Lymphatic Channels Research Articles

Operative management of penoscrotal elephantiasis

Enormous oedema of the male genitals, such as penoscrotal elephantiasis, is a very rare condition. It is usually a result of recurrent inflammation, trauma or malignancy, although the main cause is lymphatic filariasis. Furthermore, it is a challenging condition for both patient as well as the attending healthcare team. By elongation of the lymphatic channels, local oedema is initially created. In the further course, through fibrosis and thus deterioration of the lymphatic drainage, recurrent infections with irreversible elephantiac hard swelling and skin changes are evident. Depending upon the clinical stage, conservative or surgical treatment are suggested. Unfortunately, up to date, no evidence-based therapeutic protocol exists. Interdisciplinary cooperation among doctors, physiotherapists with active cooperation of the patient decide the success of the therapeutic outcome.

Uterine cysts in mares

This work is aimed at studying the etiology, prevalence, diagnosis, treatment of uterine cysts and their difference from the embryo during ultrasound examination. Endometrial cysts are often the cause of infertility and indicate pathological changes in the uterus, occurring in older mares. There are two types of uterine cysts: endometrial glandular cysts and lymphatic lacunar cysts. Endometrial cysts are usually smaller than lymphatic cysts located in the endometrium and are composed of endometrial glands. Lymphatic cysts cause obstruction of the lymphatic channels and appear as single or multilobular structures. Cysts can result from chronic degenerative changes in the endometrium and their clinical significance varies. For example, in terms of fertility, their influence is related to size, conditioning, content and location in the uterus. The presence of small cysts often indicates matte structures. In addition, larger or more active cysts have an impact on the course of pregnancy. Single large or small cysts can lead to embryonic pregnancy failure, which is the most difficult recognition of maternal pregnancy. Careful testing methods can effectively monitor the mare's condition and ensure the prospects for a successful pregnancy. This pathology is diagnosed using rectal and ultrasound examinations. There are many treatment options: they can be removed by surgery, hysteroscopic biopsy forceps, snare, laser (diode, CO2 or Nd/YAG laser), electrocoagulation or injection of 70 % ethanol (sclerotherapy method). But unfortunately, many cysts are prone to relapse. Sometimes the presence of cysts can interfere with the diagnosis of pregnancy or lead to an erroneous diagnosis of “multiple pregnancy”, since cysts under ultrasound exposure appear as filling fluid structures in the endometrial lumen. For this reason, it is important to be able to diagnose, predict consequences and treatment options in the mare.

Lymphatic Channel Distribution in Comparison With Blood Vessels in the Upper Eyelid.

To examine microscopically the distribution of the lymphatic channels in comparison with the blood vessels in the upper eyelid. Central sagittal sections of 13 upper eyelids (8 right, 5 left) from 11 Japanese cadavers, aged 36 to 87 years old (average age: 66.6 years), were histologically examined. The specimens were fixed in 10% formalin. Staining with D2-40 for lymphatic channels and with the antibody for α-smooth muscle actin for blood vessels was utilized. The lymphatic channels were mainly distributed superficially, just under the skin, but the blood vessels were situated deeper, and diffusely spread throughout the upper eyelid. The positional predispositions of the lymphatic channels and the blood vessels were different. The former is mainly superficial and the latter is deeper and diffuse.

Lymphovascular Tumoral Emboli in Inflammatory Breast Cancer Result from Haptotaxis-Mediated Encircling Lymphangiogenesis

