Omental Pedicle Flap Research Articles

Robotic Repair of Rectovesical Fistula Secondary to Open Radical Prostatectomy

Introduction: Rectovesical fistula (RVF) is a rare entity that can develop after trauma, radiation, congenital diseases, inflammatory bowel disease, and open radical prostatectomy. Herein we present our experience with robot-assisted fistula repair. Methods: Three patients were treated. The etiology of RVF developed was open radical prostatectomy in all patients. The robotic procedure was postoperative following failed open repair in two patients, and primary in the third. All patients had previously undergone fecal diversion. The operative steps were as follows: (1) cystoscopy, (2) RVF catheterization, (3) five-port transperitoneal laparoscopic mobilization of omental pedicle flap, (4) cystotomy extending toward the fistula tract, (5) robot docking, (6) dissection of the rectovesical plane, (7) interrupted rectal closure, (8) omental interposition, (9) bladder closure, (10) suprapubic tube placement, and (11) drain placement. Results: Mean operative time was 153 mins (range 120–180). No intraoperative or postoperative complications occurred. All patients remain free of fistula recurrence by cystographic studies with follow-up ranging from 2 weeks to 10 months. Bowel continuity has been restored in two patients and is planned in one. Conclusion: While we await longer follow-up and experience in larger series, robotic repair of RVF appears feasible and represents an attractive alternative to open or laparoscopic approaches. No competing financial interests exist. Runtime of video: 7 mins 55 secs

Geometric Reconstruction of the Right Hemi-Trunk After Resection of Giant Chondrosarcoma

We present a case of a giant chondrosarcoma arising from the right anterolateral chest wall and extending to the abdomen. An extensive resection of the right lower chest wall, most of the right hemidiaphragm, and most of the anterior abdominal wall on the right side was carried out. A long titanium plate was used to reconstruct the right costal margin. This plate gave attachment to two polytetrafluoroethylene meshes that were used to cover the abdominal and chest wall defects. The patches were covered with pedicled muscles and omental flaps and subsequently with rotational skin flap.

Laparoscopic repair of iatrogenic diaphragmatic hernias after sternectomy and pedicled omentoplasty

During sternectomy and pedicled omental flap transposition for the treatment of deep sternal wound infections, an ectopic diaphragmatic aperture is created. This may be the site of an iatrogenic diaphragmatic hernia, which may result in the herniation of intra-abdominal organs, and is difficult to repair. Although this complication was described as early as 1991, no effective treatment for this condition has been described previously. The defect in poststernectomy diaphragmatic hernias has features similar to other incisional abdominal wall hernias, as well as to parastomal hernias and hiatal diaphragmatic hernias. We describe our laparoscopic approach developed from experience with these other types of hernias. We use an intraperitoneal flat mesh without keyhole. Fixation of the mesh to the anterior abdominal wall and to the diaphragm is done with a combination of sutures and spiral tackers. The omental pedicle is lateralised, fixed to the diaphragm and covered with the mesh. Special caution is needed when spiral tackers are applied to the diaphragm, because fatal complications of pericardial and cardiac injury have been described in laparoscopic hiatal diaphragmatic hernia repair. We used this technique in four patients who presented with a symptomatic poststernectomy diaphragmatic hernia. No procedure-related intra-operative or postoperative complications occurred. With a follow up of at least 12 months, no clinical or radiographic recurrence of diaphragmatic herniation has been encountered. We describe a laparoscopic technique to repair this difficult diaphragmatic hernia used in four patients, with a good clinical and computed tomographic outcome at 12 months.

ROBOTIC REPAIR OF RECTOVESICAL FISTULA SECONDARY TO OPEN RADICAL PROSTATECTOMY

Abstract Introduction: Rectovesical fistula (RVF) is a rare entity that can develop after trauma, radiation, congenital diseases, inflammatory bowel disease, and open radical prostatectomy. Herein we present our experience with robot-assisted fistula repair. Methods: Three patients were treated. The etiology of RVF developed was open radical prostatectomy in all patients. The robotic procedure was postoperative following failed open repair in two patients, and primary in the third. All patients had previously undergone fecal diversion. The operative steps were as follows: (1) cystoscopy, (2) RVF catheterization, (3) five-port transperitoneal laparoscopic mobilization of omental pedicle flap, (4) cystotomy extending toward the fistula tract, (5) robot docking, (6) dissection of the rectovesical plane, (7) interrupted rectal closure, (8) omental interposition, (9) bladder closure, (10) suprapubic tube placement, and (11) drain placement. Results: Mean operative time was 153 mins (range 120–180). No intraope...

