Robotic-assisted Lympho-venous Anastomosis of the Central Lymphatic System

Abstract

Background: Central lymphatic flow disorders may be congenital or result from surgery or trauma. Congenital lymphatic lesions exhibit a plethora of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. In case of congestion of the lymphatic flow with reflux into organs and body cavities reconstructive microsurgery is a potent method to improve lymphatic flow. In this context robotic-assisted microsurgery may aid significantly in accessing the prevertebral axial lymphatic system. Methods: We report a case series of 10 patients (Age 6 mo – 52 yrs) treated by thoracic-duct vein anastomosis to improve central lymphatic flow at different locations and levels within the central lymphatic system. Interventional treatment had been evaluated and not deemed feasible due to an already impaired lymphatic flow, which would have been worsened by further embolization. Results: We successfully performed the first robotic lympho-venous anastomosis within the abdomen worldwide for an aneurysmal dilatation of the lumbar truncs leading to complete resolution of the patient`s symptoms. Due to the heterogenous nature of the disease patients were treated individually after interdisciplinary evaluation. Patients suffered from chronic chylothorax, chylaskos, protein-loosing enteropathy, chyle leak and severe peripheral edema. Thoracic-duct abnormalities included traumatic transection, thrombotic venous occlusion, atresia at the left venous angle with severe dilatation, aneurysmal dilatation and complete absence of the axial lymphatic system with collateralization via the subcutaneous tissue of the trunk. Lympho-venous anastomoses were performed in the neck, the abdomen and the lateral thoracic wall. The success of the microsurgical reconstruction varied depending on the nature of the underlying cause from mild improvement to complete resolution of all symptoms. Conclusion: In case of disruption of the central lymphatic flow leading to chronic fluid accumulation, lymphatic congestion and protein loss super/microsurgical reconstruction of the axial lymphatic system by thoracic duct-vein anastomoses provide an important means to treat these complex conditions. Robotic-assisted microsurgery represents a promising tool to further improve access and reliability.