Okay, welcome everyone. My name is Vance Broach. I'm a gynecologic oncologist at Memorial Sloan Kettering Cancer Center in the U.S. And I'd like to welcome you to today's Surgical Film Festival on Radical Vulvectomy and Complex Reconstruction. We have an incredible panel of surgeons who will be sharing their expertise on vulvar surgery and reconstruction today, and we are thrilled to have you with us. Before we get started, I want to quickly go over a few logistical items. There's going to be ample time for discussion today, so we strongly encourage you to submit questions for our panelists through the Q&A feature of this webinar. We'll do our best to address as many of these questions as possible live, and we'll continue to answer questions virtually throughout the session. Also, a recording of this webinar will be available on the new IGCS Education 360 Learning Portal starting next week. If you haven't yet logged onto the portal, it's an incredible repository of resources and includes this and all of our past film festivals as well. Now it's my pleasure to introduce my co-moderators. First, Dr. Riton Ribeiro from the Erasto Gairdner Hospital in Brazil. Dr. Ribeiro has also served with me as the co-chair of the Surgical Education Work Group of the IGCS Education Committee. Riton, I'm so grateful to have worked with you, and I can't thank you enough for being such a wonderful colleague and friend. I also want to thank Dr. Rithu Solani, Paul Cohen, Mary Aiken, and all of the IGCS staff with whom I've worked in this role. It's been such a privilege to serve as chair, and I'm so grateful to all of you for your support and guidance and friendship. It's also my pleasure to introduce the other co-moderator today, Dr. Cary Longstrott from the Mayo Clinic in the United States. And I'm very proud to announce that Dr. Longstrott is the incoming co-chair of the Surgical Education Work Group. Thank you both so much for joining me. And now I'll turn it over to Dr. Ribeiro to introduce our speakers. Thank you, Dr. Broach. There's been a pleasure to work with you. So before we get started introducing our speaker, as some may know, Dr. Broach is rotating office chair, and we are welcoming Dr. Longstrott, so my co-chair. Dr. Broach, thank you so much for all your leadership and dedication as chair of the Surgical Education Work Group, and also as this committee for the past several years. You have provided excellent surgical education opportunities to all IGCS members. In your time as chair and your final festival today showcases, you represent all that. So thank you so much for all things you have done for us. Now, it's my honor to introduce today's speakers. Joining us are Louise Eva from the National Women's at Auckland City Hospital in New Zealand, Nadja Doerhofer from the University of Leipzig, Germany, Michelle Corridi and Vance Broach from the Memorial Sloan Country Cancer Center in the United States, and finally, V. Farhadian from the Memorial Clinic in the United States. Thank you all so much for providing us your expertise, knowledge, and being with us today. I will turn it over to Dr. Carrie Langstroth to introduce our first presentation. Thank you, Dr. Ribeiro. I'm looking forward to co-chairing this meeting with you in the future and continuing to work on the Surgical Education Work Group. Without further ado, I would like to kick off today's film festival and invite Dr. Louise Eva to present Volvo Reconstruction, Local Flap Reconstruction. Go ahead and share your slides. Thank you so much. Kia ora and good evening, and thanks for the invitation to speak today. So we're discussing Volvo resection and reconstruction, and the problem with this is that everyone is different. And we don't have a one size fits all. And what you need to cover a small defect after removing a small Volvo tumour is very different from that you would need to cover the defect that's left after an accident. And you don't need to cover the defect that's left after an extensive recurrence. But the surgical principles are the same. And today we're going to discuss about how the best way is to restore anatomy, potentially function, and to enable a tension-free closure to reduce the risk of wound breakdown, which as we know is high in these patients. So generally with simple resections, we can normally get away with a primary closure. If they're slightly bigger, then we may undermine the surrounding tissue to mobilise it to achieve a primary closure. But otherwise we're looking at either local or distant flap reconstruction. So today I'm going to show you some pictures of some local advancement flaps, and then some pictures and a video of a local rotational flap. So the most common advancement flap we use is a BY, and it's called a BY because you start off with a V-shaped flap that you raise. And then by the time you've closed it, you've got a Y defect. And so you would raise the flap and move it towards your defect, and then close the area that it has come from. And that's why it's called a BY. And these are versatile flaps that can be used in many situations. This is a perineal tumour that's been resected. And as you can see, the flap's already been raised from the right. And you can see it's marking out the left-hand side and the idea is to move the V-shaped tissue medially towards the midline to join the other one to cover the deflect. And as you can see in this side, the right side has already been sutured onto the vaginal edge and the superior edge. And then the left-sided flap has been raised and is being moved medially to join the other one. And so we would join point A to point A. And these are versatile flaps that can be used for any size defects, for either superficial or deep resections. And you can either bring them in from the thigh, down from the mons or up from the buttock as shown here. And you can see the scars from the previous resection and these were raised from the buttock and moved up to cover the perineum. So in terms of rotation, they're either simple rotational or raising a pedicle rhomboid flap. These are good to cover large defects, but they're also not used so often, but I find them very useful for covering smaller defects. I'm gonna show you some pictures of larger defects and a video of using a smaller perineal defect. So this was a woman who had multifocal cancers on a background of H-cell that previously been treated elsewhere unsuccessfully medically. And she had a skinning vulvectomy with a deeper resection around the perineal area. And what we then used was a primary closure at the front and then raised rhomboid flap at the back and rotated it immediately to cover the defects and rejoin to the surrounding anal tissue. So point A would move to point A and then you would move the flap medially. As you can see, point B moves to point C to B and point C moves to point C and you can see where they finish up in the final result. And this gives a good cosmetic result. This is what she looked like six weeks later. And you can use a combination of flaps. This was a skinning, more superficial resection where we use an advancement flap on the right and a rotational flap on the left. So I'm now gonna show a video of a rotational flap to cover a perineal defect. So this video shows a vulva resection and flap reconstruction. And this is a right posterior vulval cancer. As you can see, we're marking out the measured one to two centimeter margins and outlining the edges using diathermy. This is continued the whole way around the tumour. There's then resection continued using diathermy down to the deep fascia and haemostasis using with a sealing and cutting device. And the resection is continued down across the perineum and then over the anal sphincter. and the dissection continues down to obtain a deep margin bearing in mind that the rectum and the anal sphincter may be quite close so the specimen is removed and as you can see the anal sphincter is there and the rectum is there. Now we could just close it by bringing the vagina down but that would leave a deficient perineum and not be as cosmetically pleasing therefore we're going to mobilize from the right hand side. As you can see we're marking out the length that we need and then continue that line along and this is our incision line and we're going to mobilize the flap medially to cover the defect. Now we use sharp dissection so that we ensure that we have good blood supply, making sure that we're not undermining the edges of the tissue, keeping tension on the flap so that we mobilize it far enough that it reaches where we need it to go without excessive dissection. We then obtain haemostasis as you can see this is where the flap is going to go. It's important to get haemostasis because we don't want a haematoma developing under the flap and then the flap is secured in place by suturing the fascial layers together and you can see there's no tension on the flap which is what we're looking for. Now the patient's been put in an exaggerated lithotomy position so we know that if there's no tension in this position when the legs go down there would definitely be no tension and now we're ensuring that the deep layers are not going into the rectum and then securing the fascia of the flap to the fascia under the vagina and this moves the flap into place. We then suture the edges of the flap and the subcutaneous layer to the subcutaneous vaginal tissue and then continue to close the