Chylothorax Associated With Tricuspid Dysplasia and Atrial Septal Defect in a Bullmastiff

Transudate pleural effusion associated with tricuspid dysplasia and ostium secundum-type atrial septal defect was diagnosed in a 14-month-old bullmastiff. Following administration of furosemide and an angiotensin-converting enzyme (ACE) inhibitor, the dog remained free of pleural effusion for 10 months, until he showed severe dyspnea due to chylothorax. Medical therapy was unsuccessful to avoid recurrence of life-threatening pleural chylous effusion. Ligation of the thoracic duct and apposition of an omental pedicle flap were effective in the resolution of pleural chylous leakage.

Robotic Repair of Rectovesical Fistula Resulting From Open Radical Prostatectomy

Rectovesical fistula (RVF) is a rare complication of radical prostatectomy. A 57-year-old man underwent open radical prostatectomy with recognized rectal injury, primary closure of the rectal wall, and loop colostomy. The patient developed urine leakage per rectum after colostomy closure. We diverted the fecal stream with end colostomy and placed a suprapubic tube. An open transsacral (Kraske) repair failed 1 month later. We have previously described the laparoscopic approach, and report the technique and results of our first robotic assisted operation. The operative steps were as follows: (1) cystoscopy, (2) RVF catheterization (3) five-port transperitoneal laparoscopic initial dissection (4) mobilization of omental pedicle flap, (4) cystotomy extending toward the fistulous tract, (5) robot docking (6) dissection of the rectovesical plane, (7) interrupted rectal closure, (8) omental interposition, (9) bladder closure, and (10) drain placement. Operative time was 180 minutes. Hospital stay was 1 day. The suprapubic tube was removed at 2 months after normal cystography. Bowel continuity was restored at 4 months, with no fistula recurrence at 1-month follow-up. We await longer follow-up and experience in larger series. For now, robotic repair of rectovesical fistula appears feasible and represents an attractive alternative to open and laparoscopic approaches.

Reconstruction of Chest Wall Defects After Rib Tumor Resection: A Comparison of Autogenous, Prosthetic, and Composite Techniques in 44 Dogs

To compare short- and long-term outcome and complications of chest wall reconstruction in dogs using autogenous, prosthetic, and composite autogenous-prosthetic techniques. Historical cohort. Dogs (n=44) with spontaneous tumors arising from or involving the chest wall. Medical records were reviewed for dogs with rib and/or sternal tumors treated by chest wall resection and reconstruction. Signalment, preoperative clinical features, intraoperative findings and complications, reconstruction technique (autogenous muscle flap, prosthetic mesh, or composite autogenous-prosthetic technique), and short- (< or =14 days) and long-term (>14 days) postoperative complications were determined from the medical records and telephone contact with owners and referring veterinarians. Associations between chest wall reconstruction technique and postoperative complications were tested with Cox proportional hazards. Chest wall defects were reconstructed with autogenous muscle flaps (29 dogs), prosthetic mesh (3), and a composite technique of prosthetic mesh and either autogenous muscle or omental pedicle flap (12). Early postoperative complications were recorded in 8 dogs (18.2%) and included seroma (5) and pleural effusion and peripheral edema (3). One dog had a late complication (2.3%) with a mesh-related infection 767 days postoperatively. Overall, complications occurred in 10.3% of autogenous, 25.0% of composite, and 66.7% of prosthetic reconstructions. Chest wall reconstruction with Marlex mesh alone was associated with a significantly increased risk of postoperative complications compared with autogenous reconstruction (P=.027). Reconstruction of sternal defects (3), 2 of which were performed with Marlex mesh alone, was associated with a significantly increased risk of complications compared with lateral chest wall reconstructions (P=.037). Large chest wall defects can be reconstructed with autogenous and composite techniques, but prosthetic mesh should be covered with well-vascularized autogenous muscle or omentum to decrease the risk of postoperative complications. Sternal defects should be reconstructed with rigid techniques. Chest wall reconstruction with autogenous muscle flaps or a combination of autogenous techniques with prosthetic mesh is associated with a low rate of infection and other complications.

