Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3628_Библиотеки_им_академика_М_И_Перельмана
.pdf
11.7 Pearls and Pitfalls
https://t.me/medicina_free
11.7 Pearls and Pitfalls
●
Preoperative evaluation of functionality of the
lymphatic system is key to correctly select candidates
for lympho-reconstructive techniques.
●
Currently available imaging techniques are key to
assess both the anatomy and the function of the
lymphatic system in order to accurately plan surgery.
●
Axillary scar tissue removal (i.e., “scar release”)isa
critical step for the reduction of arm volume and
improvement of shoulder mobility. An axillary
recipient site devoid of scar tissue resulting from
surgery and/or radiotherapy is needed for adequate
integration and regeneration of new lympho-venular
anastomosis after VLNT. The flap should be positioned
in the apex of the axilla alongside the axillary veins to
replace removed or nonfunctional lymph nodes.
●
The risk of seroma formation can be reduced using
quilting sutures, fibrin glue, and drains while closing
the donor site of the abdominal and lymph node flap.
●
The risk of iatrogenic lymphedema secondary to lymph
node flap harvesting is reduced if meticulous dissection
is performed within the given anatomical landmarks,
namely, the femoral vessels medially and superficial
circumflex iliac vessels caudally.
●
Reversed lymphatic mapping during surger y is
needed to distinguish lymph nodes that do not drain
the extremity from the ones that drain the extremity.
The latter lymph nodes should be excluded from the
lymph node fl ap .
●
Including the skin overlapping the adipose tissue
containing the lymph nodes provides flap tissue that
may replace skin at the recipient site (e.g., scar
retraction after axillary lymph node clearance and/or
radiotherapy) and allows clinical flap monitoring.
●
The patient should receive accurate instructions
regarding postoperative behavior, mobilization, and
physical therapy according to in-house protocols.
References
[1] DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm
lymphoedema after breast cancer: a systematic review and metaanalysis. Lancet Oncol. 2013; 14(6):500–515
[2] International Society of Lymphology Executive Committee.. The
Diagnosis and Tratment of Peripheral Lymphedema. Lymphology.
1995; 28(3):113–117
[3] Mihara M, Hara H, Hayashi Y, et al. Pathological steps of cancer-
related lymphedema: histological changes in the collecting lymphatic
vessels after lymphadenectomy. PLoS One. 2012; 7(7):e41126
[4] Zeltzer AA, Anzarut A, Hamdi M. A review of lymphedema for the
hand and upper-extremity surgeon. J Hand Surg Am. 2018; 43(11):
1016–1025
[5] Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of
sentinel-node biopsy with routine axillary dissection in breast
cancer. N Engl J Med. 2003; 349(6):546–553
[6] Soares EWS, Nagai HM, Bredt LC, da Cunha AD, Jr, Andrade RJ, Soares
GVS. Morbidity after conventional dissection of axillary lymph nodes
in breast cancer patients. World J Surg Oncol. 2014; 12:67
[7] Schünemann H, Willich N. [Secondary lymphedema of the arm
following primary therapy of breast carcinoma]. Zentralbl Chir. 1992;
117(4):220–225
[8] McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of
lymphedema in women with breast cancer 5 years after sentinel
lymph node biopsy or axillary dissection: objective measurements. J
Clin Oncol. 2008; 26(32):5213–5219
[9] Ozcinar B, Guler SA, Kocaman N, Ozkan M, Gulluoglu BM, Ozmen V.
Breast cancer related lymphedema in patients with different locoregional treatments. Breast. 2012; 21(3):361–365
[10] Shaitelman SF, Chiang YJ, Griffin KD, et al. Radiation therapy targets and
the risk of breast cancer-related lymphedema: a systematic review and
network meta-analysis. Breast Cancer Res Treat.2017; 162(2):201–215
[11] Mehrara BJ, Greene AK. Lymphedema and obesity: is there a link?
Plast Reconstr Surg. 2014; 134(1):154e–160e
[12] Siotos C, Sebai ME, Wan EL, et al. Breast reconstruction and risk of
arm lymphedema development: a meta-analysis. J Plast Reconstr
Aesthet Surg. 2018; 71(6):807–818
[13] De Brucker B, Zeltzer A, Seidenstuecker K, Hendrickx B,
Adriaenssens N, Hamdi M. Breast cancer-related lymphedema:
quality of life after lymph node transfer. Plast Reconstr S urg. 2016;
137(6):1673–1680
[14] Hirche C, Autologous Breast Reconstruction in Conjunction with
Lymphatic Microsurgery in Breast Cancer-Related Lymphedema.
