Precision and Progress: Two First-of-Their-Kind Robotic-Assisted Lymphatic Surgeries

One of the most underreported conditions that may arise in patients undergoing treatment for breast cancer is lymphedema, which manifests from procedures such as the surgical removal of the axillary lymph nodes and radiation therapy. It is characterized by excessive fluid buildup in the body’s tissue and can lead to localized swelling in the arm and in the breast itself. The condition is chronic and currently incurable.

However, two recent cases from Cleveland Clinic illustrate how robot-assisted microsurgery is leading to positive, life-altering, functional and aesthetic improvements for patients. Both describe procedures that are among the first of their kind. The initial case summarizes the first robotic-assisted supermicrosurgical lymphaticovenous bypass for breast cancer-related lymphedema of the arm performed in the United States, and the second describes the world’s first robotically assisted lymphaticovenous bypass to treat breast lymphedema.

“With robotic-assisted surgery, we apply the same highly precise techniques used in standard microsurgery, but now we have even greater accuracy and the ability to fine-tune our movements,” says Graham Schwarz, MD, Vice Chair in the Department of Plastic Surgery and Program Director of the Cleveland Clinic Microsurgery Fellowship.

Case 1

A 50-year-old woman with advanced stage breast cancer developed significant, progressive left arm lymphedema beginning in 2019 after completing her chemotherapy, surgery and radiation treatments. Now, several years later, with her metastatic breast cancer stable and under control, the issue that was most impacting her life was her severely enlarged arm. She was referred to Dr. Schwarz, and they developed a plan for staged lymphatic reconstruction. Dr. Schwarz performed an initial volume reduction surgery on her left arm to remove diseased tissue and scar. This gave the patient the ability to once again wear proper fitting clothes and resulted in significant functional and cosmetic improvements.

After a period of healing and adherence to a strict regimen of compression, a planned second procedure to microscopically reroute and enhance lymphatic drainage was performed.

In the summer of 2024, the patient underwent the first robotic-assisted lymphaticovenous bypass (LVB) for breast cancer-related lymphedema in the United States. She experienced immediate relief with noticeable softening of her arm and reduced swelling. This improved her arm function and significantly decreased the time she needed to spend on daily lymphedema management with compression therapies.

Incorporating robots into the surgical approach

Dr. Schwarz notes that through more than a decade of experience working with lymphedema patients, the Cleveland Clinic’s team of lymphatic microsurgeons have adopted a proactive approach, offering surgery earlier in the disease process. This has successfully led to less disability for patients and offers a better chance of arresting or reversing damage to the lymphatic system. He says that those at high risk after cancer treatment are carefully monitored, and each patient with early signs or symptoms of lymphedema meets with multidisciplinary team members for consultation. Typical candidates for surgery demonstrate that their condition hasn’t improved or has worsened despite trying non-surgical treatments, such as compression or physical therapy.

“I met this particular patient after she had already finished breast cancer treatments as well as breast reconstruction,” says Dr. Schwarz. “She developed lymphedema, and her arm had become very large, not just due to fluid backup in the tissues but also because her lymphatic blockage signaled the body to accumulate diseased fat and scar tissue. While certain lymphatic surgeries focus on tiny lymphatic vessels and aim to fix the plumbing, they don't treat the fat or scar tissue buildup well.”

For this patient, Dr. Schwarz explains that the team planned a staged reconstructive approach where they first removed the excess fat and scar tissue in the arm. Once the area healed, the patient underwent a planned second surgery so they could address the fluid component.

Although robotic assistance was used in the surgery, Dr. Schwarz explains that the approach is very similar to traditional LVB (i.e., lymphaticovenous anastomosis or LVA) surgery. First, the team creates a “map” of where the existing lymph drainage pathways exist along with the areas of blockage. They use specialized fluorescent imaging and ultra-high frequency ultrasound to visualize and trace the minuscule structures. Once they have been identified, the team can precisely target those areas and start the repair. Robotic assistance further enhances precision during surgery by eliminating tremors and allowing motion scaling, crucial for microsurgical accuracy and outcomes.

