Indocyanine green (ICG) lymphography using near-infrared camera system visualizes superficial lymph flows, and greatly helps lymphatic supermicrosurgeons to decide skin incision sites for LVA surgery.[5-9] However, finding lymphatic vessels is not easy even PARP inhibitor with preoperative ICG lymphography guidance, because translucent lymphatic vessels exist in the yellow fat tissue and are difficult to be illuminated by ICG lymphography during microscopic dissection. Recently, a microscope

equipped with an integrated near-infrared illumination system has been used for intraoperative evaluation of blood flow in neurosurgery.[10, 11] The microscope illuminates ICG-enhanced blood vessels during microscopic procedures, and is useful for precise blood flow evaluation after neurosurgical vascular reconstruction. The microscope is considered ideal tool for lymphatic visualization during microscopic dissection of lymphatic vessels, and we adopted the microscope for LVA surgery as intraoperative microscopic ICG lymphography. This study aimed to evaluate usefulness of the microscope for lymphatic supermicrosurgery. From August 2010 to March 2011 under the University of Tokyo Hospital ethical committee-approved protocol, we performed ICG lymphography and LVAs on 12 patients with secondary lower extremity lymphedema (LEL)

refractory to compression therapy using elastic stockings. All PD0332991 solubility dmso patients included in this study had undergone radical hysterectomy and pelvic lymphadenectomy for the treatment of uterine carcinoma, and suffered from progressive lymphedema due to obstruction of lymph flow at the pelvic region. Patients’ age ranged from 36 to 71 years (average, 52.0 years), body mass index (BMI) ranged from 19 to 29 (average, 22.9), and leg dermal backflow (LDB) stage determined by ICG lymphography ranged from

stages II to V (Fig. 1).[6] All patients gave written consent to this study. As we reported previously, 0.2 ml of 0.25% ICG was subcutaneously injected at the first web space of the foot the day before surgery for preoperative severity evaluation and intraoperative guidance.[5, 6] An operating microscope equipped with an integrated near-infrared illumination system (OME-9000; Olympus, Tokyo, Japan) was adopted for LVA surgery OSBPL9 in 7 cases; an operating microscope without the illumination system was used in other 5 cases. Incision sites were decided based on preoperative ICG lymphography using a hand-held near infrared illumination camera system (Photodynamic Eye, Hamamatsu Photonics K.K., Hamamatsu, Japan), and were usually made along the greater saphenous vein. After infiltration anesthesia with 1% lidocaine with 1:100,000 epinephrine, ∼2 cm-long skin incision was made. Adipose layer was dissected seeking for lymphatic vessels with or without guidance of intraoperative microscopic ICG lymphography using the microscope.