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Danforth et al. Plast Aesthet Res 2021;8:48 https://dx.doi.org/10.20517/2347-9264.2021.34 Page 5 of 8

VLNTs, of which 12 (87.5%) had subjective relief, and seven of ten patients with preoperative limb
measurements had objective improvements at one month. This was reported as a reduction in extremity
lymphedema index, calculated by summing the squares of the circumferences of the extremity at multiple
set levels then dividing by the patient’s body mass index. The reduction in index ranged from 0.5% to 8.7%
(mean 5.4%).

A follow-up study of 29 patients who underwent a total of 30 jejunal VLNTs with a mean follow-up of 17.6
months presented the potential complications associated with jejunal lymph node harvest . Importantly,
[10]
there were no reported cases of bowel ischemia. The reported complications included flap loss (3.3%),
hernia (13.8%), nonoperative small bowel obstructions (10.3%), and superficial surgical site infection (3.4%).
Limb measurements were not reported in this subsequent study.

In order to harvest the jejunal lymph node flap, we begin with a supraumbilical mini-laparotomy incision,
typically no more than 5 cm. Once the abdomen is entered, the jejunum is identified and delivered.
Directionality is confirmed with the identification of the Ligament of Treitz. A study of 5 cadavers
demonstrated that the highest density of nodes is present in the proximal jejunum ; therefore, we elect to
[29]
harvest from the proximal segment. We then transilluminate the jejunal mesentery to display the vascular
arcades and lymph nodes. A peripheral packet of lymph nodes and pedicles is selected if possible and
marked [Figure 1]. If no appropriate lymph nodes and associated vessels are found in the periphery of the
mesentery, the nodes closer to the root are explored. Care is taken to ensure that the corresponding bowel
segment remains well perfused by leaving the neighboring cascades intact. The posterior surface of the
mesentery is preserved, and the mesenteric defect is closed to prevent internal hernia.

Schaverien et al. suggested an alternative harvest technique in which the nodes are harvested primarily
[30]
closer to the root of the mesentery. The lymph nodes and vessels are both typically larger closer to the
mesenteric root. One concern with this technique is that the large caliber vessels will result in
disproportionate inflow into a very small capillary network connecting the arterial and venous sides of the
flap and the risk of minimal venous outflow. Therefore, the authors recommend augmenting the venous
outflow if possible. This can be done by creating a flow-through flap, as was described with the
gastroepiploic node transfer, or creating an arteriovenous loop with the distal end of the flap pedicle. No
results were included in this report.

Of note, a single case report has been published on the harvest of the ileocecal mesenteric lymph nodes, as
well as a follow-up discussion suggesting the use of the terminal ileal mesentery [31,32] . However, to our
knowledge, there are currently no larger series reporting these techniques. Also, this region may carry
higher risks given the possibility of appendiceal ischemia or the need for ileocolic resection and anastomosis
in the event of complications.

APPENDICEAL LYMPH NODES
Additional intraabdominal donor sites have been considered but, thus far, have not been found to be as
reliable or useful as the techniques previously discussed here. One of these is the mesoappendix, which
would be an ideal source as it is well known to be truly expendable, and laparoscopic harvest could be
[33]
performed safely and quickly with the assistance of a general surgeon. Ruter et al. examined the
mesoappendix as a potential lymph node donor. In the pathologic examination of 25 mesoappendix
specimens, a single lymph node was only present in two specimens (8%).