defect normally from the edges into the middle so that any dog ear will sit in the natural folds of the skin and we'll deal with that later. As you can see this is a subcuticular sutures where we bring the edges together one side then the other which closes it in a and then leaves us with the dog ear that's left. Now we can deal with this by putting scissors parallel to the skin edges and removing the dog ear so that the skin then lies flat in the natural crease of the skin fold at the outside of the labia and this is then closed with a subcutaneous stitch. So as you can see the flap now sits into place and we've restored the anatomy. We then close the corners of the edges of the flap to the native tissue using a triangular mattress stitch and here you can see it brings the vaginal edge down to close that triangular defect and then we'll do the same at the base of where we'd excise the dog ear so you go in out in out and back down again and then tie off and that will close the triangular defect of the three edges. So as you can see we've now restored the anatomy and then just close any remaining skin edges with a dissolvable monofilament to reduce the risk of infection and here we have a right rotational skin flap. Thank you. Excellent. Thank you so much Dr. Ava. That's a for a fantastic video and presentation and just a reminder to our participants or excuse me our people who are joining us and participating please submit your questions at the bottom of the screen and I just want to start off by thanking you. Most of us are doing this joining this on the 14th of September. You're doing this from the 15th of September very very early in the morning so very grateful for you to be here and to share your expertise. One question that I have to start off would be you know when you counsel patients when you meet them to what extent do you know in the office what flap you'll need or is that something that's done after the resection? That's a very good question actually I mean I think a lot I tend to overestimate the numbers that need them and quite often it's surprising when they're actually asleep how mobile the skin is but we certainly talk to most people particularly with perineal tumors about reconstructing the anatomy and that that may include a flap so we would certainly mention it to most people but I think probably there's a proportion that are expecting one and then we don't actually need to do one because we find the skin is sufficiently mobile. There's another question a couple of questions about what suture material you use is there you mentioned in the video monofilament absorbable is that something that you use your standard or are there other? Yeah certainly certainly for the skin we would use subcuticular monofilament so something like monocryl we have here and for the deeper layers we'd normally use vicryl but yeah it varies but that's the general view and if we can get away with subcuticular stitches for the skin we would do obviously in people have been previously irradiated or have got a higher risk of breakdown we may go with sort of interrupted but it really is sort of as I say a lot of this is individualized to patients and we sort of cover most things with them. Gotcha okay a couple more questions if that's okay one question a couple questions about blood supply do you use Doppler devices to locate blood vessels? Not for this sort of thing no for something like a Singapore flap or something that had got a specific blood supply then yes we'd mark out with a Doppler for that so if we're doing a pedicled flap we'd use a Doppler but for these the the blood supplies mainly through the perforators and so particularly if you've got the bit that you're moving inferiorly across the blood supply comes up from the bottom so you take the flap from the top and then you know that you won't have compromised your blood supply. Excellent and then another question about blood supply to the flap have you ever looked at near-infrared imaging as a way of evaluating for flat vascularity following your your flap? No I don't think we've actually got that here. Okay I know just to answer that question a little bit I know there's an ongoing prospective study that's open in a couple of locations looking at that not only in flaps but also in just wounds in general so it's a great question. Yeah I don't think it's reached New Zealand yet. Okay it's I you know it's not not ready for prime time certainly anywhere I think it's a more more in the theoretical stage so. All right so I think with that question we'll go ahead and move on to our next speaker. Thank you so much for an excellent talk and a wonderful wonderful discussion and so next I'd like to invite Dr. Dornhofer to present their film Bilateral Pudendal Thigh Flaps for Anatomic Reconstruction of the Vulva. Hello thank you very much for the invitation to present our reconstruction here today. My name is Nadja Dornhofer. I'm from Leipzig. I have nothing can you see my screen already? We can see it just needs to be in presenter mode. Yes now everything is fine I guess. Great so I'm from the Leipzig School of Radical Pediatric Surgery. I have nothing to disclose and this is the agenda for the next few minutes. First I would like to introduce a little bit our concept because it's a little bit different of the standard concept. Then I want to highlight that there are also strategies without anatomical reconstruction, primary wound closure and primary secondary wound healing and then I would like to show what we do for anatomical reconstruction and for local defects so not for very big defects only for local or smaller local defects and I will talk about a random skin flap and an axial pattern flap and I will have a video for the pudendal thigh flap. First and very briefly and this is our understanding of the anatomy of the vulva. You can see here this is the ontogenetic derived vulva so that is what belongs embryologically to the vulva and I show this because you see here that the outside of the outer labia so the labia mayora they do not belong to the embryonic embryological compartment of the vulva. We hypothesize and we do surgery like that for the cervical cancer and for vulva cancer as maybe some of you know we hypothesize the tumor cells migrate in the first early stages only within their embryologic compartment and so this is for the vulva. The screen compartment has three sub compartments and as for the first two tumor stages the tumor only also occult tumor cells stay within this embryologic compartment. We can always spare the outside of the labia mayora so when we do surgery like this we do not irradiate afterwards so we also have no compromises there regarding cosmetic results. This is our three-year survival results, five-year survival results. We have 100% in nodal negative patients of five-year overall survival and of course in nodal positive patients survival goes down. So there are different forms that you can use to dissect the or to resect the cancer so for bigger cancers of course you have to take the whole vulva field but depending on where the cancer is you can adjust and tailor the incision depending on tumor size and tumor localization and of course if it's here in the posterior commissura or the perineum you have a different way of reconstruct this defect afterwards than you would have for a defect in the upper vulva area. As I mentioned none of our patients is irradiated so there as I said you have no problems with vulva reconstruction. What did I mean when I say we also try to use other strategies of wound healing? Of course you can always for small cancers like this here you can make a dissection based on a vulva field resection for example and you can have a primary wound closure. This is a 90-year-old patient so she did not really care because she's a widow about intercourse anymore so this is not an aesthetic good result but it is at least functional so you can do pap smears and things like that without any problem but for a young patient of course this would not be an acceptable result. In young patients though if you have a very small cancer so this is only about one centimeter right up to the urethra you can do partial vulva field resections with after or it's a primary wound closure which also will give you very good cosmetic and functional results as you can see here but of course this is a small cancer so not comparable to the tumors I will show you later on so and what we also do sometimes is primary secondary healing what do we mean what do we we mean by that so this is a very small cancer as you can see and it was only PT1A so we did not do a radical surgery here we only excised the area in form of a posterior vulva field resection and then this was the defect right afterwards we left it open so and this was the result in three weeks after surgery and this is the result three months after surgery so with this as we call it primary secondary healing you can see that the normal skin is completely restored and so if we had closed this defect we would have had major scarring issues probably and maybe a narrowing of the introitus so we think in these cases primary secondary healing is also a way to go also here small cancer next to the urethra maybe eight millimeters we did then the lateral vulva field resection and this is the result and after primary secondary healing you can here you can see this is this is scar tissue and also here but