Mesenteric Vascularized Lymph Node Transfer

Key Points

The small bowel mesentery represents a donor site for vascularized lymph node transfer that contains numerous and redundant lymph nodes and has reliable anatomy with minimal donor site morbidity.
The small bowel mesenteric lymph node flap can usually be readily outlined before flap harvest through the use of transillumination, including its lymph nodes, their relationship to the vascular pedicle, and the remaining vascular supply to the bowel.
The mesentery of the proximal third of the jejunum contains the greatest number of lymph nodes.
Use of peripherally located lymph nodes has the advantage of better vascular inflow and outflow balance, with smaller vessels and a relatively greater capillary bed connecting the arterial inflow and venous outflow. In contrast, lymph nodes located toward the root of the mesentery are adjacent to much larger feeding vessels, which primarily supply the bowel and may require the creation of an arteriovenous loop at the distal end of the vascular pedicle or a flow-through flap inset to maintain adequate balance between arterial inflow and venous outflow.

Introduction

Vascularized lymph node transfer (VLNT) entails the microsurgical transfer of lymph nodes from a donor site to an area with lymphedema. In contrast to lymphovenous bypass surgery, VLNT can also be applied to cases of lymphedema where no suitable lymphatics are available for anastomosis, such as in patients with more advanced disease. The transferred lymph nodes in VLNT are hypothesized to improve lymphedema by acting as a surgical wick to bridge a zone of obstruction of lymphatic drainage and as a lymphatic pump that absorbs interstitial fluid and returns it to the systemic circulation.

Several different VLNT donor sites have been described, including the omentum, groin, thoracic/axillary, submental, and supraclavicular regions. The characteristics of an ideal donor site for VLNT include the ability to transfer several lymph nodes on a single vascular pedicle, reliable anatomy, minimal donor site morbidity (including the risk of donor site lymphedema), feasibility in majority of patients, and an inconspicuous scar. The jejunal mesentery is a donor site that possesses these characteristics and represents an important option for the treatment of lymphedema with VLNT.

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