Handchir Mikrochir Plast Chir. 2022;54(4):326–338
[15] Pusic AL, Cemal Y, Albornoz C, et al. Quality of life among breast
cancer patients with lymphedema: a systematic review of
patient-reported outcome instruments and outcomes. J Cancer
Surviv. 2013; 7(1):83– 92
[16] Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green-enhanced
lymphography for upper extremity lymphedema: a novel severity
staging system using dermal backflow patterns. Plast Reconstr Surg.
2011; 128(4):941–947
[17] Zeltzer AA, Brussaard C, Koning M, et al. MR lymphography in
patients with upper limb lymphedema: the GPS for feasibility and
surgical planning for lympho-venous bypass. J Surg Oncol. 2018; 118
(3):407–415
[18] Suami H, Taylor GI, Pan W-R. The lymphatic territories of the upper
limb: anatomical study and clinical implications. Plast Reconstr Surg.
2007; 119(6):1813–1822
[19] Suami H, O’Neill JK, Pan W-R, Taylor GI. Superficial lymphatic system
of the upper torso: preliminary radiographic results in human
cadavers. Plast Reconstr Surg. 2008; 121(4):1231–1239
[20] Mascagni P. Vasorum lymphaticorum corporis humani. Historia et
Ichonographia. Siena: Pazzini Carli; 1787:XIX–XXV
[21] Caplàn I. Traitement Physique de I’Ce Déme Du Bras. 1981
[22] Latorre J, Ciucci J, Rosendo A. Anatomia del sistema linfatico del
miembro superior. An Cirugìa Cardìaca y Vasc. 2004; 10(3):184–198
[23] Suami H, Chang DW. Overview of surgical treatments for breast cancer-
related lymphedema. Plast Reconstr Surg. 2010; 126(6):1853–1863
[24] Yamazaki S, Suami H, Imanishi N, et al. Three-dimensional
demonstration of the lymphatic system in the lower extremities with
multi-detector-row computed tomography: a study in a cadaver
model. Clin Anat. 2013; 26(2):258–266
[25] Caplan I. El sistema linfatico ganglionar de la region polpitea
[Doctoral thesis]. Buenos Aires: Tesis; 1966
[26] Quenu E, Lejars F. Etudes Sur Le Système Circulatoire. Vol. 1. Paris:
Steinheil; 1894
[27] Cheng MH, Chen SC, Henry SL, Tan BK, Chia-Yu Lin M, Huang JJ.
Vascularized groin lymph node flap transfer for postmastectomy
upper limb lymphedema: flap anatomy, recipient sites, and
outcomes. Plast Reconstr Surg. 2013; 131(6):1286–1298
[28] Scaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J,
Chang EI. Comprehensive review of vascularized lymph node transfers
for lymphedema: outcomes and complications. Microsurgery. 2018; 38
(2):222–229
[29] Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P,
Suominen E A . Microvascular breast reconstruction and lymph
Autologous Breast Reconstruction in Conjunction with Lymphatic Surgery
https://t.me/medicina_free
node transfer for postmastectomy lymphedema patients. Ann
Surg. 2012; 255(3):468 – 473
[30] Nguyen AT, Chang EI, Suami H, Chang DW. An algorithmic approach to
simultaneous vascularized lymph node transfer with microvascular
breast reconstruction. Ann Surg Oncol. 2015; 22(9):2919–2924
[31] Akita S, Tokumoto H, Yamaji Y, et al. Contribution of simultaneous
breast reconstruction by deep inferior epigastric artery perforator
flap to the efficacy of vascularized lymph node transfer in patients
with breast cancer-related lymphedema. J Reconstr Microsurg. 2017;
33(8):571–578
[32] Engel H, Lin C, Huang J, Cheng M. Outcomes of lymphedema
microsurgery for breast cancer-related lymphedema with or without
microvascular breast reconstruction. Ann Surg. 2018; 268(6):1076–
1083
[33] Zeltzer AA, Anzarut A, Braeckmans D, et al. The vascularized groin
lymph node flap (VGLN): anatomical study and flap planning using
multi-detector CT scanner. The golden triangle for flap harvesting. J
Surg Oncol. 2017; 116(3):378–383
[34] Hamdi M, Van Landuyt K, Van Hedent E, Duyck P. Advances in
autogenous breast reconstruction: the role of preoperative perforator
mapping. Ann Plast Surg. 2007; 58(1):18–26
[35] Patel KM, Lin CY, Cheng MH. From theory to evidence: long-term