there is no compromise in aesthetics or function of the vulva but as you can see here it's not always or actually it's rarely adequate to do a primary wound closure or do a primary secondary healing here these are patients that were referred after they had surgery obviously and here you can see what is the result after primary wound closure and here I mean intercourse is not possible and also regular pap smears and are not possible and also mitgen and can be difficult here this is also in our perspective not an aesthetic appropriate result also here this is not what should be left after a vulvar cancer surgery if not really absolutely necessary so for these cases as I said if primary wound closure or secondary healing is not appropriate we do anatomical reconstruction and the goal I will take this very short because it was said before is restore form and function we want to restore the labial folds with two adequately sized sensitive skin folds with sagittal symmetry because we think that's the most important aesthetic criteria of the vulva and it should be sufficiently wide and elastic again depending on how we have the position of the cancer we can decide which kind of dissection or resection we choose and once we choose what kind of resection we use we can use one of those four local flaps that we like and as you can see as we spare always the outside of the labia mayora we have this tissue that we can use for the reconstruction. I show you now my two favorite flaps it's one the pupal labial by VY advancement flap which I will show you in some pictures and afterwards the polyendothyte flap on the video so here is the what's quite a big cancer so we did a total vulvectomy or vulva field resection and this is the design of the flap so this is the flap basis and you can double this width to get the length of the flaps then you prepare everything down to the deep fascia as you can see here and also in the mons pubis you prepare everything down to the deep fascia and afterwards you can down you can shift the flap downwards as you can see here and then in you connect with sutures here at the end where the capillaries end we if we have enough tissue also minimize the length of the flap so we have no flap necrosis in this area then you rotate the flap inside and very important in our opinion is that you when you suture everything and you design the new vulva that you put a space holder in here so you are sure that the introitus is wide enough and that is the result right afterwards and this is the result after six months. So next is the pudendal thigh flap this is a patient that had obviously a recurrence you can see here the scar from the first surgery we removed the tumor in form of a vulva field resection and then we designed the pudendal thigh flaps as you can see here and then you can nicely rotate those flaps inside and with sutures design your new vulva again a space holder is in our opinion very important so you're sure that the introitus is wide enough at the end and this is the result and six months thereafter and this is what I prepared for you in a little video so I will start in the middle because we don't need to see the way of resection I guess so here's the defect now you make your flap design and you can design these flaps you can put them up front or you can put them more in the glottial fold depending on your defect so first you take your measurements we do that with a ruler to see how width or how the width should be from your flap and flap is getting its blood supply from the vasocudendal interna which go like this and then you have to measure the length of the flap and we like to do it with the with a suture you could also use a ruler but in our opinion this is a good way to really get the precise length you actually need now you rotate it and then you can mark your end of the flap so we for the skin incision we do we use the cold knife though probably electronic knife electric knife would also be possible because as I saw it in the video before we do also in the smaller defects we use the electric knife for the deeper tissues as you can see we use the monopolar and we go down to the deep fascia again here what you can see here and by the way is the outside of the dartos tissue the dartos tissue is the embryologic space that belongs to the labia majora and it's it defines in the medial line it defines the end of the vulva and also laterally defines the embryologic end or border of the vulva so we also like to use this sealing and cutting device as I also saw that others do and then now you take the fascia so you prepare also the fascia and also elevate the fascia because that is what is needed for the plant supply so now you can easily after you mobilized also this tissue over there you can easily rotate the two flaps then you connect it to the vagina use the donati technique for these Oh, and the good thing about these four flaps that we choose for reconstruction is that also the skin sensitivity is not too much disturbed because it's the same noble branches. So now what we knew, what I cut out is we also tried, before we did the wound closure, we also tried with a spacer whether the intruders is wide enough. So this is what we hope to achieve. We hope to achieve that with this anatomical reconstruction for the future and the more people are able and capable to do these procedures, the less patients we will have with this results and maybe with rather those results that are the common flaps that we use. And in the most of the times, complication rate is quite low. So we hope that the aesthetic function, the aesthetic and the function of the vulva afterwards is much better than after standard procedures. Thank you very much to my actual boss and to my former boss, which also conduct the Leipzig School of Radically Pelvic Surgery, where we also teach these flaps. And the next course is in October, the beginning of October in the first week, who is keen to visit us in Europe is very welcome to learn about vulva field resection and anatomical reconstruction. Thank you. Thank you, Dr. Doernhofer. Let's open up for discussion and initial question for you. Do you have any tips or tricks about wound care on this case of primary, secondary wound healing? Because are you afraid of more infections because it's so close to the anus? And do you have any specific orientation about local hygiene? And also how does it limit patient's life? I mean, functionally, can they have normal routines? How does it work? Yes, so actually we were really surprised when we tried this in our first patients with smaller defects, because the patients have no pain and they are not at all influenced in their daily life. What we recommend for wound care is that after, so several times a day, they should just shower with clean water and leave everything open. So that we recommend to do at least five to 10 times a day, whenever they were about, for example, at the toilet, they should afterwards shower. And we also recommend to use, and I know that sounds maybe not very familiar, but we encourage them to use iodine ointment because we have the experience that then we have nearly no local infection. And also the wound healing is not impaired at all. So showering and iodine ointment, that is what the patients do. And as I said, so we are always surprised even in bigger defects, if we choose this way, that the patient are not really compromised and have no pain. Of course, we discuss this in advance with them. So once we see the patient, we counsel them. So I show them pictures of all the procedures and I tell them, this is the potential flap that we might use, but if it's possible and it's a very small defect, we also discuss primary, secondary wound healing. So the patient knows in advance what is going to be expected. That's right. There are lots of questions regarding this local care. And I think you have covered these all. There is another question that according to literature, approximately 30 to 40 of flaps will have a breakdown. What precautions do you take interoperatively and postoperatively to prevent or minimize those risks for flaps? Yeah. So we think, again, reduction of bacteria in that area is very important. And therefore, again, we encourage patients to shower the wounds several times a day. We do wound care also through our nurses on the floor with disinfection and other irrigations, but nothing specific. If we have patients with high risk like diabetes or adipositas with high risk for wound breakdown, we also do annus preter sometimes for a few months or for a few weeks, let's say for six to eight weeks so that we have less of bacteria. Okay, that's good. And in which case do you use a urinary catheter or do you never? How does it work? How do you decide that? Yeah, that's a very good question. So we try to avoid urinary catheters because sometimes we noticed when we used it in earlier times that we strangulate the flap. So if the catheter runs over the flap, then sometimes the blood supply in the distance from the catheter is so low that the flap tips is getting necrotic. So that's why we do not use any urinary catheters and we encourage the patient to urinate as normal, which normally is not a problem. That's good. And regarding functional outcomes, do you see any difference from patients like a lipodendrolabial flap? Do you think sometimes when you have some traction towards the urethra, do you feel that those