Chapter 170 - Lymphedema surgical treatment Flashcards
Surgical excision for lylmphedema first described
Charles 1912
Charles procedure
1) circumferential resection of skin, subcutaneous tissue and deep fascia
2) split-skin grafting
Liposuction for lymphedema first described by
Illouz
Thompson procedure
1) resect fascia with subcutaneous tissue
2) create a flap and de-epithelialized rim of flap
3) burry flap near deep vessels to facilitate spontaneous lymphatic anastomoses
Lymphoscintigraphy vs MRI
MRI better for lymph vessels
lymphoscintigraphy better for inguinal nodes
Lymphatic transport index
0 - 45
< 10 is normal
Type of dye injection
patent blue dye (europe) isosulfan blue (Lymphazurin; US)
Pre-operating planning before venous
lymphoscintigraphy for disease and for donor site
Approximate number of lymphatic vessels in the ventromedial lylmphatic bundle of the thigh
16
Harvesting lymphatic vessels
1-4 collectors dissected from medial thigh
spare those near groin and knee
Lymphatic vessels in arm and neck and general course
Epifascial usually
Subfascial would be close to vessels
Oblique incision medial and superior to brachial artery
Search with 3x to 10x magnificationt
Appearance of lymphatic vessel
Gray shiny in early stages of lymphedema
fibrotic in late stages
Lymphatic anastomosis in the case where outflow lymphatic vessel cannot be identified
Sew to lymph node by making small incision superficially
Anastamosis between lymphatic vessels
Extremely fragile
Minimal traction allowed
10-0 absorbable polyglactin 910 with BV75-4 needle
4 simple interrupted enough
Method of venous bridge in lymphedema reconstruction
1) invaginatig two ends of the lymphatic vessel with vein as bridge
2) interposition with vein
3) multiple lymphatic vessels into one vein
Lymphovenous key points
1) ensoure no CVD
2) lymphangiography intraop can help identify vessels for anast
3) Zeiss 4x-40x mag used
Liposuction technique
1) 3 mm incision x 20-30
2) vacuum aspiration
3) compressive therapy
Miller staged subcutaneous excision beneath flaps
1) pneumatic tourniquet
2) incision from ankle to thigh
3) flap 1.5 cm thick created
4) subcutaneous tissue removed preserving sural nerve
5) resect deep fascia over calf
6) spare fascia at knee and ankle
7) resect reduntant skin
8) suction catheter placed
9) wound closed
10) bed rest 9 days with elevation
11) wrap leg tightly then mobilize
stage 2: 3 months later
Same thing again
Complication of Miller procedure
1) long hospitalization
2) poor wound healing
3) long surgical scars
4) sensory nerve loss
5) residual edema in foot and ankle
chylous disorders
accumulation of cyle in abnormal areas of the body
Primary chylous disorder symptoms
1) LE edema 54%
2) dyspnea 49%
3) scrotal/labial edema 43%
4) abdominal distention 37%
Primary chylous disorder causes
Primary lymphagiectasia 66%
Yellow nail syndrome 11%
lymphangioleiomyomatosis 9%
others 18%
LE and genitalia chylous discharge first described by
1949
Servelle and Deysson
Greatment for chyle reflux in perineum, labia, scrotum, LE
radical excisio and ligation of incompetent lymph vessels
Surgical treatment of LE chylous disorder
1) eat 60g butter and 8oz whipped cream (fatty meal)
2) ligation of vessel with care to prevent tear
3) +/- sclerotherapy
4) tetracycline 500-1000 mg in 20ml injected into lymph vessel to provoke lymphangitis
Cause of chylous ascites
Intraperitoneal rupture of the mesenteric or retroperitoneal lymphatics
or exudationg of chyle into the peritoneal cavity
Diagnosis of chylous ascite
1) bipedal contrast lymphangiography for lymphangiectasia
2) paracentesis
Medical treatment of chylous disorders
1) medium-chain TG diet
2) PTN
Surgical treatment of chylous ascites
1) Abdominal exploration
2) oversew leaking lymphatics
3) resect bowel taht’s causing protein-losing enteropathy
LeVeen shunt
shunting peritoneal to venous
Chylothorax causes
1) trauma
2) malignancy
3) lymphangiectasia +/- duct obstruction
4) leaking from diaphragm due to chylous ascites
Treatment for chylothorax
1) treat chylous ascites
2) surgical pleurodesis - excision of parietal pleura and prolonged pleural suction)
Surgical pleurodesis steps
1) fatty meal
2) thoracotomy or VATS
3) oversew or clip leaking lymphatic
4) pleurodesis
Methods of reconstructing thoracic duct steps
Thoracic duct-azygos vein anastomosis
1) right posterolateral thoracotomy
2) anastomosis done with 8-0 or 10-0 nonabsorbable interrupted sutures
Indication for thoracic duct reconstruction in chylous leak
occlusion of cervical or upper thoracic duct is the cause of lymphangiectasia and reflux of chyle into the pleural/peritoneal cavity
Normal insertion of the thoracic duct
Behind IJ, in front of vertebral vein
into left subclavian vein
