LETTER TO THE EDITOR
MICROSURGERY 35:415–416 (2015)
THE HALF NOTCHING METHOD FOR FLOW-THROUGH LYMPHATICOVENULAR ANASTOMOSIS Dear Editor,
Lymphaticovenular
anastomosis (LVA) has been known as an effective treatment for lymphedema. In LVA surgery, it is important to make as many bypasses as possible to maximize its treatment efficacy.1–5 Flow-through LVA (FT-LVA), in which two ends of a cut lymphatic vessel are anastomosed to a Y-shaped branched vein, is useful to increase the number of bypasses for a beginner lymphatic surgeon; both ends are anastomosed in an end-to-end fashion that is the easiest anastomosis type.1,2 However, after a lymphatic vessel is cut, sometimes cut ends become shorter and go among into surrounding tissues or go far away from recipient veins. In this situation, clipping vessels before cutting is useful to fix them, but it can make difficult to sew them due to smaller working space especially for surgeons with less experience of supermicrosurgery. To address this challenge, we developed a new method, half notching method, for FT-LVA. There are a lymphatic vessel and two venous branches prepared for FT-LVA. First, a half width of the lymphatic vessel is incised using microscissors; a notched site is determined based on lengths and locations of recipient veins. Second, the veins and both proximal and distal sides of the notched lymphatic vessel wall are stitched to venous branches to approximate them (Fig. 1). Then, the lymphatic vessel is completely transected with microscissors. In the state that all lymphatic vessels and veins are in a point, they exist within a field of vision. *Correspondence to: Takumi Yamamoto, Department of Plastic and Reconstructive Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–8655 Japan. E-mail: [email protected] Received 8 August 2014; Revision accepted 25 August 2014; Accepted 9 September 2014 Published online 20 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22332 Ó 2014 Wiley Periodicals, Inc.
Figure 1. A half width of the lymphatic vessel was incised, and both proximal and distal sides of the notched lymphatic vessel wall were stitched to two branches of a Y-shpaed vein (upper). Flowthrough anastomosis was completed after the use of half notching method (lower).
416
Letter to the Editor
Using this half notching method, lymphatic vessels and veins can be located in an anastomosis site, and the lymphatic vessel wall is kept opened like a mouth by the pull of contrary forces. Although further studies are required to refine procedures and to confirm the efficacy, the new method is useful to anastomose surely and not to waste time, regardless of the degrees of a surgeon’s skill. MEGUMI FURUYA, M.D., TAKUMI YAMAMOTO, M.D.*,
2. 3.
4.
MARIE YAMASHITA, M.D., AND AKITATSU HAYASHI, M.D. Department of Plastic and Reconstructive Surgery University of Tokyo Tokyo, Japan
REFERENCES 1. Yamamoto T, Narushima M, Kikuchi K, Yoshimatsu H, Todokoro T, Mihara M, Koshima I. Lambda-shaped anastomosis with intravascular
Microsurgery DOI 10.1002/micr
5.
stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011;127:1987–1992. Yamamoto T, Yoshimatsu H, Narushima M, Seki Y, Yamamoto N, Shim TWH, Koshima I. A modified side-to-end lymphaticovenular anastomosis. Microsurgery 2013;33:130–133. Yamamoto T, Narushima M, Yoshimatsu H, Seki Y, Yamamoto N, Oka A, Hara H, Koshima I. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg 2014;72:67–70. Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Shim TWH, Seki Y, Kikuchi K, Karibe J, Azuma S, Koshima I. Sequential anastomosis for lymphatic supermicrosurgery: Multiple lymphaticovenular anastomoses on one venule. Ann Plast Surg 2014;73:46–49. Yamamoto T, Yamamoto N, Azuma S, Yoshimatsu H, Seki Y, Narushima M, Koshima I. Near-infrared illumination systemintegrated microscope for supermicrosurgical lymphaticovenular anastomosis. Microsurgery 2014;34:23–27.
