Introduction to Lymphaticovenular Anastomosis Surgery: Historical Perspectives

Lymphatic surgery has a fascinating history, made unique by the characteristics of both the anatomical structures involved and the physiopathology of lymphedema. The lymphatic system is composed of an intricate network of invisible and impalpable vessels, so its anatomical and physiological comprehension is centuries behind the other systems. Since the appearance of the idea of the reconstruction of lymphatic continuity, the surgery evolved together with the technological advancements; it starts with the excision of the pathological tissue, advances through the attempt of deviating the lymphatic flux toward the deep system, pushes forward with the transposition of new lymphatic tissue, with local flaps first, and free flaps later, aimed to fill the surgical break, and the lymphaticovenous anastomosis (LVA) represents the ultimate expression, representing a direct reconstruction of lymphatic continuity. An LVA is a simple idea, intuitively effective, but implies the visualization of collectors preoperatively, the selection of the appropriate ones to bypass, the selection of reflux-free venules, a supermicrosurgical anastomosis, and the control of the dynamics. Moreover, the lymphatic system has a variable rearrangement after injury, so every patient with lymphedema has a personal adaptive system that requires a customized surgical approach, and the LVA surgery offers a complete personalized treatment. The hot topic nowadays is represented by the attention on the preoperative planning and the selection of the adequate vessels to be bypassed, and this is the result of a long evolution whose comprehension may help the reader in a better understanding of the modern techniques and the still opened questions.