Narrative review of flaps and grafts in robotic reconstructive urologic surgery.

Background and Objective: Flaps and grafts are used for filling dead space, ureteral substitution, and as mesh alternatives. The surgical robot is invaluable in urologic reconstructive surgery due to the ability of the robot to reach the deep pelvis, its minimally invasive access, the ability to use indocyanine green to identify structures and assess tissue perfusion and viability, and ergonomics for the surgeon. Robotic reconstruction can involve tissue transfer in the form of flaps and grafts to provide form and function to organs that have been damaged by iatrogenic injuries, trauma, infections, cancer, radiation injury, or congenital abnormalities. Common flaps and grafts can be readily adapted to the robotic approach. In this literature review, we examine the robotic use of flaps and grafts in reconstructive urology. Methods: A thorough literature review was conducted via a PubMed search for predefined terms. Key Content and Findings: Flaps and grafts in reconstructive urology are used for interposition, ureteral substitution, and as mesh alternatives. Omental flaps are used for tissue interposition, or to provide structure and nutrients, and are easily employed with the robot. Various robotic applications of peritoneal flaps have been described. Vascular rectus abdominis musculocutaneous flaps are well-vascularized flaps that occupy dead space and provide structural support, which can be harvested readily with the robot. Sigmoid epiploica are an excellent flap for pelvic reconstruction. Gracilis flaps and fascia lata grafts are well-tolerated and provide space occupying tissue. Boari flaps aid in robotic ureteral reconstruction, especially in the setting of long defects. Oral mucosa is excellent for ureteral or bladder neck reconstruction. Rectal mucosa is well-tolerated and easy to harvest robotically for a variety of urinary tract reconstructive applications. The appendix or ileum can be interposed for repair of damaged ureters. Conclusions: Various flaps and grafts have been adapted for robotic reconstructive urology. As the field develops, refinement of techniques and innovation in flaps and employment of the robot will propel this field forward. More studies, especially comparative studies, are needed to elucidate the flaps and grafts that are most likely to be successful with the least morbidity for each use case.

Pedicled omental flaps for complex wound reconstruction following surgery for primary spine tumors of the mobile spine and sacrum.

OBJECTIVE: Surgery for primary tumors of the mobile spine and sacrum often requires complex reconstruction techniques to cover soft-tissue defects and to treat wound and CSF-related complications. The anatomical, vascular, and immunoregulatory characteristics of the omentum make it an excellent local substrate for the management of radiation soft-tissue injury, infection, and extensive wound defects. This study describes the authors' experience in complex wound reconstruction using pedicled omental flaps to cover defects in surgery for mobile spine and sacral primary tumors. METHODS: A retrospective cohort analysis was conducted on 34 patients who underwent pedicled omental flap reconstruction after en bloc resection of primary sacral and mobile spine tumors between 2010 and 2020. The study focused on assessing the indications for omental flap usage, including soft-tissue coverage, protection against postoperative radiation therapy, infection management, vascular supply for bone grafts, and dural defect and CSF leak repair. Patient demographic characteristics, tumor characteristics, surgical outcomes, and follow-up data were analyzed to determine the procedure's efficacy and complication rates. RESULTS: From 2010 to 2020, 34 patients underwent pedicled omental flap reconstruction after en bloc resection of sacral (24 of 34 [71%]) and mobile spine (10 of 34 [29%]) primary tumors, mostly chordomas. The patient cohort included 21 men and 13 women with a median (range) age of 60 (32-89) years. The most common indication for omental flap was soft-tissue coverage (20 of 34 [59%]). Other indications included protecting abdominopelvic organs for postoperative radiation therapy (6 of 34 [18%]), treating infections (5 of 34 [15%]), providing vascular supply for free fibular bone graft (1 of 34 [3%]), and repairing large dural defects and CSF leak (2 of 34 [6%]). The median (range) follow-up was 24 (0-132) months, during which 71% (24 of 34) of patients did not require additional surgery for wound-related complications. At last follow-up, 59% (20 of 34) had stable disease and 32% (11 of 34) had recurrence, had progression of disease, or had been discharged to hospice after treatment. CONCLUSIONS: The pedicled omentum is an effective local tissue graft that can be used for complex wound reconstruction and management of high-risk closures in primary spine tumors. This technique may have a lower rate of complications than other approaches and may influence surgical planning and flap selection in challenging cases.