patients may have any difference in a functional outcome regarding urinary function? Yes, we have a few patients, but that's only one or two, I guess, that urinating is a little bit different in the way. So they say they urinate retrograde, but this is a little scar. And with one, we just remove the scar and fix it by that. And the other patient, she says she's fine with it now and it's not a big problem, but it's very rare. So last question, when you do a primary closure, how big the tumor can be? I know you use a different stating, it's staging, and we are talking about oncological cancer field surgery. So, but they usually, how big are those tumors? That I can tell because it absolutely depends on the anatomy of the patient. Because as you all know, we have patients that have very small labia majora, and we have patients that have quite big labia majora. And as we always spare, as it's a different embryologic compartment, as we always spare the outside of the labia majora, we can use this tissue. And there can be a big tumor, maybe two or three or four centimeters in a woman that has big labia majoras. Then you can use this for primary closure if it's mobilized enough. And you can have patients with small labia majora and a very small tumor, and it's not enough to do a primary closure. Then we do a VY advancement flap or something like that. So that is depending mainly on the relation between tumor size and anatomy. Okay, it was supposed to be the last question, but I think there is another one that's interesting because as you are doing cancer field surgery, maybe it's a little different than most people do. So when you have a tumor, which is very close to the urethra, do you do a partial resection? How do you measure safety margins? How do you work with that? Yeah, so I showed you the picture of the vulva with the three shades of green. That is the three sub-compartments of the vulva. And the urethra needs only to be resected if the inner compartment is involved. And if that is involved, we take the meatus urethrae. If the urethra herself is involved, then of course we also take the distant part of the urethra. And if you take up to two centimeters, there's not a big problem with incontinence afterwards. So one to two centimeters tolerated by the patients, but we only dissect or only resect the distal part of the urethra if the urethra itself is infiltrated. If it's only the inner compartment, we just take the meatus urethra and then patients have no problem. Yeah, that's interesting because it's a different concept. It's not exactly like how the length of the margin is just the compartment. That is very important. So the border of the embryologic defined compartment, the border is tumor suppressive. So for very, very, very long time, the tumor cells is not going to cross the border to the next embryologic compartment. Of course, at the end, once the malignant transformation is at the end, the tumor can go everywhere. That is no question. And we all have pictures of patients where the tumor got everywhere also on the outside of the labia majora, but for the first tumor stages and for a very long time, the tumor cells will stay within that compartment. So the resection margin is not important to us. R0, so a free margin is a free margin, whether it's one millimeter or three millimeter or five millimeter, if it's at the compartment border. So the compartment border, there doesn't matter, one millimeter or three millimeter or five millimeter, but you need to be at the compartment border. If you are within the compartment, because we not always dissect or resect the whole compartment, then if you stay within the compartment, then you'll have to have maybe a centimeter. But the compartment border is tumor suppressive. That's a great discussion. Unfortunately, we have to move on. In our hypothesis, of course, but ourselves speak for us. That's nice. So thank you so much. Next, I'm pleased to welcome Dr. Michele Corrigi presenting vulvar reconstruction following resection. Dr. Corrigi, please go ahead. Thanks for the introduction and thanks for having me. It's my pleasure to work with Dr. Broach and I'm happy to be able to share our experience. This is really more gonna be on actual vaginal reconstruction because a few of the other topics have focused on vulvar reconstruction. So in the setting of vaginal reconstruction, there's really a few goals. The first is to obliterate the dead space created by the surgery, usually after an APR or something similar. Second is to close the skin defect with healthy tissue, especially if the patient's been previously radiated. And then in a lot of cases, either a partial, usually the posterior or total vaginal reconstruction. And one thing to always mention to patients when they are coming for their preoperative counseling is that whatever skin that I'm using to reconstruct the vagina will be insensate, but can be used for intercourse in the future. So the main flaps for this surgery is the, we call it VRAM. So that's abdominal-based vertical rectus abdominis myocutaneous flap, stands for VRAM. If for some reason the VRAM cannot be used, the secondary flaps for this surgery would be a thigh-based flap, the gracilis or the profunda artery perforator flap. A flap that we also use frequently in the surgery is the omentum flap. And that's usually harvested when we're also doing abdominally-based flaps, mostly to obliterate dead space. And then the VRAM is used for the actual vaginal reconstruction. So this is just a sort of schematic showing the VRAM itself. So the blood supply is coming from the deep inferior epigastric artery and vein going into the rectus muscle. So the first thing we do when we come and do the procedure, usually there's a midline laparotomy incision, is feel sort of on the undersurface of the rectus muscle to make sure that you can actually palpate the deep inferior epigastric artery and vein and make sure that they're still in continuity after the resection. And then make the markings on the skin directly over the rectus muscle. And in patients that have midline diastasis, you have to make sure that your markings are wide enough or lateral enough to ensure that your skin markings are directly over the rectus muscle. And then during the surgery, basically this rectus muscle is harvested in block with the subcutaneous tissue in the skin over top of it, along with the anterior abdominal fascia that's sort of sandwiched between the rectus muscle and the skin component. That gets lifted off the posterior abdominal fascia, which remains, and then it gets tunneled into the abdomen. Here on the right side is the gracilis flap, which is sort of the secondary option, in my opinion, because when you rotate the gracilis muscle with the skin over top of it, it tends to create somewhat of a bulge on the inner thighs. And occasionally the distal part of the gracilis, which ends up being sort of the distal part of the vaginal reconstruction, doesn't have a great blood supply. As opposed to the VRAM, you can make a very long flap. So here is a video of a VRAM flap that's been raised. And this is for post-treatment vaginal reconstruction. So just what we can see here is the midline laparotomy incision. This is the skin subcutaneous tissue over top of the muscle. And I'll play the video here. So this is the flap fully dissected. You can see on the undersurface is the rectus muscle, which we take the entire rectus muscle. What I'm pointing out here is the pedicle to the flap that is pulsating. Then we take the entire piece, rotate it 180 degrees down into the pelvis, and then you have a partner down in the pelvis, pulling it out through the vaginal defect and into the perineum. And you can see that piece of skin will now be sutured in to recreate the vagina. And then for the abdominal closure, the posterior abdominal fascia there, as long as with the anterior abdominal fascia are closed together. So occasionally in these cases, you actually do need to perform a component separation on that side to be able to advance the anterior abdominal fascia to midline. I maybe have to do that about 10 or 15% of the time. Here's a case of a total vaginal reconstruction with a VRAM and also the omentum, as I mentioned for dead space obliteration. So you can see the omentum is fully dissected here. The center picture is showing our skin markings for our planned flap, which you have to make wide enough to tube. So this was a 10 centimeter wide flap in terms of the skin. And again, this was raised with full thickness skin, subcutaneous tissue, anterior abdominal fascia and the entire muscle. This is the flap after it's been dissected and tubed on itself. And then the inset, and that's sort of the intra-abdominal view that you can see here. And this is the view from the perineum. You can see this is the tubed VRAM that's been inset and a wide enough vaginal opening. This patient will likely still have to do dilations and things like that in the future, but we sort of make sure that it's wide enough to be able to close the abdomen skin and for her to be able to have a use of this in the future. The other thing to note, and I'll go back to this slide, is the importance of using the spy. We use the spy quite frequently after we're done with our dissection, sort of at this stage before we do the inset to make sure that the entire flap is perfused and trim any sections that are not perfused as that's going