evaluation of the mechanism of action and flap integration of distal
vascularized lymph node transfers. J Reconstr Microsurg. 2015; 31
(1):26–30
[36] Vibhakar D, Reddy , Morgan-Hazelwood W, Chang E. Chimeric pedicled
latissimus dorsi flap with lateral thoracic lymph nodes for breast
reconstruction and lymphedema treatment in a hypercoagulable
patient. J Plast ReconstrSurg. 2014; 134(3):494e–495e
[37] In bal A, Teven CM, Chang DW. Latissimus dorsi flap with
vascularized lymph node transfer for lymphedema treatment:
technique, outcomes, indication s, and review of literature. J Surg
Oncol. 2017; 115(1):72– 77
[38] Masia J, Pons G, Nardulli ML. Combined surgical treatment in breast
cancer-related lymphedema. J Reconstr Microsurg. 2016; 32(1):16–27
[39] Nguyen AT, Suami H. Laparoscopic free omental lymphatic flap for
the treatment of lymphedema. Plast Reconstr Surg. 2015; 136(1):
114–118
162
12 Nodo-Venal Shunt Microsurgery
https://t.me/medicina_free
Gurusamy Manokaran and Leela Praveen Kumar
Summary
This chapter describes the surgical technique of nodovenal shunts as they are regularly performed by the first
author. The surgery essentially consists of an anastomosis
between the “low pressure” lymphatic vascular system
and the “high pressure” vascular system of the super ficial
veins to conduct a physiological bypass. Accordingly, a
connection is established surgically between a wellfunctioning and draining lymph node in the inguinal region and a patent super ficial vein, usually in the draining
area of the greater saphenous. Most of the cases that are
treated using this technique suffer from chronic lymphedema resulting from filariasis affecting almost always the
lower limb.
Keywords: conser vative treatment, lymphatic f i lariasis,
lymphovenous anastomosis, microvascular lymph
node transfer, nodo-venal shunt, physiological bypass
surgery
12.1 General Considerations
Lymphatic filariasis is a common problem in emerging
and low-income countries such as India (see Chapter 3).
Unfortunately, most of the patients present at a late stage
of the disease, most often due to lack of education and
knowledge, poverty, and unavailability of adequate medical treatment and personnel. More recently, people have
started to understand the disease itself and the fact that
there is potentially a definitive cure for any stage of
filariasis-associated lymphedema.
The cases that present early can be managed conser-
1
vatively
little late will need some kind o f surgery to improve the
quality of life of affected patien t s. Accordi ng to the lym phedema stage, surgical procedures to be offered can
be classified as reconstruc tive or physiological (see
Chapters 7−12) and lymphoablative (see Chapters 13
and 14).
already been described in the early 1960s.
clinical cases have been performed only little later.
Since that time, various surgical modifications of lymphovenous shunts have been described, including
nodo-venal (NV) shunts.
technique that concerns the NV shunt in the inguinal
region.
(see Chapter 6), but the ones which present a
In vivo and experimental lymphovenous shunts have
2
The f irst
3,4
5,6,7,8,9,10
Accordingly, this chapter will describe the surgical
12.2 Indications and
Contraindications
●
NV shunt is one reconstructive option of treatment to
improve complete blockage or significant functional
impairment of the afferent lymphatics.
●
NV shunt is indicated in irreversible stages of
lymphedema graded II (according to the Gerusa Dreyer
11
classification
●
In grade II lymphedema, NV shunt alone can be
) or higher (see Chapter 3).
sufficient, whereas in higher grades, often additional
surgical procedures using lymphoablative or excisional
techniques are needed (see Chapters 13 and 14).
Obviously, surgery is accompanied by conservative
measures before and after the procedure of NV shunts,
including periodic antibiotics, pressure garments, and
meticulous hygiene of the feet.
