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von Reibnitz D, Weinzierl A, Barbon C, Gutschow CA, Giovanoli P, Grünherz L, Lindenblatt N. 100 anastomoses: a two-year single-center experience with robotic-assisted micro- and supermicrosurgery for lymphatic reconstruction. J Robot Surg 2024; 18:164. [PMID: 38581589 PMCID: PMC10998780 DOI: 10.1007/s11701-024-01937-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/31/2024] [Indexed: 04/08/2024]
Abstract
Robotic-assisted microsurgery has gained significant attention in recent years following the introduction of two dedicated microsurgical robotic systems specifically designed for this purpose. These feature higher degrees of movement and motion scaling which are useful tools, especially when performing surgery in areas of the body which are difficult to access. Robotic-assisted microsurgery has been implemented in lymphatic surgery as well as soft tissue reconstructive surgery at our institution over the past 2.5 years. Our study gives an insight into the details and outcomes of the first 100 consecutive (super-) microsurgical anastomoses in peripheral and central lymphatic reconstruction performed with the Symani® Surgical System between 2021 and 2024. In total, 67 patients were treated, receiving robotic-assisted lymphatic reconstruction with lymphatic tissue transfer (LTT) and/or lymphovenous anastomoses (LVA)/lympholymphatic anastomoses (LLA). No anastomosis-associated complications were recorded postoperatively. The majority of patients reported a postoperative improvement of their lymphedema or central lymphatic disorder. In conclusion, we show the successful implementation of the Symani® Surgical System into our clinical practice of lymphatic reconstruction. Although the necessary intraoperative setup and the use of intrinsic motion scaling lead to a slight increase in operating time, the presented study demonstrates the advantages of robotic assistance which becomes particularly evident in lymphatic surgery due to the involved deep surgical sites and the need for supermicrosurgical techniques.
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Affiliation(s)
- Donata von Reibnitz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland
| | - Andrea Weinzierl
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland
| | - Carlotta Barbon
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christian A Gutschow
- Department of Visceral Surgery and Transplantation, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland
- University of Zurich (UZH), Raemistrasse 71, 8006, Zurich, Switzerland
| | - Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Raemistrasse 100, 8091, Zurich, Switzerland.
- University of Zurich (UZH), Raemistrasse 71, 8006, Zurich, Switzerland.
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Imai H, Yoshida S, Mese T, Roh S, Sasaki A, Nagamatsu S, Koshima I. Osteocutaneous superficial circumflex iliac perforator flap for the lower extremity bone and soft tissue reconstruction with perforator-to-perforator anastomosis after radical debridement of tibia osteomyelitis: A case report. Microsurgery 2023; 43:713-716. [PMID: 37605559 DOI: 10.1002/micr.31100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023]
Abstract
Reconstruction of soft tissue and bone defects in tibia chronic osteomyelitis is challenging and often managed by free flap with bone graft. However, the use of osteocutaneous free flap combined with perforator-to-perforator anastomosis has not been reported. We report the case of a 62-year-old man presenting with soft tissue and bone defects with right tibial chronic osteomyelitis, which was successfully treated with an osteocutaneous superficial circumflex iliac perforator (SCIP) flap with perforator-to-perforator anastomosis. After radical debridement and excision of the sequestrum, a 17 × 10-cm skin defect and a 4 × 3-cm bone defect remained. An osteocutaneous SCIP flap, containing a 16 × 9-cm skin paddle and 4 × 2-cm iliac bone, was transferred and anastomosed to the posterior tibial perforator in an end-to-end fashion. An artificial dermis was placed to cover the soft tissue. At 1 week postoperatively, the artificial dermis was partially infected, which required small debridement. Full weight-bearing was permitted 5 weeks postoperatively, and the patient walked independently. No evidence of recurrence of osteomyelitis or skin ulcers was observed at 15 months postoperatively. Therefore, osteocutaneous SCIP flap with perforator-to-perforator anastomosis may be a potential alternative treatment for soft tissue and bone defects after radical debridement of tibia osteomyelitis.
