Real-time Indocyanine Green Videolymphography Navigation for Lymphaticovenular Anastomosis

Indocyanine green (ICG) lymphography is a useful imaging modality for evaluation of lymphedema and detection of lymphatic vessels. It also allows us to ensure patency of the anastomosed vessels intraoperatively. However, strong light from the operating microscope usually disturbs ICG fluorescence imaging. Only some built-in ICG camera systems with specific operating microscopes make real-time ICG lymphography possible in lymphaticovenular anastomosis (LVA). We applied a new high-resolution ICG videolymphography system, which is separated from the operating microscope. Because the system can divide near-infrared fluorescence light of ICG from visible light of the operating microscope, real-time ICG videolymphography-navigated LVA under operating microscope illumination is possible regardless types of operating microscopes. The study involved 10 patients with upper extremity lymphedema characterized by International Society of Lymphology stage 2 and treated by 3 lymphaticovenular anastomoses at the forearm (30 lymphaticovenular anastomoses incorporating 30 lymphatic vessels) under real-time ICG videolymphography. The rate of intraoperative detection of lymphatic vessels using real-time ICG videolymphography was 86.7% (0.25-0.85 mm in diameter), and that of lymph flow through the lymphaticovenular anastomoses was 76.7%. None of lymphatic vessels and no flow were detected under the microscope light by means of another non-built-in ICG lymphography camera. Real-time ICG videolymphography in LVA is beneficial, because the surgeon could find lymphatic vessels easily by checking dual images of original view and ICG fluorescent view and ensure accuracy of the LVA in a suture by a suture without any pauses of the surgical procedures.