●
The NV shunt is contraindicated in primary
lymphedema and in secondary lymphedema with
progressive malignancies.
●
For acute infections such cellulitis and/or lymphangitis,
an infection-free interval of at least 6 weeks is
recommended following successful treatment with
antibiotics.
●
Any infection at the surgical site such as the groin
needs to be treated before surgery.
●
It is contraindicated if there is no visible lymph node on
lymphoscintigraphy or ultrasound.
●
Incompetent drainage between superficial and deep
venous system at sapheno-femoral junction (SFJ),
diagnosed by Duplex ultrasound.
●
No reduction of limb size or volume, even after 1 week
of intensive manual lymph drainage (MLD).
●
Patients with significant comorbidities with renal,
cardiac, or pulmonary insufficiency, diabetes mellitus,
as well as active smoking present with relative
contraindications.
12.3 Preoperative Assessment
●
Prior to NV shunt surgery, a competent SFJ junction has
to be confirmed using ultrasound color Doppler.
●
Lymphoscintigraph y should confirm the presence of a
healthy and functional lymph node in the inguinal region.
●
Preoperative ultrasound should identify and allow to
mark a functional lymph node in case lymph nodes are
not palpable.
●
Finally, preoperative measurement of the limb’s
circumference is performed in a standardized manner,
Nodo-Venal Shunt Microsurgery
https://t.me/medicina_free
using the Jobst measuring scale, taking measures every
4 cm from ankle to inguinal crease. This measurement
serves as an objective baseline value to monitor the
efficacy of the surgical treatment.
12.4 Preoperative Preparation
When surgery is indicated, the patient is informed in
detail about the surgery and the potential benefits and
drawbacks, including complications. After consent ing
to surgery, the patient is admitted a couple of days prior to surgery in order to guarantee best possible result.
Therefore, conservative tre at ment in cluding MLD, compressive bandaging, respiratory physiotherapy and
physical exercises, and low-fat diet are initiated. This
helps to drain the lymph proximally toward the groin,
and eventually “bloats” the lymph nodes in the groin
on the day of surgery. Accordingly, identification of the
draining and hence functioning lymph node is much
easier.
The inguinal region is depilated the evening prior to
surgery, whereas antiseptic wash is recommended both
on the day prior to and the morning of surgery. Antibiotic prophylaxis is administered br iefly before initiating
surgery.
12.5 Surgical Technique
Surgery is usually performed under general anesthesia
but can also be executed under regional anesthesia in select cases.
The patient is positioned in supine, with the hip of the
affected extremity slightly flexed and externally rotated
and the knee in mild flexion.
After disinfection and draping, the markings are
made, f irst identif ying the inguinal crease and the femoral artery. If ultrasound marking of the lymph node
has not been made preoperatively, the surgeon tries to
identify a “bloated” lymph node by palpat ion, if possible, and marks it. Surgery is generally performed using
loupe magnification (3.2 to 4 ×). In rare cases the micro scope is indicated. Further, using microsurgical instruments is highly advised.
A vertical skin incision of 3 to 4 cm is made medial to
the course of the femoral artery. Thereafter, gentle retraction of the skin allows progressive incision of the subcutaneous tissue up to the level of the superficial fascia of
the fat, where the great saphenous vein (GSV) can be
identified. Particular care is taken to cut the fat in order
to least traumatize lymphatics adjacent to the incision.
Thereafter, the small side branches of the GSV are ligated
to obtain a segment of 4 to 5 cm proximally to the SFJ
if a lymph node has been identified in the proximity.
If needed, the skin incision can be extended distally for
better identification and isolation of the GSV.
The identification of the lymph node is usually performed by gentle palpation within the surgical wound,
whereas visual identification needs some experience. If
the surgeon neither sees, nor palpates a lymph node, further dissection is performed medial to the GSV. Basically,
an afunctional lymph node usually appears slightly pinkish, embedded in the surrounding yellow fat. Once a potential lymph node has been identified, a self-retaining
retractor is placed into the surgical access. Thereafter,
minimal dissection is performed around the lymph node
to free it from its peri-nodal fat, as unnecessary dissection
can damage the afferent and efferent lymphatics to the
node. Then the capsule of the lymph node is exposed at
its surface in order to excise a circular patch of capsule
and underlying nodular tissue. The resected tissue of the
lymph node is sent for histop athological examinat ion.