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Affiliation(s)
- Hirofumi Imai
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Shuhei Yoshida
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshiro Mese
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Solji Roh
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
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Imai H, Kawase T, Yoshida S, Mese T, Roh S, Fujita A, Uchiki T, Sasaki A, Nagamatsu S, Takazawa A, Ichinohe T, Koshima I. Peripheral T cell profiling reveals downregulated exhaustion marker and increased diversity in lymphedema post-lymphatic venous anastomosis. iScience 2023; 26:106822. [PMID: 37250774 PMCID: PMC10212982 DOI: 10.1016/j.isci.2023.106822] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/17/2023] [Accepted: 05/02/2023] [Indexed: 05/31/2023] Open
Abstract
Lymphedema is a progressive condition accompanying cellulitis and angiosarcoma, suggesting its association with immune dysfunction. Lymphatic venous anastomosis (LVA) can provide relief from cellulitis and angiosarcoma. However, the immune status of peripheral T cells during lymphedema and post-LVA remains poorly understood. Using peripheral blood T cells from lymphedema, post-LVA, and healthy controls (HCs), we compared the profile of T cell subsets and T cell receptor (TCR) diversity. PD-1+ Tim-3 + expression was downregulated in post-LVA compared with lymphedema. IFN-γ levels in CD4+PD-1+ T cells and IL-17A levels in CD4+ T cells were downregulated in post-LVA compared with lymphedema. TCR diversity was decreased in lymphedema compared with HCs; such TCR skewing was drastically improved in post-LVA. T cells in lymphedema were associated with exhaustion, inflammation, and diminished diversity, which were relieved post-LVA. The results provide insights into the peripheral T cell population in lymphedema and highlight the immune modulatory importance of LVA.
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Affiliation(s)
- Hirofumi Imai
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Takakazu Kawase
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima 734-8553, Japan
- International Center for Cell and Gene Therapy, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Shuhei Yoshida
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Toshiro Mese
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Solji Roh
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Asuka Fujita
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Toshio Uchiki
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Ayano Sasaki
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Shogo Nagamatsu
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Atsushi Takazawa
- Department of Orthopaedic Surgery, Hiroshima Hiramatsu Hospital, Hiroshima 732-0816, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima 734-8553, Japan
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
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Imai H, Yoshida S, Mese T, Roh S, Fujita A, Sasaki A, Nagamatsu S, Koshima I. Correlation between Lymphatic Surgery Outcome and Lymphatic Image-Staging or Clinical Severity in Patients with Lymphedema. J Clin Med 2022; 11:jcm11174979. [PMID: 36078909 PMCID: PMC9456713 DOI: 10.3390/jcm11174979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Lymphoscintigraphy and indocyanine green (ICG) lymphography reveal the severity of extremity lymphedema. Lower extremity lymphedema (LEL) index and NECST classification are related to the clinical severity of lymphedema. We aimed to investigate the correlation between lymphatic surgery, lymphatic imaging, and clinical severity in patients with lymphedema. Thirty-five patients with lower-extremity lymphedema who underwent lymphatic venous anastomosis (LVA) were evaluated. Ten of the thirty-five patients underwent multi-surgery (additional vascularized lymphatic transfer and/or liposuction). We investigated the correlation between the LEL index, NECST classification, lymphoscintigraphy staging, ICG lymphography staging, and rate of improvement (RI: [preoperative LEL index − postoperative LEL index]/[preoperative LEL index] × 100). The LEL index in 35 patients after LVA and all procedures decreased significantly compared to that of preoperative (272.4 vs. 256.2 vs. 243.5, p < 0.05). RI after LVA and all procedures showed positive correlations with the preoperative LEL index; however, there was no correlation with any other lymphatic image or clinical severity. LVA can reduce lymphedema circumference at any stage. Additional surgery improved the circumference. Hence, LVA as the first line of treatment, and vascularized lymphatic transfer and liposuction as additional procedures, should be considered as the standard treatment for lymphedema.
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Affiliation(s)
- Hirofumi Imai
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
- Correspondence: ; Tel.: +81-82-257-5555
| | - Shuhei Yoshida
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Toshiro Mese
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Solji Roh
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Asuka Fujita
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima 734-8551, Japan
- Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima 734-8551, Japan
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