surgical techniques for lymphovenous bypass
A series of figures illustrating the the pertinent anatomy and surgical technique for the various approaches to lymphovenous bypass. Created for Dr. Laura Tom, Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center. Submitted to Plastic Aesthetic Research for invited editorial in January 2023.
Overview of lymphatic and venous vasculature frequently used in LVB. The caliber of lymphatics varies in the published literature, although they have been categorized into initial lymphatics (0.01-0.06 mm), pre-collector (0.035–0.150 mm), and collector lymphatics (0.200 mm).[184, 185] Thus, we illustrated a collector lymphatic as the relevant structure for LVB. (A) Collector lymphatics have tight “zipper-like” junctions, specialized muscle cells, and valves that coordinate directional lymph flow via suction-derived diastolic filling.[3, 25, 174] (B) The cutaneous vessels used in LVB generally include valved subdermal venules (0.3-0.6mm) or large cutaneous veins (>1mm).[58] The microcirculatory venules and veins vary according to their ultrastructure and anatomical location, and a venule with sparse smooth muscle cells is illustrated for generalizability.[103, 186, 187]
![Patient selection and preoperative evaluation. Illustration of Koshima ICG lymphedema classification system.[100] (A) Stage 0: “Normal superficial lymphatic vessels appear as a “linear” pattern with no dermal backflow” (B) Stage 1: “Lymphatic vessels](https://images.squarespace-cdn.com/content/v1/648e40951d4aa168b1174c2d/03a961bb-f890-4007-94cb-394a1e5d5093/Screenshot+2023-10-04+at+4.55.10%E2%80%AFPM.png)
Patient selection and preoperative evaluation. Illustration of Koshima ICG lymphedema classification system.[100] (A) Stage 0: “Normal superficial lymphatic vessels appear as a “linear” pattern with no dermal backflow” (B) Stage 1: “Lymphatic vessels appear dilated and torturous with areas of ICG accumulation as a “splash” pattern” (C) Stage 2: “Contracted lymphatic vessels with loss of intraluminal diameter and thickening of the smooth muscle cell coverage Lymphatic vessels are disrupted, causing increased areas of ICG accumulation as a “stardust” pattern” (D) Stage 3: “No lymphatic vessels can be seen and there is ICG accumulation as a “diffuse” pattern.”[100]
Selection of lymphatic and venous targets. (A) The lymphatic territories (lymphosomes) can be visualized with ICG. Lymphosomes superior to inferior 1) temporal, purple; 2) occipital, blue; 3) mental, tan; 4) supraclavicular, pink; 5) subscapular, not pictured; 6) axillary, dark teal; 7) pectoral, orange; 8) superior inguinal, red; 9) lateral inguinal, salmon; 10) inferior inguinal, magenta; 11) popliteal, not pictured. [illustration of lymphosomes adapted from Suami, et al.][188] (B) Pre-incision selection of target vessels will depend on location of obstruction and the presence of fluorescent lymphatics and neighboring veins. The incision should be placed over a junction between a lymphatic and vein (X and overlying circle). The incision can be made perpendicular to lymphatic. Selecting several possible sites for incision is ideal (C) lymphatic and vein in preparation for LVB.
Operative techniques in LVB. (A) transection of the target lymphatic should demonstrate lymphatic function. This is facilitated by injection Isosulfan blue (Lymphazurin; United States Surgical Corp., Norwalk, CT) or methylene blue (American Reagent, Shirley, NY) subcutaneously along the fluorescent lymphatic pathway. (B) Intravascular stenting (IVaS) can be performed with nylon suture prior to LVB. (D) an implantation technique implants the lymphatic into the venous lumen, using a stitch to connect lymphatic adventitia to venous intima. (E) The success of the bypass can be determined by direct visualization of the unidirectional flow of fluorescence from lymphatic into the recipient vein (distal to proximal) under microscopy.
Traditional E-E LVB Configurations: Traditional Orientation: E-E Union: I-I or implantation Lymph :RV: 1:1 <0.8mm +/- ILR + Modifications: many
Traditional E-S LVB Configurations: Traditional Orientation: E-S Union: I-I or implantation Lymph :RV: 1:1 <0.8mm +/- ILR +
Traditional S-S LVB Configurations: Traditional Orientation: S-S Union: I-I Lymph :RV: 1:1 <0.8mm - ILR - Modifications: Diamond-Shaped Fuse Y and Yamamoto T. Diamond-shaped anastomosis for supermicrosurgical side-to-side lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2015; 68: e209-210. 20150905. DOI: 10.1016/j.bjps.2015.08.033.
