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Figure 2. (A) Vascularized omentum lymphatic transplant intraoperative photograph; (B) ICG fluorescence. ICG: intraoperative
indocyanine green.

abdominal operations or intra-abdominal infections.

Laparoscopic versus open approach: the debate continues
Thirty years from the first report of a laparoscopic omental harvest, the debate surrounding whether to use
an open or laparoscopic approach continues. Kamei et al. were first to report the advantages of the
[22]
laparoscopic approach: a smaller scar burden, less pain, and early recovery . However, due to the difficulty
of identifying the left gastroepiploic artery and risk of injury to the spleen, they recommend an open
laparotomy when the full volume of the omentum is required .
[22]
In 2015, Nguyen and Suami described the laparoscopic free omental lymphatic flap harvest with
anastomosis to the forearm. Both patients in their series reported significant improvement in swelling,
fatigue, heaviness, tightness, stiffness, sleep loss, aching. Neither patient experienced further episodes of
cellulitis postoperatively . Using a laparoscopic approach, they were able to reduce the risk of donor site
[15]
complications without sacrificing the benefits of free omental lymphatic flap transfer. Volume differentials
improved and lymphoscintigraphy demonstrated improved tracer uptake without subjecting patients to
postoperative GI symptoms or hernia formation. Thus, they concluded that a minimally invasive approach
to free omental transfer circumvents complications that may arise due to the celiotomy or use of a pedicled
flap. Subsequently, they conducted the largest prospective cohort study of patients undergoing laparoscopic
free omental lymphatic flap transfer. They collected long-term outcomes on 42 patients with a mean follow-
up of 14 months. 83% of patients reported subjective improvements in swelling, fatigue, heaviness, tightness,
stiffness, sleep loss, aching, and sleep quality at final follow-up . There was a mean volumetric
[16]
improvement of 22% in the affected extremity in their patient cohort, but four patients had postoperative
volume increases. They noted a 42.9% circumferential decrease in the upper extremity above the elbow and
[16]
36.4% circumferential decrease below the elbow . Their complication rate was 16% which included one
episode of pancreatitis, one patient requiring nasogastric tube replacement due to pedicle dissection close to
the body of the stomach, and one flap loss .
[16]

Chu et al. reviewed several series of cases of laparoscopic harvest of the omental flap and reported no major
complications related to the donor site, with only transient abdominal pain that quickly resolved .
[24]
However, due to the risk of complications with minimally invasive techniques, several groups argue that
successful laparoscopic free omental lymphatic flap elevation is dependent on the surgeon having both
minimally invasive and microsurgical expertise [15,16] . Alternatively, a two-team approach that involves both a
general surgeon to harvest the omentum and plastic surgeon to prepare the recipient vessels may increase
patient safety [14,24] . In the case of injury to the pancreas or massive bleeding during laparoscopic harvest, a
general surgeon will be able to quickly convert the procedure to an open method.