Safety of hand and upper extremity surgery in patients with or at risk for lymphedema: A systematic review.

BACKGROUND: Surgical procedures in patients with or at risk for lymphedema are often discouraged. This systematic review evaluates the safety of hand and upper extremity surgery in this population. METHODS: A systematic review was conducted according to PRISMA guidelines. MEDLINE, Embase, Web of Science, and the Cochrane Library were searched. Studies reporting outcomes following hand or upper extremity surgery in patients with preexisting or at-risk lymphedema were included. Primary outcomes were new-onset or worsening lymphedema; secondary outcomes included complications and tourniquet use. A qualitative synthesis was performed. RESULTS: Eight studies comprising 407 patients were included, of whom 95 had documented preexisting lymphedema; seven studies were retrospective and one was a prospective nonrandomized cohort. New-onset lymphedema was rare, and no consistent signal of permanent worsening was observed, although the overall certainty of evidence was very low. Transient postoperative swelling and minor complications were reported. One prospective cohort directly compared tourniquet-assisted with non-tourniquet surgery and found no clear difference in postoperative lymphedema, but it was underpowered and events were rare. CONCLUSION: Available very-low-certainty evidence does not demonstrate a consistent signal of permanent lymphedema progression after short-duration elective hand surgery, such as carpal tunnel release. These findings support an individualized, indication-based approach to surgical decision-making, rather than routine avoidance of indicated procedures in the affected limb. LEVEL OF EVIDENCE: IV.