Immediate Lymphatic Reconstruction: Technical Points and Literature Review

Abstract

Recent studies have provided evidence that lymphovenous bypass-microsurgical re-routing of divided lymphatics to an adjacent vein-performed at the time of lymph node dissection decreases the rate of lymphedema development. Immediate lymphatic reconstruction in this setting is technically demanding, and there is a paucity of literature describing the details of the surgical procedure. In this report, we review the literature supporting immediate lymphatic reconstruction and provide technical details to demystify the operation for surgeons who wish to provide this option to their patients.

Fig. 1.

ILR instruments and equipment setup.

Fig. 2.

Upper extremity injection sites and ICG lymphangiogram with SPY-PHI. A, B, ICG is injected at 0.1 ml into the dermis of the first and third webspace, and the volar wrist. FITC is injected at 0.1 ml into the dermis of the first and third webspace, and the volar wrist. Additional FITC injections are done into the dermis across the medial upper arm (4–5 points with 0.1 ml each) and deeper, just above muscle fascia (1 point with 0.3 ml). C, D, ICG lymphangiogram showing the standard volar, radial, and ulnar lymphatic bundles merging at the upper inner arm.

Fig. 3.

Visualization of lymphatic channels with FITC using the Mitaka microscope. A, With no filter, the lymphatic channel is slightly visible under white light. B, With a low-contrast fluorescence filter, there is visibility of non-fluorescent tissue and some fluorescence within the lymphatic channel. C, With a high-contrast fluorescence filter, there is poor visibility of non-fluorescent tissue, but excellent fluorescence seen within the lymphatic channel.

Fig. 4.

Lymphatic channel with FITC injected after ALND. A, Without the microscope, FITC is seen accumulating in the lymphatic channel up to the clip, dilating the lymphatic channel, on the right. Thoracoepigastric vein with clip on the left. B, Using the Mitaka microscope with a low-contrast fluorescence filter, there is visibility of surrounding tissue and fluorescence within the lymphatic channel.

Fig. 5.

Thoracoepigastric (sometimes referred to as accessory) vein in axilla. The vein was dissected to a length of 6 cm, and there is a valve present at the midpoint. The intercostal brachial nerve is crossing posteriorly, and the thoracodorsal vessels are seen posterior to the thoracoepigastric vein.

Fig. 6.

Alternative vein choices in the axilla. Illustrated are the medial pectoral vein running on the undersurface of the pectoralis major muscle, the lateral thoracic vein running on the lateral chest wall, the thoracodorsal vein and circumflex scapular vein (Cx) that are deeper in the axilla, and the thoracoepigastric vein (sometimes referred to as accessory) running more superficial (just below the clavipectoral fascia) to the thoracodorsal vessels.

Fig. 7.

Vein choices in the groin. The superficial epigastric vein and superficial circumflex iliac vein course laterally from the femoral vein. The external pudendal vein courses medially.

Fig. 8.

Thoracoepigastric vein with 4 branches and 4 separate anastomosis (*) of lymphatic channels at different locations and different depths in the axilla visualized through the Mitaka microscope (image is focused to deepest anastomosis; therefore, several proximal anastomosis appear blurred).

Fig. 9.

Verification of anastomotic patency using ICG and FITC. A, B, Two lymphatic channels anastomosed to the end of a vein with sutures closing the vein to itself centrally to prevent leakage. ICG seen flowing through the anastomosis, into the vein. C, D, Two lymphatic channels anastomosed to end of a vein branch. FITC seen flowing through the anastomosis, into the vein.