Two-team approach in lymphovenous anastomosis and omental lymph node flap harvest for upper limb lymphedema

Abstract

Vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) can be performed simultaneously or independently, depending on the patient’s lymphedema stage [1]. A 54-year-old woman underwent bilateral total mastectomy in 2016, with sentinel lymph node biopsy for the right breast and axillary lymph node dissection for the left breast, followed by chemoradiotherapy. The patient developed progressive lymphedema (indocyanine green dermal stage IV–V), and LVA and VLNT were simultaneously performed (Fig. 1). The patient was laid supine and draped as illustrated in Fig. 2. First, the recipient vessels (thoracodorsal artery and vein) were prepared and complete scar tissue excision of the axilla and lateral chest was performed. A general surgeon then laparoscopically harvested an omental flap while a plastic surgeon performed LVA. With well-positioned monitors and microscope (Fig. 3), both the harvest and LVA were performed without interfering with each other’s operative field (Fig. 4). The upper part of the flap, with gastroepiploic lymph nodes, was inset in the Fig. 2. Immediate postoperative image, illustrating draping and incision sites for lymphovenous anastomosis (blue arrow), vascularized lymph node transfer (green arrow), and laparoscopic omental harvest (red arrows).