LYMPHATIC SURGERY

Surgical Techniques for Lymphoedema Treatment

Surgical techniques are intended for cases that do not respond to medical treatment and include two categories: ABLATIVE or PHYSIOLOGICAL procedures.

The choice of technique or how to combine different techniques is determined based on consultations, patient interviews, and the results of lymphatic MRI (lymphorisonance), a crucial preoperative examination that provides a clear view of the type and severity of lymphoedema being addressed.
Each case will be assigned a personalised therapeutic plan tailored to the patient's specific needs, with the aim of achieving the highest possible level of care.

The ultimate goal remains helping the patient regain as much autonomy as possible; each specialist finds the most suitable compromise between theoretical guidelines and the patient’s personal experience.

Ablative Surgical Procedures

These procedures involve the removal of pathological tissue using various techniques, all aimed at reducing the weight and size of the affected areas.

  • Modified Liposuction
    Generally reserved for cases where the affected areas are largely composed of fibrotic tissues (commonly referred to as lipoedema), this type of surgery enables selective reshaping of the affected areas while preserving competent lymphatic pathways. This allows treatment where physiological techniques may not be ideally suited.

    In cases with coexisting degrees of lymphoedema, this technique can also be combined with ablative and physiological interventions to achieve more comprehensive care outcomes.

  • Volume Reduction Surgery
    Primarily intended for more severe cases of lymphoedema, where the affected areas largely consist of fibrotic tissues, ablative surgery aims to remove varying amounts of pathological tissue. This not only alleviates issues related to the size and weight of the affected limbs, significantly improving the patient's quality of life, but it also selectively reshapes the affected areas, enabling treatment where other therapies may be less effective.

    Lastly, and perhaps most importantly, this approach can facilitate the activity of remaining competent lymphatic vessels, helping to break the vicious cycle that often leads to irreversible disease progression. This combination approach is particularly beneficial when these surgeries are paired with physiological interventions (autologous lymph node transplantation and lymphatic-venous bypass) or liposuction, creating more sophisticated care levels through the synergistic effects of these techniques.

Physiological Surgical Procedures

These types of procedures aim to reconstruct competent lymphatic pathways that allow for the drainage of excess lymph from the affected areas. These are highly specialised interventions performed with the aid of a surgical microscope.

  • Lymph Node Transplantation (ALNT - VLNT)
    This procedure is reserved for cases where the lymphatic system is hypoplastic or absent, or where there is an interruption in the lymphatic drainage flow, whether due to iatrogenic, traumatic, or post-infectious causes.
    The procedure involves the autologous transplantation of a tissue unit, known as a flap, containing lymph nodes. This flap is transplanted to the site where the lymph nodes are either absent or incompetent. The most commonly used donor areas include the lateral cervical region, the dorsal area, and the groin. To avoid complications in the donor area, typically only three to four lymph nodes are harvested.

    The transplanted tissue not only aids in the absorption of excess lymph in the receiving area but also establishes a new, long-term equilibrium through the formation of new lymphatic vessels.
    Autologous lymph node transplantation can also be employed for preventative purposes. There is an essential synergy between oncological resective surgery and plastic conservative/reconstructive surgery in cancer patient care.

    For instance, in cases where a mastectomy is required due to carcinoma, after the oncological removal, breast reconstruction is performed during the same procedure using an abdominal fat flap. This flap is rich in adipose tissue for restoring breast volume and shape, as well as lymph nodes to prevent the onset of upper limb lymphoedema.

  • Lymphatic-Venous Anastomosis or Lymphatic-Venous Bypass
    According to our approach, this technique is best indicated in cases of hyperplastic or hypertrophic lymphoedema, where lymphatic vessels are present—sometimes in greater numbers or length than normal—but lack competence and cannot perform their transport function. The goal of these procedures is to create various bypasses at the microscopic level between small lymphatic vessels and subcutaneous venules, allowing the flow to be diverted from the blocked lymphatic system to the venous system.

For more information, please visit www.centrolinfedema.it, the website of the team of experts I am part of.