Hand Surgery in Patients with a History of Lymphedema: A Review of Current Concepts and Opinions.

Lymphedema may be primary (because of congenital lymphatic abnormalities) or secondary (commonly caused by cancer treatments). It progresses from pitting edema to fibrotic, nonpitting swelling. Diagnosis involves limb measurements and imaging like lymphoscintigraphy, indocyanine green lymphography, and magnetic resonance imaging lymphangiography. Treatment begins with complete decongestive therapy, and unresponsive cases may undergo microsurgical procedures such as lymphaticovenous shunts or vascularized lymph node transfer. Historically clinicians advised against procedures like needle sticks or tourniquet use in lymphedema-affected limbs. However, recent evidence disproves these concerns. Surveys show hand surgeons are more open to operating on lymphedema patients than other specialists. Several small studies report no considerable worsening of lymphedema after surgery, although transient flare-ups and minor infections have been noted. No studies confirmed deep infections, and most erythema-related cases resolved with oral antibiotics. Patients with prior breast cancer surgery, especially those who underwent axillary lymph node dissection, were previously thought to be at high risk. However, multiple studies show that hand surgery does not increase the risk of developing lymphedema in this group. Tourniquet use and avoiding routine prophylactic antibiotics are generally considered safe. Hand surgery appears safe for patients with or at risk of lymphedema; however, caution is warranted given the lack of consensus guidelines and recommendations. There is a lack of standardized guidelines, and surgeon practices vary widely. Further interdisciplinary research is needed to establish clear protocols and ensure optimal outcomes for these vulnerable patients.