to contribute to wound healing problems. For postoperative instructions, usually I have these patients restricted from sitting at greater than 45 degrees for about three to six weeks to take any pressure off the flap, but they are allowed to ambulate. They can recline in a chair and then I allow them to start intercourse with dilation in about three months' time. And that's all I have. Thank you for having me. Thanks so much for a really outstanding talk and so grateful to have you as a colleague. A question that came in from the chat is, do you ever consider a sigmoid neovagina or a bowel interposition for vaginal reconstruction? And if so, when? I, in my experience, have not performed that procedure. I think, you know, that would be a patient who, for whatever reason, you can't perform an abdominal flap or a thigh-based flap, then we'd sort of revert to that option. Gotcha. And so when you're making a decision or counseling a patient regarding an abdominal-based flap or a thigh-based flap, what are some of the things that you consider? Is it just the size of the defect or the intended postoperative function? Can you help us with that? Sure. My go-to is basically always an abdominal-based flap because I think in most patients, even if it needs to be a total vaginal reconstruction and it needs to be a wide flap, you can still recruit skin, you know, laterally or from the other side. And that's actually something to mention too, because sometimes the stoma needs to be created after you're sort of stapling the skin closed to make sure that when you're recruiting that skin from the contralateral side, that the stoma ends up still in an appropriate position. And then in terms of the fascial closure, like I said, a component separation really allows you to bring, even if you're taking the entire anterior abdominal fascia over the rectus muscle, you can still usually recruit the contralateral side and doing a component separation, you can close the fascia. So I would say basically in 90% of patients, I would do an abdominal-based flap. If for some reason you can't, for whatever reason the rectus muscle on that side is not working or they've had previous surgeries or for whatever reason, then I revert to a thigh-based flap, usually the gracilis flaps. I don't prefer that flap because like I mentioned, sometimes when you do the rotation, depending on the thickness of their subcutaneous tissue, they can end up with sort of a bulge on the upper inner thigh that patients don't love. And sometimes the distal tip of the gracilis doesn't have the best perfusion. So the actual vagina ends up being a bit shortened, but that's really my go-to is the abdomen, unless for some reason I can't use it. Yeah, and you brought up the point about diversions, which are always things that we think about. And I think that's sometimes when people have a V-rim, sometimes limits the ability to make a diversion. If for whatever reason, one of the stomas had to be on the right side, is that something that would change your approach to maybe a more of a vaginal approach or is that something that wouldn't? No, we still, the stoma then usually just goes out of the oblique instead of, it just is a little bit more lateral. And again, I think it would be important to basically get a sense of where the midline fascia is gonna be closed before the stoma gets placed through the oblique on that side. Gotcha. Okay, great. Well, thank you so much for an outstanding talk. I really appreciate it. Thank you. So I am actually going to be our next presenter and I'm gonna be presenting on vulvar central lymph node mapping and biopsy and one of femoral central lymph node mapping and biopsy. Let me share my screen here. All right, so this talk is about inguinephemeral sentinel lymph node mapping and biopsy. And traditionally, when we thought about assessing the lymph nodes in patients with vulvar cancers, patients had full inguinephemeral lymph node dissections. The problem with this is that it's often associated with pretty significant morbidity, wound breakdown, infection, and long-term complications with lymphedema. And so the notion of sentinel node biopsy for vulvar cancer has been well-studied and its efficacy and oncologic safety has been demonstrated in a few prospective randomized studies, GRG173 and the Groin's V study. And now it's really become our standard practice when assessing inappropriate patients with vulvar cancer. Traditionally, we've mapped the sentinel nodes using a combination of blue dye and radionuclide lymphocentigraphy with technetium-99. But this can be cumbersome and challenging to patients. They have to get multiple injections. And so the use of near-infrared imaging and indesigning green has become much more popular. We actually looked at our own experience at MSK and published this in 2019 in the International Journal, evaluating how we identify lymph nodes in patients with vulvar cancers. And we saw that during this 19-year period, all these different modalities were used and different combinations of these different modalities were used, we started introducing near-infrared imaging and IC-Green in 2012. And when we look at the efficacy of identifying the sentinel lymph node in these patients, what we've found is that the most efficacious way of identifying these nodes is with a combination of technetium-99 and IC-Green, and that technetium-99 and blue dye identifies nodes maybe about 92% of the time. We have, in some patients, looked at IC-Green alone, and that seems to be quite effective as well, about 96% identification of nodes in that setting. This graph that's gonna show in a second is demonstrating the utilization of different detection modalities over this time, from 2000 to 2019. And since we started introducing IC-Green in 2012, it's really gained popularity quite quickly. That's seen in the green line. The blue line, which demonstrates blue dye, has dropped off precipitously, and it's only used in about 15% of cases. And the dip in the red line, which indicates lymphocentigraphy, is using IC-Green alone. So in this talk, I'm gonna review the selection criteria for eligible patients for sentinel lymph node mapping in vulvar cancer. I'll demonstrate the injection technique with IC-Green for sentinel node mapping, and demonstrate the use of IC-Green in near-infrared imaging for SLN detection. I'm gonna show two cases. This first one is a patient with squamous cell carcinoma, about a two-centimeter lesion, just left of the midline. And the second is this patient with a bit larger tumor that's eroding the right labia minora, about four centimeters anterior, and again, midline. Both of these would be appropriate patients for sentinel node mapping, as they have unifocal primary vulvar tumors. The tumor size is less than or equal to four centimeters. Neither of them had suspicious nodes on exam or on imaging. And both of them would require bilateral mapping as the lesions were less than or equal to two centers from midline. So again, just demonstrating this, about two centimeter lesion left of midline, but still within proximity to the midline, warranting bilateral mapping. In the first case, and again, in the second case, anterior lesion, certainly crossing midline, four centimeters in size. When performing immunofemoral sentinel lymph node mapping, it's important to select the use of either Blue Dye or IC-Green plus Technetium 99. Either of the colored dyes alone has never been proven to be an effective substitute for Technetium 99. In the original prospective studies, lymphocytography was added due to the failure of the Blue Dye alone. So it's important to do that in conjunction. IC-Green is distributed as a powder, and it's reconstituted into sterile saline for injection. And it's ideal for this because it has a spectral absorption at about 800 nanometers, which is present in the near-infrared range, and so it's visible with a near-infrared light source and camera. This is a schematic demonstrating the sites for injection of IC-Green. This is consistent with NCCN guidelines. The peripheral injection in a few three to four sites, one to two milliliters each of the IC-Green solution is recommended and preferred to ensure adequate uptake into the lymphatics. So here we're performing the injection in the first patient. This, again, is using IC-Green. The idea is to get that little dermal wheel. That's really the best spot for lymphatic uptake of the IC-Green. You can see we're injecting peripherally here, the leading edge of the tumor bilaterally, and then a little bit more posterior to ensure adequate uptake into the lymphatics. And then again, we're doing this on the other patient, again, at the leading edges, and then a bit more posteriorly. Most common site for the sentinel node in these patients is the superficial anguinal nodes that are medial to the vessels. There are superficial nodes that are lateral to the vessels, and that's a much less common mapping site. So the primary mapping site would be the superficial. So the next thing would be to choose your near-infrared light sourcing camera. This is sort of the original model that we used with a near-infrared light source on the left there, and then a display that is sort of on that screen there, and this can overhang the patient. It's a bit cumbersome, and more contemporarily, we use the handheld near-infrared light sourcing camera, which allows, it's a little bit easier