Principles of surgical treatment of chronic lymphoedema

Lymphoedema, refractory to non-operative management, may require surgical t reatment. Potential indications include impaired Limb function, recurrent e pisodes of cellulitis and lymphangitis, intractable pain, lymphangiosarcoma and cosmesis (patient unwilling to undergo more conservative treatment and willing to proceed even with experimental operations). The principle of ex cisional operations is to remove excess tissue to decrease Volume of the ex tremity. Good reduction can be achieved with staged resection of the subcut aneous tissue, with resection of the excess skin and using the remainder fo r coverage. However, prolonged hospitalization, poor wound healing, long su rgical scars, sensory nerve loss, residual oedema of the foot and ankle and poor cosmetic results can be significant problems and prevent offering suc h procedures short of a large and truly disabling lymphoedema, not respondi ng to medical measures. Physiologic operations have been aimed at restoring lymphatic transport capacity, most frequently with lymphovenous anastomose s or lymphatic grafting. Chylous reflux due to valvular incompetence has be en treated effectively by ligation and excision of retroperitoneal lymphati cs, with or without lymphovenous anastomoses. Lymphovenous anastomoses oper ations for obstructive lymphoedema have been performed for several decades, but their use continues to be controversial. Such reconstructions can be i ndicated in a subset of patients who have proximal obstruction with preserv ed or dilated lymphatics distally. While few groups have reported good late clinical results, direct confirmation of long-term patency of lymphovenous anastomoses in patients is unavailable. Lymphatic grafting is a promising operation, but it requires true microsurgical expertise and commitment to t reat this frequently frustrating and difficult disease. Long-term patency r ates associated with documented clinical improvement have to be reported in larger number of patients, operated on in more than one centre before this operation can be recommended fur treatment as an alternative to conservati ve measures. The large number of individual surgical techniques of physiolo gical and excisional operations that are practiced today worldwide to treat lymphoedema continues to be testimony to our frustration in dealing with t his difficult problem.