Optimizing Outcomes in Lymphedema Reconstruction | Journal CME Article-Journal CME Article: Optimizing Outcomes in Lymphedema Reconstruction Video 2 of 4

Video Transcription

I'd like to perform the entire bypass under the microscope. The skin has been injected with epinephrine for hemostasis.  We carefully go down through the dermis with the micro-instruments and we're looking for any small branch or vein as well as lymphatics. This is a typical lymphatic arm.  The leg will also be the same. There's a lot of fat deposition from the lymphedema.  And I use the micro-instruments for all dissection. I also injected isosulfone blue where the isogen has been injected and if the lymphatics  have isosulfone blue, it will turn blue and make it easy to see that. Here I'm looking for any possible lymphatics as well as small veins.  There's a small vein inferior to the sub, which we actually ended up using as a recipient vein. So we have to identify both lymphatic and vein.  Here we see something kind of green here. At this point, we can turn the fluorescent mode of the microscope and here is the lymphatic where we have seen.  Having this fluorescent mode can be very helpful. And there's some examples of lymphatic vessels.  This is essentially a very nice looking lymphatic vessel that is plump with lymphatic fluid. This one has some damage, as you can see the corrugation, but still functioning.  This lymphatic has the isosulfone uptake. So it's blue and makes it easy to identify. This is an example of a lymphofluorescence bypass. This is just the fast forward.  There are a number of things you can see here. Number one, there's a lot of lymphatic fluid coming out of a lymphatic vessel, which is important.  So it is a functioning lymphatic system. And the vein has no backflow and there's no clamp on it. So this is how I would like to perform end-to-end anastomosis.  Always find a good lymphatic vessel with a lot of lymphatic flow, and then use a vein with no backflow as the recipient vein.  And this is a background of approximately one millimeter, over one millimeter, and lymphatic vessel shares by 0.3, and the vein is approximately 0.5.  And you can see when we did a milk test, there was a lot of lymphatic vessel fluid going into the vein.  And here's another one where you can see we are trying to milk the blood from the main side into the lymphatic, but because of the pressure, it just would not go through there.  And after anastomosis, you can see the ICGN going across anastomosis into the vein.

Video Summary

The procedure involves performing a lymphatic bypass under a microscope, utilizing micro-instruments and techniques to identify lymphatics and veins for anastomosis. The skin is injected with epinephrine for hemostasis and isosulfone blue to highlight lymphatics. Fluorescent microscopy aids in identifying and mapping lymphatic vessels. A suitable lymphatic vessel with ample fluid is selected, and a vein with no backflow serves as the recipient. The process ensures efficient lymphatic drainage, verified through successful milking tests and visible dye transfer post-anastomosis, demonstrating effective lymphatic and vascular connections.

Keywords

lymphatic bypass

fluorescent microscopy

anastomosis

isosulfone blue

micro-instruments