After truncating the lymph node, the surgeon should
see adequate punctual bleeding from the lymph node
that stops with gentle pressure with a gauze after 2 to
3 minutes. Once blee ding stops, oozing of milky fluid indicating lymph flow may be seen from the lymph node’s
truncated and exposed surface.
The GSV is then clamped distally and competence at
the SFJ is checked, excluding the presence of backflow
(anterograde and retrograde streaking of the vein).
Thereafter, the vein is transected at an adequate distance
from the SFJ, which allows to reach the selected lymph
node to be shunted easily (▶ Fig. 12.1 and ▶ Fig. 12.2).
The venous end is then prepared by trimming the adjacent adventitia and enlarged by a longitudinal incision
creating a “fish mouth”-like vascular opening. The venous
end is then placed over the lymph node and a microvascular anastomosis is performed using the “heal-to-toe”
technique (also known as the “open-book” technique)
with a continuous suture using 6–0or7–0 nonresorbable
monofilament suture. Care is taken to precisely set the
stich including the full thickness of the venous wall and
the breached capsule of the lymph node in order to put
over the transected vein over the truncated lymph node
(▶ Fig. 12.3, ▶ Fig. 12.4, ▶ Fig. 12.5, ▶ Fig. 12.6, ▶ Fig. 12.7,
▶ Fig. 12.8, ▶ Fig. 12.9, ▶ Fig. 12.10). After completion of
the anastomosis, the clamp is released to free lymph flow.
Following adequate hemostasis, the wound is closed in a
layered manner using usually resorbable monofilament
suture. Most often, the surgical wound is left without
drains, but in select cases, a drain is inserted and generally removed on postoperative day 2.
Previously, NV shunts were performed using an endto-side technique in order to leave the veins in continuity.
The author modified the technique describing an end-toend method, “connecting and attaching” the vein to the
164
12.8 Complications
https://t.me/medicina_free
Fig. 12.1 (a, b) The author’s (Dr. Manokaran)
modified technique of nodo-venal shunt
where it is done in an end-to-end style.
truncated lymph node. The end-to-end technique enables
minimal dissection of the lymph node, and the freed venous “stump” reached the ideal node that is not always
close to the GSV more easily. Accordingly, improved reduction of the limb volume could be achieved when compared to the end-to-side lymph node shunt technique.
12.6 Postoperative Care
Mild compression with a compressive and adhesive plaster
such as dynaplast is applied to the wound. Compression
bandage is put around the legs. The patient is maintained
on strict bedrest for 24 hours after surgery. Thereafter, the
patient starts mobilization with full weight-bearing. Further, the patient executes respiratory physiotherapy with
breathing exercises using a spirometer.
The surgical wound is first inspected after 48 hours,
while dressings are usually changed and drains removed,
if in place, in order to discharge the patient. On day 2 or 3
after surgery, the compression bandage is replaced by a
customized compression garment up to mid-thigh long.
The patient is maintained on periodic oral antibiotics
and antiparasitic treatment including doxycycline 100 mg
twice daily and Banocide Forte thrice daily for 5 days a
month for at least 2 years, followed 5 days a year for another 5 years. The patient is seen in an outpatient clinic at
4 weeks and 6 months after surgery, during which circumferential measurements of the extremities are taken. Further clinical controls are scheduled every 6 months.
12.7 Patient Education
●
All patients are put on low-fat diet to reduce the load
on the lymphatics in the early stages.
●
All patients are best educated on how to maintain
general hygiene.
●
Patients are advised to maintain good oral hygiene to
ideally avoid recurrent lymphangitis.
●
Fungal infections in between the toes and intert rigo
in the skinfolds need to be prevented and treated
if present to reduce the risk of recur rent
lymphangitis.
●
Patients are advised to wear compression stockings
throughout the day and elevate the lower extremity at
rest. No nocturnal bandage is indicated.
●
In cases of skin changes like thickening and
discoloration, unidirectional massage using a cream or
ointment containing 1% salicylic acid should be used
for external massage at bedtime to take away the
hyperpigmentation and small nodules for at least 3
months. If necessary, it can be extended to 6 months.
Prolonged usage can induce vitiligo-like
depigmentation.
