Effectiveness of manual lymphatic drainage in intensive phase I therapy of breast cancer-related lymphedema-a retrospective analysis.

BACKGROUND: The standard therapy for lymphedema of any origin is complex physical decongestive therapy (CDT). It comprises manual lymph drainage (MLD), compression therapy (CT), exercise therapy (ET), skincare, and patient education. Additionally, intermittent pneumatic compression (IPC) can be applied. However, the contribution of MLD to decongestion is repeatedly questioned. PATIENTS AND METHODS: This study re-analyzes a previous study during a 3-week decongestion period, comparing two different types of compression bandaging at the weekend. Sixty-one patients with unilateral breast cancer-related lymphedema were included. The patients received the same therapy (CDT + IPC) except for the different weekend compression bandaging. MLD was performed twice a day on weekdays. The volume of the affected arm was measured on days 1, 5, 8, 12, 15, 19, and 22. For the analysis, the data of both study groups were pooled. RESULTS: During the week, the patients showed a significant volume reduction (- 155.23 mL (week 1), - 101.02 mL (week 2), - 61.69 mL (week 3), respectively; p < 0.001 each) with a high effect size. On the weekends without MLD, they showed a slight, but also significant increase (12.08 mL (weekend 1), 8.36 mL (weekend 2), 4.33 mL (weekend 3), respectively; p < 0.001 each) with a medium effect size. CONCLUSIONS: We showed a strong effect of MLD on volume reduction. Differences from other studies are the larger study population and the more intensive application of MLD. If applied intensively, MLD is strongly decongestive during a 3-week decongestion therapy for breast cancer-related lymphedema.

The history of anatomical research of lymphatics - From the ancient times to the end of the European Renaissance.

Very often, descriptions of the scientific discovery of the lymphatic system start with Gaspare Aselli, probably because of his so captivating account. Nevertheless, there was prior and even very old evidence of the lymphatic vessels, which was of course known to Aselli himself, as he cited most of these antique references. In fact, the first insights were contributed by the Hippocratic School. The Alexandrian School added quite a lot but unfortunately most of that knowledge is not extant and can only be appreciated by translations or citations by other authors such as Galen. The 'dark' middle ages did not add to the anatomical knowledge of the lymphatics, and only the rise of the Renaissance brought new insights. Even at that time, Aselli was not the first to identify at least some components of the lymphatic system, but he was actually the first to present a proper account in a book dedicated to the "lacteal veins". Afterwards the interest rose enormously and cumulated in one of the first priority - or plagiarism - disputes, the Rudbeck-Bartholin feud. Surprisingly, William Harvey, the discoverer of the systemic blood circulation, ignored, at least in part, the progress of the discoveries in lymphatic circulation. This narrative review tries to summarize the major contributions to the anatomical knowledge of the lymphatic system from the ancient times up to the end of the European Renaissance.

New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study.

AIMS: The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS: Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS: The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS: A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.

Segmental anatomy of the vastus lateralis: guidelines for muscle-sparing flap harvest.

BACKGROUND: The vastus lateralis muscle is a versatile donor site for pedicled and free flaps that, despite great potential, remains unpopular. Although the muscle is classically described as a single belly, evidence exists for a more complex morphology. The aim of this study was to investigate the segmental anatomy of the vastus lateralis muscle and the feasibility of selective flap harvest. METHODS: Ten cadaveric lower limbs were investigated. Muscular partitions were identified according to morphologic architecture, vascular supply, and nerve supply; guidelines for selective flap harvest were described. Twenty-three segmental vastus lateralis (n = 14) or chimeric anterolateral thigh-vastus lateralis flaps (n = 9) were raised based on neurovascular segmental supply, and used as noninnervated free flaps for reconstruction of moderate and large defects of the head and neck, trunk, or lower limbs. Intraoperative electrostimulation was used to confirm segmental innervation. Lower limb function was evaluated through the Lower Extremity Functional Scale. RESULTS: The authors clearly identified three anatomical partitions, which receive a constant segmental neurovascular supply, and two aponeuroses. The authors successfully applied the proposed guidelines for flap harvesting to all 23 patients. Intraoperative electrostimulation confirmed functional integrity of both the flap and the spared partitions. All muscle flaps survived. Donor-site morbidity was negligible, with comparable mean preoperative and postoperative Lower Extremity Functional Scale values (67.7 versus 67.4; p > 0.05). CONCLUSIONS: This study provides detailed knowledge on the morphologic and neurovascular anatomy of the vastus lateralis muscle, which supports the authors' guidelines for selective flap harvesting. The technique described is safe and minimizes surgical damage.