Simplifying Supermicrosurgical End-to-Side Lymphaticovenous Anastomosis Using a Triangular Silicone Background Sheet Spacer

Supermicrosurgical lymphaticovenous anastomosis (LVA) is an established but technically demanding treatment for lymphedema. A key challenge is maintaining simultaneous visualization of both lymphatic and venous lumens. We present our method of using a triangular silicone background sheet as an inter-vessel spacer to simplify LVA. After placing the initial posterior wall suture, the spacer is inserted between the lymphatic vessel and recipient vein to provide controlled, tremor-free exposure of both lumens. The degree of tension is adjusted by the depth of spacer insertion. Strategic spacer positioning can also alter unfavorable vessel orientation by converting acute angulation between the lymphatic vessel and recipient vein into a perpendicular or obtuse configuration, thereby optimizing the conditions for anastomosis. This technique was applied to 503 consecutive patients undergoing 3,153 lymphaticovenous anastomoses over nine years. It is especially helpful in end-to-side LVA by enabling stable retraction, facilitating single-surgeon workflow, and permitting multiple lymphatic anastomoses to one recipient vein. Patency was confirmed after every anastomosis by venous washout or venous-lymphatic reflux. The triangular background sheet spacer is an inexpensive and readily available adjunct that improves lumen exposure and stability during LVA. This innovation addresses a key barrier to effective and reliable anastomotic outcomes in supermicrosurgery.