Case Presentation
A 48-year-old Pakistani woman, presented to the plastic surgery outpatient department (OPD) in March 2020. She complained of persistent and painful swelling in her right groin and inner thigh that had been progressively worsening over the past four months. She had a history of deep venous thrombosis (DVT) and was taking oral anticoagulant therapy. One year prior to her visit, she had undergone a surgical procedure called the Trendelenburg operation, (which involved the ligation of the saphenofemoral junction and the removal of varicose veins through stripping). After the surgery, she developed a slow-growing swelling in her right groin, which the doctors treated using aspiration, compression bandaging, and sclerotherapy. This management provided temporary relief but was ineffective. The patient also had a medical history of diabetes and hypertension, and she was on medication for both.
Examination
On physical examination, doctors found a large swelling measuring approximately 65 cm by 25 cm in the right groin and inner thigh. The swelling was tense, cystic, and slightly tender to the touch. The overlying skin appeared warm, red, and shiny. Additionally, a long transverse scar was present in the groin area, along with multiple smaller scars throughout the entire lower limb, which indicated her previous varicose vein surgery. The circumference of her right thigh, measured during the initial presentation, was 96 cm, which had reduced to 73 cm during her most recent follow-up, while her other thigh measured 65 cm. The rest of her physical examination was unremarkable.
Investigations
Doctors conducted certain investigations, including a complete blood count (CBC), which showed an elevated white blood cell count of 22,000 with a predominance of neutrophils (82%). Her glycosylated hemoglobin (HbA1c) levels were high at 8.2%, indicating poor glucose control. Liver function tests were normal, and her hepatitis profile was negative. Doctors performed needle aspiration, which revealed straw-colored fluid, and sent it for routine analysis and cytology.
Doctors performed magnetic resonance imaging (MRI) to make a definitive diagnosis, which revealed a large, thin-walled hypoechoic lesion. Based on these findings, the doctors suspected that the swelling was a refractory giant lymphocele. Thus, they admitted the patient to the hospital in preparation for surgery.
Surgical Management
They performed the procedure under general anaesthesia and positioned the patient on her back with her legs bent. They administered subdermal injections of methylene blue dye at four points surrounding the swelling, both in the thigh and the anterior abdominal wall. The doctors conducted the procedure to track the absorption of the dye. This aided in identifying any lymphatic vessels that were draining into the cystic cavity.
They made a stab incision at the highest point of the swelling, resulting in the drainage of 6 liters of yellow, straw-colored fluid. Furthermore, they made a transverse incision over the swelling. They excised the scar tissue and explored the cavity very carefully. Despite the exploration, they found no traces of the methylene blue dye within the cystic cavity. They excised the pseudobursa (a sac-like structure), except for a small portion covering the femoral triangle. They took this approach to avoid damaging the femoral vessels due to the presence of dense adhesions.
The doctors took out the drain after two weeks, and they discharged the patient with oral prophylactic antibiotics and pain medication. The patient had the skin-holding bolsters for an additional four weeks. After six weeks, the patient returned for a follow-up examination, and he had a small collection on the inner side of the thigh, measuring 7 cm × 5 cm × 3 cm. Doctors then aspirated this collection and applied a pressure dressing. During subsequent follow-up visits scheduled every three months for a year, the circumference of both lower limbs was measured. The measurement of the right thigh was nearly identical to that of the left thigh. The lymphocele had completely disappeared, and no recurrence of swelling was seen.
Discussion: Lymphocele
Lymphocele formation is a common complication of complicated surgeries, often occurring within a few weeks or up to a year after the procedure. Risk factors include lymph node dissection, pelvic surgery, and renal transplantation. Obesity and diabetes are also associated with lymphedema, which can be managed through weight loss intervention and glycemic control. In this case, the patient had varicose veins and underwent surgery that disrupted the lymphatic channels, leading to lymphocele formation.
During surgery, certain measures can be taken to reduce the risk of lymphocele formation, such as careful control of lymphatic channels and leaving the retroperitoneum open for drainage. Placing a surgical drain has also been shown to be effective in preventing lymphocele. Small lymphoceles often resolve on their own, while larger ones may require intervention.
Conservative management includes compression bandaging, limb elevation, prophylactic antibiotics, and drainage through needle aspiration or catheter insertion. Sclerotherapy is commonly used but may not be effective for large lymphoceles. In this case, the patient underwent multiple sessions of aspiration and sclerotherapy without success.
When conservative methods fail or for large lymphoceles, surgical intervention is necessary. Surgical procedures include lymphadenectomy, fenestration, marsupialization, lymphovenous bypass, or a combination of lymphovenous bypass and sclerotherapy. The success of sclerotherapy depends on the size of the lymphocele, with larger cavities requiring additional surgery. Lymphovenous bypass is suitable for mild-to-moderate conditions, while a combination of techniques may be needed for more severe cases.
In the presented case, due to the absence of superficial veins for anastomosis, a pedicled gracilis muscle flap was used to fill the dead space left by the lymphocele. This prevented the formation of an empty space where fluid could accumulate and reduced the risk of recurrence. The lymphadenectomy and muscle flap procedures successfully resolved the lymphocele.
Conclusion: Lymphocele
In conclusion, lymphoceles are a known complication of complicated surgeries, and risk factors include lymph node dissection, pelvic surgery, and obesity. Conservative management and sclerotherapy are initial treatment options, but surgical intervention may be necessary for extensive or refractory lymphocele. Techniques such as lymphovenous bypass or the use of muscle flaps can effectively resolve the condition and prevent a recurrence.
