Overview

The surgical treatment of lymphedema has evolved tremendously since the early 21st century. With the advances in microsurgical techniques, new options are available for patients suffering from the physical and emotional sequelae of symptomatic lymphedema. The development of lymphatic microsurgery occurred much later than other areas in reconstructive microsurgery. This is likely due to a lack of understanding about lymphedema, the anatomy and physiology of the lymphatic system, and the pathophysiology of lymphedema. The study of lymphedema has been plagued with difficulty in directly assessing physiological changes and structural components, reproducing surgical outcomes, and differences in evaluating clinical conditions. However, recent strides in new technology, techniques, and improved skill-sets have resulted in an improved understanding of the disease process, which has guided the development of new surgical techniques and furthered understanding of the disease.

Much of the recent increased interest in this field can be attributed to the immense population of people plagued by either primary or secondary lymphedema. In industrialized countries, secondary extremity lymphedema continues to be prevalent in patients receiving comprehensive treatment for either breast or gynecological cancers with regional lymph node dissection and/or radiation. Once symptomatic lymphedema occurs, few options exist for this subpopulation of patients who, many times, have fought emotional and physical battles through the cancer treatment process. Being able to provide valuable surgical and nonsurgical treatment options to this patient population has significant implications for not only the individual patient but also the healthcare system. Cost considerations are valued in the physical strain and lost opportunities in various activities related to patients’ personal and professional lives.

Many controversies exist in the assessment and treatment of lymphedema, including universal diagnostic criteria, methods of limb measurements, and treatment options by variable medical specialties. The staging and treatment of lymphedema have no universal consensus among medical specialties, including breast oncologists, gynecological oncologists, rehabilitation specialists, medical oncologists, radiologists, radiation oncologists, vascular surgeons, and reconstructive microsurgeons. Individualized clinical experiences have led to disparate treatment options in various specialties, increasing the difficulties in choosing from the vast array of available choices.

Much of the interest related to lymphedema surgery among reconstructive microsurgeons has been garnered by the introduction of lymphovenous anastomosis and vascularized lymph node transfer techniques. Although these techniques were first described prior to the 21st century, clinical interest in using these techniques surged only recently. Using specifically learned microsurgical techniques, procedures resulting in lymphatic fluid shunting into the venous system can provide relief and decompression of a lymphedematous extremity. Furthermore, it is possible that re-establishing lymphatic connections can provide for an outflow of stagnant lymphatic fluid to flow centrally in the body. In addition to these techniques, reported clinical series have provided validation of these methods and have further garnered interest within the surgical community.

Born from these techniques and reinforced by enthusiastic surgeons, new surgical societies have been created, dedicated conferences have been held, and innovative techniques have been described. The compounding effects of these events have further strengthened the evolving and growing field of lymphedema surgery. The timely nature of this compilation of chapters cannot be underestimated. The rapid rise in interest in the surgical treatment of lymphedema necessitates a comprehensive understanding of not only the surgical treatment options available but also the nonoperative and diagnostic modalities used in the care of this patient population. Many of the world’s authorities in their respective areas of expertise have made contributions to this textbook. With the vast experience treating these clinical conditions, this group of authors provides a pragmatic and thoughtful approach that can be understood by all readers across all relevant specialties.

Lymphedema Surgery: Principles and Practice is structured in such a way as to provide the readers with an in-depth, practical knowledge of the disease process, diagnostic tools, nonsurgical and surgical treatment options, and scientific outcomes assessment. The intent of this logical, stepwise chapter list is to allow for treatment of patients with lymphedema to be incorporated into the clinician’s practice.

