Laparoscopic Omental Lymph Node Flap Transfer for Lower Extremity Lymphedema: Insights into Lymphangiogenesis and Clinical Outcomes.

Background: Lower extremity lymphedema is a chronic surgical disease marked by lymphatic obstruction, fibrosis, and recurrent infection. Conservative therapy is often inadequate in advanced cases. Vascularized lymph node transfer (VLNT) restores drainage through lymphangiogenesis and node regeneration. The omentum, rich in lymphoid tissue and VEGF-C secretion, is an underutilized donor site. This study evaluated the safety, efficacy, and mechanistic outcomes of laparoscopic omental lymph node flap transfer. Methods: This retrospective case series evaluated, twelve patients (14 limbs) with advanced lower extremity lymphedema underwent laparoscopic omental VLNT. Outcomes included limb circumference reduction, resolution of lymphangitis, lymphoscintigraphic improvement, and donor-site morbidity. Lymphoscintigraphy at 12 months assessed functional restoration and tracer uptake as surrogates of lymphangiogenesis. Results: At a mean follow-up of 27 (12-43) months, the mean circumference reduction was 29%, greatest in distal segments. All recurrent lymphangitis resolved, and chronic wounds healed within 3 months. Lymphoscintigraphy demonstrated enhanced drainage, reduced dermal backflow, and increased tracer uptake within transferred flaps, suggesting functional integration. Flap survival was 93%, with no gastrointestinal complications or donor-site hernia. Patients reported improved skin texture, reduced heaviness, and greater walking tolerance. Conclusions: Laparoscopic omental VLNT is a safe and effective option for refractory lower extremity lymphedema. Clinical improvements were supported by lymphoscintigraphic consistent with lymphangiogenesis and lymphatic restoration. This minimally invasive approach represents an important advancement in physiologic lymphedema surgery.