to use in the operating room, and we can show the images on the screens that are in the OR, the laparoscopic screens, and so that's us using it there and just confirming adequate injection. This has the laser and the near-infrared light sourcing camera built into that one piece there. We also confirm the location of the nodes with a gamma counter that displays the technetium-99, and so we oftentimes will use this to help localize the area of the node preoperatively so we can ideally locate the area where the incision will be. That's done on both sides, and so the gamma counter and the near-infrared light sourcing camera are used to localize, and the first thing we typically do, we'll just use that camera to make sure that there's adequate uptake of the icy green, and oftentimes, as you can see here, you can see the lymphatics in the groins, and that also helps localize the incision, make sure we're putting it right in the right spot and minimizes the extent and the size of the incision that we need to make, and that's shown there on the right. When you're visualizing these things, there's three different modes in the near-infrared light source imaging. There's the overlay mode, which is the green mode. Then there's the spy mode, which is the black and white that you were seeing there, and then there's color-segmented fluorescence, which where red colors indicate greater uptake. Here, we're just confirming, again, the node with the gamma counter and making the incisions on the patient's left side. So we use the gamma counter, and then again, we can use the near-infrared imaging. You can see the lymphatic channels there with the near-infrared imaging, knowing that we're there. And again, this would demonstrate the spy mode, dark background, white lights, probably the best contrast. This is the color-segmented fluorescence mode. Both of these can be used in addition to the overlay mode, where we see the uptake as green. And in this module, there is a laser that shows the area of focus. So as we get closer to the node, dissecting the FAT away, the color set or the spy mode really shows that node quite well. And this is nice because you can do this in real time. You can see your hand in relationship to the instruments and the node, and we can find that node and remove it. Check at ex vivo for uptake of the technetium-99. Check the bed for any residual technetium-99. Now, this is just demonstrating it again with that handheld module. So the same deal, we check the uptake to begin with to see if we can see the lymphatic uptake and better localize the incision that we're going to make. We mark the incision site and then make it about two, three centimeters for the incision is the ideal. Obviously it can be extended if we miss or if we make a mistake, but ideally that's the size of the incision that we would need. And then we dissect around the node. And utilize the camera intermittently to make sure we're in the right spot. So again, this is with the spy mode, looking at the lymphatics and the node that you can kind of see right underneath there is probably a layer of fat just overlying that. And we can see that in real time, which is quite helpful. So there it is displayed on the camera. So then once we've localized the node and we remove it, and, you know, we can check to make sure that we've gotten the node and there's no more proximal nodes or other areas, you can see it actually right there visually. And now with the node very well dissected, you can see even with the overlay mode really beautiful uptake of the icy green and it's very clear that that's, that's the node that we're looking for. And, and then it's removed. Great, I look back at the camera like an idiot, and then, and then now the nodes are moved, and we, you know, again we'll check this ex vivo to make sure that we have adequate uptake and we also check proximally to make sure that there were no more proximal nodes this node is as common as in the, as in the proximal superficial chain. And that's just checking the node ex vivo and we can see it beautifully and there's no residual icy green in the dissection bed. And that's that. Awesome. It's a wonderful presentation. So thank you so much, Dr. Birch. That's up and up for discussion with the attendees, and I have a question is, it's a little bit different from endometrial cancer once you can evaluate other lymph nodes, when you are doing a power of lymphadenectomy, right, and look for suspicious nodes, so you can follow the memorial monogram and here, you go straight to the lymph node because you have an incision that limitates you, right. So do you think it's an issue, do you think you have to have different, take care of different situations so you may not lose any positive lymph nodes? Yeah, it's a, it's a, it's a really great question. And that's definitely something that we think about anytime we're doing this. It's, it's very important that, you know, the, the node is the most proximal node. I think it's easy sometimes, particularly if the, if the dye has sat in the, in the dissection area for long enough, you start picking up nodes that are, are, are distal to the, to the real sentinel node. And you miss, you know, a metastasis. So that's why I say, you know, it's really important to know the lymphatic drainage. It's almost always the proximal superficial nodes, the nodes that are medial to the vessels, not the nodes that are lateral to the vessels. And sometimes it's the deep nodes as well. And so after it's removed, if you, if you've removed the superficial nodes that are medial to the vessels, it's almost always possible to see any icy green that might be in the deep nodes. And you can be pretty certain that if you don't see any node, any, any icy green in that area, that you don't have a more proximal deep node, but you know, the, the drainage from the vulva is a bit variable as you, as you pointed out. And so, you know, it's really important that none of the more proximal nodes, which may in fact be the sentinel are missed. Now there's great data from, you know, both prospective studies and, you know, and looking at a retrospective experience that, you know, this is a very effective way of identifying these nodes and oncologic outcomes are quite good. But you know, that's only if you do the, if the technique's done properly. And the, you know, the other thing that I think people think about from time to time is freezing these nodes to see for occult metastases, which might indicate the need for a full inguinal femoral lymphadenectomy. It's hard because freezing a node, you know, you really get one, maybe two sections through that node and you know, that you could easily miss a two millimeter or bigger metastasis with a frozen. And so I typically don't freeze these nodes. I counsel patients that we wait for final pathology and that there's a chance that we need to go back and do a full inguinal femoral lymph node dissection. The other value of doing that is that if, if we need to do a full node dissection, we can have some of our colleagues, our plastic surgery colleagues consider immediate lymphatic reconstruction, which I know we're going to hear about in a minute. And that, you know, allows to us to both remove all those nodes, but also minimize the potential for post-op complications. It's hard to keep, you know, our plastic surgery colleagues on standby for that, you know, without preparing for that. And that's just a lot for one day. So that's more than you asked, but hopefully that answers that question. Actually, there was a question about frozen section, so you have to answer it. So that's good. And there's also a question about, do you always use technetium with ICG or do you feel you can move and use just ICG, how do you feel it? My personal feeling is that the technetium doesn't add a whole lot and that in the future we will use ICG alone. That sort of was shown in our retrospective data. In order to prove that, we do have a prospective study at MSK evaluating this and where patients get both, you're blinded to the results of the technetium 99, you find the node with ICG alone, and then evaluate the bed as well as the node to see if there's any uptake to see if we missed it. Hopefully that'll put this to rest once and for all. And it's certainly not the wrong thing to do to use technetium 99, but it is cumbersome. Patients have to get two injections, the NUCMAT injection for which they're not under general anesthesia, which is uncomfortable and it extends the day to a full day for something that can be done in five minutes in the operating room. And it's expensive. So to be able to use one detection methodology is really, would be really great. And I do think that the green dye has a huge benefit over blue dye alone. And so if any modality is going to eliminate the need for near-infrared imaging, or excuse me, for lymphocentigraphy, it'd be ICG. Yeah, that's good. There is, this one is asked, can you repeat how do you do your dilution of the ICG just to make sure everybody got it? Because that's a very common question. Yeah, it's the same way we do it for cervix or for endometrial. And honestly, the way I do it is make sure that the nurses that I'm working with know how to do it so that I don't mess it up. But I believe it's one milligram of IC green to two milliliters of sterile saline. And then that's the solution. Okay, so a final question is, what's your opinion about video