Inflammatory breast cancer (IBC) is characterized by numerous tumor emboli within lymphatics. In a recent study, we observed tumor embolic budding both in vitro and in vivo within lymphovascular spaces and proposed this to account for the plethora of tumor emboli seen in IBC. These observations did not address, however, how lymphovascular invasion is initiated or the mechanisms involved. In the present study, using the well-characterized patient-derived xenograft (PDX), Mary-X, which exhibited florid lymphovascular invasion (LVI) in athymic mice (LVI) as defined by E-cadherin-positive tumor emboli within lymphatic channels distinguished by podoplanin and LYVE1 membrane and Prox1 nuclear immunoreactivities and spontaneous spheroidgenesis in vitro and human cases of IBC which showed similar LVI, we compared laser-captured microdissected emboli from Mary-X and from the cases of human IBC to non-embolic areas. Mary-X and IBC emboli expressed high levels of E-cadherin and no evidence of epithelial–mesenchymal transition (EMT). Mary-X spheroids expressed high levels of VEGF, especially VEGF-C, and stimulated both vascular and lymphatic endothelial haptotaxis. We then transplanted Mary-X serially into green, cyano, red, and nestin-green fluorescing protein (GFP-, CFP-, RFP-, and nestin-GFP) transgenic reporter mice in various combinations. Multicolor murine imaging studies indicated that reporter-labeled stroma initially encircled clumps of tumor cells and then served as a scaffold that supported nestin-GFP-labeled endothelial haptotaxis resulting in encircling lymphangiogenesis, confirmed by dual LYVE1 immunofluorescence. The present studies demonstrate a possible mechanism of a critical step of the tumor emboli formation of IBC.

The Upper Extremity Lymphatic System Is Not Symmetrical in Individuals: An Anatomic Study Utilizing ICG Lymphography and SPECT/CT Lymphoscintigraphy.

We evaluated whether superficial lymphatic anatomy and functional lymph node drainage are symmetric between the right and left upper extremities of healthy female volunteers, and if handedness is associated with symmetry of superficial lymphatic anatomy. Symmetry of lymphatic anatomy has been assumed historically. This assumption of individual anatomic symmetry is being utilized clinically and in research without validation. 36 normal female volunteers underwent bilateral indocyanine green (ICG) lymphography and lymphoscintigraphy of the upper extremities. Eight collecting vessel pathways of each upper extremity were mapped on ICG lymphography. 13 lymph node groups were visualized on lymphoscintigraphy. Symmetry of lymphatic anatomy and functional drainage were established by comparing the right and left extremities of each participant. Hand dominance was assessed by hand grip strength on a hand dynamometer. Among the 36 participants, 10 (28%) showed symmetry of all eight upper extremity lymphatic pathways with ICG. However, only 1 (3%) participant demonstrated complete symmetry amongst the 13 lymph node groups. Total symmetry of lymphatic channels was observed on ICG in seven (39%) participants with hand dominance and three (17%) participants without hand dominance (X2 = 2.215, P = 0.137). Lymphatic anatomy and functional drainage of the upper extremities are not consistently symmetric. Functional nodal drainage as demonstrated by lymphoscintigraphy shows less symmetry than anatomic studies of lymphatic channels using ICG. Symmetric lymphatic anatomy does not appear to correlate with hand dominance. These findings challenge the prevailing assumption of left-right lymphatic symmetry.

647. INDOCYANINE GREEN (ICG) IDENTIFICATION OF A CISTERNA CHYLI LEAK FOLLOWING RADICAL OESOPHAGO-GASTRECTOMY WITH 2-FIELD LYMPHADENECTOMY: DESCRIPTION OF A NEW TECHNIQUE

