When conservative treatments and therapies aren’t enough to relieve painful inflammation and swelling from lymphedema, some patients turn to surgery. Over the past two decades, medical advancements in microsurgery, led by pioneering surgeons like Dr. Jay Granzow, have transformed the way doctors treat lymphedema. Experienced surgeons now use minimally invasive and highly successful techniques to help reduce lymphedema symptoms and improve quality of life.

Microsurgery Options to Treat Lymphedema

Depending on the stage and severity of a patient’s lymphedema, surgeons may perform one or more of the following microsurgical procedures:

Lymphaticovenous anastomosis (LVA) or lymphaticovenous bypass (LVB). LVA and LVB are used interchangeably and are among the most common surgical treatments for lymphedema. The procedure helps lymphatic channels drain properly by connecting lymphatic vessels to small veins to bypass damaged areas.

Vascularized lymph node transfer (VLNT). This microsurgery replaces lost lymph nodes with healthy ones to help drain excess lymphatic fluid. Doctors use reverse lymphatic mapping to avoid injury at the donor site.

Suction-assisted protein lipectomy (SAPL℠). Developed by Dr. Jay Granzow, a specialized liposuction procedure that removes solid protein and fat deposits from advanced-stage lymphedema patients. After this treatment is complete, patients undergo conservative therapies to further drain the remaining fluid and improve symptoms.

When performed by a skilled surgeon, these procedures are extremely effective in producing significant, long-term improvements in patients with lymphedema.

Robot Assistance Enters the Chat in Recent Years

Multiple academic medical centers have recently touted the use of robot assistance to increase precision for LVB surgeries. Both the Cleveland Clinic and Cedars-Sinai used robot assistance for LVB surgeries to treat breast-cancer-related lymphedema. Robot-assisted surgical teams believe that robotic technology is enabling significant advancements in lymphedema treatments.

But is the cost and complexity associated with this new technology truly improving patient outcomes?

Potential Benefits of Robot-Assisted LVB Surgery

The medical centers using robot assistance name the following as primary benefits gained from using this technology:

  • Enhanced precision when sewing minuscule vessels
  • Tremor elimination to improve accuracy and reduce margin of error
  • Motion scaling that translates the surgeon’s larger movements into smaller ones
  • Freedom of movement in hard-to-access locations and awkward positions

Potential Downsides of Robot-Assisted LVB Surgery

When examining new biomedical technology, it’s important to consider if the benefits outweigh the costs.

Let’s take a more careful look.

The most important parts of an LVA surgery are surgeon experience, patient selection, patient preparation and therapy optimization, operative site selection, and intraoperative decision making. These are not changed with the addition of a robot.

What is certain is that robotic surgery adds complexity, time and cost to the surgeries. This means that more can go wrong and less surgery can be accomplished in a given time in the operating room.

What is also not mentioned is that the surgeon’s choice of instruments and tools will be much more limited to the tools that can be used by the robot. The surgeon’s favorite specialized lymphedema instruments, such as specialty scissors, needle holders and forceps are not available. Some scissors are heavier to be able to cut scar better. Others are more fine to address the tiny vessels themselves. Some scissors have sharp tips, others have blunt tips. Forceps come in multiple different sizes, which is critical especially for very small vessels. Needle holders have different tips for different sutures depending on the size and fragility of the particular vessel wall, etc.

Limitations in instrument choice can also significantly limit the speed of surgery in tough conditions, such as when significant amounts of scar or inflammation are present in the more complex LVA cases.

Also not mentioned is that tactile sensation, which is the surgeon’s ability to touch and feel the tissues with the instruments, is lost with the robot. This can significantly impact a surgeon’s ability to carefully separate and divide the delicate tissues associated with LVA surgery.

One advantage of the robot is that surgical accuracy could be improved for surgeons not used to making fine lymphedema movements or surgeons with a tremor. This advantage would be most apparent during the actual suturing of the vessels, which typically is the shortest portion of any LVA surgery. There is no speed advantage here for an experienced lymphedema surgeon.

The other advantage that robotic surgery confers is the possibility of operating in tight and otherwise inaccessible spaces. This is not an issue in LVA surgery, where the overall surgical access to the vessels is quite good for experienced lymphedema surgeons.

The other certainty is added cost, which could create issues with insurance coverage of hospital access.

The Verdict on Robot-Assisted Surgery for Lymphedema

Robot-assisted surgery has provided significant benefits in many fields, such as urology and OB-Gyn surgery. The move to advance our current knowledge and technology is a welcome one. However, in its current iteration, the benefits of the robot in lymphatic surgery are limited. In fact, the drawbacks of additional significant cost, complexity, and loss of touch for the surgeon seem to outweigh the benefits at this point.

Surgeon Skill and Experience Are Most Crucial for Patients

Continuous improvement of patient outcomes is the goal for every surgical team. For highly skilled and experienced surgeons like Dr. Granzow, LVA and LVB procedures are routine and are not improved by robotic surgery in its present form.

Dr. Granzow has been performing lymphedema surgery since 2005 and pioneered the first integrated lymphedema surgery treatment system, known as the Granzow System℠. This system addresses both solid and fluid excess and swelling caused by lymphedema through conservative therapy, vascularized lymph node transfer (VLNT), lymphaticovenous anastomosis (LVA), and Granzow Suction Assisted Protein Lipectomy (SAPL™).

If you have been diagnosed with lymphedema and are suffering from swelling, pain, and other symptoms, contact the experts at the Granzow Lymphedema and Lipedema Center of Jacksonville, Florida, to discuss your options.