Chapter 42: Lymphatic Surgery and Surgery of Lymphatic Disorders

INTRODUCTION

Whereas the mainstay of treatment of lymphedema and other lymphatic disorders has long been non-operative, there is, nonetheless, a century of history of attempts to simplify management and improve patient outcomes using a variety of surgical approaches. These have included efforts to remove unsightly tissue overgrowth and lymphatic tumor masses; promote lymph drainage through prelymphatic tissue channels, skin flaps, and omental transplants; and reroute obstructed lymph flow through direct lymphatic and lymph node shunts back into the venous system. Recent advances in microsurgery, refinements in noninvasive dynamic lymphatic system imaging, and improved approaches to resection have built upon this historic tradition and the contributions of pioneering surgical lymphologists to make lymphatic microsurgery and surgery of lymphatic disorders an increasingly important, safe, and practical option in these chronic vexing disfiguring, disabling, and at times, life-threatening congenital and acquired conditions. Moreover, future improvements in the scope and outcome of these procedures include minimally invasive and robotic approaches possibly coupled along with tissue engineering and stem cell and tissue transplantation. These improvements, and ultimately fetal restitution or reconstruction, to prevent or treat these lymphatic disorders will require both the intellect and skill of surgeons on research teams and in clinical multimodal management.

HISTORY OF SURGERY FOR LYMPHATIC DISORDERS

Operations for the treatment of patients with lymphatic disorders can be traced back to 1908 when Handley¹ described his technique of "lymphangioplasty," consisting of running silk threads subcutaneously in an effort to provide a conduit for lymphatic drainage. The procedure was eventually abandoned because postoperative infection and spontaneous extrusion of the implanted foreign material commonly occurred. Shortly after this, in 1912, Kondoleon² introduced the predominant surgical procedure for lymphedema that would be used for 50 years thereafter. He based the procedure named after him on observations in dogs that lymph flow passed through the muscular system and drained through the subcutaneous tissue and that furthermore, in human elephantiasis, that fascia was unusually hard, thickened, and fixed to the surrounding adipose tissue.³ The Kondoleon procedure, which consists of a wide excision of the fascia with a concomitant partial excision of the hypertrophic adipose tissue, was hailed as a unique advance in surgical treatment for patients with elephantiasis at the 1918 American Medical Association meeting⁴ and was widely used by leading surgeons around the world up until the 1960s. Other excisional operations, such as Charles' total resection of subcutaneous tissue,⁵ Thompson's subfascial drainage of a scarified skin flap,⁶ and Servelle's total surface lymphangiectomy,⁷ also aimed at removing excess tissue to decrease volume of the swollen extremity.^{8,9,10,11,12,13,14,15,16} However, prolonged hospitalization, poor wound healing, long surgical scars, sensory nerve loss, residual edema of the foot and ankle, and poor cosmetic results have been important problems resulting from these major debulking operations. Their use today is largely restricted to ...