Surgical Lymphovenous Shunts
Lymphovenous shunts (LVS) are communications between the lymphatic and venous systems. They exist naturally at certain critical parts of the body. Surgical LVSs aim to create an alternate pathway for lymph fluid to flow and bypass the obstruction thereby reducing the swelling in the affected body part.
Often performed as a day surgery, this procedure can be done under local anaesthesia with minimal downtime.
Lymphovenous anastomoses
Lymphovenous anastomoses (LVA), also referred to as lymphaticovenous anastomoses, lymphovenular anastomoses, or lymphovenous bypass, is a sophisticated surgical technique that primarily focuses on creating a bypass channel to facilitate the smoother flow of lymph fluid into the venous system, thereby aiding in the reduction of swelling in limbs affected by lymphedema.
This procedure entails the meticulous connection of tiny lymphatic vessels, typically ranging from 0.3mm to 0.8mm in diameter, to a nearby small vein branch, executed in an end-to-end manner. It demands a surgeon with specialised training in supermicrosurgery to effectively perform LVA, ensuring the creation of a functional bypass channel.
LVAs have emerged as a cornerstone in the treatment of various stages of lymphedema. The procedure, characterized by 2cm incisions, can be conducted under local anesthesia, often qualifying as day surgery, thus minimizing disruption to the patient’s daily routine.
When considering this treatment option, it is crucial for patients to exercise discernment in selecting a surgeon. Opting for a practitioner with comprehensive training in supermicrosurgical LVA is vital. While a failed LVA generally entails minimal repercussions, the resultant reduction in swelling tends to be insignificant. Therefore, a careful evaluation of a surgeon’s credentials and expertise is a critical step in ensuring a successful outcome.
Lymphovenous implantation
In the initial phase of developing microsurgical techniques to reconstruct the lymphatic system, the capabilities of surgeons were somewhat restricted due to the rudimentary nature of the available sutures and microscopes. Consequently, the early lymphatic vessel surgeries (LVSs) primarily involved transplanting healthy lymphatic vessels into comparatively larger veins. This procedure was initially documented as lymphovenous anastomoses in medical literature, a term that continues to cause considerable confusion today. A more appropriate term for this procedure would be lymphovenous implantation (LVI).
During this procedure, surgeons utilize U-shaped microvascular sutures to insert one or more lymphatic vessels into the spacious cavity of the recipient vein, a process likened to telescoping.
Although this method is relatively straightforward and does not necessitate advanced supermicrosurgical training, it presents a significant drawback: the venous blood frequently interacts with the external surface of the lymphatic vessel, heightening the risk of clot formation. This aspect casts doubts on the long-term reliability of this technique. Moreover, there have been instances documented in the past where the formation of blood clots escalated, circulating upwards and inducing complications in the blood flow.
Therefore, it is advised to reserve the use of LVIs for scenarios where the implementation of super micro surgical LVAs is not feasible.
Using a microscope, a surgeon can stitch a lymph (green) vessel (0.3mm to 0.8mm) to a vein (blue) using ultra-fine sutures. This picture shows the various configurations of LVA
Multiple lymph vessels (green) are usually telescoped into a larger vein (blue). This technique can be prone to clotting and is typically reserved as a backup when supermicrosurgical LVA is not possible.
Lymph node to vein anastomoses
In 1968, pioneers Nielubowicz and Olszewski embarked on the first venture of implanting lymph nodes into a dog’s large abdominal vein, marking the inception of lymph node to vein anastomosis (LNVA) in the realm of surgical lymphatic vessel surgeries (LVS).
Currently, the body of evidence pertaining to LNVA and other lymph node-venous shunt techniques is predominantly confined to retrospective studies and a handful of case series. Consequently, the efficacy of these techniques remains a focal point of ongoing research and discussions. It is worth noting that LNVA is frequently integrated with other procedures like lymphovenous anastomoses (LVA), liposuction, and additional surgical debulking methods, which potentially muddles the clear assessment of its standalone effectiveness. This, coupled with the inability to directly observe the impact of the shunt and the scant evidence supporting its effectiveness as a singular treatment for lymphedema, hinders its broad acceptance among reconstructive surgeons.
A lymph node is divided preserving its blood supply. The cut edge is sutured to a hole in the vein to allow lymph fluid to drain into the venuos circulation.
Lymph node to vein anastomoses
In 1968, pioneers Nielubowicz and Olszewski embarked on the first venture of implanting lymph nodes into a dog’s large abdominal vein, marking the inception of lymph node to vein anastomosis (LNVA) in the realm of surgical lymphatic vessel surgeries (LVS).
Currently, the body of evidence pertaining to LNVA and other lymph node-venous shunt techniques is predominantly confined to retrospective studies and a handful of case series. Consequently, the efficacy of these techniques remains a focal point of ongoing research and discussions. It is worth noting that LNVA is frequently integrated with other procedures like lymphovenous anastomoses (LVA), liposuction, and additional surgical debulking methods, which potentially muddles the clear assessment of its standalone effectiveness. This, coupled with the inability to directly observe the impact of the shunt and the scant evidence supporting its effectiveness as a singular treatment for lymphedema, hinders its broad acceptance among reconstructive surgeons.
A piece of skin attached at its base (orange) is telescoped into a larger vein so that the small lymphatic capillaries in the skin empty into the vein. This is usually used for upper extremity lymphedema.