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However, in many cases, using only a select portion of the omentum may be more appropriate than
transferring the entirety of it. For example, if the planned recipient site is the more distal extremity, use of
the entire omentum may bring excessive bulk. Additionally, previous abdominal operations, intra-
abdominal adhesions, and scarring may limit omental harvest. Even patients without a history of abdominal
surgery often have irregular perfusion of the omentum, and intra-operative perfusion assessment with
indocyanine green or similar technique is valuable to appropriately tailor the flap and decide on outflow
veins .
[23]

Another technique, sometimes described as “gastroepiploic lymph node transfer”, is to harvest only the
perivascular tissue and lymph nodes surrounding and including the right or left gastroepiploic vessels while
sparing the remainder of the omentum. It is important to note that in the literature, when referring to
VLNT, the terms “gastroepiploic” and “omental” are used somewhat interchangeably. Both terms are used
to describe the same lymph node basin. Gastroepiploic VLNT has been described laparoscopically in several
[25]
studies with reasonable operative duration and safety [13,16,24] . Robotic harvest has been reported as well .
Again, perfusion of the gastroepiploic nodes should be assessed, especially when the majority of the
omentum is not included.

Some studies have suggested that treating a lymphedematous extremity with two VLNTs (one proximal and
one more distally) may be beneficial, and the omentum can easily be split into two flaps from a single donor
site. The two flaps can be used for the treatment of bilateral lymphedema or two sites in a single extremity.
[16]
Three recent studies have shown success with double omental VLNT to a single limb. Ciudad et al. first
reported their initial series of seven patients with upper and lower limb lymphedema who underwent
double omental VLNT and demonstrated a mean circumference reduction rate (CRR) of 43.7% at 9 months
[14]
without any reported complications. In 2018, Kenworthy et al. published a series of 16 patients who had
double omental VLNT. They also reported improved clinical symptoms and a decrease in postoperative
cellulitis; additionally, visible uptake into the transplanted omentum was present on lymphoscintigraphy
(50%, three of six patients) and ICG lymphangiogram (20%, one of five) at 1 year follow-up. Similarly, there
were no donor site complications in that study. Finally, in 2019, another series of 16 patients treated with
[17]
double omental VLNT for lower extremity lymphedema was published by Maruccia et al. . Mean CRR was
43.4% above the knee and 58.3% below the knee at 12 months, and validated quality of life survey scores
improved significantly.

In 2019, Ciudad et al. published a series of patients who underwent double gastroepiploic VLNT with a
[18]
simultaneous excisional procedure, radical reduction with preservation of perforators. This study achieved
the greatest mean CRR among VLNT reports. Sixteen patients were included and had a mean follow-up of
14.2 months. Mean CRR was 74.5% for upper extremity procedures and 68% for the lower extremity.

Reported complications, with rates ranging from 0% to 16%, following omental VLNT include flap loss,
pancreatitis, delayed return of bowel function, and hernia [13,26] . There have been no reports of bowel injury
or ischemia. Both the proximal and distal ends of the gastroepiploic vein can be anastomosed on transfer to
allow dual venous outflow to decrease the risk of venous hypertension in the omental lymph node flap.
[27]
Another option is to moderate inflow by creating an arterial flow-through flap .
[28]
JEJUNAL MESENTERIC LYMPH NODE TRANSFER
Use of the jejunal mesenteric lymph nodes for VLNT was recently described as an additional intra-
abdominal option for VLNT. Coriddi et al. initially published the concept of the jejunal VLNT in 2017 .
[29]
[19]
In this initial study, including fifteen patients with an average follow-up of 9.1 months, 14 had viable