Procedure performed: Excision of lymphedema pocket of right upper inner thigh with multiple layer reconstruction and wound VAC application.

Indication: This pt is a female who has developed lymphedema on bilateral lower extremities and on the medical aspect of her right inner thigh had developed a pocket which had significant entrapment of lymphatic fluid with irreversible changes and hypertrophy. The pt developed the pocket of tissue approximately the size of a bowling ball which hung from the upper inner distal medial right thigh and did hang on the ground. It severely impacted her lifestyle and limited her ability to exercise and ambulate and after seeking consultation from multiple doctors finally agreed to allow for excision of this area. Details,risks, and benefits of the operation were gone over with her. All of her questions were answered. All pertinent informed consents were gone over and signed. Medial clearance was obtained preoperatively.

Procedure: the patient was brought into the operative suite and placed in the supine position with all dependent portions carefully padded. After successful induction of general endotracheal anesthesia, was prepped and draped in usual fashion. Incision was made on the anterior and posterior surface of this massive lymphatic contained extravasation from the distal inner right thigh. Dissection was carried down through the skin and subcutaneous tissue with Bovie electro cautery. Once the lymphatic channels were encountered, harmonic scalpel was then used in order to coagulate and cuaterize the lymphatic channels, Meticulous treatment of the lymphatic channels with the Harmonic scalpel was able to accomplished full thickness from anterior to posterior. The superficial and deep venous system of the leg was kept intact, and a significant amount of skin and lymphatics was able to be removed and debulked from this area. The required free ties were placed, and after perfect hemostasis was obtained, chromic suture was used in the depths of the wound to close off the deep layer. Chromic suture were also used in the deep and subdermal layer in interrupted fashion in hopes of causing some inflammatory changes and provide for closure of this area. Metallic staples were placed to re approximate the skin loosely with multiple areas of separation to allow for lymphatic egress. All soft tissue appeared to be pink, healthy and viable at the termination of procedure. A wound VAC was then applied to account for this lymphatic egress. This served as the only dressing required, but a circumferential Ace wrap was applied for gentle compression of the lower extremity. The pt tolerated the procedure well with an estimated intraoperative blood
loss of 100 mL. she was taken from the operating room, extubated in stable condition to the recovery room. She will be admitted for pain control and wound care.

Thanks in advance