Abstract Background Chyle leak is a rare but feared complication post oesophago-gastrectomy, with far-reaching clinical and resource impacts including infection, re-admission and prolonged hospital stay, invasive procedures, and potentially missing the adjuvant therapy window. Low volume leaks can be managed medically via low-fat diet, nutritional support, and somatostatin analogues. Those of higher volume, or where medical management has failed, require radiological or surgical techniques. Where described, these techniques address leaks from a thoracic duct source and are therefore not applicable in patients having undergone oesophago-gastrectomy with radical two- or three- field lymphadenectomy, or where the suspected leak source is from abdominal lymphatics. Methods We report the case of a 78-year-old male diagnosed with cT4a N1 M0 oesophageal adenocarcinoma of the gastro-oesophageal junction. Following neoadjuvant chemotherapy, he underwent robotic-assisted two-phase oesophago-gastrectomy with two-field lymphadenectomy, in which the thoracic duct was identified and ligated. He returned one week post discharge with a left chylothorax. Drinage and medical management were unsuccessful, as were two radiological and one laparoscopic attempt at embolization of the leak. We describe a novel technique utilising indocyanine green (ICG) to identify and facilitate control of a cisterna chyli leak post-oesophago-gastrectomy with radical lymphadenectomy. Results Laparoscopy was performed and indocyanine green injected into the proximal jejunum submucosa, draining via mesenteric lymphatics to the cisterna chyli. Subsequent thoracoscopy revealed a prominent lymphatic channel around the left crus which was ligated. However, further leak was seen through the hiatus upon administration of high-fat jejunostomy feed. Re-laparoscopy revealed a leak from the cisterna chyli which was successfully ligated with ethibond sutures, leading to cessation of chyle leak and successful discharge of the patient, who subsequently received adjuvant therapy within the treatment window. Conclusion We describe a safe and effective novel technique for management of chyle leak from abdominal lymphatics or the cisterna chyli following oesophago-gastrectomy with radical two-field lymphadenectomy. https://drive.google.com/file/d/1nCNnowdJVPlV0GOleXVNVMshuU19kCb/view?usp=sharing

Prophylactic Buried Dermal Flap: A Simple Method for Axillary Reconstruction after Lymph Node Dissection.

Breast cancer-related lymphedema is characterized by progressive limb enlargement and occurs in up to 30% of breast cancer patients following axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) is a preventative technique used to reduce lymphedema rates by performing lymphovenous anastomoses of disrupted afferent lymphatics. This study presents a novel method of axillary reconstruction following ALND using a buried dermal flap that provides local tissue with intact subdermal lymphatics to the axillary dead space. A single-center retrospective review was performed to assess breast cancer patients who underwent modified radical mastectomy without reconstruction between 2018 and 2023. Groups were divided into those who had ILR alone (group 1) and those who had buried dermal flap with attempted ILR (group 2). There were 31 patients included in this study: 18 patients in group 1 and 13 patients in group 2. Patient demographics, comorbidities, and breast cancer history were similar between the groups. There was no significant difference in the mean number of lymphovenous anastomoses performed (1.6 versus 1.7, P = 0.84). Mean operative time of 224.4 ± 51.9 minutes in group 1 was similar to 223.4 ± 30.4 minutes in group 2 (P = 0.95). We introduce a novel method of axillary reconstruction following ALND using a buried dermal flap that is inset into the axillary dissection space and over the area of ILR. We propose that it is an efficient accessory procedure to augment ILR by providing supplementary intact lymphatic channels to the area of lymphatic injury, while obliterating the axillary dead space.

Use of intraoperative microvascular Doppler during subinguinal microsurgical varicocelectomy in children reduces complications.

This study assessed the impact of intraoperative microvascular Doppler ultrasonography (MDU) during microsurgical subinguinal varicocele correction in children. Nineteen patients who underwent intraoperative MDU during subinguinal microsurgical varicocelectomy between 2021 and 2023 were included in this study. Each patient's age, varicocele side, clinical examination findings, preoperative ultrasonography results, intraoperative findings, spermatic artery counts and findings in terms of MDU use, postoperative complications, and results were evaluated. All varicoceles were on the left side and the average age of the patients was 15.2 years. The indications for varicocelectomy were testicular hypotrophy (n = 10) and scrotal pain or fullness (n = 9). When a surgical microscope was used, testicular artery pulsation was detected in only five patients, whereas it was detected in all cases when MDU was used. In 16 cases, a single testicular artery was identified, and two arteries were identified in three cases. Additionally, in a case where a spermatic vein was suspected, it was not ligated due to the detection of pulsation with an arterial pattern using MDU. Two to three lymphatic channels were isolated and preserved, an average of 7.5 vessels were ligated, and five external spermatic veins were identified and ligated. There were no complications, and six of the patients with testicular hypotrophy showed signs of the catch-up growth phenomenon. The use of MDU during subinguinal microsurgical varicocelectomy in children not only increases the success rate but also minimizes complications such as hydrocele and recurrence.

