New minimally invasive vascularized lymph node transfer for lymphedema

Jan. 16, 2021

Physicians at Mayo Clinic's campus in Phoenix/Scottsdale, Arizona, have developed a new outpatient surgical procedure for patients experiencing lymphedema refractory to traditional therapy.

In May 2020, Alanna M. Rebecca, M.D., and Chad M. Teven, M.D., plastic and reconstructive surgeons, and Johnny Yi, M.D., urogynecologic surgeon, performed a first-of-its-kind single-port robotic omental harvest, which uses a free lymph node transfer, for minimally invasive surgical treatment of lymphedema. The objective of this new surgical treatment method is to minimize donor site morbidity while alleviating debilitating lymphedema symptoms.

The novel single-port feature reduces what was formerly an 8- to 12-inch incision to an approximately 1-inch incision, making a significant impact on the size of the patient's donor site scar as well as reducing pain and postoperative discomfort, says Dr. Teven. Dr. Rebecca also indicates that this method decreases potential for hernia.

Both surgeons note that there is not yet U.S. Food and Drug Administration approval for this indication, yet they have not seen any issues from payers in this regard.

The robotic arms used in the single-port procedure allow for much greater flexibility and thus precision compared with the previously used laparoscopy — optimal for both the surgeon and the patient's outcome, according to Dr. Rebecca. Mayo Clinic in Phoenix/Scottsdale, Arizona, is one of a few medical centers in the nation that have a single-port robot to date. "With laparoscopy, the arms are straight and fixed," she explains. "It was like you had your arms locked and were trying to hand something to yourself. With the robotic arms, when doing dissection, you can do far more detailed work because the robotic arms can articulate so much."

Dr. Rebecca says their team prefers using omental tissue for lymph node transfer because unlike other sites, the omentum doesn't have the risk of injuring the lymph basin, thus creating secondary lymphedema. Risks with using the omentum may include bowel or other internal organ damage, though it's very rare, she indicates.

Single-port robotic omental harvest

In this procedure, surgeons perform a robot-assisted omental flap harvest using a single-port approach — a 2.5-centimeter vertical abdominal incision — in contrast to standard robotic harvest. After intraperitoneal insertion of a balloon-tip trocar, surgeons place a cannula and insufflate the abdomen. Lymph node clusters are identified through injection of cyanine dye into the omentum and subsequent fluorescent angiography. The recipient site is prepped, and the omentum is then dissected, captured in an endobag and inspected via fluorescent angiography. In a conjoined or segmented flap, the omental tissue is transferred to the affected site. If needed, surgeons use skin grafting and lipectomy at the donor site.

Operative time is typically 3 to 4 hours; hospitalization is overnight. The surgeons hope the procedure will be performed on an outpatient basis in the future.

Benefits of the lymph node transfer include significant reduction of pain and swelling in the lymphedemic anatomy, most often the arm, says Dr. Teven. The surgery also allows patients to decrease antibiotic use. Additionally, quality-of-life benefits with lymph node transfer are compelling for patients who were previously hampered in many aspects of everyday life by lymphedema.

"This surgery allows patients to participate in normal activities of daily living: Putting on pants, wearing their wedding rings, getting in the car, going to work and walking all become possible," says Dr. Rebecca. "Prior to surgery, a 90-pound patient could be wearing a size XXL shirt just to fit over a swollen arm."

The patient who underwent the single-port robotic surgery for lymphedema in May 2020 has provided positive anecdotal feedback, including significant clinical improvement such as the ability to wear the usual size pants and shoes, which the surgeons note is a significant accomplishment for patients experiencing lymphedema of the lower extremities.

The surgeons have formed a multidisciplinary work group for lymphedema treatment, an effort that has been eight years in the making.

Appropriate candidates for this procedure include patients diagnosed with breast, skin penile, bladder and gynecologic cancers who have undergone lymph node dissection. Or, for earlier intervention, patients for whom lymph node dissection has been indicated may be referred. The surgeons say the procedure is also beneficial for patients with new-onset, idiopathic lymphedema, such as patients Dr. Rebecca has encountered who have suddenly developed lymphedema after activities such as twisting a knee during kickboxing or after a total hip replacement.

Lymphedema, swelling that typically occurs in the extremities, results from removal of or damage to a patient's lymph nodes during cancer treatment. Without the lymph basin or its proper function, movement of fluid is hindered, resulting in lymphatic system blockage. With the lymph fluid unable to properly drain, swelling develops.

Lymphedema can present quality-of-life issues, as it can be painful and debilitating. Untreated lymphedema can result in infections including cellulitis and lymphangitis, or lead to lymphangiosarcoma, a rare soft tissue cancer.

For more information

Any medical professional treating a patient's lymphedema may refer a patient for single-port omental harvest.