endoscoping in a lymphadenectomy in the context of send-down lymphoid dissection? I mean, the incision is so small to begin with. It's such a minimally invasive procedure to begin with. I'm not sure that the endoscopy adds a great deal. I think if you're thinking about doing a full lymphadenectomy, then that does add quite a bit. And I've seen people do it. And it's really a remarkable thing and quite small incisions to get the instruments in there and to open that space is pretty impressive. But for SLN detection, I'm not sure that it's adding much in terms of post-surgical recovery. And it's certainly more challenging. In terms of timing, it takes maybe 10 minutes per groin to do SLN. And again, that might add a little bit of overtime with the endoscopy. I think with any surgical technique, whatever you're most facile, whatever you feel like you can do and get the best outcomes for your patients is reasonable. And so I don't know that I would personally adopt that, but I think if people are very skilled endoscopists and that is the easiest way for them to do this, then that's great. The one advantage that I can see that I think we don't really get with the traditional way of doing the sentinel node is that when you're remote from that, you can see the channels coming from the vulva probably clearer than you can when you just cut down and you find the node. Sometimes we just feel like we're digging in fat and then all of a sudden we see a node and you just pray that it's not on top of the vessels and you have it out and you realize how close you were and it's just terrifying. And so to see that lymphatic vasculature, to see that anatomy, I do think is probably easier with the endoscopic approach. Great. Thank you, Dr. Brodsch. And now I would like to invite our final presentation. That will be Dr. Vehi Farhadian presenting lymphovenous bypass to reduce low extremity lymphedema. Dr. Farhadian, please go ahead. Dr. Farhadin, can you hear me? Hi, everyone. I can hear you. I can't. I'm just trying to share my... Okay. Perfect. So, hi, everybody. Thanks for the invitation. So, one week ago, we were doing the lymphomaniac bypass surgery for upper extremity lymphedema. And after spending about seven to eight hours on a microscope, my resident asked, are we able to do this just using 2.5 loops? And I've been thinking about that question. And I was trying to decide if there are any shortcuts for this procedure. And just to give you a perspective, here we can see a picture from the microscope. The yellow background, the small square in the yellow background is just one millimeter. And the suture that we are using is the 12-foot suture, which is about more than 12 times thinner than the regular hair. So, I have no disclosures. And lymphedema is a chronic debilitating disease, which affects approximately 2 million people worldwide. And it is characterized by progressive swelling, ulcerative fibrosis, and abnormal deposition of adipose tissue. And recent advances in microsurgery and other modalities of lymphedema surgery changed the treatment paradigm of lymphedema disease, switching the concept that conservative treatment is the first-line treatment for the lymphedema, and surgery is only secondary. So, when we think about the surgical treatment of lymphedema, I think we have to have this approach that the key factor for the successful surgery is going to be doing the right procedure for the right patient. And in order to choose the right procedure, I use this algorithm of patient selection. So, when I see my patients, the first question that comes to my mind is, is this lymphedema a fluid-predominant lymphedema or is it already a solid-predominant lymphedema? And to answer these questions, we can do several examinations, starting with a physical exam and getting a good history, trying to understand if the patient is responding to complex decongestive therapy. And we also can do bi-impanded spectroscopy, which allows us to determine the excessive extracellular fluid in the extremities. And we also can do MRI, which can allow us to see the excessive lipodystrophy. So, once we answer this question, if it's a fluid-dominant or solid-dominant disease, then next is to do the ICG lymphography for me and to understand what is the extent of lymphatic injury. So, this can help me to confirm the diagnosis and it also can help stratify the disease severity. And based on this, we can choose what type of procedure to do. So, if the patient is in fluid-predominant state, we have two types of procedures, physiologic procedures for the surgery. One is lymphovenous bypass surgery and the other is lymph node transfer or lymph vessel transfer surgery. And ICG lymphography becomes handy to decide which procedure we should do for this patient. So, if we just try to put black and white lines, then if the patient has any linear ICG pattern during the ICG lymphography, then the patient should be qualified for lymphovenous bypass procedure. And if the patient demonstrates splash, stardust, or diffuse backflow patterns, then we should consider doing lymph node transfer procedure. So, this is a demonstration of fluid-dominant and solid-predominant disease. On the left, we can see a very advanced lymphedema, but however, there is no pitting at all during physical examination. And these patients typically do not respond to completely congestive therapy and there is no reduction of the volume after treatment. While on the right side, we can see that there is, again, significant swelling, however, there is also plus three pitting, which tells us that the patient is in a more slightly fluid-predominant state. So, when we do the ICG lymphography, we can appreciate different patterns. So, from left to right, disease gets worse, and typically, there is also correlation between the backflow patterns and the quality of the lymphatic vessels of that arm. So, when we see splash, stardust patterns, most likely the collecting lymphatic vessels are going to be either contracted or sclerotic. And when we do the ICG lymphography, it is important to do both immediate scan and also what we call delayed scan. And there is no standardized technique for this, but studies have shown that by at least waiting six hours, it should be enough to demonstrate the plateau phase. And what I mean by this, on the left side, we can see the immediate scan. And on this patient, for one extremity, there is a linear pattern. On the other extremity, there is just some splash and stardust pattern close to the injection site. However, after waiting for six hours, we are able to demonstrate that the left lower extremity is completely covered by stardust pattern. And on the right lower extremity as well, there is a stardust pattern on the most proximal part. So, this patient initially presented to us and complained only from lymphedema of the left lower extremity. However, ICG lymphography is able to demonstrate that the patient has also lymphatic injury on the right lower extremity as well and should get a surgery for it. So, next comes choosing the procedure. And as we mentioned, lymphobinus bypass surgery is now considered super microsurgery. And why we say super microsurgery? Because the size of the vessels are very small. Typically, they are between 0.2 to 0.8 millimeters. And we use superfine instruments for this. And the tip of the instruments, the forceps, are 0.05 to 0.1 millimeter. And they are very gentle and very easily damaged, unfortunately, and quite expensive. So, then once we make this incision and we find the lymphatic vessels and small venules, we can utilize different types of anastomosis. And the key factor to deciding what type of anastomosis we should do is trying to make a connection in a way that there won't be any backflow of the blood. So, preventing blood reflux into the lymph vessel is important for making sure that this anastomosis is going to work in the future. And here we can see on the left upper angle, this green ruler, it actually shows the 0.2 millimeter, 0.3 millimeter sizes. So, the lymphatic vessel over in this picture has 0.3 millimeter size. And there is a demonstration of different types of anastomosis starting to end to site, end to end into susception, otherwise known as octopus technique, and to site to end into susception as well. And interestingly, sometimes we can see the results even right on the table by the end of the surgery. Here is the case. So, we did the, this is just intraoperative imaging with ICG, lymphatic mapping, and then venous mapping. And this is at the end of the surgery, and we can already visually see that the lower extremity lost some volume. So, this is a case of right lower extremity lymphedema. And the patient has a history of prostatectomy, right internal lymphadenectomy, radiation therapy, immunotherapy. And the patient presented with complaining right lower extremity lymphedema. So, next we did the physical exam. And we had a fluid dominant disease, and we moved forward with ICG lymphography. And again, the immediate scan shows linear patterns on both lower extremities, but delayed scan shows that the right lower extremity linear patterns are already covered with the stardust superficial pattern. And there is an abnormal dermal backflow on the left lower extremity as well. So, demonstrating that the patient has abnormal lymphatic flow on the left side. And he also had a penile lymphedema. So, in addition to ICG lymphography