Use of Intraoperative Manual Drainage for the Detection of Lymphatic Ducts for Lymphaticovenous Anastomosis

Abstract

Background: Manual lymphatic drainage (MLD) is a widely accepted conservative treatment for lymphedema. Lymphaticovenous anastomosis (LVA) is a minimally invasive bypass surgery that improves lymphedema. However, identifying the lymphatic duct can be challenging during LVA. Transient dilation of the lymphatic ducts can be accomplished with intraoperative MLD, which can definitively identify and isolate the lymphatic ducts. This study describes the use of this intraoperative MLD procedure.

Methods: LVA procedures that used intraoperative MLD were compared with those that did not. The lymphatic diameter, LVA site, rate of cellulitis episodes, and indocyanine green (ICG) lymphography pattern characteristics between the 2 groups were compared. The surgeon performed MLD distal to the incision.

Results: The intraoperative MLD drainage (+) and drainage (-) groups consisted of 269 and 189 anastomoses, respectively. The median lymphatic duct diameter in the drainage (+) group was significantly larger (0.6 vs 0.5 mm; P < 0.001). The drainage (+) group had significantly higher linear pattern rates preoperatively (76.2% vs 37.6%; P < 0.001), lower extremity (68.4% vs 51.9%; P < 0.001), distal site (81.8% vs 63.5%; P < 0.001), and postoperative improvement by local ICG lymphography pattern (22.7% vs 14.3%; P = 0.03). The rate of cellulitis episodes was significantly lower in the drainage (+) group.

Conclusions: The successful detection rate of the lymphatic duct based on the intraoperative MLD was high on the distal side of the extremity and the lymphatic duct without sclerosis. This method was also effective for early-stage lymphedema.