JITHU RAMANATHAN MS GENERAL SURGERY

Anatomy and Physiology

The exact origin of lymphatic

vessels is a matter of disagreement among embryologists

The original theory of Sabin Huntington and McClure -

origin from the venous system

lymphatics form by fusion of mesenchymal spaces or clefts, centripetal theory

 Developmental arrest or

abnormalities can result in primary hypoplasia or absence of ducts and lymph nodes sacs can produce unilocular or multilocular lymph cysts termed cystic hygromas
the axilla, mediastinum, retroperitoneum, or intestinal mesentery

Abnormal growth of jugular lymph

These cysts also may be found in

 In addition to the protein that

cannot be reabsorbed by the venules, red blood cells, bacteria, and other larger particles can be evacuated only through the lymphatics.

Although lymphatics can be

found in the intermuscular fascia, they are absent in muscles, tendon, cartilage, brain, and cornea.

 The main function of the lymphatic system is to clear

the interstitial spaces of excess water and particulate matter.

 The severity of unilateral limb lymphoedema can be

classied as: mild: < 20% excess limb volume; moderate: 2040% excess limb volume; severe: > 40% excess limb volume.

 The congenital lymphedemas are hypoplastic in 92

percent of cases
In proximal hypoplasia, the lymphedema is more

extensive, involving the entire extremity, and it occurs equally among males and females.
The combination of proximal and distal hypoplasia

shows features of both groups and tends to be progressive.

 The primary hyperplastic lymphedemas are

uncommon (8 percent), and those with bilateral hyperplasia usually can be recognized by diffuse capillary angiomata on the lateral sides of the feet.

Grade (Brunner)
Subclinical (latent) :There is excess interstitial uid and

histological abnormalities in lymphatics and lymph nodes, but no clinically apparent lymphoedema
I Oedema pits on pressure and swelling largely or

completely disappears on elevation and bed rest

II Oedema does not pit and does not signicantly reduce

upon elevation
III Oedema is associated with irreversible skin changes,

i.e. brosis, papillae

Clinical Manifestations
Lymphedema is a clinical diagnosis and should be restricted to

situations where other causes of edema have been excluded or a specific lymphatic abnormality has been demonstrated.
The presence of bilateral dependent pitting edema usually

indicates a renal or cardiac etiology.

Other generalized hypoproteinemias may be seen in

malnutrition, cirrhosis, and protein-losing enteropathy, or they may be idiopathic.

Allergies or hereditary causes are unusual. In unilateral edema, venous disease is the most likely cause

 The patient with lymphedema complains of

swelling and fatigue

Limb size increases during the day and

decreases at night but is never normal.

It is important to determine whether there is a

family history of primary lymphedema and whether the patient has visited any countries where filariasis is endemic suggests small bowel lymphangiectasia.

The presence of weight loss and diarrhea On examination, lymphedema is

characteristically firm and rubbery but nonpitting.

fluid of high protein concentration.

Lymph vesicles may be present containing

 Complications of lymphedema

such as infection, cellulitis, erythema, and hyperkeratosis may be present.

It is important to document

limb size to identify isolated limb gigantism and the KlippelTrnaunay syndrome that may have hypoplastic lymphatics in addition to venous abnormalities, capillary nevus, and limb elongation.

Diagnostic Studies
Dye Injection- patent blue& sky

blue dye If the collecting vessels are obstructed or inadequate, the dye diffuses through the dermal lymphatics to produce a marbled appearance called dermal backflow.
Lymphography- Lipiodol CT MRI USG

Radionuclide Lymphatic Clearance

Radionuclide scanning using

human serum albumin labeled with radioactive iodine or technetium 99m colloid has been used to monitor lymphatic clearance by serial scanning.

Analysis of Tissue Fluid

lymphedema fluid has a protein content of more than

1.5 g/dL The ratio of albumin to globulin also is higher in lymphedema fluid than in plasma

Management
Supportive Treatment
primary objectives remain for control of edema,

maintenance of healthy skin, and avoidance of the complications of cellulitis and lymphangitis. Elevation Exercise sequential pneumatic compression boots to massage the leg

 The onset of redness, pain,

and swelling usually signifies early cellulitis or lymphangitis, which can be recognized by red streaking up the leg. The usual causative organism is staphylococcus or beta-hemolytic streptococcus, which must be treated vigorously, usually with intravenous antibiotics

Complete decongestive therapy or manual lymph drainage

manual manipulation of the

lymphatic ducts, short stretch compression bandaging, therapeutic exercise, and skin care.
Emil Vodder

The technique was pioneered by CDT is generally effective on

non-fibrotic lymphedema and less effective on more fibrotic legs,

 Another frequent complication is eczema, which

usually will respond to hydrocortisone cream. Antifungal agents may be necessary, topically and systemically, for chronic infections, particularly between the toes. In contrast to the stasis edema of venous insufficiency, ulceration is unusual, although fissures and lymph fistulas can develop and require surgical excision.

surgery
Homans procedure
Operative Treatment Sistrunk Charles Kinmonth's modification of

Homans's procedure
Thompsons reduc-

tion operation

Bypass procedures

Thompsons reduction operation; the buried dermal ap.

Charles procedure

 Nielubowicz and Olszewski, who divided a lymph node,

removed the pulp under magnification, and sutured the node capsule with its afferent lymphatics into a vein. This procedure is more suitable for secondary lymphedema than primary, in which the disorder lies in the lymphatic channels themselves connection was developed by Cordeiro and modified by Degni, who used a special needle for insertion of lymphatic vessels directly into veins and fixed them there by a single suture vessels of 0.50.8 mm diameter using supermicrosurgical techniques, with promising results.

. Another promising technique of direct lymphovenous

direct lymphati- covenular anastomosis has been carried out on

Thank you