Indocyanine Green Lymphangiography as an Adjunct for the Optimal Identification and Management of Lymphatic Leaks in the Groin

Abstract

Background The treatment of lymphatic leaks and lymphoceles in the groin can be challenging with no optimal management determined to date. We postulate that indocyanine green (ICG) lymphangiography improves visualization of the site of a lymphatic leak and can optimize their management.

Methods A retrospective review was conducted of all cases in which ICG lymphangiography was used in the management of lymphatic leaks in the groin over an 18-month span. The inciting surgical procedure resulting in the leak was determined. Following thorough debridement, ICG was injected intradermally in the distal extremity and the site of the lymphatic leak was documented (superficial or deep) and oversewn. Outcomes were reported with regard to healing, infection, time to drain removal, and adjunctive procedures.

Results Fifteen patients underwent ICG lymphangiography during the surgical treatment of a lymphatic leak in the groin during the study period. In all cases, the site of the lymphatic leak was accurately identified and oversewn. In eight cases, the site of the lymphatic leak was in the subcutaneous tissue superficial to the femoral vessels rather than medial to the femoral vessels in the area of the lymph node basin. A local muscle flap was used in 10 cases simultaneously. All wounds healed primarily without an associated wound or infection.

Conclusion ICG lymphangiography facilitated the identification of lymphatic leaks in the groin and optimized their management in these challenging cases, many of which may have been missed if the area around the inguinal lymph node basin was treated exclusively.

Keywords

ICG lymphangiography - lymph leak - lymphoceles

Presentation

This study was presented at the American Society for Reconstructive Microsurgery Annual Meeting, Phoenix, Arizona, January 14, 1018.

Financial Disclosure

The authors have no disclosures or financial interests to disclose in the preparation, presentation, or submission of this manuscript.

