The omental flap is a versatile flap that has been used locally as a pedicled flap for many decades. Its uses have included thoracic coverage, treatment of lymphedema, head and neck reconstruction, and soft tissue restoration in Parry–Romberg Syndrome, among others.1–6 McLean and Buncke7 first described free transfer of the omentum flap for a scalp wound in 1972 via a traditional open laparotomy. The first laparoscopic harvest of the omentum was reported in 1993 using a 2 trocar technique by Saltz et al.8 The key points of this operation involved identifying the omentum laparoscopically and then creating an 8 cm mini-laparotomy incision to exteriorize the flap and perform isolation of the vascular pedicle. Subsequent modifications have resulted in a nearly entirely minimal access harvest.3,9,10 We describe our operative technique in detail and include our video presentation as supplemental content (see Supplemental Digital Content, Video, http://links.lww.com/SCS/A256, which demonstrates laparoscopic harvest of omental free flap for cranial reconstruction).
The patient is placed in the supine position for flap harvest with the legs adducted if possible. After the induction of general anesthesia, the first team performs wound preparation and identification of recipient artery and veins (Fig. 1A). We try to have available 2 recipient veins; however, in this case, only a single recipient and donor vein were available. We used the superficial temporal artery and vein in this instance.
At the conclusion of the recipient vessel isolation the second operative team performs laparoscopic harvest of the omental flap. Please refer to the embedded video for operative videos of the flap harvest (see Video, Supplemental Digital Content, which demonstrates laparoscopic harvest of omental free flap for cranial reconstruction). A nasogastric tube is placed to decompress the stomach. Abdominal access is initially via a periumbilical 10 mm trocar. Abdominal insufflation up to 20 to 30 mm Hg pneumoperitoneum is commenced and complete peritoneoscopy is performed. Four separate 5-mm trocars are placed under direct vision, 2 each on either side of the abdomen (Fig. 1B). With the primary surgeon standing to the patient's right, the omentum is delivered out of the lower abdomen and reflected to the left upper quadrant using atraumatic graspers. The assistant, standing on the left side, tents up the omentum exposing the relatively transparent attachments to the transverse colon. The Harmonic Scalpel (Ethicon Endosurgery, Somerville, NJ) is used to divide these attachments. Conventionally, we work from the hepatic flexure toward the splenic flexure. With the splenic flexure identified, the omentum is distracted toward the midline and the short gastric vessels are taken down off of the spleen with the Harmonic Scalpel. The greater curvature attachments are taken down. The omentum is distracted back down into the lower abdomen and the greater curvature of the stomach is tented upward so that the gastroepiploic vessels can clearly be visualized. This arcade is taken off the greater curvature of the stomach with care so as not to damage this arcade. We move in a right to left direction until we meet our original dissection plane at the short gastric region. The flap will be nearly fully mobilized except for the remaining attachments near the pylorus; these are the right gastroepiploic artery and vein and are the primary pedicle of this flap.
The flap is exteriorized through a 4-cm subxiphoid incision (Fig. 1C). A laparoscopic grasper is used to position the distal end of the flap beneath the subxiphoid incision prior to its creation as this will result in desufflation and make the flap otherwise difficult to retrieve. We use a Weitlaner retractor to aid exposure. The flap is gently exteriorized with care to avoid twisting. Under loupe magnification and a headlight, the last 4 to 6 cm of the pedicle is isolated with defatting to facilitate microvascular anastomosis. The flap pedicle is divided as proximally as possible.
Subsequent microvascular transfer is done using standard techniques. The second team takes this time to close the abdominal cavity using heavy nonabsorbable sutures for the abdominal fascial closure at the subxiphoid incision. The port incisions are closed with absorbable buried dermal sutures and skin glue.
Patients have standard postop flap checks according to our unit's protocol and are allowed to eat a bland diet on postop day 1.