First Clinical Use of an Omental Pedicle Flap for the Surgical Correction of a High Intra-Abdominal Testicle

Sir: Intra-abdominal testes are five times as likely to undergo malignant degeneration as testicles within the inguinal canal.1 High intra-abdominal testes are the most difficult to correct, with the results of testicular viability and function frequently being disappointing. The high failure rate (26 percent)2 is likely due to the fact that testicular blood flow is reduced up to 80 percent with spermatic vessel ligation, leading to insufficient germ cell perfusion.3 Another procedure used in this situation is microvascular autotransplantation, but this operation requires vessels of adequate size and expertise in microsurgical technique. Therefore, especially when the contralateral testicle is normal, an orchiectomy is preferred due to the high risk of testicular atrophy associated with most of the salvage procedures. However, if the chances of postoperative viability of the testicle could be increased, perhaps more salvage orchiopexies would be performed. In situations where the testicular vessels are not adequate for microvascular autotransplantation and the collateral circulation from the vas deferens is not sufficient to maintain testicular viability, a different technique is needed. Our solution was to perform an orchiopexy in two stages with the use of an omental pedicle flap. Our patient had a single left intra-abdominal hypoplastic testicle superior to the left common iliac artery. There was no vas deferens attached to the gonad due to previous operations. His vascular pedicle was too small (0.5 mm in diameter) to permit safe microvascular transfer. Therefore, the testicle was marsupialized in an omental flap to allow external neovascularization of the testicle (Fig. 1, above). The patient returned to the operating room 6 months later. The testicular pedicle was divided and the omental flap was lengthened (Fig. 1, below). It was transferred down through the midline between the rectus muscles, just above the pubic bone, into the left hemiscrotum. The testicle remains viable and the patient continues to demonstrate normal testosterone levels, maintaining his secondary male sexual characteristics.Fig. 1.: (Above) Left high intra-abdominal hypoplastic testicle and omental flap. (Below) Neovascularized testicle within the omental flap, demonstrating adequate length for scrotal placement.There are several indications for use of the omentum in reconstructive surgery,4 thanks to its plasticity, volume, and ability to neovascularize adjacent tissue through the induction of angiogenesis.5 Clinical use of the omentum to perform a two-stage orchiopexy has not previously been described. In summary, a two-stage transposition to the scrotum of a high intra-abdominal testicle was performed successfully via an omental pedicle flap. The omental pedicle flap for orchiopexy has several advantages, including the ease of lengthening the flap, so that the testicle can be transferred into the scrotum, and neovascularization of the testicle, decreasing its probability of atrophy. This procedure should be performed in two stages, to allow angiogenesis and neovascularization of the testicle to occur. Due to the high rate of atrophy associated with the standard orchiopexy of intra-abdominal testes, we propose that our procedure be added as a surgical option to increase the likelihood of preserving testicular viability and function. This is especially important in patients who have only a single functional testicle, to prevent their need for life-long treatment with exogenous testosterone. Steven A. Earle, M.D. University of Miami School of Medicine Jackson Memorial Hospital Deirdre M. Marshall, M.D. Division of Plastic and Reconstructive Surgery Andrew S. Labbie, M.D. Division of Urology Miami Children’s Hospital Miami, Fla.

Perineal wound complications after abdominoperineal resection.

Perineal wound complications following abdominoperineal resection (APR) is a common occurrence. Risk factors such as operative technique, preoperative radiation therapy, and indication for surgery (i.e., rectal cancer, anal cancer, or inflammatory bowel disease [IBD]) are strong predictors of these complications. Patient risk factors include diabetes, obesity, and smoking. Intraoperative perineal wound management has evolved from open wound packing to primary closure with closed suctioned transabdominal pelvic drains. Wide excision is used to gain local control in cancer patients, and coupled with the increased use of pelvic radiation therapy, we have experienced increased challenges with primary closure of the perineal wound. Tissue transfer techniques such as omental pedicle flaps, and vertical rectus abdominis and gracilis muscle or myocutaneous flaps are being used to reconstruct large perineal defects and decrease the incidence of perineal wound complications. Wound failure is frequently managed by wet to dry dressing changes, but can result in prolonged hospital stay, hospital readmission, home nursing wound care needs, and the expenditure of significant medical costs. Adjuvant therapies to conservative wound care have been suggested, but evidence is still lacking. The use of the vacuum-assisted closure device has shown promise in chronic soft tissue wounds; however, experience is lacking, and is likely due to the difficulty in application techniques.

