Vascularized Lymph Node Transfer for Lymphedema

Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.

A first report of robotic-assisted sentinel lymph node mapping and inguinal lymph node dissection, using near-infared fluorescence, in vulvar cancer.

e17027 Background: Vulvar carcinoma is a rare gynecologic malignancy which has seen a considerable evolution in surgical techniques over the last several decades. However, the morbidity associated with inguinal lymph node dissections remains significant. The majority of patients undergoing full lymphadenectomy will have some complication, with wound breakdown being the most common. In males, robotic inguinal lymph node dissection has been described for penile cancer. This report represents a first use of near-infared fluorescence for sentinel inguinal lymph node mapping, and the first description of complete robotic inguinal lymph node dissection for patients with vulvar malignancies. Methods: Bilateral robotic-assisted inguinal lymph node mapping and and lymphadenectomy was performed using the daVinci Xi system with a near-infared fluourescence. Results: The patient presented at 81 years old with a 3 cm lesion on the left labia. In the operating room, the vulvar lesion was injected circumferentially with indocyanine green. A 1 cm incision was made in the skin over the apex of the left femoral triangle carried past the underlying campers fascia. The tissue plain was developed overlying the femoral triangle using a tissue expander balloon. Under visual guidance, an 8 mm camera port and two 8 mm instrument ports were placed and the robot docked. The ipsilateral sentinel lymph nodes were identified using near-infared fluorescence and resected. We then performed a complete left superficial inguinal lymph node dissection. The right side was then performed in identical fashion. No sentinel node was identified on the right side. Radical hemivulvectomy was then performed without difficulty. All 11 lymph nodes were negative for disease. She was returned to the OR once for replacement of her JP drains. Her postoperative course was otherwise unremarkable and she is currently 15 months postoperative without complications or recurrence. Conclusions: Sentinel lymph node mapping and superficial inguinal lymph node dissection using robotic-assisted techniques and near-infared fluorescence is feasible and warrants further investigation.

Pedicled Transfer of the Superficial Inguinal Lymph Node Flap for Lymphedema

Background Vascularized lymph node transfer is performed for select patients with lymphedema who remain refractory to nonsurgical therapies. Typically, this involves a microvascular free tissue transfer of donor lymph nodes to the affected area. We describe our experience with the transfer of a pedicled adipofascial flap containing the superficial inguinal lymph nodes for lower extremity lymphedema or penoscrotal lymphedema. Methods In eight patients, a unilateral pedicled superficial inguinal lymph node flap was harvested. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease. Blood supply was from either the superficial circumflex iliac vessels or the superficial inferior epigastric vessels. In certain patients, concurrent lymphaticovenular anastomosis was attempted as well. Results Four patients underwent pedicled superficial inguinal lymph node flap transfer for lower extremity lymphedema and for the other four patients the indication was penoscrotal lymphedema. Seven of the eight study patients reported improvements in their lymphedema symptoms. Postoperative complications included cellulitis in one patient and hematoma in another patient; neither patient required reoperation. Conclusion The pedicled superficial inguinal lymph node flap is a feasible and safe treatment option for either lower extremity lymphedema or genital lymphedema. This case series provides the basis for additional studies regarding the potential use of this vascularized lymph node flap in select patients.