Takumi Yamamoto

A modified side-to-end lymphaticovenular anastomosis.

Lymphaticovenular anastomosis (LVA) is a useful treatment for compression‐refractory lymphedema with its effectiveness and minimal invasiveness. However, LVA requires supermicrosurgery, where lymphatic vessels with a diameter of 0.5 mm or smaller are anastomosed using 11‐0 or 12‐0 suture. To make LVA easier and safer, we adopted a modified side‐to‐end (S‐E) anastomosis in LVA surgery.

Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: A case report

Lymphatico‐venous anastomosis (LVA) is used to resolve lymph retention in lymphedema. However, the postoperative outcome of lower limb lymphedema is poorer than that for upper limb lymphedema, because of the location lower than the heart level. Improvement of the therapeutic outcome requires application of as many anastomoses as possible in a limited operation time, particularly since there is a positive correlation between the number of anastomoses and the therapeutic effect of LVA. In this case, we described a method to increase the efficiency of lymphatico‐venous anastomosis for bilateral severe lower limb lymphedema through efficient identification of lymph vessels and veins suitable for anastomosis using indocyanine green (ICG) contrast imaging and AccuVein, a noncontact vein visualization system, respectively. Ten LVAs were succeeded at seven incisions, and the operation time was 3 hours and 5 minutes. Accuvein can be used for identification of subcutaneous venules with a diameter of about 0.5–1.0 mm. We used this approach in surgery for a case of bilateral lower limb lymphedema, with a resultant improvement in the surgical outcome.

Technical simplification of the supermicrosurgical side-to-end lymphaticovenular anastomosis using the parachute technique.

Supermicrosurgical side‐to‐end (S‐E) lymphaticovenular anastomosis (LVA) is the most favorable anastomotic configuration for the treatment of lymphedema because it creates antegrade and retrograde lymph flow while preserves the native lymph flow. However, it is technically demanding and its successful performance has been limited only to the experienced LVA surgeons. This study aimed to evaluate the applicability of parachute technique in S‐E LVA and its potential in decreasing the technical complexity of the procedure.

Modified lambda-shaped lymphaticovenular anastomosis with supermicrosurgical lymphoplasty technique for a cancer-related lymphedema patient

Supermicrosurgical lymphaticovenular anastomosis (LVA) has become a useful option for the treatment of compression‐refractory lymphedema with its effectiveness and less invasiveness. It is important to make as many bypasses as possible for better treatment results of LVA operation. We report a secondary lymphedema case successfully treated using a modified lambda‐shaped LVA. A 62‐year‐old female with secondary lower extremity lymphedema (LEL) refractory to conservative treatments underwent LVA operation. A modified lambda‐shaped LVA was performed at the left groin. In modified lambda‐shaped LVA, two lymphatic vessels were transected, and both ends of the proximal and distal sides were converged respectively for an end‐to‐side and end‐to‐end anastomoses to one vein. Using modified lambda‐shaped LVA, four lymph flows of two lymphatic vessels could be bypassed into a vein. Six months after the LVA surgery, her left LEL index decreased from 261 to 247, indicating edematous volume reduction. Modified lambda‐shaped LVA effectively bypasses all lymph flows from two lymphatic vessels, when only one large vein can be found in the surgical field.

Antegrade and retrograde lymphatico‐venous anastomosis for cancer‐related lymphedema with lymphatic valve dysfuction and lymphatic varix

In healthy people, no retrograde lymph flow occurs because of valves in collecting lymph vessels. However, in secondary lymphedema after lymph node dissection, lymph retention and lymphatic hypertension occurs and valvular dysfunction induces retrograde lymph flow. In this case reported, we focused on retrograde lymph flow and performed retrograde lymphatico‐venous anastomosis (LVA) simultaneously with antegrade LVA. A 67‐year‐old Japanese woman had worsening edema in her right thigh and hip area for 3 years. She had previously undergone extended hysterectomy with lymph node dissection for endometrial cancer 8 years before. Indocyanine green test showed antegrade and retrograde lymph flow. Four LVAs were made in the right medial thigh and right lower abdominal area under local anesthesia. Lymphedema showed rapid improvement within 12 months and compression therapy was not required at 24 months after LVA. Retrograde LVA has a possibility of a more efficacy for secondary lymphedema.

Establishment of supermicrosurgical lymphaticovenular anastomosis model in rat.

