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techniques.

Relevant anatomy
[19]
The greater omentum is derived from the peritoneal layers covering the anterior and posterior stomach .
The right omentum continues to the lower portion of the superior duodenum. The left omentum continues
laterally to enclose the short gastric branches of the splenic artery. The omentum can extend inferiorly as an
apron toward the pelvis to cover the small intestine before turning on itself and extending superiorly to
envelop the transverse colon. The greater omentum is perfused by the left and right gastroepiploic arteries.
The superior aspect of the omentum contains these vessels and the accompanying veins as they pass inferior
and parallel to the greater curvature of the stomach.

Operative technique
Open omental harvest
[14]
The procedure is performed through a short midline epigastric incision, 6-8 cm in length . The omentum
is identified. The right portion of the omentum is separated off the transverse mesocolon without disruption
to its blood supply to prevent bowel ischemia. Dissection is continued to the greater curvature of the
stomach, where the branches to the greater curvature are ligated, while preserving a safe distance from the
gastroepiploic pedicle. Dissection proceeds parallel to the greater curvature of the stomach toward the right
and left extent of the gastroepiploic vessels. When the flap has been mobilized, the gastroepiploic vessels are
clipped and divided . Most often, the right gastroepiploic is used as the primary pedicle. It is usually
[15]
possible to palpate lymph nodes near the proximal pedicle which may be included but caution is required to
avoid the pancreas . Kenworthy et al. advocate for the use of ICG angiography to assess perfusion of the
[14]
flap as there are frequently regions of relative ischemia within the omentum . Once the flap is harvested,
[14]
the gastroepiploic vessels are anastomosed to the already-isolated and prepared recipient vessels. To avoid
venous hypertension after microanastomosis of the primary artery and vein, a distal venous anastomosis
[15]
second recipient vein should be considered .
A unique advantage of the VOLT is that the consistent caliber of the gastroepiploic vessels, running
longitunally through the flap, enableing division of the omentum into multiple flaps. Thus far, omentum is
the only donor site that is capable of flap transfer to multiple recipient sites, or a dual-level transfer . In the
[14]
upper extremity, arterial recipient vessels include the radial recurrent artery or end to side on the distal
radial artery, and venous recipient vessels include deep vena comitans or the cephalic vein .
[14]

Laparoscopic omental harvest
The laparoscopic omental harvest begins with a 10-mm infraumbilical port and insufflation. 5-mm ports are
placed lateral to the right rectus abdominis, above and below the level of the umbilicus. Any adhesions
noted on visualization of the omentum should be taken down at this stage. The stomach is retracted
anteriorly and the short gastric vessels supplying the greater curvature of the stomach are individually
clipped and divided, maintaining the line of dissection parallel to the greater curvature of the stomach, to
preserve the length of the gastroepiploic vessels. As before, the right or left gastroepiploic vessels can be
preserved for eventual anastomosis. The omentum is then separated from both the stomach and the
transverse colon, as described before. After extending one of the port incisions to 4-cm, the omentum can
be removed from the abdominal cavity and used as a free flap [19-24] [Figure 1].

HISTORY OF THE OMENTUM FLAP
Although the free vascularized omental flap has come into favor for treatment of lymphedema, it was first
described as a pedicled flap . In 1966, Goldsmith, De Los Santos, and Beattie first described the use of
[25]
[26]
omental tissue for the treatment of lower extremity lymphedema . One end of the gastroepiploic pedicle