and mapping, currently at Mayo Clinic we also do contrast enhanced ultrasonography to map the lymphatic vessels. And we inject a special dye, a special contrast, and this is my partner, Dr. Kristen Lee, doing the ultrasound. Here we can see and appreciate the contrast being uptaken by the lymphatic vessels. So, we are evaluating this as an alternative for the ICG lymphography for the patients who are not able to tolerate iodine based contrast. And also, this can help us to bypass a couple of limitations that ICG lymphography has, such as inability to penetrate more than two centimeters of the depth. And also, ultrasonography helps with more accurate identification of veins. So, next I'm going to inject the ICG dye and perform mapping. You can see on the screen with a green marker, I'm just going to follow the linear pattern. After this, we will use infrared vein finder to mark the superficial veins. On the left side, we have the lymphatic mapping and vein mapping using only contrast-enhanced ultrasonography. On the right side, we also have the ionocyanidin-green lymphography and infrared vein mapper. So we can appreciate that most of the lymphatic vessels that we were able to detect by ionocyanidin-green lymphography, we were able to see also with ultrasound. However, in this proximal leg, there are some vessels that we were able to detect with ultrasound. However, we were not able to see with ionocyanidin-green mapping. And the reason was that this area was already covered by superficial dermal backflow. So, and then we based our incisions. This is a demonstration of lymphatic vessel, how the ectatic lymphatic vessel has the pumping function and actively draining lymph fluid. So when we do the lymphovenous bypass connections, it is very important to choose a functioning or ectatic lymph vessel that is full with lymph fluid and properly drained at extremity. And here, we did some antisite anastomosis and antisite intersection. And we also confirmed the patency of anastomosis using the infrared camera. So for this patient, I ended up doing six incisions and within these six incisions, we did nine lymphovenous anastomosis. And this is the pre-op picture followed with post-op day three and post-op one month. There was a 35% volume reduction for this patient. And I think from the images, you can appreciate that post-op day three leg looks better than the rest. And this is important because in our recovery period, we recommend our patients to keep the compression dressings for almost 24 seven. And this actively decongest is the lymph. And however, in post-op one month, this patient is already went to his normal lifestyle using his old press surgical compression stockings. And even with that, the patient reports a significant improvement in symptoms. He reported that there is less heaviness of the legs. And he noticed that when he does the compression, he doesn't have to spend as much of time as he used to. And the leg decompresses very easily and responds to treatment quickly. And this is another case. Again, the patient presented with left lower extremity lymphedema, history of hysterectomy, bilateral lymphadenectomy with radiation. There was significant pitting in this case as well. So we moved with ICG lymphography. And again, there was a demonstration of some linear pattern on the left side. It's unfortunately not visible. And also in a delayed scan, we were able to see the problems on the right lower extremity as well. So this is the preoperative markings again with ICG mapping, vein mapping, and strategic incision markings. We ended up doing six incisions on this patient. And within the six incisions, 14 lymphobinosomatosomosis. And those are pre-op post-op one month and post-op three month pictures. And again, we can appreciate that when the patients are during their immediate recovery period, there is a significant volume reduction because compression plus surgery always works better than either surgery alone or compression alone. And this patient is very happy with the outcome. When she saw us back in November, her activity was very limited. And this picture post-op for three months was taken during the summer. And she's teaching, giving swimming lessons and very active. She limited the use of compression dressings. And with all of this, she still reports significant improvement in symptoms, subjective symptoms. And she spends less time during the day for managing the lymphedema. So in a conclusion, the teamwork is very important for a successful surgery. And it involves the patient to be compliant with the conservative management. We need to have a good lymphedema therapist on board and obviously the surgeon. So the answer to the question of my resident, if the surgeries are doable with LOOP, I don't think we can do any bypasses for this procedure. You really need to have the instruments. You really need to be trained to do the super microsurgery. And you need to use the microscope by like 20 or even higher magnification. And early surgical intervention is the key to reverse the pathophysiology of this disease. Thank you very much. Thank you so much, Dr. Faradian. And just one question I have for you is let's say, you know, we've tried to coordinate these surgeries before and it's sometimes it ends up being quite a long day or you're on standby for something that may or may not happen. You know, if we are unable to coordinate this at the time of lymphadenectomy, would you follow these patients or would you recommend intervention sort of prophylactically before they have symptoms? Well, I think I do the studies for the immediate, I think you're referring to immediate lymphatic reconstruction and this presentation was for the treatment, therapeutic lymphatic reconstruction. So there are studies that already have proven that the immediate lymphatic reconstruction is useful and without reconstruction, the report of the incidence of lymphedema can be from 25 to up to 70% based on what type of additional therapies have been done. With immediate reconstruction, the incidence goes as low as up to 10%. And there are two approaches. The most common approach now is to do the immediate lymphatic reconstruction right after lymphadenectomy during the same surgery. But as you mentioned, sometimes it's difficult to organize. So I think bringing the patient back and doing within the first month lymphovenous bypass is another approach. And some of the, my mentor, Dr. Wei Chen from Cleveland Clinic, he used to do this, but the challenge is also sometimes you lose the patients during the follow-up period and scheduling immediately another surgery when they underwent one big surgery already can be quite challenging. So there is an alternative, but I think logistics are difficult. Great. And then Arun, do you have any hints for those of us that do lymphadenectomies that could be, that we could use interoperatively to decrease the risk of lymphedema or anything we could do postoperatively that could be used to reduce that risk? I think the presentation that was just before me just gave a good presentation about the hints, how we can decrease the risk of the lymphedema and doing the central lymph node biopsy with reverse mapping. Those are all the keys and preserving the lymph nodes that are going to drain the lower extremity. Those are very important key factors to reduce the risk of the lymphedema. And I think the postoperatively following, setting up a monitoring system with a lymphedema clinic, and also to do ICG lymphography during the recovery time is also can be another monitoring system to catch the disease early on and intervene while we have the healthy lymphatic vessels to do the connections so the patients can benefit. Great. And, and I'm not aware, but are you aware of any data that was just monopolar, bipolar, or, or CLPS would be better than the other for preventing this? Uh, I'm not aware, to be honest, uh, about this. I, if, um, surgical, uh, if, um, thermal injury, uh, has, um, during the dissection, uh, what's the effect of it? Great. Well, thank you so much for your, um, awesome talk today. And, and I want to, I think that's about all we have time for today. Um, thank you. I want to thank everybody for attending this session. And I would especially like to thank all of our experts, uh, presenters. Uh, and I'd like to thank my co-moderators. And I'd also like to say a special thanks to Dr. Broach for his leadership, uh, for the last year as he was the film, the film festival chair, and this is his final film festival. Thank you for your volunteer service and, uh, for providing, top-notch surgical education at IGCS. Uh, the recording for today's session will be available on the new IGCS Education 360 Learning Portal. Uh, you should receive information about this, uh, in the next week via email, or you can look at the IGCS website. And I hope you will all join us, um, for the New York, in New York City for IGCS, September 29th through October 4th, first. Um, and you can visit our website for additional information on that. I wish you all continued health and safety and everybody, I hope you stay well. Have a great day.

vaginal reconstruction

abdominal-based flaps

vertical rectus abdominis myocutaneous flap

VRAM flap

abdominal fascia

omentum flap

total vaginal reconstruction

lymphovascular mapping

bypass surgery

lymphedema treatment

lymphovenous bypass

multidisciplinary approach

fluorescence imaging