Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic

Abstract

Background Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic.

Methods Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA.

Results LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5–23.6%, average 13.23%). No postoperative complication was observed.

Conclusion LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.

Keywords

lymphedema - microsurgery - supermicrosurgery - indocyanine green - anastomosis

Prior Presentations

We presented in part at the 22nd Annual Congress of the Japan Society for Innovative Techniques in Plastic Surgery in Tokyo, Japan on February 18, 2017.

Disclaimers and Disclosure

None.

Ethics

This study was conducted under an ethical institutional review board-approved protocol (16–19).

Publication History

Received: 26 December 2021

Accepted: 23 April 2022

Article published online:
11 July 2022

• References

• 1 Koshima I, Yamamoto T, Narushima M, Mihara M, Iida T. Perforator flaps and supermicrosurgery. Clin Plast Surg 2010; 37 (04) 683-689 , vii–iii
• 2 Yamamoto T. Onco-reconstructive supermicrosurgery. Eur J Surg Oncol 2019; 45 (07) 1146-1151
• 3 Yamamoto T, Narushima M, Doi K. et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 127 (05) 1979-1986
• 4 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
• 5 Yamamoto T, Ishiura R, Kato M. Hands-free vein visualizer for selection of recipient vein with an intact valve in lymphatic supermicrosurgery. J Plast Reconstr Aesthet Surg 2015; 68 (06) 871-873
• 6 O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990; 85 (04) 562-572
• 7 Yamamoto T, Narushima M, Kikuchi K. et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011; 127 (05) 1987-1992
• 8 Yamamoto T, Narushima M, Yoshimatsu H. et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg 2014; 72 (01) 67-70
• 9 Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. Factors associated with lymphosclerosis: an analysis on 962 lymphatic vessels. Plast Reconstr Surg 2017; 140 (04) 734-741
• 10 Yamamoto T, Narushima M, Koshima I. Lymphatic vessel diameter in female pelvic cancer-related lower extremity lymphedematous limbs. J Surg Oncol 2018; 117 (06) 1157-1163
• 11 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126 (03) 752-758
• 12 Yamamoto T, Yoshimatsu H, Narushima M. et al. Sequential anastomosis for lymphatic supermicrosurgery: multiple lymphaticovenular anastomoses on 1 venule. Ann Plast Surg 2014; 73 (01) 46-49
• 13 Chan VS, Narushima M, Hara H. et al. Local anesthesia for lymphaticovenular anastomosis. Ann Plast Surg 2014; 72 (02) 180-183
• 14 Yamamoto T, Kikuchi K, Yoshimatsu H, Koshima I. Ladder-shaped lymphaticovenular anastomosis using multiple side-to-side lymphatic anastomoses for a leg lymphedema patient. Microsurgery 2014; 34 (05) 404-408
• 15 Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Koshima I. Split intravascular stents for side-to-end lymphaticovenular anastomosis. Ann Plast Surg 2013; 71 (05) 538-540
• 16 Yamamoto T, Koshima I. Supermicrosurgical anastomosis of superficial lymphatic vessel to deep lymphatic vessel for a patient with cellulitis-induced chronic localized leg lymphedema. Microsurgery 2015; 35 (01) 68-71
• 17 Rodriguez JR, Fuse Y, Yamamoto T. Microsurgical strategies for prophylaxis of cancer-related extremity lymphedema: a comprehensive review of the literature. J Reconstr Microsurg 2020; 36 (07) 471-479
• 18 Yamamoto T, Yamamoto N, Kageyama T. et al. Technical pearls in lymphatic supermicrosurgery. Glob Health Med 2020; 2 (01) 29-32
• 19 Yamamoto T, Yamamoto N, Yoshimatsu H, Hayami S, Narushima M, Koshima I. Indocyanine green lymphography for evaluation of genital lymphedema in secondary lower extremity lymphedema patients. J Vasc Surg Venous Lymphat Disord 2013; 1 (04) 400-405.e1
