EDITOR: Chronic, severe, limb lymphoedema can be a debilitating condition for a patient, in terms of both the cosmetic appearances of the limb and its mechanical function. The condition may result from localized or systemic congenital agenesis of lymph vessels, or secondary to mechanical obstruction of lymph flow. The latter may occur due to malignancy, surgery, radiotherapy or filiariasis [1]. The consequent perilymphatic extravasation of proteinaceous fluid causes hypertrophy of the affected limb, with unsightly induration of the skin. In a minority of patients, conservative therapy is unsuccessful. Rarely, tissue reduction surgery may be attempted by performing Charles' or Homans' procedures. Charles' procedure involves radical excision of skin and subcutaneous tissue with skin grafts. Homan's procedure involves elliptical excisions of skin and subcutaneous tissue with primary closure. A 46-yr-old female weighing 90 kg presented for Homans' procedure. When she was aged 28 yr, pelvic radiotherapy - following a Wertheim's operation for cervical carcinoma - led to incapacity through chronic lymphoedema of her left leg. She was otherwise fit and well except that she was a non-insulin-dependent diabetic. Preoperatively, her blood haemoglobin concentration was 13.1 g dL−1, and 6 units of blood were cross-matched. Standard patient monitoring was established. Then a 20-G cannula was inserted into a vein on the dorsum of the patient's left hand. After preoxygenation, general anaesthesia was induced with midazolam 3 mg, fentanyl 100 μg and a propofol infusion 1% (target plasma concentration = 5 μg mL−1). Bag and mask ventilation of the lungs was straightforward, and vecuronium 10 mg was administered. The patient's trachea was intubated with a size 8-cuffed oral endotracheal tube (Mallinckrodt UK Ltd, Bicester, UK), correct placement being confirmed by auscultation, and the lungs ventilated using a Dräger Julian ventilator (Dräger Medical UK Ltd, Hemel Hempstead, UK) attached to a circle-breathing system. A 14-G cannula was inserted into a vein on the dorsum of the left wrist. In the operating room, the patient was carefully positioned in the right lateral position. Anaesthesia was maintained using a target-controlled propofol infusion 1% (3-5 μg mL−1), a remifentanil infusion (1 mg h−1) and a 50/50 air-oxygen respired mixture. Morphine 10 mg, ondansetron 4 mg and vancomycin 1 g were administered. The recorded blood loss (surgical suction and swab weights) during the 150 min procedure was 2220 mL. Six units of packed blood cells, colloid 1 L and Hartmann's solution 1 L were infused intravenously (i.v.), via a fluid-warming device. The patient was extubated uneventfully at the end of the operation; she required minimal postoperative pain relief (oral acetaminophen) and was discharged from the hospital after a week. The initial management of limb lymphoedema is conservative; compression bandaging and elevation oppose the Starling forces that produce fluid extravasation [2]. General skin care reduces the incidence of infection. Surgery is reserved for patients in whom the size and weight of a limb inhibit its use. Surgery may involve bypass procedures (lymphovenous and lymphaticovenous anastomoses) or debulking procedures [3]; the latter include Homans' [4] and Charles' [5] procedures. Anaesthesia for Homans' procedure may be complicated by serious haemorrhage. Intraoperative blood loss may be limited by the application of a tourniquet, but this is not practicable if the lymphoedema extends proximally. Blood loss may be overestimated, because 'intraoperative blood loss' combines actual blood loss and 'third space' tissue oedema loss. The procedure is not subjectively very painful, despite extensive skin incisions, although regional anaesthesia may be employed as an adjunct to general anaesthesia in order to reduce perioperative blood loss [6]. Postoperatively, steep elevation of the affected limb reduces tissue oedema formation, which decreases both tension on suture lines and serosanguinous fluid loss through the wound, augmenting healing. S. M. White T. Hunt Department of Anaesthetics; St. Thomas' Hospital; London, UK