Technical pearls in lymphatic supermicrosurgery

Lymphedema is becoming a major public issue with improvement of cancer survival rate, as the disease is incurable and progressive in nature, and the number of cancer survivor with lymphedema is increasing over time. Surgical treatment is recommended for progressive lymphedema, especially when conservative therapies are ineffective. Among various lymphedema surgeries, supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular with its effectiveness and least invasiveness. There are many technical knacks and pitfalls in LVA surgery. In preoperative evaluation, indocyanine green lymphography is recommended for considering indication and incision sites. Intraoperatively, intravascular stenting method, temporary lymphatic expansion maneuver, field-rotating retraction, and several navigation methods are useful. The most important postoperative care is immediate compression after LVA surgery. Compression is critical to keep lymphatic pressure higher than venous pressure, allowing continuous lymph-to-venous bypass flow. These technical pearls should be shared with lymphedema surgeons for better lymphedema management.