A 23-year-old female fire fighter was ejected from a fire truck and sustained an isolated scalp soft tissue injury after impact with the pavement (Fig. 2A). This wound was down to the outer table of the skull and accounted for approximately 40% of the hair-bearing scalp and was nearly completely devoid of pericranium. She underwent operative debridement followed by laparoscopic free omental flap transfer by the previously described approach. The recipient vessels were the ipsilateral superficial temporal artery and vein: the flap pedicle had to be tunneled for about 4 cm to reach these vessels. An end-to-end anastomosis was possible for both sets of vessels. Only a single vein was found on both the recipient and donor sides. The flap vein was approximately 2.5 mm and the artery 1.5 mm. The flap was skin grafted at the same setting to provide complete soft tissue coverage (Fig. 2B). The patient did well postoperatively and was discharged on postop day 10. She had no ileus and no other complications. She has had stable long-term coverage over 3 years of follow-up (Fig. 2C and D).
The omental free flap is a versatile flap for many reconstructive situations.11–13 Its many advantages include a large surface area and it will cover circumferential injuries of the extremities, or as in this case, expansive scalping injuries. It can be folded, wrapped, and stuffed into crevices not accommodated for by other flaps. It has a donor site that is arguably one of the least conspicuous of all free flaps and there is little donor site functional disability in contrast to many other options such as the latissimus dorsi and rectus abdominus flaps. Contouring of this flap in the head and neck region is also easier in comparison to the bulk of the anterolateral thigh and latissimus dorsi free flaps. The omentum flap can be single layered, folded, or trimmed to make a smooth contour to the scalp. Secondary contracture of the overlying skin graft also helps to provide a nice smooth surface to the recipient site.
Laparoscopic harvest allows for a 2-team approach and many experienced laparoendoscopic surgeons will find themselves comfortable harvesting this flap using the technique described. However, care must be taken around the right gastroepiploic pedicle to prevent damage to the flap. In our institution the microsurgeon undertakes the final pedicle dissection using loupe magnification when the flap is exteriorized to prevent injury. The pedicle can be lengthened safely by transillumination and dividing minor arcade vessels which allows the pedicle reach outside the zone of injury without the need for vein grafts. We recommend that this be done prior to flap pedicle division to minimize ischemic time. The caliber of the pedicle is large enough to allow end-to-end or end-to-side anastomosis to most standard recipient vessels. Additionally, we were able to tunnel the pedicle by employing the defatting technique descried above. While the single veins our flap had may be concerning, we did not encounter flap congestion in our patient. Another key point of this procedure is that the omental free flap can be harvested relatively quickly. Our operative times are usually less than 1 hour for flap elevation.
We note that care should be taken when selecting appropriate patients for omental flap harvest. Patients on either side of the body mass index spectrum may have too little or too much omentum for transfer, though excess omentum can be shortened if necessary. A history of prior abdominal surgery and inflammatory conditions should be noted on preoperative evaluation: our group recently encountered a patient during pedicled omental harvest for sternal osteomyelitis who had undiagnosed diverticulitis causing phlegmon and adhesion formation involving the bulk of the flap which prevented use of the omental flap. In patients with a thin omentum, soft tissue coverage may be limited over important structures such as exposed hardware. We have successfully addressed this issue by folding the flap 2 or 3 times on its self. There are other disadvantages to this flap. The omental flap typically requires a skin graft to resurface it. This adds to patient morbidity and limits its application on weight-bearing surfaces. Last, incisional hernias will occur with regular use of this flap but since the risk is low, this should not preclude consideration of this flap as a reconstructive option.
The laparoscopic free omental flap is a great option for coverage of large wounds of varying etiology including cancer resection and traumatic injury. Its large bulk, long pedicle, and ease of harvest along with low donor site morbidity make it an attractive reconstructive option. While it will not support a weight-bearing reconstruction, it will cover circumferential defects of the leg. We have detailed our 2-team, minimally invasive approach and included video supplementation along with a case report of successful use of this flap in complex head and neck injuries. The laparoscopic omental free flap should be considered a routine part of the reconstructive surgeons armamentarium.
Special thanks to Dr Ricky Clay for digital reformatting of our video files.
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