Hello - I would like suggestions as to which code(s) would be most appropriate for lymphatic venous bypass. Here is the operative note. Thank you for your time. Michelle
PREOPERATIVE DIAGNOSIS: Postmastectomy lymphedema of the right upper extremity, refractory to treatment.
POSTOPERATIVE DIAGNOSIS: Same.
1. Lymphaticovenous bypass of the right upper extremity times 3.
2. Use of the operative microscope for microsurgical technique.
3. Use of SPY for lymphatic visualization.
ESTIMATED BLOOD LOSS: 3 cc.
INDICATIONS FOR PROCEDURE: is a 57-year-old female who has had right breast cancer and underwent mastectomy and reconstruction. She has a substantial right upper extremity lymphedema for quite some time and has been refractory to all conservative treatments. Based on her clinical presentation and after lengthy evaluation in clinic, we offered the patient attempted improvement of her lymphedema with a lymphaticovenous bypass.
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area. The risks, benefits, possible complications, and alternatives were reviewed. After a lengthy discussion, signed written consent was obtained. The patient was then taken back to the operative suite where the proper patient, position, location, and operative site were confirmed with verification. General anesthesia was induced and the patient was intubated without event. The bed was then turned 90 degrees in the room and the right upper extremity was then prepped and draped in sterile fashion. We then again confirmed proper patient, position, location, and operative site with a robust timeout.
We began the procedure by first identifying the lymphatic drainage in the right upper extremity. This was done using the SPY Elite machine. Technique used was by intradermal injection in all of the webspaces of the right hand with Indocyanine green. We used 0.02 cc of Indocyanine green at each injection site. We then imaged the lymphatic drainage from these injections site and marked with a marking pen along the hand. This mapped our lymphatic system. Then under the SPY machine, we are able to visualize the venous system which we also marked at a different color. Once we had our lymphatic system and venous system marked out, we identified areas of crossover for potential anastomosis. In the end, we had a series of different options; however, proximal to the wrist, we had very limited availability of lymphatic drainage. In fact, for much of the forearm into the upper arm, there was only one notable dominant lymphatic drainage channel and rather than risk damaging this and worsening her lymphedema, we elected to proceed with bypass more distal in the arm.
We then began the procedure with a transverse incision over a few areas identified over the dorsal right wrist that had potential for anastomosis. We then brought to the operative microscope into the field and under microscope magnification, completed our dissection, identified lymphatics, and small venules in proper orientation and position for anastomosis. As we were searching to confirm that we had identified appropriate lymphatic drainage sites, we then injected 0.2 mL Lymphazurin blue just proximal to our incision area and watch as the lymphatics changed color. These lymphatics were then marked to confirm these are appropriate lymphatics for anastomosis.
Both on the radial and ulnar side of the dorsal wrist, we had opportunities for anastomosis based on the anatomy and identified vessels and lymphatics. We began on the radial side where we transected the lymphatic. We then clipped the distal vein and placed Heifetz clamp proximally and then transected the vein. We then anastomosed the 2 lymphatics into this proximal vein segment. This was done with 11-0 nylon suture. We then took off the clamp, confirmed no substantial backbleeding to the vein, but the vein did refill and passed a compression test indicating adequate fill of the vein. We then turned our attention to the ulnar side where similarly, we transected the lymphatic, clipped the distal vein and hyperextended the proximal vein and then transected the vein. Here, we performed anastomosis of the distal lymphatic to the proximal venous drainage system. We then took of the micro clamp and confirmed adequate flow with no notable backbleeding at the anastomotic site. Once we confirmed hemostasis at both of our anastomotic sites, we then confirmed hemostasis throughout using electrocautery and bipolar cautery. At this point, we had completed 3 lymphaticovenous anastomoses with success and they all remained patent. We were able to visualize blue dye tracking from the lymphatic into the venous system.
At this point, we gently irrigated the wound, removed the stay stitches from the skin, and then closed the wound with a 4-0 running nylon suture. The hand was then cleansed and placed with Xeroform gauze and then gentle Ace wrap dressing. The patient will be admitted for observation overnight and the right upper extremity will be elevated. She can transition back to her compressive garment after 3 days.