“Some patients are very happy with just removing the extra fat and skin so that their arms are about the same size, and they can move more easily,” says Dr. Schwarz. “But with this patient, and many of the other patients that we're working with lately, they see how much their quality of life has improved, and they are eager to maximize their result.”

He continues, “After liposuction only, the limb doesn't stop accumulating fluid, and consistent, lifelong compression is still mandatory for long-term success. LV bypass surgery helps to reduce this fluid backup and eases the burden of needing constant compression. It gives patients more of their time and freedom. Patients often see improvement almost immediately, and the downtime is so minimal.”

Patients who have the surgery done will typically go home the same day with acetaminophen. The recovery process usually involves patients staying in compression for a few months before allowing them to gradually decrease their compression regimen.

Case 2

A 42-year-old female experienced significant in-breast lymphedema following lumpectomy and radiation for right breast cancer. The patient was in extreme pain, which affected her daily activity and quality of life significantly. Her condition did not improve with constant compression or physical therapy.

Dr. Schwarz and his team performed the world’s first robotically assisted in-breast LVB procedure. The patient experienced almost immediate relief and is back to enjoying life more fully. 

How robotic precision and better surgical access improves lymphedema treatment

Dr. Schwarz notes that what’s unique about this case is the location of the lymphedema.

“Typically, when we’re talking about breast cancer-related lymphedema, most think of lymphedema occurring in the arm,” he explains. “But probably more often than we ever think about, there are issues with lymphatic drainage in the breast itself, and unfortunately, this is something that’s very much underreported. What was particularly special about this case was that our patient was having significant functional limitations due to breast pain and swelling. It was disruptive to their life despite all of the non-surgical therapy she had been doing.”

Recognizing the success the robotic LVB procedure had in treating lymphedema in the arm, Dr. Schwarz and his team decided to apply the technique to treat the patient’s in-breast lymphedema. The ability to use robotic assistance, in this case, was ideal since the blockages were in a hard-to-access spot for standard supermicrosurgery.

“When working at ultra-high magnification on submillimeter structures, even the smallest tremor and difficult hand positioning can make an impact. The robotic system removes this tremor and allows the surgeon to adjust larger movements to ultrasmall ones.” Dr. Schwarz notes that precision, consistency and freedom of movement, even in awkward positions, are among the greatest benefits of using robotic assistance.

Looking ahead

One of the things Dr. Schwarz is most excited about with these robotic techniques is their potential for preventative lymphatic surgeries. These surgeries are performed at the same time as cancer surgery when the lymph nodes are removed.

“The surgeons at Cleveland Clinic have really been pioneers with immediate lymphatic reconstruction,” says Dr. Schwarz. “The challenge with this kind of surgery in breast cancer patients is that it is performed deep within the armpit. So again, being able to do those very precise surgeries at such a small scale in a difficult location is not always straightforward. The robot allows us to better access areas that require challenging surgical setups.”

Dr. Schwarz also believes there’s potential to treat lymphatic conditions that affect other areas deep in the body, such as in the abdomen, groin, and head and neck that occur after cancer surgery or that result from congenital anomalies. These robotic-assisted techniques are not limited to lymphatic surgery. “Our team has also used this microsurgical robotic technology to connect small blood vessels during tissue flap reconstructions after cancer removal surgery,” he adds.

The Cleveland Clinic Department of Plastic Surgery is a global leader in pioneering robotic technology in advanced lymphatic and cancer reconstruction, now adding microsurgical robotic procedures to their novel, minimal access, robotic tissue flap (DIEP) harvest offerings.

“We’re thrilled our patients had such successful outcomes in these two, unique cases and are encouraged to have seen equally impactful results for others over these last months. Our entire robotic reconstructive team is excited to incorporate this cutting-edge technology into personalized treatment plans, giving us more tools to deliver the best outcomes for our patients.”