Section I

To understand the basis of lymphedema surgery, one must appreciate the history, controversies, triumphs, and pitfalls of the specialty. As history has a curious way of repeating itself, outlining these aspects of the specialty is important for the clinician’s understanding prior to incorporating lymphedema surgery into practice. These principles and theories set the stage for the current understanding of the physiologic principles and pathologic changes in the lymphedematous condition. The chronic and dynamic state of lymphedema development is a complex disease process requiring an appreciation for the dynamic physiologic changes of vascular systems, where chronic outflow obstruction leads to characteristic changes in downstream lymphatic vessels in a similar fashion to the venous systems. Quite a few animal and cadaveric studies have been published recently, which may facilitate us to modify surgical technique and provide better treatment outcome. The basic research at the molecular level may increase the understanding of the pathophysiology of lymphedema, such as adipogenesis, inflammation, and fibrosis. The possibility of discovering a medication for curing or improving lymphedema by further molecular research is not far from reality. Primary lymphedema and concomitant vascular lesions may have even more complicated etiology and require more investigation to solve the problems.

Section II

Lymphoscintigraphy has been used for the diagnosis of lymphedema since the early 1990s, but the updated staging system may differentiate the lymphatic severity for patient selection for variable surgical techniques. Since the advances in the technology, the application of indocyanine green lymphography is an important topic to the diagnosis of lymphedema. It is also used for the surgical guide of lymphovenous anastomosis. Development of the new modalities of magnetic resonance imaging and computed tomography has also been very helpful for diagnosis and tracking outcomes of lymphedema. Crucial to the incorporation of lymphedema patients into one’s clinical practice is a thorough understanding of the nonsurgical or conservative treatment options available. Many patients will receive physiotherapy with compression garments during the course of lymphedema treatment. What entails appropriate treatment for patients with various stages of disease? How do we ensure that we maximize functional outcomes following therapy? Multiple forms and treatment protocols exist that can enhance the treatment process and the recovery of patients, and these options are outlined within this section.

Section III

A major strength of this book is the detailed descriptions of the surgical treatment options available for the treatment of lymphedema. In addition to physiological procedures—lymphatic microsurgical techniques, nonphysiological procedures—excisional and debulking therapies are discussed in detail. Commonly employed techniques for later-stage disease include the use of these excisional techniques to remove the lymphedematous tissue burden from the often overweight and bulky extremity without or with vascularized lymph node transfer. In addition, each vascularized lymph node flap method commonly utilized today, including updated omental and mesenteric vascularized lymph node, is discussed in a step-by-step method, thus allowing for safe and effective flap harvest. Although many of these named flaps are used for other various reconstructive procedures, their composite nature and the inclusion of vascularized lymph nodes require special consideration and dissection techniques to ensure successful and reproducible outcomes. Supermicrosurgical techniques are evaluated, including various methods for lymphovenous anastomosis and the technical aspects of these procedures. In addition, important considerations for the evaluation of usable vessels, appropriate surgical site selection, and choice of technique are reviewed to ensure consistent outcomes following lymphovenous bypass surgery. The lymphatic microsurgical preventing healing approach that was newly developed concept and technique is included in this section. We are delighted to have a vast collection of video contributions from various authors, greatly enhancing the overall quality of the textbook.

Section IV

Understanding how outcomes are assessed following lymphedema treatment is as important as the treatment itself, and this is integrated into each technique chapter. As lymphedema surgery continues to expand, a patient-centered approach to treatment planning will be instrumental to the growth and sustainability of the specialty. Although mastering surgical methods is the foundation for ensuring successful outcomes, a systematic, standardized approach to outcomes assessment is crucial for a number of reasons. Objective evaluations are more easily determined, which can help to predict outcomes and generalize treatment protocols. In addition, standardized outcomes assessments are more easily reportable and valuable to the surgical community to further enhance the global understanding of lymphedema surgery. As interest and experience continue to expand, patient-reported outcome measures will be the benchmark used by others to justify the various treatment options available.

Summary

The surgical treatment options for lymphedema and worldwide clinical experiences are rapidly expanding. As this expansion occurs, a comprehensive and structured compilation of focused chapters can provide clinicians with an organized and systematic approach to this group of patients. Descriptions of treatment options are greatly enhanced by detailed, step-by-step videos describing each procedure and many technical aspects surrounding each procedure. Altogether, each section can provide the clinician with a thorough and comprehensive knowledge base to adopt lymphedema treatment into their practice.