Chapter 170 - Lymphedema surgical treatment

Question 1

Surgical excision for lylmphedema first described

Answer 1

Charles 1912

Question 2

Charles procedure

Answer 2

1) circumferential resection of skin, subcutaneous tissue and deep fascia
2) split-skin grafting

Question 3

Liposuction for lymphedema first described by

Answer 3

Illouz

Question 4

Thompson procedure

Answer 4

1) resect fascia with subcutaneous tissue
2) create a flap and de-epithelialized rim of flap
3) burry flap near deep vessels to facilitate spontaneous lymphatic anastomoses

Question 5

Lymphoscintigraphy vs MRI

Answer 5

MRI better for lymph vessels

lymphoscintigraphy better for inguinal nodes

Question 6

Lymphatic transport index

Answer 6

0 - 45

< 10 is normal

Question 7

Type of dye injection

Answer 7

patent blue dye (europe)
isosulfan blue (Lymphazurin; US)

Question 8

Pre-operating planning before venous

Answer 8

lymphoscintigraphy for disease and for donor site

Question 9

Approximate number of lymphatic vessels in the ventromedial lylmphatic bundle of the thigh

Answer 9

16

Question 10

Harvesting lymphatic vessels

Answer 10

1-4 collectors dissected from medial thigh

spare those near groin and knee

Question 11

Lymphatic vessels in arm and neck and general course

Answer 11

Epifascial usually
Subfascial would be close to vessels

Oblique incision medial and superior to brachial artery

Search with 3x to 10x magnificationt

Question 12

Appearance of lymphatic vessel

Answer 12

Gray shiny in early stages of lymphedema

fibrotic in late stages

Question 13

Lymphatic anastomosis in the case where outflow lymphatic vessel cannot be identified

Answer 13

Sew to lymph node by making small incision superficially

Question 14

Anastamosis between lymphatic vessels

Answer 14

Extremely fragile
Minimal traction allowed
10-0 absorbable polyglactin 910 with BV75-4 needle
4 simple interrupted enough

Question 15

Method of venous bridge in lymphedema reconstruction

Answer 15

1) invaginatig two ends of the lymphatic vessel with vein as bridge
2) interposition with vein
3) multiple lymphatic vessels into one vein

Question 16

Lymphovenous key points

Answer 16

1) ensoure no CVD
2) lymphangiography intraop can help identify vessels for anast
3) Zeiss 4x-40x mag used

Question 17

Liposuction technique

Answer 17

1) 3 mm incision x 20-30
2) vacuum aspiration
3) compressive therapy

Question 18

Miller staged subcutaneous excision beneath flaps

Answer 18

1) pneumatic tourniquet
2) incision from ankle to thigh
3) flap 1.5 cm thick created
4) subcutaneous tissue removed preserving sural nerve
5) resect deep fascia over calf
6) spare fascia at knee and ankle
7) resect reduntant skin
8) suction catheter placed
9) wound closed
10) bed rest 9 days with elevation
11) wrap leg tightly then mobilize

stage 2: 3 months later
Same thing again

Question 19

Complication of Miller procedure

Answer 19

1) long hospitalization
2) poor wound healing
3) long surgical scars
4) sensory nerve loss
5) residual edema in foot and ankle

Question 20

chylous disorders

Answer 20

accumulation of cyle in abnormal areas of the body

Question 21

Primary chylous disorder symptoms

Answer 21

1) LE edema 54%
2) dyspnea 49%
3) scrotal/labial edema 43%
4) abdominal distention 37%

Question 22

Primary chylous disorder causes

Answer 22

Primary lymphagiectasia 66%
Yellow nail syndrome 11%
lymphangioleiomyomatosis 9%
others 18%

Question 23

LE and genitalia chylous discharge first described by

Answer 23

1949

Servelle and Deysson

Question 24

Greatment for chyle reflux in perineum, labia, scrotum, LE

Answer 24

radical excisio and ligation of incompetent lymph vessels

Question 25

Surgical treatment of LE chylous disorder

Answer 25

1) eat 60g butter and 8oz whipped cream (fatty meal)
2) ligation of vessel with care to prevent tear
3) +/- sclerotherapy
4) tetracycline 500-1000 mg in 20ml injected into lymph vessel to provoke lymphangitis

Question 26

Cause of chylous ascites

Answer 26

Intraperitoneal rupture of the mesenteric or retroperitoneal lymphatics

or exudationg of chyle into the peritoneal cavity

Question 27

Diagnosis of chylous ascite

Answer 27

1) bipedal contrast lymphangiography for lymphangiectasia

2) paracentesis

Question 28

Medical treatment of chylous disorders

Answer 28

1) medium-chain TG diet

2) PTN

Question 29

Surgical treatment of chylous ascites

Answer 29

1) Abdominal exploration
2) oversew leaking lymphatics
3) resect bowel taht’s causing protein-losing enteropathy

Question 30

LeVeen shunt

Answer 30

shunting peritoneal to venous

Question 31

Chylothorax causes

Answer 31

1) trauma
2) malignancy
3) lymphangiectasia +/- duct obstruction
4) leaking from diaphragm due to chylous ascites

Question 32

Treatment for chylothorax

Answer 32

1) treat chylous ascites

2) surgical pleurodesis - excision of parietal pleura and prolonged pleural suction)

Question 33

Surgical pleurodesis steps

Answer 33

1) fatty meal
2) thoracotomy or VATS
3) oversew or clip leaking lymphatic
4) pleurodesis

Question 34

Methods of reconstructing thoracic duct steps

Answer 34

Thoracic duct-azygos vein anastomosis

1) right posterolateral thoracotomy
2) anastomosis done with 8-0 or 10-0 nonabsorbable interrupted sutures

Question 35

Indication for thoracic duct reconstruction in chylous leak

Answer 35

occlusion of cervical or upper thoracic duct is the cause of lymphangiectasia and reflux of chyle into the pleural/peritoneal cavity

Question 36

Normal insertion of the thoracic duct

Answer 36

Behind IJ, in front of vertebral vein

into left subclavian vein