The Lymphatic System—A Surgeon’s Point of View

Lymphedema is a chronic and debilitating disease that affects up to 250 million patients worldwide. Recent advances in understanding its pathophysiology, along with improved diagnosis and microsurgical techniques, have enhanced our ability to cope with the challenging task of treating this disease. This review provides an overview of the disease from a surgeon’s point of view, including existing imaging modalities used for preoperative assessment, as well as surgical procedures used in its treatment. The advantages and drawbacks of various existing modalities used for the pre- or intraoperative assessment of lymphatic vessels are discussed. Lymphedema treatment has shifted from palliative debulking procedures (liposuction and direct excision) to those aimed at restoring lymphatic flow and countering the pathophysiology of the disease (lymphaticovenous anastomosis and vascularized lymph node transfer). A combination of both approaches can result in a synergistic benefit for patients and is discussed in this review. Despite recent advances, some controversies persist, and further studies are needed to better define surgical treatment algorithms.