The lymphatic drainage of the goat heart.

The detailed knowledge of the morphological structure, drainage pathways and patterns, the first tier lymph node of the cardiac lymphatic and its relationship with the circulatory system has not yet been completed. Although, the cardiac lymphatics had been described with renewed interest in past years, which was attributed to the transparent nature of lymphatic vessels that are difficult to be observed. In this study, cardiac lymphatics of the goat heart were perfused by a direct microinjecting technique with a radiopaque mixture. This demonstrated the subepicardial and subendocardial lymph capillary networks communicating with transmyocardial lymph vessels and then entering to subepicardial collecting lymph vessels that were directed toward the atrio-ventricular sulcus where they form a confluence from which the main cardiac lymph channels. We also found that: 1) the quantity and caliber of collecting lymph vessels varied in each goat heart; 2) drainage patterns of lymph vessels in the goat heart were different in individuals; 3) the first tier lymph node that each major lymph vessel drained to was different; and 4) multiple lymphatic-venous anastomosis sites have been confirmed to exist in the subepicardium of the left and right ventricles of each goat heart, which may be the morphological structure to accelerate the return of intercellular fluid to the venous system during excessive exercise of the heart. Therefore, the information may provide reference for further study in physiological and pathological conditions of the human heart.

Lymphatic Patterns in the Superficial Circumflex Iliac Artery Perforator Flap.

Lymphedema is a chronic condition, characterized by fluid buildup and tissue swelling and is caused by impairment of the lymphatic system. The lymph interpositional flap transfer technique, in which lymph flow is restored with a flap that includes subdermal lymphatic channels, is an option for surgical reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap can be used for this purpose. This study aimed to describe and characterize the lymphatic patterns within the vascular territory of the SCIP flap. This cross-sectional multicenter study involved 19 healthy volunteers aged ≥18 years of both sexes assessing the bilateral SCIP flap zone. Superficial lymphatic patterns were evaluated at 4-, 14-, and 24 minutes after indocyanine green (ICG) lymphography injection. Standardized procedures were implemented for all participants in both hospitals. The linear pattern was predominant bilaterally. The median number of lymphatic vessels and their length increased over time. Most lymphatic vessels in the SCIP flap were oriented toward the inguinal lymph node (ILN). However, the left SCIP zone lymphatic vessels were directed opposite to the ILN. The two sides SCIP zones were not significantly different. The primary direction of the bilateral lymphatic vessels was toward the ILN, although only single-side lymphatic vessels were in the opposite direction. These findings emphasize the importance of assessing lymphatic axiality and coherent lymphatic patterns prior to undertaking the SCIP as an interposition flap, to ensure effective restoration of lymphatic flow.

Cystic Lymphangioma of the Breast in a 4 Year Old: Case Report

Cystic lymphangioma, also known as cystic hygroma, is a rare congenital malformation of the lymphatic system characterized by congenital blockage of lymphatic channels or sequestered lymphatic sacs. They are frequently observed in childhood, yet their occurrence in the breast is exceedingly uncommon and is more frequently seen in adults, with only a small number of cases documented in children. We report a case of a 4-year-old female who presented with a large right breast lump which has progressively developed since birth and was diagnosed as mammary cystic lymphangioma after local excision. There was no recurrence of the lesion at the 1 year follow-up.

Gingival acquired lymphangiectasia as a long-term effect of post-oncology intervention: A 20-year institutional audit