Laparoscopically harvested omental flap for immediate breast reconstruction: a retrospective single-center study of 300 cases.

BACKGROUND: The laparoscopically harvested omental flap (LHOF) has been used in partial or total breast reconstruction, but most studies on LHOF were case reports or small case series. However, the clinical feasibility and oncological safety of LHOF in oncoplastic breast surgery remains controversial. This study reported our experience applying LHOF for immediate breast reconstruction. METHODS: Between June 2018 and March 2022, 300 patients underwent oncoplastic breast surgery using LHOF at our institution. Their clinicopathological data, complications, cosmetic outcomes, and oncologic outcomes were evaluated. RESULTS: All patients underwent total breast reconstruction using LHOF after nipple-sparing mastectomy. The median operation time was 230 min (ranging from 155 to 375 min). The median operation time for harvesting the omental flap was 55 min (ranging from 40 to 105 min). The success rate of the laparoscopically harvested pedicled omental flap was over 99.0%. Median blood loss was 70 ml, ranging from 40 to 150 ml. The volume of the flap was insufficient in 102 patients (34.0%). The overall complication rate was 12.3%. Subcutaneous fluid in the breast area (7%) was the most common reconstruction-associated complication, but most cases were relieved spontaneously. The incidence rate of omental flap necrosis was 3.3%. LHOF-associated complications occurred in two cases, including one case of incisional hernia and one case of vascular injury. Cosmetic outcomes were satisfactory in 95.1% of patients on a four-point scale by three-panel assessment and 97.2% using the BCCT.core software. Two local and one systemic recurrence were observed during a median follow-up period of 32 months. CONCLUSIONS: The LHOF for immediate breast reconstruction is a safe and feasible method that involves minimal donor-site morbidity, satisfactory cosmetic outcomes, and promising oncologic safety.

Flaps and Grafts in Robotic Reconstructive Surgery.

PURPOSE OF REVIEW: The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques. RECENT FINDINGS: Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.

The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis.

BACKGROUND: Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs). METHODS: A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS). RESULTS: Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF. CONCLUSIONS: Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.

Successful Management of Multiple Giant Anterior Sacral Meningoceles Through an Anterior Approach in a Patient With Marfan Syndrome: A Case Report and Literature Review.

Meningoceles refer to the protrusion of meninges filled with cerebrospinal fluid (CSF) through a bone defect. There is scarce literature on the management of multiple giant anterior sacral meningoceles (ASMs). We report the case of a patient with Marfan syndrome presenting with gait disturbances and dizziness triggered by posture changes due to multiple giant ASMs. The patient was managed through an anterior approach involving a multidisciplinary team of surgeons. Care was taken to limit the persistence of CSF leak using an omental pedicled flap. This technique has only been mentioned twice in the literature for such cases. A literature review was conducted focusing on the evolution course and surgical strategy of meningoceles.

Immediate breast reconstruction with laparoscopically harvested omental flap: A retrospective analysis with a maximum 12-year follow-up.