Pedicled Omental Flaps as an Adjunct in the Closure of Complex Spinal Wounds

A retrospective clinical study. To evaluate the safety and efficacy of using an omental flap in complex spine reconstruction in patients at high-risk for wound dehiscence. Postoperative wound dehiscence represents a major cause of morbidity in patients undergoing instrumented spinal reconstruction. A variety of approaches for the prevention and treatment of this problem have been previously described in the literature; however, the use of omental flaps has received little attention. In this retrospective analysis, 5 patients were studied both clinically and radiographically. The study population included 4 women and 1 man, with a mean age of 49 years (range, 31-67 years). All patients underwent an omental flap procedure at the time of spinal reconstruction because of significant soft tissue defects or active spinal infection. Mean clinicoradiographic follow-up was 53 months (range, 36-115 months). At the time of follow-up, all patients had well-healed surgical wounds with an acceptable structural and esthetic result. One patient in the study group experienced minor supra-fascial wound dehiscence. In terms of spinal outcome, all patients achieved successful bony arthrodesis; 1 patient, however, developed symptomatic adjacent segment degeneration and was treated by extension of the fusion construct. In patients undergoing thoracolumbar surgery who are at high risk of spinal wound dehiscence, closure using a pedicled omental flap is a viable procedure that may limit the risk of dehiscence and improve outcome.

The Pedicled ‘Policeman’ Flap Salvage of Exposed Vascular Prosthesis – A Case Report

A case report of a patient with exposed, infected, subcutaneous, extra-anatomical, vascular prosthesis is presented, which was successfully salvaged using pedicled omental flap after other reconstructive procedures had failed.

The omentum–polypropylene sandwich technique: an attractive method to repair large abdominal-wall defects in the presence of contamination or infection

Repair of abdominal wall defects in the presence of contamination or infection continues to be a significant problem for surgeons. The loss of tissue warrants reinforcement of the abdominal wall, preferably by autologous material. However, autologous repair often requires extensive operations that carry a high morbidity. Moreover, the lack of sufficient fascia may be so extensive that insertion of a prosthetic material is inevitable. Polypropylene (PP) is the most appropriate material to use under these circumstances, but without coverage, the mesh will wrinkle and ultimately be extruded. The present report describes an alternative technique for repair of heavily contaminated abdominal-wall defects. Two patients with a very large heavily contaminated abdominal wall defect due to necrotizing fasciitis in one patient and a lion's bite in the other were treated with the omental sandwich technique. After radical debridement, resulting in a full thickness loss of the abdominal wall, the peritoneum was restored using absorbable polyglactin mesh. The fascial defect was bridged with a PP mesh that was fixed to the adjacent myoaponeurosis and covered with a pedicled omental flap. In both patients the omentum was covered with a split skin. Wound healing in both patients was without complications. Both patients had a sufficient abdominal wall, without signs of herniation after a follow up of 4 and 30 months, respectively. The omental sandwich technique is an attractive method to repair large abdominal wall defects in the presence of contamination or overt infection.

Complete coverage of in situ aortograft by total omental pedicle flap as the most reliable treatment of aortoesophageal fistula

Aortoesophageal fistula secondary to a thoracic aortic aneurysm is usually a fatal disease with few survivors reported previously. We encountered 2 consecutive patients who were treated successfully with esophagectomy and in situ aorta reconstruction using cryopreserved homograft that was wrapped completely with omental pedicle flap. For the construction of omental flap, the right gastroepiploic artery was resected at the root and all the vessels entering the greater curvature and the transverse colon were resected at the adherent edges. Because the gastroepiploic arcade is totally preserved, large amounts of omental tissue could be obtained, with an excellent blood supply mainly from the left gastroepiploic artery. This type of omental flap is highly mobile, easily transferred to the left hemithorax, and has enough volume to cover the in situ aortic graft completely including anastomosis lines. Thus, our omental coverage appears to be the most reliable method to prevent postoperative graft infection.