Abstract Background: Gingiva is a keratinised mucosa akin to the skin and is exposed in all modalities of treatment of oral cancer. Acquired lymphangiectasia are acquired dilatations of lymphatic channels secondary to an external cause. They are extremely rare in the oral cavity despite that oral cancers are treated with different treatment modalities. Methods: The archives of the Oral and Maxillofacial Pathology Department of our institute were retrospectively reviewed from 2001 to 2021. Of the 9566 cases of oral biopsies, 4596 were confirmed cases of oral cancer including salivary gland carcinoma. These cases were followed up for the presence of post-neoplastic and post-therapeutic gingival lesions. Results: Of the 4596 patients, <10% patients reported recurrence or new primary of squamous cell carcinoma in the gingiva. Two patients were histopathologically diagnosed with acquired lymphangiectasia of gingiva after 12 years following surgery and radiation therapy as treatment for oral squamous cell carcinoma and mucoepidermoid carcinoma, which has been described in our report for the first time in the literature. Conclusion: Even though acquired lymphangiectasia of gingiva is very rare, lymphatic malformations should be included in the clinical differential diagnosis of post-therapeutic gingival proliferative pathologies in order to ensure appropriate treatment and prevent over-diagnosis of this benign condition.

Characterization of driver oncogenic mutations of in-transit melanoma metastases.

9586 Background: In-transit melanoma (ITM) is a distinctive form of melanoma metastasis, marked by aggressive locoregional progression and characterized by the entrapment of tumor cells within the lymphatic channels before reaching regional lymph nodes (LN). The mechanisms leading to lymphatic trapping rather than progression to distant metastasis are not well-understood. Previous research indicates a clonal origin for ITM, suggesting specific early-stage genetic alterations may drive this clinical phenotype. In this study, we sought to identify driver oncogenic mutations specific to ITM that may serve as potential targets. Methods: We analyzed data from the MSK-IMPACT database, which includes targeted sequencing of 341-468 genes for patients with cutaneous melanoma. Patients were stratified into four groups based on the type of sample sequenced: in-transit, primary tumor, regional LN, and distant metastases. We examined the prevalence of driver mutations and genetic variants across these groups, adjusting for multiple comparisons. Results: A total of 528 patients were included, of which 74 were in the ITM, 103 in the primary, 133 in the regional LN, and 218 in the metastatic group. The mean age of the cohort was 59 years (SD = 16) and 67% were male. Among the in-transit samples, 68% were treatment-naïve at the time of sequencing, 36% received anti-PD1 monotherapy, and 12% received anti-PD-1 combination therapy. None of the patients received targeted therapy. NRAS Q61 driver mutations were significantly more common in ITM than all other groups (all p<0.05). NF-1 driver mutations were significantly less common in ITM than distant metastasis (p=0.007) (Table). Comparative analysis across all genes showed a lower incidence of NF-1 mutations in ITM relative to metastatic samples (12% vs 38%, p=0.007). Gene interaction analysis showed mutual exclusivity between NRAS and PAK5 mutations in ITM (p=0.02), but not in other groups (p>0.05). Conclusions: This study reveals distinct driver oncogenic mutations specific to ITM, characterized by a high incidence of NRAS mutations, retained NF-1 function and the novel finding of mutual exclusivity between NRAS and PAK5. Closer examination of the interplay between NRAS, NF-1 and PAK5 interactions in ITM may provide deeper insights into the molecular mechanisms of ITM and offer potential therapeutic targets for ITM. [Table: see text]

Combined Percutaneous Transhepatic Lymphatic Embolization and Peroral Duodenal Mucosal Radiofrequency Ablation to Manage Protein-Losing Enteropathy

Percutaneous transhepatic lymphatic embolization (PTLE) and peroral esophagogastroduodenoscopy (EGD) duodenal mucosal radiofrequency (RF) ablation were performed to manage protein-losing enteropathy (PLE) in patients with congenital heart disease. Five procedures were performed in 4 patients (3 men and 1 woman; median age, 49 years; range, 31–71 years). Transhepatic lymphangiography demonstrated abnormal periduodenal lymphatic channels. After methylene blue injection through transhepatic access, subsequent EGD evaluation showed methylene blue extravasation at various sites in the duodenal mucosa. Endoscopic RF ablation of the leakage sites followed by PTLE using 3:1 ethiodized oil–to–n-butyl cyanoacrylate glue ratio resulted in improved symptoms and serum albumin levels (before procedure, 2.6 g/dL [SD ± 0.2]; after procedure, 3.5 g/dL [SD ± 0.4]; P = .004) over a median follow-up of 16 months (range, 5–20 months). Transhepatic lymphangiography and methylene blue injection with EGD evaluation of the duodenal mucosa can help diagnose PLE. Combined PTLE and EGD–RF ablation is an option to treat patients with PLE.