MICROSURGERY 35:415–416 (2015)
THE HALF NOTCHING METHOD FOR FLOW-THROUGH LYMPHATICOVENULAR ANASTOMOSIS Dear Editor,
Lymphaticovenular
anastomosis (LVA) has been known as an effective treatment for lymphedema. In LVA surgery, it is important to make as many bypasses as possible to maximize its treatment efficacy.1–5 Flow-through LVA (FT-LVA), in which two ends of a cut lymphatic vessel are anastomosed to a Y-shaped branched vein, is useful to increase the number of bypasses for a beginner lymphatic surgeon; both ends are anastomosed in an end-to-end fashion that is the easiest anastomosis type.1,2 However, after a lymphatic vessel is cut, sometimes cut ends become shorter and go among into surrounding tissues or go far away from recipient veins. In this situation, clipping vessels before cutting is useful to fix them, but it can make difficult to sew them due to smaller working space especially for surgeons with less experience of supermicrosurgery. To address this challenge, we developed a new method, half notching method, for FT-LVA. There are a lymphatic vessel and two venous branches prepared for FT-LVA. First, a half width of the lymphatic vessel is incised using microscissors; a notched site is determined based on lengths and locations of recipient veins. Second, the veins and both proximal and distal sides of the notched lymphatic vessel wall are stitched to venous branches to approximate them (Fig. 1). Then, the lymphatic vessel is completely transected with microscissors. In the state that all lymphatic vessels and veins are in a point, they exist within a field of vision. *Correspondence to: Takumi Yamamoto, Department of Plastic and Reconstructive Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–8655 Japan. E-mail: [email protected] Received 8 August 2014; Revision accepted 25 August 2014; Accepted 9 September 2014 Published online 20 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22332 Ó 2014 Wiley Periodicals, Inc.
Figure 1. A half width of the lymphatic vessel was incised, and both proximal and distal sides of the notched lymphatic vessel wall were stitched to two branches of a Y-shpaed vein (upper). Flowthrough anastomosis was completed after the use of half notching method (lower).
416
Letter to the Editor
Using this half notching method, lymphatic vessels and veins can be located in an anastomosis site, and the lymphatic vessel wall is kept opened like a mouth by the pull of contrary forces. Although further studies are required to refine procedures and to confirm the efficacy, the new method is useful to anastomose surely and not to waste time, regardless of the degrees of a surgeon’s skill. MEGUMI FURUYA, M.D., TAKUMI YAMAMOTO, M.D.*,
2. 3.
4.
MARIE YAMASHITA, M.D., AND AKITATSU HAYASHI, M.D. Department of Plastic and Reconstructive Surgery University of Tokyo Tokyo, Japan
REFERENCES 1. Yamamoto T, Narushima M, Kikuchi K, Yoshimatsu H, Todokoro T, Mihara M, Koshima I. Lambda-shaped anastomosis with intravascular
Microsurgery DOI 10.1002/micr
5.
stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011;127:1987–1992. Yamamoto T, Yoshimatsu H, Narushima M, Seki Y, Yamamoto N, Shim TWH, Koshima I. A modified side-to-end lymphaticovenular anastomosis. Microsurgery 2013;33:130–133. Yamamoto T, Narushima M, Yoshimatsu H, Seki Y, Yamamoto N, Oka A, Hara H, Koshima I. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg 2014;72:67–70. Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Shim TWH, Seki Y, Kikuchi K, Karibe J, Azuma S, Koshima I. Sequential anastomosis for lymphatic supermicrosurgery: Multiple lymphaticovenular anastomoses on one venule. Ann Plast Surg 2014;73:46–49. Yamamoto T, Yamamoto N, Azuma S, Yoshimatsu H, Seki Y, Narushima M, Koshima I. Near-infrared illumination systemintegrated microscope for supermicrosurgical lymphaticovenular anastomosis. Microsurgery 2014;34:23–27.