PURPOSE: To evaluate the clinical efficacy of immediate breast reconstruction with free or pedicled laparoscopically harvested omental flaps (LHOFs). METHODS: Between March 2011 and 2021, 82 patients who underwent immediate breast reconstruction with free or pediculated omental flaps were enrolled. Breast total or partial mastectomy, laparoscopic greater omentum harvest, and breast reconstruction were carried out in an orderly manner. Postoperative operative results, cosmetic outcomes, and complications were investigated. RESULTS: Seventeen cases of free LHOF and 65 cases of pedicled LHOF were performed. Cosmetic results were mostly satisfactory (61% excellent, 35% good), with a soft breast that was natural in appearance. Satisfaction investigation showed that 96.2% of patients were satisfied with the reconstructed breast. Uneventful follow-up showed no abdominal complications at the donor site, and the surface skin displayed no swelling. No major complications were found, except for three cases of necrosis. One patient developed slight hematoma. Two patients were found to have local recurrence, and one had distant metastasis. Twenty-four patients accepted radiotherapy, but no size reduction was noted after radiotherapy. We followed the patients to determine their survival status. All patients were alive, except for 1 in the free LHOF group who died 31.2 months after surgery. CONCLUSION: Immediate breast reconstruction with LHOF provides a soft reconstructed breast with relatively little donor-site deformity and is useful for breast tumor-specific immediate reconstruction.

Laparoscopic harvest and free transplantation of great omentum flap for extensive tissue defects in complex wounds.

Introduction: The repair of extensive tissue defects remains a challenge, although great progress has been made in reconstructive surgery. The transplantation of a single huge flap or several flaps in combination will inevitably result in donor-site morbidity. Here we report our experience in the repair of these wounds with laparoscopically harvested great omentum flaps. Methods: Twelve patients with extensive tissue defects caused by deep burn injury, avulsion injury, and open fracture underwent free omental flap transplantation and split-thickness skin grafting. The patient demographics, wound characteristics, and complications postsurgical operation were recorded. Prior to omentum flap transplantation, these patients underwent debridement, vacuum sealing drainage treatment, and/or fixation of fractures. All omentum flaps harvested using laparoscopic technique were anastomosed to recipient vessels, and split-thickness skin grafting was performed 14 days after omental flap transplantation. Results: The mean defect size was 471 cm2 and the mean omental flap size was 751.1 cm2. Among all 12 cases, the omental flaps survived well except for distal partial necrosis in one case. Skin grafting was also achieved in all cases, and all patients achieved complete wound coverage. All donor sites achieved primary healing without major complications. The mean follow-up time was 30 months with satisfactory appearance and functional outcome. Conclusion: For the reconstruction of extensive tissue defects in complex wounds, the free transfer of an omental flap may be an ideal option because of its well-vascularized and pliable tissue with reliable vascular anatomy, as well as minimized donor-site morbidity.

The increased angiogenic capacity and decreased inflammatory response when a mesh is used in combination with an omental flap. A prospective experimental study.

BACKGROUND: The use of a surgical mesh for abdominal wall reconstruction is well established and has been used for long with minor complications, whereas the omental flap has been used for decades in reconstructive surgery. AIM: To demonstrate the increased angiogenic capacity and the reduced inflammatory markers of a synthetic mesh when used in combination with an omental flap. Furthermore, we compare two independent meshes when used alone or in combination with the omental flap. MATERIALS AND METHODS: Twenty-eight rats were included in the study. To determine the effect of using an omental flap under two different meshes, the animals were separated into four groups, i.e., group A (flap + mesh 1), group B (flap + mesh 1 + silicone), group C (flap + mesh 2), and group D (flap + mesh 2 + silicone). A silicone sheet was placed as a barrier between the mesh and the flap. All groups were sacrificed 8 weeks post-operatively. RESULTS: The use of a silicone sheet barrier between any of the two synthetic meshes and the omental flap in an abdominal wall defect is accompanied by a markedly reduced angiogenesis in terms of a cluster of differentiation (CD)-34 (p < 0.001) and factor VIII (p = 0.0012) and by increased inflammatory response CD-68 (p = 0.0024) and visual scoring (p < 0.001). CONCLUSIONS: Τhe increased angiogenic capacity and the reduced inflammatory markers of a synthetic surgical mesh when used in combination with an omental flap make it a useful option in the reconstruction of an abdominal wall defect on a large or contaminated wound.

Reconstruction of Infected Mediastinal Wound with an Omental Flap Harvested Laparoscopically After Cardiac Surgery: Report of Two Cases and Literature Review.