Progressive Pulmonary Tuberculosis – Progress Beyond the Walls

Tuberculosis is caused by Mycobacterium tuberculosis. If the treatment is inadequate or if host defenses are impaired, the apical lesion in primary tuberculosis expands into adjacent lung tissues and may spread via airways, lymphatic channels, or the vascular system. It may also circulate back to the lung and cause miliary pulmonary disease. Systemic miliary tuberculosis occurs when bacteria disseminate through the systemic arterial system to involve any organ. In the present study, we discuss five such cases of systemic miliary tuberculosis wherein the deceased succumbed to the illness.

Lymphatic network drainage resolves cerebral edema and facilitates recovery from experimental cerebral malaria

While brain swelling, associated with fluid accumulation, is a known feature of pediatric cerebral malaria (CM), how fluid and macromolecules are drained from the brain during recovery from CM is unknown. Using the experimental CM (ECM) model, we show that fluid accumulation in the brain during CM is driven by vasogenic edema and not by perivascular cerebrospinal fluid (CSF) influx. We identify that fluid and molecules are removed from the brain extremely quickly in mice with ECM to the deep cervical lymph nodes (dcLNs), predominantly through basal routes and across the cribriform plate and the nasal lymphatics. In agreement, we demonstrate that ligation of the afferent lymphatic vessels draining to the dcLNs significantly impairs fluid drainage from the brain and lowers anti-malarial drug recovery from the ECM syndrome. Collectively, our results provide insight into the pathways that coordinate recovery from CM.

Immediate lymphatic reconstruction: Lessons learned over eight years

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach used to reduce the risk of developing secondary lymphedema, and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction in breast cancer-related lymphedema (BCRL) in New England. Over the course of our experience, we made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of indocyanine green (ICG) imaging to identify baseline lymphatic anatomical variation, utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and addition of a lower extremity vein graft to mitigate venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements, and deploying clips for possible future radiation exposure, enables future studies on ILR patient outcomes. In this contribution, we aimed to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction in BCRL.

Lymphatic spread from left-sided intrahepatic cholangiocarcinoma: reconsiderations based on the lymphatic drainage from the liver

Intrahepatic cholangiocarcinoma (ICC) is known to have a high frequency of lymph node metastasis. Lymph node dissection (LND) is recommended for accurate staging, but the survival benefit of LND remains unclear. Knowledge of the pathways and direction of lymphatic drainage to the regional lymph nodes is essential when considering LND to improve patient survival. The liver has three lymphatic drainage pathways: portal, sublobular, and subcapsular. Of these, the portal lymphatic pathway, which lies along with the portal tracts, is the primary pathway. The efferent portal lymphatic vessels from the left-sided liver, which continue from the portal lymphatic pathway of the liver, communicate with the lymphatic vessels and lymph nodes along the hepatic artery at the hepatoduodenal ligament. In addition, lymphatic flow may also present along the left embryonic (aberrant) hepatic artery in the lesser omentum, based on our experience. This pathway is the previously reported pathway from the left-sided ICC to the lesser curvature of the stomach. However, through this pathway, ICC cells reach lymph nodes along the root of the left gastric artery but not the perigastric lymph nodes along the lesser curvature because of the opposite direction of lymph flow. Although further analyses using a large number of cases are needed to confirm these observations, these two pathways, along the hepatic artery at the hepatoduodenal ligament and the left embryonic (aberrant) hepatic artery in the lesser omentum should be considered when performing LND in the case of ICC in the left-sided liver.

EnBloc Resection of Sentinel Lymph Nodes with the Hysterectomy Specimen in Endometrial Cancer.

