Establishing a Lymphatic Venous Anastomotic Training Model in Pig Trotters

Abstract

Background Lymphatic venous anastomosis (LVA) is a widely accepted surgical procedure for lymphedema. To obtain the best outcomes, surgeons should be well trained. A recent study introduced an LVA training model using pig trotters for their utility and structural similarity to human tissues. However, details regarding the utilization of anastomosis models, such as feasible points for training based on vessel anatomy, have not been clarified. Therefore, we assessed the anatomical details of lymphatic vessels and veins of trotters to establish a practical training model of LVA.

Methods Ten frozen trotters were used. After thawing at room temperature, indocyanine green fluorescent lymphography was used to visualize the lymphatic course. To dissect the lymphatic vessels and veins from the distal to the proximal end, whole skins were detached thoroughly from the plantar side. Data from the lymphatic vessels and veins were collected based on their courses, diameters, and layouts to clarify adjacent points feasible for LVA training.

Results Both lymphatic vessels and veins were classified into four major courses: dorsal, medial, lateral, and plantar. The majority were dorsal vessels, both lymphatic vessels and veins. The adjacent points were always found in the distal dorsum center and were especially concentrated between the metacarpophalangeal (MP) joint and central interphalangeal crease, followed by the medial and lateral sides.

Conclusion The most relevant point for LVA surgical training in the trotter was the dorsal center distal to the MP joint, where parallel vessels of similar sizes were found in all cases. This practical LVA surgical model would improve surgeon skills in not only anastomosis but also preoperative fluorescent lymphography.

Keywords

lymphatic vessel - LVA - training model

Authors' Contributions

M.K. contributed to the conception and design of the study, analysis, and interpretation of data, and drafting and completing the article. Ma.K. contributed to the design of the study, interpretation of data, and revision of the article for important intellectual content. D.M. contributed to imaging device creation (fluorescent lymphography). R.N. and K.L. contributed to the acquisition of the data. S.Y. and M.O. contributed to the revision of the article and contributed important intellectual content. All authors critically revised the article. All authors have read and approved the final manuscript.

Publication History

Received: 16 November 2020

Accepted: 27 January 2021

Article published online:
11 March 2021

• References

• 1 Garza RM, Chang DW. Lymphovenous bypass for the treatment of lymphedema. J Surg Oncol 2018; 118 (05) 743-749
• 2 Gloviczki P, Fisher J, Hollier LH, Pairolero PC, Schirger A, Wahner HW. Microsurgical lymphovenous anastomosis for treatment of lymphedema: a critical review. J Vasc Surg 1988; 7 (05) 647-652
• 3 Banda CH, Mitsui K, Ishiura R, Danno K, Narushima M. A supermicrosurgery pig foot training model for practice of lymphaticovenular anastomosis. Microsurgery 2020; 40 (01) 91-92
• 4 Kato M, Watanabe S, Iida T, Watanabe A. Flow pattern classification in lymphatic malformations by Indocyanine Green lymphography. Plast Reconstr Surg 2019; 143 (03) 558e-564e
• 5 Mito D, Kurita M, Miyamoto S, Okazaki M. Miniaturization of Indocyanine Green fluorescence imaging device using a smartphone. Plast Reconstr Surg 2020; 145 (01) 230e-232e
• 6 Yamamoto T, Yamamoto N, Yamashita M, Furuya M, Hayashi A, Koshima I. Establishment of supermicrosurgical lymphaticovenular anastomosis model in rat. Microsurgery 2017; 37 (01) 57-60
• 7 Cifuentes IJ, Rodriguez JR, Yañez RA. et al. A novel ex vivo training model for acquiring supermicrosurgical skills using a Chicken Leg. J Reconstr Microsurg 2016; 32 (09) 699-705
• 8 Navia A, Tejos R, Yañez R, Cuadra A, Dagnino B. Optimizing the Chicken Wing Anatomy: nomenclature review and description for microsurgery and supermicrosurgery training. J Reconstr Microsurg 2020; (e-pub ahead of print) DOI: 10.1055/s-0040-1718393.
• 9 Albano NJ, Zeng W, Lin C, Uselmann AJ, Eliceiri KW, Poore SO. Augmentation of Chicken Thigh Model with Fluorescence imaging allows for real-time, high fidelity assessment in supermicrosurgery training. J Reconstr Microsurg 2021; 37 (06) 514-518
• 10 Oliver G. Lymphatic vasculature development. Nat Rev Immunol 2004; 4 (01) 35-45
• 11 Onoda S, Kimata Y, Matsumoto K, Yamada K, Tokuyama E, Sugiyama N. Histologic evaluation of lymphaticovenular anastomosis outcomes in the rat experimental model: comparison of cases with patency and obstruction. Plast Reconstr Surg 2016; 137 (01) 83e-91e
• 12 Leuzzi S, Maruccia M, Elia R. et al. Lymphatic-venous anastomosis in a rat model: a novel exercise for microsurgical training. J Surg Oncol 2018; 118 (06) 936-940
• 13 Suami H, Schaverien MV. Swine hind limb model for supermicrosurgical lymphaticovenular anastomosis training. J Plast Reconstr Aesthet Surg 2016; 69 (05) 723-725
• 14 Gentileschi S, Servillo M, Albanese R, De Bonis F, Tartaglione G, Salgarello M. Lymphatic mapping of the upper limb with lymphedema before lymphatic supermicrosurgery by mirroring of the healthy limb. Microsurgery 2017; 37 (08) 881-889
• 15 Mihara M, Seki Y, Hara H. et al. Predictive lymphatic mapping: a method for mapping lymphatic channels in patients with advanced unilateral lymphedema using indocyanine green lymphography. Ann Plast Surg 2014; 72 (06) 706-710
• 16 Shinaoka A, Koshimune S, Yamada K. et al. A fresh Cadaver Study on Indocyanine Green Fluorescence Lymphography: a new whole-body imaging technique for investigating the superficial lymphatics. Plast Reconstr Surg 2018; 141 (05) 1161-1164
• 17 Shinaoka A, Koshimune S, Yamada K. et al. Correlations between tracer injection sites and lymphatic pathways in the leg: a near-infrared fluorescence lymphography study. Plast Reconstr Surg 2019; 144 (03) 634-642