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In contrast, Kenworthy et al. advocate for an open approach through a limited incision as it allows for use of
[14]
microsurgical instruments and finer control . In their series of 38 patients, they had an overall
complication rate of 15.8%. Donor site complications included one patient developing transient pancreatitis
[14]
and two patients developing ileus. Among 54 flaps, they only report one flap loss. Importantly,
preoperatively patient-reported cellulitis was present in 44.7% of patients and this number decreased to
13.2% postoperatively .
[14]
Most recently, several groups have adapted the surgical robot for harvest of the free omental flap as poor
visualization and inability for fine dissection have been a concern during laparoscopic harvest. Multiple
types of robotic-assisted intra-abdominal procedures have shown decreased hospital stay, operative blood
loss, and postoperative complications. Ciudad et al. first reported robotic-assisted harvest of the right
[35]
gastroepiploic lymph node flap for the treatment of lymphedema in 2016 . Using a two-surgeon approach,
a general surgeon performed the flap harvest with guidance from a plastic surgeon. A single 12-mm
supraumbilical port was placed for optical trocar and camera placement, followed by 8-mm ports 8 cm
lateral and 5 cm below the supraumbilical port on the right and lower left abdomen. 5-mm assistance port
was also inserted into the epigastrium. Dissection begins by identifying the omentum and its attachment to
the greater curvature of stomach and transverse colon. As in laparoscopic harvest, the omentum is separated
from the transverse colon. The vertical gastric branches are then ligated while making sure to maintain an
optimal flap width of 5 cm, and to maintain dissection parallel to the greater curvature of stomach. This
dissection moves toward the right, toward the pedicle at the right gastroepiploic artery and vein. After the
craniocaudal dissection is complete, the left gastroepiploic vessels are ligated. In the final step of the
operation, the right gastroepiploic pedicle artery and vein are separated, ligated, and divided . Noted
[35]
advantages of robotic-assisted as compared to the laparoscopic harvest include: superior visualization of the
anatomy in space, which improves precision of the dissection, lowering the risk of vascular pedicle injury.
[36]
[35]
Robot-assisted harvest eliminates tremor and provides for motion scaling . For patients, the robot-assisted
harvested offers better cosmetic outcomes compared to an open technique [17,35] . Improved instrument
articulation in the robotic system is another advantage . The superior visualization and instrumentation
[17]
are thought to better preserve the quality of the omental tissue for transfer [17,35] .

Frey et al. describe a series of five robotic-assisted omental flap harvests using the Intuitive robot . Four
[34]
patients underwent standard robotic flap harvest with 5 ports and one patient underwent single-port
harvest. All patients underwent dual-level transfers, and the flap was split based on nodal distribution and /
[34]
or watershed regions identified with near-infrared fluorescent angiography . The authors noted improved
visualization and depth perception compared to laparoscopy . Robotic equipment offers fluorescent optics
[34]
[34]
which can be used to visualize the vascular and lymph node patterns as well . Felmerer et al. recently
compared the complication profile of multi-port robot-assisted omental VLNT to supraclavicular
vascularized lymph node transfer . In their series, three patients experienced the sensation of abdominal
[36]
tension but no other donor site morbidities. In the supraclavicular VLNT group, 12 patients experienced
donor site complications and one patient required reoperation . Thus, they conclude that robot-assisted
[36]
omental VLNT is superior due to low donor site morbidity .
[36]
As healthcare systems aim to decrease costs, the cost effectiveness of laparotomy, laparoscopy, and robotic
use should be considered. In the case of robot-assisted omentum harvest, there is an increased cost of
robotic interventions that must be considered along with benefits . Recently, Simianu et al. compared the
[35]
cost-effectiveness of open, laparoscopy, and robotic colectomy. They found that open colectomy cost more
and achieved lower QOL than robotic and laparoscopic approaches . From both the societal perspective
[37]
and healthcare sector perspective the robotic colectomy cost more than laparoscopic and yields minimal