Background: Lymphaticovenular anastomosis (LVA) is becoming a choice of treatment for compression‐refractory lymphedema. However, LVA requires highly sophisticated microsurgical technique called supermicrosurgery, and no training model for LVA has been developed. This study aimed to develop and evaluate feasibility of a new LVA model using rat thigh lymphatic vessels. Methods: Ten Sprague‐Dawley rats were used for the study. After preoperative indocyanine green (ICG) lymphography, lymphatic vessels in posteromedial aspect of the thigh were dissected. In right limbs, the largest lymphatic vessel was anastomosed to the short saphenous vein or its branch, and the remaining lymphatic vessels were ligated (LVA group). In left limbs, all lymphatic vessels were ligated (control group). Anastomosis patency was evaluated intraoperatively and at postoperative 7 days. Results: Courses of lymphatic vessels in the thigh were constant; lymphatic vessels run along the short saphenous vein. The mean diameter of lymphatic vessel used for LVA was 0.240u2009±u20090.057 mm, and the mean diameter of vein was 0.370u2009±u20090.146 mm. All lymphatic vessels were translucent and very thin like human intact lymphatic vessels. In LVA group, intra‐ and post‐operative anastomosis patency rates were 100% (10/10) based on ICG lymphography. In control group, intra‐ and post‐operative patency rates were 0% (0/10). Conclusions: Rat lymphatic vessels are thin, translucent, and fragile similar to intact human lymphatic vessels. The LVA model uses easily accessible lymphatic vessels in the thigh, and is useful for training of supermicrosurgical LVA.

Supermicrosurgical anastomosis of superficial lymphatic vessel to deep lymphatic vessel for a patient with cellulitis-induced chronic localized leg lymphedema.

Supermicrosurgical lymphaticovenular anastomosis (LVA) has been reported to be useful for the treatment of obstructive lymphedema. However, LVA has a potential risk of anastomosis site thrombosis. It is more physiological to use a lymphatic vessel as a recipient vessel of lymphatic bypass surgery, because there is no chance for blood to contact the anastomosis site. We report a chronic localized lower leg lymphedema case treated with supermicrosurgical superficial‐to‐deep lymphaticolymphatic anastomosis (LLA). A 66‐year‐old male with a 60‐year history of cellulitis‐induced left lower leg lymphedema suffered from very frequent episodes of cellulitis and underwent LLA under local infiltration anesthesia. LLA was performed at the dorsum of the left foot. A dilated superficial lymphatic vessel was found in the fat layer, and a nondilated intact deep lymphatic vessel was found along the dorsalis pedis artery below the deep fascia. The superficial lymphatic vessel was supermicrosurgically anastomosed to the deep lymphatic vessel in a side‐to‐end fashion. After the surgery, the patient had no episodes of cellulitis, and the left lower leg lymphedematous volume decreased. Superficial‐to‐deep LLA may be a useful option for the treatment of secondary lymphedema due to obstruction of only the superficial lymphatic system.

Use of non-enhanced angiography to assist the second toetip flap transfer for reconstruction of the fingertip defect

Toetip flap transfer is a useful reconstructive method for fingertip defect, but elevation of a toetip flap is technically demanding because of difficulty to dissect a pedicle vein of the flap. Recently, nonenhanced angiography (NEA) has been reported to be useful for preoperative visualization of the digital vessels without contrast enhancement or invasiveness. We report a case in which preoperative NEA visualized a vein suitable for a venous pedicle of a second toetip flap and facilitated successful toetip flap transfer for reconstruction of a fingertip defect. A 27‐year‐old male suffered from the right middle fingertip crush amputation in Tamai zone 1. The fingertip was reconstructed using a second toetip flap with preoperative NEA guidance. A pedicle vein was easily found and dissected exactly where NEA visualized. Nine months after the toetip flap transfer, the reconstructed right middle finger was functionally and aesthetically pleasing, and the toe nail at the donor site was preserved without any morbidity. NEA may help a surgeon to find drainage veins for a toetip flap, which leads to easier and more secure toetip flap transfer.

Autologus groin lymph node transfer for “sentinel lymph network” reconstruction after head‐and‐neck cancer resection and neck lymph node dissection: A case report

Local or distant metastatic recurrence after therapy is observed in 20–30% of cases of head‐and‐neck cancer. An unfavorable course may occur after cervical lymph node dissection due to loss of immunoprotective lymph nodes in the head‐and‐neck region. To overcome this problem, we performed autologous lymph node transplantation from the groin after head‐and‐neck cancer resection and cervical lymph node dissection. The patient was a 63‐year‐old man with squamous cell carcinoma in the mesopharyngeal lateral wall. After tumor resection and right cervical lymph node dissection, a lymph node‐containing superficial circumflex iliac artery perforator flap was transplanted from the left groin. Pathological examination showed that cancer had invaded the primary tumor tissue stump. Thus, radiotherapy (66 Gy) was performed for the residual tumor from days 28 to 84 after surgery. At 12 months after surgery, no recurrent lesion or has developed. The biopsy of flap and lymphatic vessel endothelial hyaluronan receptor‐1 (LYVE1) immunostaining shows creditable lymph network in the flap, compared with normal free flap. This case suggests that autologous lymph node transplantation may keep watch on cancer recurrence by reconstruction of the lymph node system in the resected region, and we suggest that this approach may be very useful in cancer therapy.

Sensate superficial inferior epigastric artery flap innervated by the iliohypogastric nerve for reconstruction of a finger soft tissue defect.

In the era of perforator flaps, lower‐abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flaps region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55‐year‐old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end‐to‐side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes‐Weinstein test and moving 2‐point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical and clinical studies are required to clarify anatomy and clinical usefulness of the IHN.