Rutherford's Section 25: Lymphedema скачать в хорошем качестве

Rutherford's Section 25: Lymphedema

#Lymphedema #VascularSurgery #SurgicalManagement #Rutherford #Microsurgery #LymphaticGrafting #LVA #Liposuction #StagedExcision This video delves into the surgical management of lymphedema, drawing specifically from chapters 167 to 169 of Rutherford’s Vascular and Endovascular Therapy 10th Edition. Lymphedema is defined as the progressive buildup of protein-rich fluid due to a lymphatic system drainage failure, often presenting as extremity oedema. It can be primary (congenital) or secondary (acquired). Early surgical attempts were radical excisional procedures like the Charles procedure, which involved removing skin and subcutaneous tissue but led to complications. Functional procedures aiming to divert lymph flow were also attempted with limited success. Microsurgery marked a significant shift towards directly fixing lymphatic drainage. Modern surgical planning relies heavily on visualizing the lymphatic system. While direct contrast lymphography (Kinmonth procedure) was early but invasive and could worsen lymphedema, current key imaging tools include MR lymph angiography for detailed anatomy and lymphosyntigraphy to assess lymphatic function and transport routes. Intraoperative vital dyes help identify tiny lymphatic vessels. Assessing donor sites with lymphosyntigraphy is crucial before lymphatic grafting to avoid causing new lymphedema. Surgical risks vary, generally low for subcutaneous procedures but higher for extensive excisional ones. Reconstructive techniques aim to restore drainage. Autologous lymphatic grafting, using the patient's own vessels, is indicated for secondary lymphedema with a localized blockage, ideally after at least six months of failed conservative therapy to prevent tissue changes. Grafts, typically taken from the inner thigh while sparing convergence zones, are connected using microsurgery. Lymphovenous anastomosis (LVA) connects lymphatics to veins, suitable for relatively recent secondary lymphedema without chronic venous insufficiency. Preoperative prep might involve limb elevation, and surgery uses delicate microsurgical techniques. Excisional methods focus on debulking when reconstruction is insufficient or impossible. Liposuction targets excess adipose tissue accumulated in chronic lymphedema, requiring essential long-term compression therapy post-op. Staged subcutaneous excision (Miller technique) is a major operation for severe, disabling cases unresponsive to other treatments, involving the removal of thickened subcutaneous tissue and excess skin. Surgery also addresses primary chylus disorders where fatty lymphatic fluid accumulates, potentially requiring procedures like ligating leaky vessels, cyst removal, bowel resection, or thoracic duct ligation/reconstruction depending on the location. Conservative therapy (compression, exercise, skin care) remains the first line; surgery is reserved for specific patients after non-operative care has not achieved desired results. Continued advancements are refining techniques and outcomes.