Background: Deep sternal wound infection and dehiscence are two serious complications after open cardiac surgery. Omental flap harvesting is recognized as one of the management options, with traditionally non-favorable outcomes due to laparotomy stress on patients. Objective: Herein, however, we report our experience with two patients who have developed a mediastinal wound infection following coronary artery bypass grafting and were reconstructed with omental flaps harvested laparoscopically. Case Presentation: Two 74-year-old females, who were known to have multiple comorbidities, developed a sternal wound infection after coronary artery bypass graft. Several operative trials and non-operative measures have been attempted to manage the infections and/or reconstruct the wound but failed. Both patients then underwent laparoscopic omental flap harvesting for reconstruction and exhibited significant clinical improvement postoperatively. Discussion: Omental flap is considered a feasible option for reconstruction of sternal wound dehiscence developing after open cardiac surgery because it is usually well-vascularized, contains a large number of immunologically active cells and has the ability to absorb wound secretions. The traditional method of harvesting is conventional laparotomy, but it carries high rates of morbidity. Therefore, laparoscopic harvesting can be utilized as an alternative with better outcomes. Conclusion: Laparoscopic omental flap harvesting is considered a feasible and safe procedure to manage sternal wound dehiscence after open cardiac surgery, with satisfactory surgical outcomes.

Pediatric patient with a complex Abdominal Wall defect reconstructed with sandwich omental flap. A case report.

INTRODUCTION AND IMPORTANCE: Low grade Fibromyxoid sarcoma (LGFMS) is a rare soft tissue sarcoma. LGFMS has an indolent clinical behavior but it is prone for late local recurrence and metastasis. In children it is commonly seen in the subcutaneous tissues relative to adults where it presents in deep soft tissues. These patients are best managed in a specialized unit with a multidisciplinary team. For patients with sarcoma, wide local excision remains the treatment of choice. Large complex abdominal wall defects present a unique reconstructive challenge to the surgeon following tumor removal. CASE PRESENTATION: Here, we present a case of a 9-year old pediatric male patient with complex abdominal wall defect post excision of a recurrent fibromyxoid sarcoma, reconstructed with a sandwich omental flap, monofilament polypropylene mesh (Bard® Mesh) and split-thickness skin graft (STSG). CLINICAL DISCUSSION: Despite the success of covering the defect, the patient still had quite a bit of morbidity with the following:abdominal hernia defect and tumor recurrence. Our case demonstrates the diagnostic and therapeutic challenges in management of sarcomas hence the need for these patients to be managed through a multidisciplinary approach. CONCLUSION: The omental flap is quite versatile, and knowing how to raise it does not require sophisticated microsurgical skills. It adds to the reconstructive surgeon's armamentarium, especially in resource-limited settings.

＜Editors' Choice＞ Long-term outcomes of lateral skull base reconstruction with a free omental flap and facial nerve reconstruction.

In lateral skull base reconstruction, it is necessary to seal the defect in the lateral skull base, fill the dead space, and, sometimes, reconstruct the facial nerve. However, this procedure is difficult to perform with a standard musculocutaneous flap. Therefore, for such cases, an omental flap is used in our hospital because of its flexibility. In this study, we report our experience with the procedure (lateral skull base reconstruction with a free omental flap) and its long-term outcome and facial nerve reconstruction, with special focus on facial nerve recovery. This study is a technical note and a retrospective review. It was conducted in Nagoya University Hospital. Overall, 16 patients (12 women and 4 men; mean age: 55.1 years) underwent lateral skull base reconstruction with a free omental flap after subtotal temporal bone resection or lateral temporal bone resection during 2005-2017. The main outcome measures were postoperative complications and facial nerve recovery: Yanagihara score and House-Brackmann grading system. Complications included partial necrosis and minor cerebrospinal fluid leakage in 2 patients. Facial nerve recovery could be observed more than 12 months after surgery, with a mean Yanagihara score of 19.6 and House-Brackmann grade of 3.60. The free omental flap is a reliable method for lateral skull base reconstruction, especially in cases where facial nerve reconstruction is needed. To the best of our knowledge, this is the first report on facial nerve recovery after lateral skull base reconstruction.