• References

• 1 Manci N, Marchetti C, Esposito F. , et al. Inguinofemoral lymphadenectomy: randomized trial comparing inguinal skin access above or below the inguinal ligament. Ann Surg Oncol 2009; 16 (03) 721-728
• 2 Twine CP, Lane IF, Williams IM. Management of lymphatic fistulas after arterial reconstruction in the groin. Ann Vasc Surg 2013; 27 (08) 1207-1215
• 3 Van den Brande P, von Kemp K, Aerden D. , et al. Treatment of lymphocutaneous fistulas after vascular procedures of the lower limb: accurate wound reclosure and 3 weeks of consistent and continuing drainage. Ann Vasc Surg 2012; 26 (06) 833-838
• 4 Helm CW, Hatch K, Austin JM. , et al. A matched comparison of single and triple incision techniques for the surgical treatment of carcinoma of the vulva. Gynecol Oncol 1992; 46 (02) 150-156
• 5 Lin JY, DuBeshter B, Angel C, Dvoretsky PM. Morbidity and recurrence with modifications of radical vulvectomy and groin dissection. Gynecol Oncol 1992; 47 (01) 80-86
• 6 Hopkins MP, Reid GC, Morley GW. Radical vulvectomy. The decision for the incision. Cancer 1993; 72 (03) 799-803
• 7 Paley PJ, Johnson PR, Adcock LL. , et al. The effect of sartorius transposition on wound morbidity following inguinal-femoral lymphadenectomy. Gynecol Oncol 1997; 64 (02) 237-241
• 8 Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 2000; 89 (07) 1520-1525
• 9 Gould N, Kamelle S, Tillmanns T. , et al. Predictors of complications after inguinal lymphadenectomy. Gynecol Oncol 2001; 82 (02) 329-332
• 10 Gaarenstroom KN, Kenter GG, Trimbos JB. , et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003; 13 (04) 522-527
• 11 Rouzier R, Haddad B, Dubernard G, Dubois P, Paniel BJ. Inguinofemoral dissection for carcinoma of the vulva: effect of modifications of extent and technique on morbidity and survival. J Am Coll Surg 2003; 196 (03) 442-450
• 12 Dardarian TS, Gray HJ, Morgan MA, Rubin SC, Randall TC. Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma. Gynecol Oncol 2006; 101 (01) 140-142
• 13 Micheletti L, Bogliatto F, Massobrio M. Groin lymphadenectomy with preservation of femoral fascia: total inguinofemoral node dissection for treatment of vulvar carcinoma. World J Surg 2005; 29 (10) 1268-1276
• 14 Judson PL, Habermann EB, Baxter NN, Durham SB, Virnig BA. Trends in the incidence of invasive and in situ vulvar carcinoma. Obstet Gynecol 2006; 107 (05) 1018-1022
• 15 Tyndall SH, Shepard AD, Wilczewski JM, Reddy DJ, Elliott Jr JP, Ernst CB. Groin lymphatic complications after arterial reconstruction. J Vasc Surg 1994; 19 (05) 858-863 , discussion 863–864
• 16 Ramasastry SS, Liang MD, Hurwitz DJ. Surgical management of difficult wounds of the groin. Surg Gynecol Obstet 1989; 169 (05) 418-422
• 17 Ploeg AJ, Lardenoye JW, Peeters MP, Hamming JF, Breslau PJ. Wound complications at the groin after peripheral arterial surgery sparing the lymphatic tissue: a double-blind randomized clinical trial. Am J Surg 2009; 197 (06) 747-751
• 18 Töpel I, Betz T, Uhl C, Steinbauer MG. The impact of superficial femoral artery (SFA) occlusion on the outcome of proximal sartorius muscle transposition flaps in vascular surgery patients. J Vasc Surg 2011; 53 (04) 1014-1019
• 19 Croft RJ. Lymphatic fistula: a complication of arterial surgery. BMJ 1978; 2 (6131): 205-210
• 20 Porcellini M, Iandoli R, Spinetti F, Bracale U, Di Lella D. Lymphoceles complicating arterial reconstructions of the lower limbs: outpatient conservative management. J Cardiovasc Surg (Torino) 2002; 43 (02) 217-221
• 21 Bernhard VM, Towne JB. , eds. Complications in Vascular Surgery. St. Louis, MO: Quality Medical Publishing; 1991
• 22 Kalman PG, Johnston KW. Consequences of groin lymphatic fistulae after vascular reconstruction. Vasc Endovascular Surg 1991; 25: 210-213
• 23 Roberts JR, Walters GK, Zenilman ME, Jones CE. Groin lymphorrhea complicating revascularization involving the femoral vessels. Am J Surg 1993; 165 (03) 341-344
• 24 Baek Y, Won JH, Kong TW. , et al. Lymphatic leak occurring after surgical lymph node dissection: a preliminary study assessing the feasibility and outcome of lymphatic embolization. Cardiovasc Intervent Radiol 2016; 39 (12) 1728-1735
• 25 Steele SR, Martin MJ, Mullenix PS, Olsen SB, Andersen CA. Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks. Am J Surg 2003; 186 (01) 9-12
• 26 Khalil IM, Sudarsky LA. Management of infected early postoperative lymph leak in the groin. Vasc Endovascular Surg 1992; 26: 474-479
• 27 Herrera FA, Kohanzadeh S, Nasseri Y, Kansal N, Owens EL, Bodor R. Management of vascular graft infections with soft tissue flap coverage: improving limb salvage rates--a veterans affairs experience. Am Surg 2009; 75 (10) 877-881
• 28 Thomas III WO, Parry SW, Powell RW, McGee GS, Rodning CB. Management of exposed inguinofemoral arterial conduits by skeletal muscular rotational flaps. Am Surg 1994; 60 (11) 872-880
• 29 Illig KA, Alkon JE, Smith A. , et al. Rotational muscle flap closure for acute groin wound infections following vascular surgery. Ann Vasc Surg 2004; 18 (06) 661-668
• 30 Colwell AS, Donaldson MC, Belkin M, Orgill DP. Management of early groin vascular bypass graft infections with sartorius and rectus femoris flaps. Ann Plast Surg 2004; 52 (01) 49-53
• 31 Morasch MD, Sam II AD, Kibbe MR, Hijjawi J, Dumanian GA. Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery. J Vasc Surg 2004; 39 (06) 1277-1283
• 32 Shermak MA, Yee K, Wong L, Jones CE, Wong J. Surgical management of groin lymphatic complications after arterial bypass surgery. Plast Reconstr Surg 2005; 115 (07) 1954-1962
• 33 Maser B, Vedder N, Rodriguez D, Johansen K. Sartorius myoplasty for infected vascular grafts in the groin. Safe, durable, and effective. Arch Surg 1997; 132 (05) 522-525 , discussion 525–526
• 34 Laustsen J, Bille S, Christensen J. Transposition of the sartorius muscle in the treatment of infected vascular grafts in the groin. Eur J Vasc Surg 1988; 2 (02) 111-113
• 35 Maddox JS, Sabino JM, Buckingham EB. , et al. Utility of indocyanine green fluorescence lymphography in identifying the source of persistent groin lymphorrhea. Plast Reconstr Surg Glob Open 2014; 2 (09) e210
• 36 Boccardo F, Dessalvi S, Campisi C. , et al. Microsurgery for groin lymphocele and lymphedema after oncologic surgery. Microsurgery 2014; 34 (01) 10-13
• 37 Yamamoto T, Yoshimatsu H, Koshima I. Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg 2014; 67 (11) 1573-1579
• 38 Schwartz MA, Schanzer H, Skladany M, Haimov M, Stein J. A comparison of conservative therapy and early selective ligation in the treatment of lymphatic complications following vascular procedures. Am J Surg 1995; 170 (02) 206-208
• 39 Kwaan JHM, Bernstein JM, Connolly JE. Management of lymph fistula in the groin after arterial reconstruction. Arch Surg 1979; 114 (12) 1416-1418
• 40 McShannic JR, O'Hara PJ. Management of femoral lymphatic complications following synthetic lower extremity revascularissation: early and late results. Vasc Endovascular Surg 1997; 31: 703-711
• 41 Stadelmann WK, Tobin GR. Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping. Plast Reconstr Surg 2002; 109 (04) 1274-1280
• 42 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
• 43 Yamamoto T, Matsuda N, Doi K. , et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128 (04) 314e-321e
• 44 Yamamoto T, Yamamoto N, Doi K. , et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 128 (04) 941-947
• 45 Yamamoto T, Yamamoto N, Narushima M. , et al. Lymphaticovenular anastomosis with guidance of ICG lymphography. J Jpn Coll Angiol 2012; 52: 327-331
• 46 Narushima M, Yamamoto T, Ogata F, Yoshimatsu H, Mihara M, Koshima I. Indocyanine green lymphography findings in limb lymphedema. J Reconstr Microsurg 2016; 32 (01) 72-79