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Figure 3. (A) Intraoperative image illustrating the insetting of a flow-through omental flap [39] ; (B) Postoperative MRA imaging of an
operative extremity after flow-through omental flap inset. The blue arrow reflects the location of the cephalic vein. The red arrows
correspond to the arterial anastomoses. *denotes lymph nodes [39] .

differences in QOL. Thus, the laparoscopic approach was considered more frequently cost-effective across a
wide range of willingness to pay thresholds . However, robotics can surpass laparoscopy in cost-
[37]
effectiveness if per-case instrument costs decrease, robotic operating room time decreases, increased QOL,
and decreased hernia rates . They conclude, that with increased use of robotic technology in colon surgery,
[37]
[37]
the burden to prove its benefits over laparoscopy remain . Similarly, El Hachem et al. compared clinical
outcomes and costs associated with robotic single-site surgery compared with those of conventional
laparoscopy (CL) in gynecology . They found that compared to CL, robotic surgery had comparable
[38]
clinical outcomes, but higher operative times, higher disposable equipment cost per case and higher total
hospital charges .
[38]

CONCLUSION
Vascularized omental lymph node transplant is a suitable physiologic treatment option for individuals with
ISL stage II or III lymphedema and may be especially beneficial for patients with lymphedema-related
cellulitis. Vascularized free omental tissue may be harvested laparoscopically or via a laparotomy, but care
should be taken to minimize intra-abdominal complications and incisional hernia. Recent advances in
robotic surgery make this an attractive harvest method due to superior visualization of the omentum and
more precise dissection which minimizes disruption to lymphatic tissue as compared to laparoscopy.
However, further investigation on novel minimally invasive approaches for VOLT and novel uses for the
flap are necessary [Figure 3A and B].

DECLARATIONS
Authors’ contributions
Design, conception, drafting of the manuscript, manuscript preparation: Skladman R
Manuscript preparation: Moritz WR
Manuscript preparation: Tenenbaum EJ
Design, conception, editing of the manuscript, manuscript preparation: Christensen JM
Design, conception, administrative supportconception, administrative support: Sacks JM

Availability of data and materials
Not applicable.