Current Research on the Use of the Omental Flap in Breast Reconstruction and Post-Mastectomy Lymphedema: A Focus on Omental-Vascularized Lymph Node Transfer.

The novel use of the omental flap in breast reconstruction has been increasing in research popularity within the last few decades. This technique has its roots in the early 20th century as surgeons explored the use of the omentum for a variety of reconstructive purposes across various surgical subspecialties. The current literature shows evidence of the benefits of using the omentum in autologous breast reconstruction compared to the more traditional abdominal, flank, thigh, and gluteal donor flap reconstruction. This method introduces a viable option for patients that do not meet the criteria for the traditional autologous reconstruction techniques allowing for the restoration of more natural appearing breasts without the added complication of donor-site mortality. Additionally, the omentum, with its rich source of vascularized lymph nodes, has been studied as a potential source for lymph node transfer in the treatment of mastectomy-associated lymphedema. In this review, we highlight the most recent research on the current practices of omental-based breast reconstruction techniques and their use in postmastectomy lymphedema. We discuss the history and natural progression of the development of omental-based reconstruction as an autologous breast reconstruction technique, highlight the latest advances and challenges for the utility of the omental flap in current surgical procedures, and present future directions for the potential role of omental-based breast reconstruction in postmastectomy breast surgery.

Catastrophic Propeller Brain Injury with Large Scalp Defect Treated with Omental Flap.

In this study, we report a case of catastrophic propeller brain injury with large scalp defect treated with omental flap reconstruction. A 62-year-old man was accidentally caught in a powered paraglider propeller during maintenance. The rotor blades impacted the left part of his head. On arrival at the hospital, he presented with a Glasgow Coma Scale score of E4V1M4. On some areas on his head, skin was noticeably cut off, and the brain tissue out-slipped through an open skull fracture. Continuous bleeding from the superior sagittal sinus (SSS) and the brain surface was observed during emergency surgery. Massive bleeding from the SSS was controlled using a number of tenting sutures and hemostatic agents. We evacuated the crushed brain tissue and coagulated the severed middle cerebral arteries. Dural plasty using the deep fascia of the thigh was performed. The skin defect was closed using an artificial dermis. The administration of high-dose antibiotics has failed to prevent meningitis. Moreover, the severed skin edges and fasciae were necrotic. Plastic surgeons performed debridement and vacuum-assisted closure therapy to promote wound healing. Follow-up head computed tomography revealed hydrocephalus. Lumbar drainage was performed; however, sinking skin flap syndrome was observed. After removing the lumbar drainage, cerebrospinal fluid leakage occurred. We then performed cranioplasty with a titanium mesh and omental flap on day 31. After the surgery, perfect wound healing and infection control were achieved; however, severe disturbance of consciousness remained. The patient was transferred to a nursing home. Primary hemostasis and infection control are mandatory. An omental flap has been determined to be effective in controlling infection by covering the exposed brain tissue.

Divided omental flap wrapping a multiple-branched graft replaced with an infected thoracic aortic aneurysm: A case report.

The omental flap is often used to fill the space around the artificial vascular graft as a network sheet to prevent artificial vascular infection. In this study, we report a case in which the omental flap was divided into three parts to fill the dead spaces around the multiple-branched graft, as well as to wrap the suture lines of the graft after graft replacement in a patient with an infected thoracic aorta. An 88-year-old woman was admitted to the hospital with fever and impaired consciousness. Computer tomography revealed an aortic arch aneurysm with enlargement. After emergency stent-graft interpolation and antibiotic treatment, an infected thoracic aortic aneurysm was removed, and a multiple-branched graft replacement of the upper arch was performed. After harvesting an omental flap based on the right gastroepiploic vessels, the omental flap was divided into three on the basis of the epiploic vessels. The middle part of the omental flap was used to fill the space around the lesser curvature of the arch and the distal anastomotic site, the accessory part was used to fill the space between the ascending aorta and the superior caval vein, and the right part was used to wrap the three cervical branches, separately. Fifteen months after surgery, the patient had recovered enough to resume work without any signs of inflammation.