We demonstrate the surgical technique of removing the sentinel lymph nodes with its afferent lymphatic vessels attached to the hysterectomy specimen. Stepwise demonstration of the technique with narrated video footage. Sentinel lymph node sampling has been established as an acceptable staging method in endometrial cancer cases.1 Lymphatic anatomy has been described according to three consistent channels for endometrial cancer dissemination: (1) an upper paracervical pathway draining external or obturator lymph nodes; (2) a lower pathway draining internal iliac lymph nodes; and (3) the infundibulo-pelvic pathway with a course along the broad ligament.2 A study in patients with cervical cancer identified tumor cells in the afferent lymphatic vessels of the upper pathway, even when the corresponding sentinel node was negative (3/20 patients).3 This could be an important prognostic factor in patients with cervical cancer. Since the typical position of sentinel nodes is the same in both endometrial and cervical cancers, we aimed to assess the feasibility of removing 'enbloc' the sentinel node with its afferent lymphatic vessels, and the uterus.4 INTERVENTIONS: The Da Vinci Xi surgical system was used. Indocyanine green was injected cervically, the pelvic surgical spaces were developed, and the sentinel lymph nodes, along with the afferent lymphatic vessels, were identified using the Firefly infrared camera. The lymphovascular tissue was mobilized and separated from the uterine artery, which was skeletonized and ligated. Colpotomy was performed and the specimen was retrieved vaginally. Emerging evidence regarding diagnosis, characterization, and treatment of endometrial cancer has introduced a new era, based on minimally invasive techniques for staging through sentinel lymph node biopsy, molecular classification, and personalized treatment algorithms that include immune checkpoint inhibitors and targeted therapies.5 Lymph node staging is one of the most significant prognostic factors in endometrial cancer patients and is a guide for adjuvant treatment. Sentinel lymph node biopsy is not inferior to conventional lymphadenectomy and is in fact a better way of identifying low-volume cancer through the use of ultrastaging, as part of the sentinel node algorithm.6 The dissection technique described in this video could offer an improvement in the staging of endometrial cancer, ensuring that the true sentinel lymph node is identified and that potential cancer cells inside the afferent lymphatic vessels are also excised. Therefore, it could be utilized as a more accurate way of planning adjuvant treatment and consequently improving recurrence and survival; however more studies are needed to further evaluate the feasibility and sensitivity of identifying disease in the afferent lymphatic vessels. This novel surgical technique emphasizes the importance of anatomical knowledge and offers inspiration for studies with potential clinical benefit that should follow.

Lymphaticovenous anastomosis in rabbits: A novel live experimental animal model for supermicrosurgical training

BackgroundLymphaticovenous anastomosis is widely used in lymphedema management. Although its effectiveness in reducing edema in patients can be clinically observed, evaluating the long-term outcomes of this technique can be complex. This study established an animal model to assess the outcomes of lymphaticovenous anastomosis technique at 15 and 30-days post-surgery using indocyanine green lymphography, Patent Blue V dye injection, and histopathological examination. MethodsAn experimental model was established in the hindlimbs of 10 rabbits using the popliteal vein and afferent lymphatic vessels in the popliteal area. The subjects were divided into two groups: the first group (n = 5) underwent patency assessment at 0 and 15 days, and the second group (n = 5) at 0 and 30-days, resulting in 20 anastomoses. Patency was verified at 0, 15, and 30-days using indocyanine green lymphography and Patent Blue V injection. Histopathological examinations were performed on the collected anastomosis samples. ResultsThe patency rate was 90% (19/20) initially, 60% (6/10) at 15 days post-surgery, and 80% (8/10) at 30-days. The average diameter of lymphatic vessels and veins was 1.0 mm and 0.8 mm, respectively. The median number of collateral veins was 3; the median surgical time was 65.8 min. Histopathology revealed minimal endothelial damage and inflammatory responses due to the surgical sutures, with vascular inflammation and thrombosis in a single case. Local vascular neoformations were observed. ConclusionThis study highlights the reliability and reproducibility of using rabbits as experimental models for training in lymphaticovenous anastomosis technique owing to the accessibility of the surgical site and dimensions of their popliteal vasculature.