Principles of surgical treatment of chronic lymphoedema.

Lymphoedema, refractory to non-operative management, may require surgical treatment. Potential indications include impaired limb function, recurrent episodes 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 excisional operations is to remove excess tissue to decrease volume of the extremity. Good reduction can be achieved with staged resection of the subcutaneous tissue, with resection of the excess skin and using the remainder for coverage. However, prolonged hospitalization, poor wound healing, long surgical scars, sensory nerve loss, residual oedema of the foot and ankle and poor cosmetic results can be significant problems and prevent offering such procedures short of a large and truly disabling lymphoedema, not responding to medical measures. Physiologic operations have been aimed at restoring lymphatic transport capacity, most frequently with lymphovenous anastomoses or lymphatic grafting. Chylous reflux due to valvular incompetence has been treated effectively by ligation and excision of retroperitoneal lymphatics, with or without lymphovenous anastomoses. Lymphovenous anastomoses operations for obstructive lymphoedema have been performed for several decades, but their use continues to be controversial. Such reconstructions can be indicated in a subset of patients who have proximal obstruction with preserved 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 treat this frequently frustrating and difficult disease. Long-term patency rates 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 for treatment as an alternative to conservative measures. The large number of individual surgical techniques of physiological and excisional operations that are practiced today worldwide to treat lymphoedema continues to be testimony to our frustration in dealing with this difficult problem.