Successful omental flap coverage repair of a rectovaginal fistula after low anterior resection: a case report.

BACKGROUND: Rectovaginal fistula (RVF) is a troublesome and refractory complication after low anterior resection (LAR) for rectal cancer. An omental flap repair was performed for the RVF caused due to Crohn's disease and childbirth trauma. However, there are few cases of an omental flap repair for RVF after LAR. Herein, we present a successfully repaired case of RVF by omental flap coverage after LAR for rectal cancer. CASE PRESENTATION: A 50-year-old female patient with advanced rectal cancer underwent laparoscopic LAR with double-stapling technique anastomosis and achieved curative resection. She complained of a stool from the vagina and was diagnosed with RVF on the postoperative day (POD) 18. Conservative therapy was ineffective. We performed laparoscopic fistula resection and direct closure of the vagina and rectum, designed the omentum that could reach the pelvis, repaired RVF by omental flap coverage, and performed transverse colostomy on POD 25. She was discharged on initial POD 48. Seven months after the initial operation, colostomy closure was administered. There was no recurrence of RVF found 1 year after the initial operation. CONCLUSIONS: The patient achieved an omental flap coverage for RVF. We successfully performed the omental flap coverage repair in patients with RVF after the leakage of LAR. An omental flap may become an alternative treatment for muscle flap or an effective treatment for RVF.

Outcomes of perineal wound closure techniques after abdominoperineal resections in rectal cancer: an NSQIP propensity score matched study.

Perineal defects following abdominoperineal resections (APRs) for rectal cancer may require myocutaneous or omental flaps depending upon anatomic, clinical and oncologic variables. However, studies comparing their efficacy have shown contradictory results. We aim to compare postoperative complication rates of APR closure techniques in rectal cancer using propensity score-matching. The American College of Surgeons Proctectomy Targeted Data File was queried from 2016 to 2019. The study population was defined using CPT and ICD-10 codes for patients with rectal cancer undergoing APR, stratified by repair technique. Perioperative demographic and oncologic variables were controlled for by propensity-score matching. Multivariate logistic regression analysis was performed for wound and major complications (MCs). Of the 3291 patients included in the study, 85% underwent primary closure (PC), 8.3% rectus abdominis myocutaneous (RAM) flap, 4.9% pedicled omental flap with PC, and 1.9% lower extremity (LE) flap repair. Primary closure rates were significantly higher for patients with stage T1 and T2 tumors (p < 0.001). RAM and LE flaps were most used with multi-organ resections, 24% and 25%, respectively (p < 0.001). Similarly, cases with T4 tumors used these flaps more frequently, 30% and 40%, respectively (p < 0.001). After propensity score matching for comorbidities and oncologic variables, there was no significant difference in 30-day postoperative wound or MC rates between perineal closure techniques. The complication rates of the different closure techniques are comparable when tumor stage is considered. Therefore, tumor staging and concurrent procedures should guide clinical decision making regarding the appropriate use of each technique.

Upper thoracic empyema and concomitant superior vena cava syndrome treated with reconstructive surgery using a pedicled omental flap.

