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Introduction Massive localised lymphedema (MLL) is considered a rare large, pendulous localised benign overgrowth of lymphoproliferative tissue commonly seen in patients with morbid obesity. Histologically, it may be mistaken for well-differentiated liposarcoma; hence, it is also known as pseudosarcoma. Presentation of case We describe the successful management of MLL of the left medial thigh in a 35-year-old man weighing 220 kgs (BMI 80.8 kgs/m2). He underwent a concurrent laparoscopic sleeve gastrectomy with surgical resection of the MLL. He recovered well and during our last follow up six months after the operation, he is ambulating well and weighs 148 kgs (BMI 54.4 kgs/m2). Discussion MLL is a form of secondary lymphedema resulting in disruption or compression of normal lymphatic drainage due to fat accumulation in obese patients. Patients usually delay treatment for even up to a decade, when it becomes sufficiently large enough to restrict mobility and daily activities, or when it becomes infected. MLL is primarily a clinical diagnosis. A detailed history regarding its slow growth spanning over the years makes malignancy less likely. However, if left untreated, MLL may progress to angiosarcoma. Imaging studies such as computed tomography (CT) and a Magnetic Resonance Imaging (MRI) are usually performed to rule out malignancy or vascular malformations. A tissue biopsy is not recommended unless there are suspicious pigmented lesions. Conclusion MLL remains to be underdiagnosed. Due to the obesity epidemic, clinicians must be aware of this once rare disease. The role of concurrent bariatric surgery with surgical resection of MLL warrants further studies., Highlights • Massive localised lymphedema is a rare, benign overgrowth of lymphoproliferative tissue commonly associated with obesity. • Patients usually delay seeking treatment until it affects their daily activities, or when it becomes infected. • A tissue biopsy is not recommended unless there are suspicious pigmented lesions. • MLL remains to be underdiagnosed. Due to the obesity epidemic, it is essential that clinicians be aware of this disease. • The role of concurrent bariatric surgery with surgical resection of MLL warrants further studies.