Fundamental and essential techniques for supermicrosurgical lymphaticovenular anastomosis: the art of Isao Koshima’s supermicrosurgery

Lymphaticovenular anastomosis (LVA) is a highly effective, minimally invasive surgical treatment for lymphedema. The effect of LVA appears immediately after the creation of lymph-to-venous pathway. However, the long-term outcome of LVA is not always promising when the lymph-to-venous anastomosis has any potential risk of occlusion. The reasons of postoperative LVA occlusions are considered both a technical matter in performing LVA and a strategic matter in preoperative planning. This report focuses on intraoperative techniques of LVA to avoid postoperative occlusions. Depending on the types of undesirable surgical procedures, lymphaticovenular anastomoses are at risk of future occlusions in early, mid-, or late-postoperative course. The authors describe fundamental and essential techniques to perform supermicrosurgical LVA, and the true concept of Isao Koshima’s supermicrosurgery, in which the pith and marrow of the doctrine is not only the way of handling the small vessels or needles, but also the surgeons’ skills to feel intima of the vessels and lymphatic flow itself