Superior vena cava (SVC) syndrome refers to a constellation of symptoms secondary to obstruction of blood flow through the SVC. In this condition, venous blood that usually drains into the SVC is diverted into the inferior vena cava (IVC) via collateral veins. Reconstructive surgery is challenging in such cases owing to the anomalous venous system. In this case report, we describe reconstructive surgery using a pedicled omental flap in a patient with upper thoracic empyema and concomitant SVC syndrome. A 68-year-old man underwent resection of malignant thymoma, the bilateral brachiocephalic veins, and a part of the right upper lobe, followed by polytetrafluoroethylene (PTFE) graft placement for venous system reconstruction, 2 years prior to presentation. He developed postoperative upper thoracic cavity empyema, which necessitated PTFE graft removal. Although the infection was controlled after 2 months, multiple right upper lobe pulmonary fistulas persisted, and the patient was referred to our department for further evaluation. Contrast-enhanced computed tomography revealed SVC syndrome characterized by SVC obstruction and consequent drainage of venous blood from the upper trunk into the IVC via collateral vessels. We debrided necrotic and infected tissues, and a pedicled omental flap was placed for upper lobe fistula coverage. The patient showed an uncomplicated postoperative course, and no recurrent empyema or pulmonary fistulas were observed 3 years postoperatively. Flaps associated with the SVC system show high venous pressures. The use of a pedicled omental flap was deemed feasible because this graft reaches the upper thorax even though it is associated with the IVC system.

Application of pedicled greater omentum flap tamponade combined with laparoscopic fenestration in diaphragmatic hepatic cyst.

OBJECTIVE: To investigate the efficacy and clinical application advantage of omental tamponade with vascular pedicle combined with Laparoscopic fenestration for the treatment of diaphragmatic hepatic cyst. METHODS: A total of 56 patients with diaphragmatic hepatic cysts underwent laparoscopic surgery in a single tertiary academic medical center from January 2010 to October 2020, including 21 patients (non-omental group) underwent laparoscopic fenestration of liver cysts, and 36 patients underwent laparoscopic liver cyst fenestration combined with vascular pedicle omentum tamponade (omental group). The general conditions and follow-up results of the two groups were compared and annalyzed. RESULTS: The operation time of the omental group was longer than that of the non-omental group (P = 1.358E-4). There was no significant difference in postoperative complications, postoperative laboratory values and hospital costs (P>0.05). The length of hospital stay in omental group was shorter than that in non-omental group (P = 0.034). In the omental group, recurrence occurred in 1 of 35 patients (4.65%) who were followeded up 12 months after surgery. In the non-omental group, of the 21 patients followed, 3 patients (14.28%) recurred 6 months after surgery, and 8 patients (38.10%) recurred 12 months after surgery. CONCLUSION: It is an effective method to prevent the recurrence of diaphragmatic hepatic cyst after laparoscopic fenestration by packing the cyst with vascularized omentum.

Reconstruction with omental flap and negative pressure wound therapy after total pelvic exenteration of anal fistula cancer: a case report.

INTRODUCTION: Surgery for anal fistula cancer (AFC) associated with Crohn's disease usually entails extensive perineal wounds and dead space in the pelvis, which is often filled with a myocutaneous flap. However, use of a myocutaneous flap is invasive. We report a case of total pelvic exenteration (TPE) for AFC in which a myocutaneous flap was avoided by using an omental flap and negative pressure wound therapy (NPWT). CASE PRESENTATION: The patient was a 47-year-old woman who had been treated for Crohn's disease involving the small and large intestine for 30 years and had repeatedly developed anal fistulas. She was referred with a diagnosis of AFC that had spread extensively in the pelvis. We performed laparoscopic TPE via a transperineal endoscopic approach. To prevent infection in the large skin defect and extensive pelvic dead space postoperatively, the perineal wound was reconstructed using an omental flap and NPWT. During 20 days of NPWT, the wound steadily decreased in size and closed on postoperative day (POD) 20. She was discharged without complications on POD 30. DISCUSSION: NPWT is useful for preventing perineal wound infection and promoting granulation tissue formation. However, direct contact with the intestine may lead to intestinal perforation. In this case, the combination of an omental flap with NPWT effectively prevented surgical site infection. The flap filled the large pelvic dead space and physically separated the intestine from the polyurethane foam used for NPWT. CONCLUSION: NPWT and an omental flap may become an option when performing TPE.