• 20 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
• 21 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
• 22 Yamamoto T, Narushima M, Yoshimatsu H. et al. Dynamic indocyanine green (ICG) lymphography for breast cancer-related arm lymphedema. Ann Plast Surg 2014; 73 (06) 706-709
• 23 Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Hayashi A, Koshima I. Indocyanine green lymphography findings in primary leg lymphedema. Eur J Vasc Endovasc Surg 2015; 49 (01) 95-102
• 24 Brahma B, Yamamoto T. Breast cancer treatment-related lymphedema (BCRL): an overview of the literature and updates in microsurgery reconstructions. Eur J Surg Oncol 2019; 45 (07) 1138-1145
• 25 Yamamoto T, Yamamoto N, Fuse Y, Narushima M, Koshima I. Optimal sites for supermicrosurgical lymphaticovenular anastomosis: an analysis of lymphatic vessel detection rates on 840 surgical fields in lower extremity lymphedema. Plast Reconstr Surg 2018; 142 (06) 924e-930e
• 26 Yamamoto T, Yoshimatsu H, Yamamoto N, Narushima M, Iida T, Koshima I. Side-to-end lymphaticovenular anastomosis through temporary lymphatic expansion. PLoS One 2013; 8 (03) e59523
• 27 Yamamoto T, Matsuda N, Todokoro T. et al. Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema. Ann Plast Surg 2011; 67 (06) 637-640
• 28 Yamamoto T, Yamamoto N, Hara H, Mihara M, Narushima M, Koshima I. Upper extremity lymphedema index: a simple method for severity evaluation of upper extremity lymphedema. Ann Plast Surg 2013; 70 (01) 47-49
• 29 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
• 30 Yamamoto T, Yamamoto N, Hayashi N, Hayashi A, Koshima I. Practicality of lower extremity lymphedema index: lymphedema index versus volumetry-based evaluations for body-type corrected lower extremity volume evaluation. Ann Plast Surg 2016; 77 (01) 115-118
• 31 Yamamoto T, Koshima I. Upward retraction for lymphaticovenular anastomosis in the deep fat layer. Microsurgery 2014; 34 (07) 586-587
• 32 Yamamoto T, Yamamoto N, Azuma S. et al. Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis. Microsurgery 2014; 34 (01) 23-27
• 33 Yamamoto T, Yamamoto N, Numahata T. et al. Navigation lymphatic supermicrosurgery for the treatment of cancer-related peripheral lymphedema. Vasc Endovascular Surg 2014; 48 (02) 139-143
• 34 Yamamoto T, Yoshimatsu H, Koshima I. Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg 2014; 67 (11) 1573-1579
• 35 Yamamoto T, Yoshimatsu H, Yamamoto N. Complete lymph flow reconstruction: a free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis. J Plast Reconstr Aesthet Surg 2016; 69 (09) 1227-1233
• 36 Yamamoto T, Yamamoto N, Ishiura R. Application of a multi-directional transformable retractor for lymphatic supermicrosurgery using SEKI method. Microsurgery 2017; 37 (06) 729-730
• 37 Hayashi A, Yoshimatsu H, Visconti G. et al. Intraoperative real-time visualization of the lymphatic vessels using microscope-integrated laser tomography. J Reconstr Microsurg 2021; 37 (05) 427-435
• 38 Brahma B, Putri RI, Reuwpassa JO. et al. Lymphaticovenular anastomosis in breast cancer treatment-related lymphedema: a short-term clinicopathological analysis from Indonesia. J Reconstr Microsurg 2021; 37 (08) 643-654
• 39 Chen WF, Bowen M, Ding J. Immediate limb compression following supermicrosurgical lymphaticovenular anastomosis: is it helpful or harmful?. Int Microsurg J 2018; 2 (01) 1
• 40 Yamamoto T, Yamamoto N, Yamashita M, Furuya M, Hayashi A, Koshima I. Efferent lymphatic vessel anastomosis (ELVA): supermicrosurgical efferent lymphatic vessel-to-venous anastomosis for the prophylactic treatment of subclinical lymphedema. Ann Plast Surg 2016; 76 (04) 424-427