In 1912, Kondoleon recognized that lymphedema only affects the tissues above the muscle fascia; the muscle compartment and deeper areas of the limb were not affected. He hypothesized that the muscle fascia was a barrier between the superficial and deep lymphatic systems. Consequently, he made long incisions along the extremity and removed strips of muscle fascia in an effort to allow superficial lymph drain into deeper lymphatics [3–5]. He removed subcutaneous tissue beneath the skin excision so that a path existed between skin and muscle.

Kondoleon’s procedure had minimal efficacy and no evidence of physiologic benefit. Reasons for the lack of improvement were hypothesized to be as follows: (1) the deep lymphatics are also abnormal and unable to drain superficial tissues, and/or (2) a neo-fascia reforms that again blocks superficial to deep drainage [2]. Although the Kondoleon procedure was abandoned, it served as the basis for the staged-skin/subcutaneous excisional procedures that are used today.

In 1962 Thompson described an operation based on the work of Kondoleon (1912), Sistrunk (1918), and Homans (1936) [2]. Because Kinmonth showed that lymphedema also has abnormal deep lymphatics, it was hypothesized that the muscle compartment is not swollen because lymph is propelled by muscle contraction and pulsation of blood vessels [2, 6]. Sistrunk modified the physiologic Kondoleon operation by removing deeper fascia and adding the excision of skin and more subcutaneous fat [4–7]. Homans furthered Sistrunk’s excisional procedure to include removal of all deep fascia and subcutaneous fat by raising thin vascularized skin flaps and applying them to the underlying muscle in staged procedures [8].

Thompson modified Homans’ procedure by de-epithelializing his thin skin flap, which he then buried into an intramuscular area along the entire extremity [2]. He hypothesized that by burying the flap into the muscle he would facilitate superficial drainage into the deep compartment as well as prevent fibrosis/neo-fascial formation that may re-separate the superficial and deep systems. In 1970, Thompson reviewed his experience using the procedure on 79 limbs (56 legs, 23 arms) [9]. He found that 61 % of his patients had “good” results and 33 % had “satisfactory” outcomes; all subjects had a reduced risk of infection [9]. Patients with secondary lymphedema of the lower extremity had a greater chance of having “good” results (83 %), compared to patients with primary disease (58 %) [9]. Thompson hypothesized that patients with primary lymphedema do not benefit as much from his technique because their deep lymphatics are more abnormal compared to patients with secondary disease [9].

Although there is evidence that Thompson’s procedure may improve lymphatic flow [10, 11], any physiologic benefit likely is based on the wide excisional component because skin/subcutaneous excisions (without a buried dermal flap) also have been shown to potentially improve lymphatic function [12–14]. Currently, the Thompson procedure does not appear to offer any additional benefit compared to staged skin/subcutaneous excision without burying a skin flap into muscle. In contrast to the Homans procedure, the Thompson operation is more complicated, and patients are at risk for epithelial sinuses and skin necrosis at the site where the de-epithelialized flap is sutured to the native skin (1/3 of patients in Thompson’s series) [9].

Pedicled transposition of omentum was first described by Goldsmith and De Los Santos as a treatment for lymphedema in 1966 [15]. They hypothesized that the lymphatics in the omentum would be able to bridge the lymphedematous extremity and allow drainage of lymph from the limb. In 1974, Goldsmith published his long-term evaluation of the technique [16]. He performed the procedure in 22 patients (13 legs, 9 arms) [16]. Only ten patients (45 %) were thought to have benefit based on the following criteria: decreased size of the extremity, reduced infections, increased function, or reduction of tissue turgor [16]. One-third of the patients had major complications: hernia, infection, wound dehiscence, pulmonary embolus, gastric ulcer, adhesions causing bowel obstruction, and death from intestinal necrosis [16]. After Goldsmith reviewed his experience with omental transposition he questioned “whether the clinical results of omental transposition justify its continued performance…. I have been impressed with favorable reports of simpler operations such as the Thompson operation or the subcutaneous excision of lymphedematous tissue… if I were asked to recommend an operation… I would suggest that one of these two procedures be performed since neither operation violates the peritoneal cavity as does omental transposition” [16].

Hurst et al. described an enteromesenteric bridge procedure in eight patients [17

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