Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3628_Библиотеки_им_академика_М_И_Перельмана

great details in anastomosing lymphatic vessel< 0.3mm.

EMI microsurgery instruments are nice to have, especially for someone who is just starting supermicrosurgery. The ability to use a locking needle holder can help to decrease hand tremor, and it definitely helps to attack difficult-to-reach areas. The fingers do not need to exert forces onto the needle holder to hold the needle in place. The tremor will become quite obvious under 20 × magnification.

The titanium-made instruments are very nice to have, but great care is needed since they are more delicate than the stainless-steel instruments. Most mishaps happen during cleansing and preparation for sterilization after operation.

Stents. More suitable for normal or ectatic lymphatic vessels. Be careful about performing SEA to severe ectatic lymphatic vessel due to extremely thin, almost transparent, lymphatic wall. It is prone to tear and leakage during anastomosis. Lymphatic lumen will become indistinguishable due to thin, transparent lymphatic wall. Intraluminal stenting technique with a commerciall y available stent (Crownjun, Japan) or a fragment of nylon 5–0(1–2 mm) can aid to overcome this problem.

The degree of lymphedema reduction after LVA is de­pendent on the size and quality of the lymphatic vessels found and used for LVA.

Avoid insect bites or open wounds, for example, mosquito bites, to prevent cellulitis.

Dry lab

Transfer of lymphatic vessels is, in principle, a vascular surgical by pass procedure of lymphatic vessels to treat lymphedema. Autologous lymph vessel transfer (ALVT) technique is favored for patients with lymphedema caused mainly by a localized impairment of the lym­phatic transporting system in the axillary, groin or pel­vic region. The medial side of the knee region may be also affected, after orthop edic interventions, as well as distal areas of extremities, after peripheral interventions and trauma.

There are two anatomical regions in the lower extrem­ity where the lymphatic vascular network is particularly at risk when manipulating surgically, i.e., the groin, in­cluding the inguinal lymph nodes and the medial side of

The grafts always run within the subcutaneous tissue. In order to minimize any fric tion, tubes with a greater diameter like Redon tubes or urinary catheters with a length corresponding to the length of the distance are in­serted first. Before that, a polyfil thread (2–0) is inserted and fixed outside on both openings in order to pull the lymphatic grafts later on. The tubes are moistened; the tiny suture of the graft is connec ted to the thicker thread within the tube. Now, within the moistened tube, the graft is pulled without friction to the opposite side. The tube is removed and the graft lies within the subcutane­ous tissue without tension.

A short, longitudinal superficial skin incision is made medial to the femoral artery, After the blunt dissection, stained lymphatic vessels are sought out, right down to the fascia, since the bigger collectors are found just above this structure. The lymphatic collectors are stained green­ish blue. The incision is lengthened according to the course of the stained lymphatic collectors. Staining indi­cates a collector is functional. Within the knee region, the collectors are very close together, whereas above this area lymphatic collectors are spreading and building a net­work. Therefore, the harvesting should be stopped above the kn ee region. Oftentimes, at the peripheral part of the grafts, small branches can be seen and dissected. Using these branches allows for a greater number of anastomo­ses compared to the number of chosen bigger collectors. One to three collectors of the ventromedial bundle, con­sisting of about 16 ones, are normally taken resulting in four to six possible peripheral anastomoses. Centrally, the main collectors are also often divided and about three to four anastomoses can be performed at the central end­ings of the grafts, if the lymphatic collectors are harvested as free grafts (▶ Fig. 9.1).