12.8 Complications
●
Wound dehiscence
●
Seroma
●
Lymphocele
●
Lymphorrhea
Nodo-Venal Shunt Microsurgery
https://t.me/medicina_free
Fig. 12.2 Schematic diagram of an end-to-end nodo-venal shunt or anastomoses modified by Gurusamy Manokaran: (a) Healthy
inguinal lymph node adjacent to great saphenous vein or its tributary. (b) Lymph node is minimally dissected to avoid destruction of
afferent and efferent lymphatics. Truncation of the lymph node followed by ligation and transection of the vein distally. The proximal
venous stump is transected obliquely and “fish-mouthed” to best match the size of the circumference of the lymph node at the
truncation site. (c) Anastomosis between great saphenous vein and lymph node is performed with 6–0or7–0 nonresorbable,
monofilament, continuous suture using the “heel-to-toe” technique. (d) Presentation of a lymph node shunt after completing the
anastomoses.
166
Fig. 12.3 Preoperative markings of the landmarks.
https://t.me/medicina_free
12.8 Complications
Fig. 12.4 Identification of great saphenous vein and a func-
tioning lymph node (forceps).
Fig. 12.5 Isolation and distal ligation of great saphenous vein.
Fig. 12.7 Trimming of the fat to expose the lymph node (purple
tissue adjacent to the tip of the scissor).
Fig. 12.6 Proximal transection of great saphenous vein.
Fig. 12.8 The capsule of the lymph node is picked with the
forceps and cut with an # 11 blade.
Nodo-Venal Shunt Microsurgery
https://t.me/medicina_free
Fig. 12.9 The great saphenous vein has been fish-mouthed and
the first suture of the anastomosis is being placed.
References
[1] Lee BB, Bergan J, Rockson SG, eds. Lymphedema: A Concise
Compendium of Theory and Practice. USA: Springer; 2011:11–564
[2] Nielubowicz J, Olszewski W. Experimental lymphovenous anastomosis.
Br J Surg. 1968; 55(6):449–451
[3] Nielubowicz J, Olszewski W. Surgical lymphaticovenous shunts in
patients with secondary lymphoedema. Br J Surg. 1968; 55(6):440–442
[4] Sedlácek J. Lymphovenous shunt as supplementary treatment of
elephantiasis of lower limbs. Acta Chir Plast. 1969; 11(2):157–162
[5] Gilbert A, O’Brien BM, Vorrath JW, Sykes PJ. Lymphaticovenous
anastomosis by microvascular technique. Br J Plast Surg. 1976; 29(4):
355–360
[6] Bresadola F, Mannella P, Sortini A, et al. Peripheral lymphatico-
venous anastomosis. New surgical technic. [in Italian]. Minerva Chir.
1978; 33(23–24):1711–1718
Fig. 12.10 After completion of nodo-venal shunt, “cobra-hood”
appearance of the great saphenous vein is seen.
[7] Degni M. New microsurgical technique of lymphatico-venous
anastomosis for the treatment of lymphedema. Lymphology. 1981;
14(2):61–63
[8] al Assal F, Cordeiro AK, De Souza e Castro I. A new technique of
microlympho-venous anastomoses. Experimental study. J Cardiovasc
Surg (Torino). 1988; 29(5):552–555
[9] Campisi C. Use of autologous interposition vein graft in management
of lymphedema: preliminary experimental and clinical observations.
Lymphology. 1991; 24(2):71–76
[10] Kinjo O, Kusaba A. Lymphatic vessel-to-isolated-vein anastomosis for
secondary lymphedema in a canine model. Surg Today. 1995; 25(7):
633–639
[11] Dreyer G, Coutinho A, Albuquerque R. [Clinical manifestations of
lymphatic bancroftian filariasis]. AMB Rev Assoc Med Bras. 1989;
35(5):189–196
168
Section VII
https://t.me/medicina_free
Lymphoreductive Procedures,
Secondary Procedures, and
Tips and Tricks
Edited by Christoph Hi rche, Katrin Seidenstücker,
and Moustapha Hamdi
13 Suction-Assisted Lipectomy 171
14 Excisional Procedures 177
15 Secondary Procedures after
Reconstructive Microsurgery 184
16 Tips and Tricks for Modern
Surgical Management of
Chronic Lymphedema 193
VII
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана