Groin lymphorrhea complicating revascularization involving the femoral vessels

doi:10.1016/S0002-9610(05)80839-6

The American Journal of Surgery

Volume 165, Issue 3, March 1993, Pages 341-344

https://doi.org/10.1016/S0002-9610(05)80839-6 Get rights and content

Seven (4%) of 193 patients developed lymphoceles in 8 (2%) of 316 groin wounds after 211 arterial reconstructive procedures. Included were 91 aortic, 15 extra-anatomic, and 105 infrainguinal revascularizations. Lymphoceles developed in otherwise uncomplicated wounds in 6 (8%) of 73 patients with oblique incisions and bilaterally in 1 (1%) of 120 patients with vertical incisions (p=0.01). This difference may be related to the surgical technique, with increased lymphatic damage and inadequate woundclosure in the oblique approach. No increased incidence of lymphorrhea was noted in those patients undergoing aortic reconstruction regardless of the type of incision used (p=0.15), or when compared with patients who had undergone extra-anatomic or infrainguinal bypass (p=0.14). Each lymphocele was persistent, and external fistulas spontaneously occurred in three. Diagnosis was based upon clinical awareness and the appearance of the groin mass. Conservative management was uniformly unsuccessful, and operative ablation of the lymph fistula and lymphocele proved to be definitive therapy.

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2021, Annals of Vascular Surgery
Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.
Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients
2018, Journal of Vascular Surgery
Venous-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-established therapy for refractory cardiopulmonary failure. Femoral cannulation offers a quick and effective means of providing circulatory support but is not without complication. Inflammation or lymphatic disruption at the site of cannulation can cause the formation of lymphoceles, leading to the patient's discomfort and possibly necessitating intervention. The purpose of this study was to evaluate the incidence of in-hospital lymphocele formation in VA-ECMO patients and to identify predictors for their development.
We conducted a single-center retrospective review of 192 patients who underwent femoral VA-ECMO insertion and subsequent decannulation from March 2007 to August 2016 for cardiogenic shock. Baseline demographics, risk factors, and cannulation strategies were examined. Groin lymphocele formation was assessed as the primary outcome.
Median age was 58 years (interquartile range, 48-67 years) with a median duration of support of 4 days (interquartile range, 2-6 days). Lymphocele formation was identified in 31 patients (16%). Patients who developed lymphoceles were more likely to have post-heart transplantation primary graft dysfunction (PGD) as an indication for ECMO support compared with those who did not (54.2% vs 8%; P < .001). ECMO duration was similar between groups, but lymphocele patients were more likely to have undergone femoral cutdown procedures (68% vs 42%; P = .010). Compared with those PGD patients who did not develop lymphoceles, PGD lymphocele patients had higher rates of diabetes mellitus preoperatively (62% vs 8%; P = .006). Thirteen (42%) patients required surgical incision and drainage, and 4 of these patients (31%) required repeated surgical intervention.
Lymphocele formation is relatively common after femoral VA-ECMO. There was a significantly higher incidence of lymphocele formation in diabetic patients requiring support for PGD after heart transplantation.
Utility of electrofusion for the femoral approach in vascular surgery: A randomized prospective study
2015, Annals of Vascular Surgery
The local complications are frequent after a femoral approach in vascular surgery and are often the cause of a delay in healing. Electrofusion showed its effectiveness to decrease the complications in general surgery but was not tested in vascular surgery. The aim of our study was to evaluate if the use of electrofusion in the approach to femoral vessels improved healing at 1 month by decreasing the local complications.
This prospective randomized study was conducted in 2 centers from May 1, 2012 to April 30, 2013. All the patients requiring a surgical access of the femoral trigone were included in 2 French teaching hospitals. Femoral artery surgical exposure was carried out using electrofusion or according to the conventional technique (diathermy or cold scalpel) according to a protocol of randomization. The principle criterion of the study was a complete healing at 1 month. The secondary criteria were the appearance of cutaneous, infectious, or lymphatic local complications.
Two hundred ninety-two femoral approaches were carried out in 221 consecutive patients. One hundred forty-eight approaches were carried out with electrofusion and 144 according to the conventional technique. The demographic and operative characteristics were similar between the 2 groups. At 1 month, 86.3% of the approaches were healed without statistically significant difference between the 2 groups (88.5% vs. 84%, P = 0.241). There were less local complications (P = 0.012) and seromas (P = 0.012) in the electrofusion group. This difference could be linked with the least quantities (P = 0.036) and durations (P = 0.014) of drainage observed after approaches carried out with electrofusion. On the other hand, the incidence of cutaneous or infectious complications was not different between the 2 groups.
In our series, the use of electrofusion decreased the lymphatic complications after a femoral approach. However, the correction of this single parameter was not sufficient to improve the rate of healing at 1 month.
Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: Supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation
2014, Journal of Plastic, Reconstructive and Aesthetic Surgery
Lymphorrhea can occur after surgical intervention to the lymphatic system. Most cases with lymphorrhea can be treated conservatively, but some cases are refractory to conservative treatments and require further surgical treatments.
Eight patients developed inguinal lymphorrhea after surgical intervention in the groin region. Navigation lymphatic supermicrosurgery (NLS) was performed for the treatment of iatrogenic lymphorrhea refractory to conservative treatments. Lymphatic vessels ruptured in a lymphorrhea lesion were identified under intraoperative indocyanine green (ICG) lymphography navigation and were anastomosed to a recipient vessel; an intact lymphatic vessel or a vein was selected as a recipient. Feasibility and efficacy of the method were evaluated.
Among eight inguinal lymphorrhea patients, four patients with refractory lymphorrhea underwent NLS under local anesthesia. In all cases, a lymphatic vessel that caused an intractable lymphorrhea was successfully anastomosed to a recipient vessel (to an intact lymphatic vessel in one case, and to a venule in three cases), and the lymphorrhea was completely cured without lymphorrhea recurrence or lymphedema development. Treatment duration in NLS was significantly shorter than that in conservative treatments (5.0 ± 2.4 vs. 30.0 ± 8.1 days, P = 0.006).
Intraoperative ICG lymphography helps a surgeon to find lymphatic vessels in and near a lymphorrhea lesion, which allows secure and easier treatment for an intractable lymphorrhea with preservation of lymph drainage function.
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Management of lymphatic fistulas after arterial reconstruction in the groin
2013, Annals of Vascular Surgery
Citation Excerpt :
A further cohort study revealed a conservative approach was unsuccessful and suggested operative ligation of any lymph leak was definitive. This study also found a higher incidence of lymphoceles arising in oblique incisions compared with vertical incisions.17 The presence of secondary infection and prosthetic graft material may alter the decision to treat a leak conservatively.
Since its original description in the British Medical Journal in 1978, the treatment of lymphatic fistulas in the groin remains contentious. Lymph leaks remain a common cause of morbidity in patients who have undergone groin dissection. The aim of this review was to examine the evidence for prevention and treatment of lymphatic fistulas after arterial surgery in the groin.
A systematic review of the English language literature was undertaken to determine the success of the various treatment options described.
A comprehensive literature search identified 46 studies describing several treatment options for lymphatic fistulas. A qualitative synthesis of these studies was performed. There was no consensus definition of lymphatic fistula. Treatments reviewed were: conservative management; lymphatic ligation; vascularized muscle flaps; and negative pressure wound therapy (NPWT). Due to poor study quality and the paucity of data no one treatment could be identified as superior.
There was no quantifiable cut-off for either the amount of lymphatic output or number of days postoperatively that leakage continued to help determine when conservative measures should be abandoned and surgical intervention undertaken. There is some evidence supporting use of vascularized muscle flaps to reduce the volume of lymphatic drainage and help prevent secondary graft infection. The use of NPWT is also promising, but must be weighed against the associated risk of anastomotic bleeding and requirement for additional inpatient stay.

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¹: From the Division of Vascular Surgery, Section of Surgical Sciences, Francis Scott Key Medical Center, and the Johns Hopkins Medical Institutions, Baltimore, Maryland.

View full text

Groin lymphorrhea complicating revascularization involving the femoral vessels

Surg Clin North Am

J Vasc Surg

J Vasc Surg

J Urol

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Urol

Taber's cyclopedic medical dictionary

Lymph leakage (lymphorrhea)

Surgery

Management of lymph fistula in the groin after arterial reconstruction

Arch Surg

Persistent lymphatic fistula: unusual complication of femoro-femoral arterial bypass

J Cardiovasc Surg

Lymphatic fistula: a complication of arterial surgery

BMJ

Treatment of lymphorrhea with exposed or infected vascular prosthetic grafts in the groin using sartorius myoplasty

J Cardiovasc Surg

The normal anatomy of the lymphatic system in the human leg

Br J Surg

Current concepts of lymphatic transport

Surg Gynecol Obstet

Lymphangiographic findings in patients with leg edema after arterial reconstructions

Acta Chir Scand

Leg edema following femoro-popliteal autogenous vein bypass

Arch Surg

The effect of ionizing radiations on the regeneration and behavior of mammalian lymphatics

AJR Am J Roentgenol