Traditional S-E LVB Configurations: Traditional Orientation: S-E Union: I-I Lymph :RV: 1:1 <0.8mm + ILR - Modifications: "Modifed S-E," dilation (SEATTLE) Yamamoto T, Yoshimatsu H, Narushima M, et al. A modified side-to-end lymphaticovenular anastomosis. Microsurgery 2013; 33: 130-133. 20120914. DOI: 10.1002/micr.22040. Yamamoto T, Yoshimatsu H, Yamamoto N, et al. Side-to-End Lymphaticovenular Anastomosis through Temporary Lymphatic Expansion. Plos One 2013; 8: e59523. DOI: 10.1371/journal.pone.0059523.
T/Y shaped LVB Configurations: Alternative Combined Configurations Orientation: E-Ex2 Union: I-I Lymph :RV: 1:2 <0.8mm + ILR - Modifications: Half notching Visconti G, Hayashi A, Salgarello M, et al. Supermicrosurgical T-shaped lymphaticovenular anastomosis for the treatment of peripheral lymphedema: Bypassing lymph fluid maximizing lymphatic collector continuity. Microsurgery 2016; 36: 714-715. 20160105. DOI: 10.1002/micr.30019. Furuya M, Yamamoto T, Yamashita M, et al. The half notching method for Flow-through lymphaticovenular anastomosis. Microsurgery 2015; 35: 415-416. 20140920. DOI: 10.1002/micr.22332.
π-shaped LVB Configurations: Alternative Combined Configurations Orientation: E-Sx2 Union I-I Lymph :RV 1:1 <0.8mm + ILR - Ayestaray B and Bekara F. pi-shaped lymphaticovenular anastomosis: the venous flow sparing technique for the treatment of peripheral lymphedema. J Reconstr Microsurg 2014; 30: 551-560. 20140328. DOI: 10.1055/s-0034-1370356.
λ-shaped LVB Configurations: Alternative Combined Configurations Orientation: E-S+E-E Union: I-I Lymph :RV: 1:2 <0.8mm + ILR - Modifications: Half notching Yamamoto T, Narushima M, Kikuchi K, et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011; 127: 1987-1992. DOI: 10.1097/PRS.0b013e31820cf5c6. Fuse Y and Yamamoto T. Half notching method for supermicrosurgical lambda-shaped lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2016; 69: e13-14. 20150905. DOI: 10.1016/j.bjps.2015.08.039.
Double barrel LVB Configurations: Alternative Combined Configurations Orientation: E-E Union: I-I Lymph :RV: 2:1, 2:2, 1:1 <0.8mm + ILR + Modifications: Walrus (2:2) elephant (1:1 with size mismatch) Masoodi Z, Steinbacher J, Tinhofer IE, et al. "Double Barrel" Lymphaticovenous Anastomosis: A Useful Addition to a Supermicrosurgeon's Repertoire. Plast Reconstr Surg Glob Open 2022; 10: e4267. 20220419. DOI: 10.1097/GOX.0000000000004267.
Octopus LVB Configurations: Alternative Combined Configurations Orientation: E-E Union: Implantation Lymph :RV: multiple:1 <0.8mm - ILR - Chen WF, Yamamoto T, Fisher M, et al. The "Octopus" Lymphaticovenular Anastomosis: Evolving Beyond the Standard Supermicrosurgical Technique. J Reconstr Microsurg 2015; 31: 450-457. 20150413. DOI: 10.1055/s-0035-1548746.
MVLA LVB Configurations: Alternative Combined Configurations Orientation: E-E Union: I-I or implantation Lymph :RV: multiple:1 <0.8mm - ILR + Campisi CC, Ryan M, Boccardo F, et al. A Single-Site Technique of Multiple Lymphatic-Venous Anastomoses for the Treatment of Peripheral Lymphedema: Long-Term Clinical Outcome. J Reconstr Microsurg 2016; 32: 42-49. 20150601. DOI: 10.1055/s-0035-1549163.
Coupler Assisted Bypass LVB Configurations: Alternative Combined Configurations Orientation: E-E Union: implantation Lymph :RV: 2:1, 3:1 <0.8mm - ILR + Spoer D.L., Berger L.E., Towfighi P.N., Deldar R., Gupta N., Huffman S.S., Sharif-Askary B., Fan K.L., Parikh R.P. & Tom L.K.. Lymphovenous Coupler-Assisted Bypass (CAB) for Immediate Lymphatic Reconstruction. Journal of Reconstructive Microsurgery. Status: Submitted January 2023
ladder-shaped LVB Configurations: Alternative Combined Configurations Orientation: S-S Union: I-I Lymph :RV: multiple:1 <0.8mm - ILR - Yamamoto T, Kikuchi K, Yoshimatsu H, et al. Ladder-shaped lymphaticovenular anastomosis using multiple side-to-side lymphatic anastomoses for a leg lymphedema patient. Microsurgery 2014; 34: 404-408. 20131226. DOI: 10.1002/micr.22215.