Indications

With the development of many new muscle and myocutaneous transplants, the indications for omental transplantation have decreased. One would naturally choose one of the more accessible transplants for most difficult wound closure problems and avoid the need for a laparotomy. Previous abdominal surgery also eliminates the omentum as a transplant because it routinely becomes scarred down in the healing process. Because of the expanse of rich vascular and lymphatic network of the omental apron, its primary use now is in situations that require a new blood supply or lymphatic drainage, or an extensive vascular film to restore moving tissue planes. These involve cases of lymphedema, radioneurosclerosis, and scarring around joints and tendons.3 Lymphedema of the lower extremity has not responded well to omental transplantation. The multibranched arterial arcade has also been used as a source of vessels to restore the arterial arch and digital common volar digital vessels in the hand.8

Goldsmith was the first to use the greater omentum in the treatment of chronic lymphedema on an intact pedicle based on the right or left gastroepiploic vessels9 (see Case 3). Results were not dramatic. Contributing factors may have been stretching of the vascular pedicle or pressure on the pedicle as it traverses the chest wall and axilla. It is postulated that, in situ without tension or pressure, the omentum has remarkable absorptive powers. To explore this hypothesis, we designed a simple experiment in dogs as follows: The greater omentum was exposed through a midline abdominal incision and freed from the transverse colon and the greater curvature of the stomach isolating it on the right gastroepiploic vessels. Once mobilized, it was brought out of the abdomen and placed in a container of Ringer's solution colored with methylene blue, taking care to keep all tension and pressure off the pedicle. After 60 minutes, the blue dye was incorporated in the intravascular end lymphatic spaces of the entire omentum and was eliminated in the urine as evidenced by blue coloring. The same procedure was repeated in five animals with identical results. Encouraged by this confirmation of the original hypothesis, we operated with good results on three patients with chronic lymphedema of the upper extremities after mastectomy (see Case 4).

Operative Techniques

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