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

Publication Date:
14 October 2020 (online)

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