Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 715 - файл

upper and lower limbs. Lymphedema can be categorized as pri­mary or secondary. Primary lymphedema is caused by intrinsic defects in the development of the lymphatic system and can occur at various stages of life (i.e., congenital lymphedema, lymph­edema praecox, and lymphedema tarda). Secondary lymphedema is caused by extrinsic interruptions in the lymphatic system such as infection, malignancy, or tissue trauma. Lymph node dissection is the most common cause of tissue trauma resulting in secondary lymphedema. Of note, breast cancer-related lymphedema (BCRL) is the most common noninfectious secondary lymphedema in the United States that signicantly impacts patients’ quality of life [15]. Therefore, the prevention and treatment of BCRL still remains a challenge. The likelihood of developing BCRL is related to the extent of therapeutic interventions ranging from sentinel lymph node biopsy to axillary lymph node dissection (ALND) and adjunct radiation. Since the introduction of sentinel lymph node biopsy for surgical staging in 1992 by Drs. Morton and Cochran, the incidence of BCRL has been reduced to 5–7% [16]. However, among patients undergoing axillary lymph node dissection (ALND), the reported incidence of BCRL is approxi­mately 20%. The reported incidence of BCRL is even higher among patients undergoing both ALND and radiotherapy, ranging from 25% to 40% [16].

The clinical manifestations of lymphedema and the time of presentation are variable among patients. The most common early sign is extremity swelling, but occasionally patients report pain and recurrent cellulitis as their primary complaints. Identifying a patient’s stage of lymphedema begins with a thorough clinical examination. While various staging systems have been reported, the most widely accepted staging system is the International Society of Lymphology (ISL) staging system which grades lymphedema based on the clinical ndings and its natural pro­gression [17] (Table 8.1). Subclinical or stage 0 lymphedema refers to an early stage of dysfunctional lymph transport without clinical manifestations. Stage 1 is characterized by reversible edema either with extremity elevation or compression with or without pitting edema. Conversely, in stage 2, lymphedema pres­ents as irreversible pitting edema and some tissue brosis, which

While lymphoscintigraphy has been the standard imaging modality for lymphedema, ICG lymphangiography has become a widely utilized tool in this patient population. ICG lymphangiog­raphy is a noninvasive test that allows precise, real-time evalua­tion of the supercial lymphatic drainage with the added advantage of not utilizing radioactive particles. Similar to lymphoscintigra­phy, ICG lymphangiography permits a qualitative evaluation of

Identifying ow patterns can guide microsurgical options avail­able. The main goal of lymphedema microsurgery is to restore drain­age of excess interstitial uid. This is in contrast to earlier surgical procedures that involved excision of the brotic and nonfunctional tissues, which are still useful for advanced- staged lymphedema. The main indication for lymphedema microsurgery is early stage lymph­edema prior to adipose deposition and tissue brosis. The three main lymphatic microsurgical procedures are lymphaticovenous anasto­mosis (LVA), vascularized lymph node transfer (VLNT), and the combination of microsurgical breast reconstruction with lymph node transfer (known as the Barcelona Cocktail) [19]. The supermi­crosurgical LVA was rst described by Koshima in 2000 and became popular after the introduction of new technology and indocyanine green lymphangiography [20]. In this procedure, several remaining lymphatic channels with linear ow are anastomosed to subdermal veins. Vascularized lymph node transfer (VLNT) was developed in animal studies in the 1990s. In this procedure, a lymph node bed of tissue vascularized by a named pedicle is transferred to a distant location as a free tissue transfer. This is a surgical option that allows restoring uid drainage once LVA is not possible in the setting of absent lymphatic vessels by bringing in new healthy lymph nodes. Commonly used donor sites for lymph node transfer include the submental nodes, supraclavicular nodes, inguinal nodes, lateral tho­racic nodes, or omentum. These are then transferred using standard microsurgery techniques to the affected regions as needed. Additionally, a vascularized lymph node transfer can be combined with free ap breast reconstruction using a deep inferior epigastric artery perforator (DIEP) ap. In this procedure, the supercial ingui­nal lymph nodes are dissected with the DIEP ap and oriented in the axilla during free ap inset (Fig.8.2).

2.5 mg/ml solution. The initial injection volume is dependent upon the planned procedure. During the procedure, additional doses may be used but should not exceed 2mg/kg total dose. A larger dose may be required in areas of increased deposits of adi­pose tissue. In pediatric patients, smaller doses may be used based on body weight and age. Of note, a number of psychiatric, neuro­logic, and cardiac drugs are associated with increased clearance and should therefore be documented and communicated with anesthesia in order to optimize dosage. These medications include

1. Prepare and drape imaging equipment in a sterile manner.

2. Reconstitute 25mg of ICG in 10ml of sterile water, yielding a

2.5mg/ml solution.

continue to shake gently until the ICG is dissolved. If precipi­tation persists, discard the solution and prepare a new solu­tion.)

4. Inject 2ml of the solution via peripheral IV.

5. Flush with 10cc normal saline.

6. Turn down the operating room lights and use the imaging

device to evaluate tissue perfusion of mastectomy aps. Areas of hyperintensity have higher rates of tissue perfusion, while areas of hypointensity have poor tissue perfusion. Quantication of tissue perfusion is facilitated by percentages relative to the highest perfused areas displayed as an onlay (Fig.8.3).

1. Prepare and drape imaging equipment in a sterile manner.