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Intraoperatively Detected But Previously Indocyanine Green–Negative Lymphatic Vessels May Have Misprized Potentials and Should Not Be Neglected in Lymphaticovenous Bypass Surgery

Scaglioni, Mario F. MD*†; Uyulmaz, Semra MD; Arvanitakis, Michael MD; Lineaweaver, William C. MD, FACS§; Zhang, Feng MD§

doi: 10.1097/SAP.0000000000001781

Introduction Identification of patent lymphatic vessels without fibrosis and with high flow is difficult but crucial in the preoperative planning of lymphaticovenous anastomosis (LVA). Lymphatic vessels on the operating field cannot always be visualized preoperatively because of the anatomical and physiological characteristics of lymphedema tissue. The purposes of this study were to demonstrate our clinical experience in identifying indocyanine green (ICG)–negative lymphatics intraoperatively and to emphasize the therapeutic potential of performing anastomoses with ICG-negative lymphatics.

Methods Indocyanine green–positive lymphatic ducts were marked preoperatively in 5 patients with lower extremity lymphedema; moreover, if ICG-negative lymphatics were identified during surgery, they were used for additional LVA thus implementing multiple anastomoses in one surgical setting.

Results In total, 33 LVAs were performed in 5 patients with lower extremity lymphedema, of which 11 LVAs were implemented with ICG-negative lymphatics. Immediately after the anastomosis, a strong lymphatic drainage could be appreciated in all cases. Six months postoperatively patients reported a subjective decrease in limb circumference and pressure sensation.

Conclusions We believe that ICG-negative lymphatics found intraoperatively should be evaluated for additional LVAs in order to maximize drainage effect and might provide better outcomes.

From the *Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne;

Department of Plastic and Hand Surgery, University Hospital Zurich, Zurich; and

Kantonssiptal Sant Gallen, Sant Gallen, Switzerland; and

§Joseph M. Still Burn and Reconstructive Center, Jackson, MS.

Received June 30, 2018, and accepted for publication, after revision October 28, 2018.

M.F.S. and S.U. should be considered co–first authors.

Conflicts of interest and sources of funding: none declared.

Reprints: Mario F. Scaglioni, MD, Department of Plastic and Hand Surgery, Lucerne Knatonsspital, Spitalstrasse, 6000 Luzern 16 Switzerland. E-mail:

Online date: March 14, 2019

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