Sternotomy Reconstruction with Omentum Followed by Large Diaphragmatic Hernia

Poststernotomy mediastinitis carries significant morbidity and mortality. Aggressive wound debridement combined with a pedicled omental flap, with or without a pedicled muscle flap, has gained acceptance in the management of difficult sternal wound infections. Two cases of poststernotomy mediastinitis and sternal wound reconstruction with a pedicled omental flap were complicated by a large anterior diaphragmatic hernia containing the large bowel.

非結核性慢性膿胸症例に対する開窓術後閉創術式の検討 : 大網充填術施行例と筋弁充填術施行例の比較

非結核性慢性膿胸症例に対する開窓術後閉創術式の検討 : 大網充填術施行例と筋弁充填術施行例の比較

Graft for Mycotic Thoracic Aortic Aneurysm: Omental Wrapping to Prevent Infection

Nine cases of mycotic thoracic aortic aneurysm were treated surgically between July 1995 and March 2003. The aneurysms were located in the ascending aorta in 1 patient, the descending thoracic aorta in 5, and the thoracoabdominal aorta in 3. Preoperatively, 3 patients were in shock due to rupture of the aneurysm. All patients underwent aneurysmectomy and in-situ graft placement. In 5 patients, the graft was covered with a pedicled omental flap to prevent postoperative graft infection. There were 2 hospital deaths: one patient died of multi-organ failure, and the other died from intrathoracic bleeding. After discharge, one patient died from intrathoracic bleeding 3 months after surgery. These 3 patients had not received omental wrapping. Postoperative graft infection did not occur in the 6 surviving patients during a mean follow-up period of 4.0 +/- 3.1 years. It was concluded that covering the prosthetic graft with a pedicled omental flap may help prevent postoperative graft infection and improve the surgical results.

Technical aspects in the management of complex vesicovaginal fistulae

Thirteen complex vesicovaginal fistulae were successfully closed by a technique of wide separation and water-tight closure of vagina from the urinary bladder and augmentation of the repair with a pedicled omental interposition flap.

Omental wrapping of esophageal rupture in combination with T-tube drainage

Esophageal rupture is a potentially fatal condition. Rapid and correct diagnosis and urgent surgical treatment are mandatory. Various surgical treatment methods have been reported. We introduced a new surgical procedure for treatment of spontaneous esophageal rupture. Upon thoracotomy continuing to laparotomy, a T-tube was inserted into the esophageal lumen through the ruptured site. The ruptured esophageal wall was sutured interruptedly, and the insertion site was covered with the pedicle omental flap. The T-tube was replaced by a thinner catheter tube from postoperative day (POD) 45 and finally withdrawn on POD 66. The patient was discharged in good condition on POD 98. The procedure described here is safe and effective. It is applicable for patients restricted to minimally invasive surgery, those with poor general condition and severely infectious contamination but without a widely necrotic esophageal wall around the ruptured site.

猫の皮膚欠損を伴った慢性開放性化膿性治癒不全創4症例に対する小茎大網弁移植術

Omental pedicle flaps were created in cats having chronic, non-healing suppurative wounds with a chest-wall defect and constrictive pleuritis resulting from the wound. In the case of constrictive pleuritis complicated by severe dyspnea, after surgery, the wound healed, and dyspnea was alleviated. The 2 cats with large non-healing skin wounds recovered without any complications. In the animal with skin lesions at hock and abdomen, the abdominal wound healed, whereas the hock wound suffered a relapse resulting from suture dehiscence.

胸膜肺全摘後気管支断端ろう及び膿胸に対して遊離腹直筋弁と大網を併用して治療した１例

症例は42歳, 男性.悪性胸膜中皮腫に対して右胸膜肺全摘術施行後4ヵ月経って気管支断端瘻と膿胸を発症した.開窓して, 82日後に根治術を施行した.胸腔内を掻爬した後, 右下腹壁動静脈を茎とする遊離腹直筋弁と右胃十二指腸動静脈を茎とする有茎大網弁を作成した.大網を胸腔内に誘導して瘻孔を閉鎖した上で, 大網の左胃十二指腸動静脈と腹直筋弁の右下腹壁動静脈を顕微鏡下に吻合し, 血流の良好な部分をドップラーで確認して, 気管支断端を被覆した大網の上に重ねて充填した.術後経過は良好で, 根治術後4年以上経過して, 膿胸の再発は認めていない.遊離腹直筋弁と大網の併用は, 断端部の補強と, 死腔を減少させる上で有効な方法である.