Introduction to Lymphedema Surgery: Principles and Practice

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.