conception and design: A.H., H.Y., and J.P.H.; analysis and interpretation: A.H., H.Y., G.V., G.G., N.H., T.Y., and J.C.Y.; data collection: A.H., H.Y., and S.S.; statistical analysis: A.H., H.Y., G.V., and S.S.; writing the manuscript: A.H., H.Y., and J.P.H.; critical revision of the manuscript: A.H., H.Y., G.V., J.C.Y., and J.P.H.; final approval of the manuscript: A.H., H.Y., G.V., G.G., T.Y., J.C.Y., and J.P.H.


This study was presented at the 2020 American Society of Reconstructive Microsurgery Annual Meeting.

* These authors contributed equally to this work.

Publication History

Received: 24 May 2020

Accepted: 02 September 2020

Article published online:
14 October 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
  • 2 Salgarello M, Mangialardi ML, Pino V, Gentileschi S, Visconti G. A prospective evaluation of health-related quality of life following lymphaticovenular anastomosis for upper and lower extremities lymphedema. J Reconstr Microsurg 2018; 34 (09) 701-707
  • 3 Hayashi A, Hayashi N, Yoshimatsu H, Yamamoto T. Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema. J Surg Oncol 2018; 117 (02) 290-298
  • 4 Czedik-Eysenberg M, Steinbacher J, Obermayer B. et al. Exclusive use of ultrasound for locating optimal LVA sites-a descriptive data analysis. J Surg Oncol 2020; 121 (01) 51-56
  • 5 Yang JC, Wu SC, Chiang MH. et al. Intraoperative identification and definition of “functional” lymphatic collecting vessels for supermicrosurgical lymphatico-venous anastomosis in treating lymphedema patients. J Surg Oncol 2018; 117: 994-1000
  • 6 Cho MJ, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36 (07) 514-521
  • 7 Hayashi A, Visconti G, Yamamoto T. et al. Intraoperative imaging of lymphatic vessel using ultra high-frequency ultrasound. J Plast Reconstr Aesthet Surg 2018; 71 (05) 778-780
  • 8 Chen TC, Cense B, Pierce MC. et al. Spectral domain optical coherence tomography: ultra-high speed, ultra-high resolution ophthalmic imaging. Arch Ophthalmol 2005; 123 (12) 1715-1720
  • 9 Hee MR, Izatt JA, Swanson EA. et al. Optical coherence tomography of the human retina. Arch Ophthalmol 1995; 113 (03) 325-332
  • 10 Heydon-White A, Suami H, Boyages J, Koelmeyer L, Peebles KC. Assessing breast lymphoedema following breast cancer treatment using indocyanine green lymphography. Breast Cancer Res Treat 2020; 181 (03) 635-644
  • 11 Burnier P, Niddam J, Bosc R, Hersant B, Meningaud JP. Indocyanine green applications in plastic surgery: a review of the literature. J Plast Reconstr Aesthet Surg 2017; 70 (06) 814-827
  • 12 O'Connor WN, Valle S. A combination Verhoeff's elastic and Masson's trichrome stain for routine histology. Stain Technol 1982; 57 (04) 207-210
  • 13 Wolfs JAGN, de Joode LGEH, van der Hulst RRWJ, Qiu SS. Correlation between patency and clinical improvement after lymphaticovenous anastomosis (LVA) in breast cancer-related lymphedema: 12-month follow-up. Breast Cancer Res Treat 2020; 179 (01) 131-138
  • 14 Yamamoto N, Yamamoto T, Hayashi N, Hayashi A, Iida T, Koshima I. Arm volumetry versus upper extremity lymphedema index: validity of upper extremity lymphedema index for body-type corrected arm volume evaluation. Ann Plast Surg 2016; 76 (06) 697-699
  • 15 Yamamoto T, Yamamoto N, Doi K. et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 128 (04) 941-947
  • 16 Koshima I, Kawada S, Moriguchi T, Kajiwara Y. Ultrastructural observations of lymphatic vessels in lymphedema in human extremities. Plast Reconstr Surg 1996; 97 (02) 397-405 , discussion 406–407
  • 17 Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. LEC score: a judgment tool for indication of indocyanine green lymphography. Ann Plast Surg 2013; 70 (02) 227-230
  • 18 Yamamoto T, Narushima M, Yoshimatsu H. et al. Indocyanine green velocity: lymph transportation capacity deterioration with progression of lymphedema. Ann Plast Surg 2013; 71 (05) 591-594
  • 19 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
  • 20 Boccardo F, Fulcheri E, Villa G. et al. Lymphatic microsurgery to treat lymphedema: techniques and indications for better results. Ann Plast Surg 2013; 71 (02) 191-195