Reconstructive Procedures: Lymphedema Surgery

Lymphedema can develop soon after the disruption to the lymphatic system, or many years later. In early lymphedema, there is mild swelling and heaviness in the limb. As lymphedema progresses, there may be more obvious swelling in the affected limb, the occurrence of infections, and/or reduced function including reduced hand dexterity or difficulties with walking. In the later stages of lymphedema, the persistent swelling can lead to fibrosis of the fat and chronic skin changes and hardening. In severe and long-standing cases, there may even be the development of a cancer known as angiosarcoma.

The International Society of Lymphangology (ISL) classified lymphedema into 3 stages according to the clinical features. Briefly, they are:

 

Stage 1: Reversible swelling of the involved body part

Stage 2: Irreversible swelling of the involved body part

Stage 3: Chronic fibrosis and irreversible skin changes; elephantiasis

In LVB, special machines and techniques are used to identify the superficial, clogged lymphatics, and divert their flow by suturing them to neighboring veins. This is akin to relieving a traffic jam on a main thoroughfare by creating a diversion to a parallel highway. The advantage of this procedure is that they are extremely low risk, can be performed under local anesthesia if desired, and require very small incisions and minimal downtime.

For VLNT, lymph nodes are taken from a part of your body where lymph nodes are in excess and transplanted to the affected limb. In select patients, VLNT can be performed together with other procedures such as extremity or breast reconstruction to achieve dual aims simultaneously. VLNT procedures usually require a few days of hospital stay and about 1 to 2 weeks downtime.

In severe cases of ISL stage 3 lymphedema, physiological techniques may no longer be possible due to the amount of fibrosis and skin changes. For these situations, excisional surgery such as liposuction or removal of fibrotic skin can be performed to debulk the affected body part.

Post-surgery, patients will still have to continue taking care of their lymphedema, as none of these treatments can be said to be 100% effective. However, many patients report reduced symptoms and weight of the affected limb, and there are some who completely stop lymphedema therapy altogether.

You will either be admitted to the hospital the day before or on the day of surgery. If a general anaesthetic is planned, you will be asked to fast for at least 8 hours before surgery. LVBs can often be performed under local anaesthesia with or without sedation, in a day surgery setting. If a VLNT or excisional techniques are planned, you may require a few days’ hospital stay. In general, lymphedema surgery can last from 3 to 6 hours.

As with any surgery, general risks include pain, bleeding, and infection. Post-operative pain is usually well controlled after surgery with medication, and the risk of bleeding and infection leading to the need for another procedure is low. There is also the general anaesthetic risk, which will be explained to you by the anaesthetist, and is typically low especially if you are healthy. Specific to VLNT, if there is any sign of problems with the blood supply to the transferred lymph nodes, you may be brought back to the operating theatre expediently. Other known sequelae include scarring and numbness at the operative sites, which are usually managed well in the post-operative period.