Immediate Lymphatic Reconstruction: A Technical Modification Eliminating the U-Stitch With a Mini-Forceps

Immediate lymphatic reconstruction (ILR), originally described as the lymphatic microsurgical preventative healing approach (LYMPHA), reduces the risk of developing lymphedema secondary to breast cancer treatment. ILR involves the intussusception of arm lymphatic channels into a vein draining centrally. However, performing this technique in a deep surgical field is technically challenging. We introduce a technical modification to ILR by repurposing a pulmonary wire to facilitate the intussusception technique. Intraoperatively, fluorescein isothiocyanate (FITC) was injected into the first and forth webspaces on the dorsum of the hand and the volar wrist. A vein graft was harvested from the lower leg during the axillary lymph node dissection. The accessory branch of the axillary vein was isolated. Lymphatic channels were identified under a 560-nm filter in the axillary bed. The largest-diameter channel was selected and isolated. An anastomosis was performed between the vein graft and targeted lymphatic channel utilizing the intussusception technique. A mini-forceps was passed retrograde through the vein graft to grasp the lymphatic channel. The channel was then intussuscepted into the vein graft and released. The vein graft was sutured to the surrounding peri-lymphatic fat using 8-0 sutures. Lymphatic flow from the proximal end of the vein graft was confirmed with FITC imaging. The vein graft was then anastomosed to the accessory vein using a coupler device. Patency was confirmed by visualizing FITC dye crossing the anastomosis and filling the recipient vein. Use of mini-forceps in ILR improves lymphatic channel manipulation in a deep surgical field and eliminates the U-Stitch.