A lymphocele is a localized collection of lymphatic fluid that forms a soft, fluid-filled lump, typically near a site of previous surgery. This complication arises when the delicate network of lymphatic vessels is disrupted, causing lymph to leak and accumulate in a body cavity or surrounding tissue. While many lymphoceles are small and cause no issues, larger collections can lead to significant discomfort and may require medical intervention to resolve. Understanding the spectrum of treatment options, from simple observation to advanced surgical techniques, is the first step toward getting rid of them.
What is a Lymphocele and Why Does it Occur?
A lymphocele is a postoperative complication resulting from surgical trauma that involves the lymphatic system. The most common cause is a lymphadenectomy, the surgical removal of lymph nodes often performed for cancer treatment. When lymphatic vessels are damaged during this dissection, they may not seal properly, allowing lymph to continuously leak into the surrounding space. This accumulation of fluid creates a localized swelling, often developing within weeks or months following the operation.
While many small lymphoceles are asymptomatic, larger ones can exert pressure on nearby anatomical structures. Symptoms can include localized pain, abdominal fullness, or pressure on the bladder causing urinary frequency. Compression of major blood vessels can also lead to issues like deep vein thrombosis or edema in the legs.
Non-Invasive and Conservative Treatment Options
For many small or newly formed fluid collections, the initial approach involves watchful waiting, as the body can often reabsorb the fluid spontaneously. These asymptomatic lymphoceles may resolve without intervention as the body manages the lymphatic leak and resorbs the accumulated fluid. This observation strategy is preferred for collections that are not causing pain, are not infected, and are not compressing vital structures.
If the lymphocele is symptomatic or growing rapidly, fine-needle aspiration may be performed to drain the fluid and provide immediate relief. This minimally invasive procedure uses a thin needle under image guidance, such as ultrasound, to withdraw the lymph. However, simple aspiration is often temporary, with a very high recurrence rate because it does not seal the underlying lymphatic leak.
Aspiration carries the risk of introducing bacteria, potentially leading to an infected lymphocele. For this reason, percutaneous catheter drainage is often favored over a single aspiration attempt for symptomatic cases. A small catheter is temporarily left in place for continuous drainage. The tube is typically removed once the fluid output decreases below a certain threshold, such as 50 milliliters per day.
Sclerotherapy and Interventional Radiological Techniques
When conservative catheter drainage fails to stop the leak, the next step is often sclerotherapy, an image-guided technique that aims to permanently close the lymphocele cavity. This procedure involves injecting a chemical irritant, known as a sclerosant, directly into the collection after the fluid has been drained through a catheter. The goal of the sclerosant is to irritate the inner lining of the lymphocele sac, causing an inflammatory reaction that leads the walls to fuse together and obliterate the space.
The procedure is performed by interventional radiologists using ultrasound or CT guidance. Common sclerosing agents used include absolute alcohol (ethanol), povidone-iodine, or the antibiotic doxycycline. The sclerosant is instilled into the cavity and left to “dwell” for a specific period before being drained or left in place.
Sclerotherapy often requires multiple sessions, typically repeated weekly, and the drainage catheter must remain in place until the fluid output is consistently low. The combination of percutaneous catheter drainage and sclerotherapy significantly increases the success rate for resolving persistent lymphoceles.
Surgical Procedures for Persistent Lymphoceles
For lymphoceles that are large, complicated, infected, or have failed to resolve after multiple attempts at sclerotherapy, surgical management becomes necessary. The most common surgical technique is laparoscopic fenestration, also known as marsupialization, which is a minimally invasive approach. This procedure involves creating a wide opening in the wall of the lymphocele sac into the peritoneal cavity, the space containing the abdominal organs.
The purpose of fenestration is to allow the lymphatic fluid to drain internally into the abdominal space, where the peritoneum can efficiently absorb the fluid. Laparoscopic fenestration offers a high success rate and is associated with a shorter hospital stay and quicker recovery compared to open surgery. Careful technique is required to avoid injury to adjacent organs, such as the ureter or bladder.
In rare and complex situations, complete surgical excision of the lymphocele sac may be considered. This is a more extensive operation with a higher risk profile and is typically reserved as a last resort for persistent collections that cause severe, ongoing symptoms.