Laparoscopic Omental Flap Harvest

Abstract

Despite being a very important tool in the large armamentarium of reconstructive surgery, it has lost much of its use due to its donor site morbidity secondary to laparotomy. With the advent of laparoscopy and therefore minimizing its morbidity, harvesting the omentum laparoscopically has become the preferred modality for this flap. In this chapter we present the essential steps for laparoscopic harvest of omentum for pedicled or free tissue transfer.

Indications

• 1. Large soft tissue defect in any location requiring vascularized tissue

• 2. Mediastinal defect with or without infection

• 3. Advanced and end-stage lymphedema

• 4. Large soft tissue free flap needed in a morbidly obese patient

Possible Complications

• 1. Inadvertent bleeding or pedicle injury and the need to convert to open technique

• 2. Inadvertent intra-abdominal visceral injury

• 3. Flap partial or total necrosis after inset

• 4. Abdominal hernia at the flap delivery site

Essential Steps

Preoperative Markings

• 1. One umbilical camera port and three other operative trocar ports

Intraoperative Details

• 1. Patient is placed in the supine position under general anesthesia.

• 2. Prepping and draping of the abdomen and recipient defect in a sterile fashion.

• 3. Pneumoperitoneum and access using Veress needle and Optiview trocar.

• 4. Three additional 5 mm trocars are inserted under vision.

• 5. Dissection is done either by using ultrasonic energy source or monopolar cautery. Gentle traction and minimal touch technique are required throughout the harvest.

• 6. Colo-epiploic detachment is performed along avascular plane.

• 7. Transpose the entire omentum cranially to expose the entire colon.

• 8. All attachments between the splenic flexure on the left and hepatic flexure on the right is divided for extra mobility.

• 9. The lesser sac is entered and short gastric and left gastroepiploic vessels are ligated. Surgical hemoclips may be required to divide any large vessels for better hemostasis.

• 10. Section of anastomotic branches between the Barkow’s arcade and gastroepiploic arcade.

• 11. Avoid traction injury to the spleen or thermal injury to the stomach edge.

• 12. The omentum is then mobilized from its gastric attachments pedicled on the right gastroepiploic artery.

• 13. Infraumbilical or epigastric incision is extended, approximately 3 cm for atraumatic extraction.

For Pedicled Use

• 14. Transposition of omentum to the recipient defect followed by inset

For Free Tissue Transfer

• 15. Dissect the right gastroepiploic artery.

• 16. Prepare the recipient soft tissue defect , divide the flap pedicle, and render the flap ischemic, ready for free tissue transfer.

• 17. Microsurgical anastomosis is performed.

Postoperative Care

• 1. Free flap: Monitoring (Doppler signal) every 1 h for the first 48 h followed by checking every 2 h for the consecutive 48 h then checking every 4 h until discharge

• 2. General regular patient postoperative monitoring

• 3. Pain control

Operative Dictation

Diagnosis :

• 1. Large soft tissue defect (any location) requiring vascularized tissue

• 2. Mediastinal defect

• 3. Advanced and end-stage lymphedema

Procedure: laparoscopic omental flap harvest

Indications

This is an X-year-old male/female presenting with extensive soft tissue defect requiring vascularized tissue for coverage.

Or

This is a Y-year-old male/female advanced upper/lower limb lymphedema resistant to conservative and physiologic surgical measure. As a last option, patient is a good candidate for ablative surgery and coverage with vascularized lymphoid tissue.

Description of the Procedure

After obtaining an informed consent, the patient was taken to the operating room. He was placed in supine position. A proper time out was performed. Perioperative antibiotics were given. Sequential compression devices were placed. General anesthesia was instituted. Pressure points were padded. A nasogastric tube and Foley catheter were inserted. The patient was prepped and draped in the sterile surgical usual fashion.

Attention was then turned to the abdomen that was insufflated with a Veress needle up to 14 mmHg. A 10-mm midline fascial opening was obtained and direct entry in sharp fashion was performed and without injury to deep structures. A 10mm trocar is inserted through the preiously created fascial opening. A laparoscopic camera is inserted thourhg the 100mm torcar. Insertion of additional two working 5-mm trocars lateral to the left rectus muscle and another 5-mm trocar lateral to the right rectus muscle is all placed under direct vision.

After exploration of the abdomen , the omentum was reflected cranially for better exposure. Dissection was done by using ultrasonic harmonic energy source. Gentle traction and minimal touch technique were maintained throughout the harvest. Colo-epiploic detachment was performed along the avascular plane. All attachments between the splenic flexure on the left and hepatic flexure on the right were divided for extra mobility. The lesser sac was entered and short gastric and left gastroepiploic vessels were ligated. Surgical hemoclips are often needed to clip any large vessels before dividing them for better hemostasis. Section of anastomotic branches between Barkow’s arcade and gastroepiploic arcade was completed. Any traction injury to the spleen or thermal injury to the stomach edge was avoided.

(Depending on the amount of mobilization needed, the omentum may be left attached to the greater curvature of the stomach. Most often, full mobilization is needed, and the omentum is released off its gastric attachments, pedicled based on the right gastroepiploic artery that is meticulously dissected.)

For Pedicled Use (Mediastinal Coverage)

An upper epigastric incision was made near the xiphoid through the mediastinal defect . The omentum was delivered from the abdominal cavity into the sternal wound without tension or torsion on the pedicle. (For deep mediastinal wound, delivery of the flap can be performed through an opening in the diaphragm or pericardium.) Flap inset was completed.

For Free Tissue Transfer

After preparing the donor vessels at the recipient defect, the right gastroepiploic pedicle was skeletonized carefully. The flap was rendered ischemic, ready for transfer. An infraumbilical incision was extended, approximately 3 cm for atraumatic extraction. The flap was extracted and transferred to the soft tissue defect and inset. Microvascular anastomosis was performed. Split-thickness skin graft was applied on a part or the whole flap for adequate monitoring.

Intra-abdominal hemostasis and irrigation were secured, and the trocar sites were closed with interrupted deep dermal suture using 4-0 Monocryl. Patient tolerated the procedure well and was transferred to PACU in stable conditions.