The omentum: its use as a free vascularized graft for reconstruction of the head and neck

Omentum transplantation for malignant tumors: a narrative review of emerging techniques and clinical applications

Omentum transplantation has emerged as a versatile and effective technique across various surgical disciplines due to its unique properties of immunological surveillance, anti-inflammatory effects, and wound healing promotion. In breast cancer surgeries, it has been utilized to manage locoregional issues and immediate reconstruction, providing satisfactory cosmetic outcomes and minimal complications, particularly in patients who had previously undergone irradiation. For esophageal cancer, omental reinforcement has significantly reduced anastomotic leak rates and postoperative complications, supporting its use in esophagectomy and complex cardiothoracic surgeries. In gynecological surgeries, the use of omental flaps has shown excellent results in neovaginal reconstruction following pelvic exenteration, offering distinct advantages over myocutaneous flaps by reducing morbidity and preserving sexual function. Additionally, omental transposition has proven beneficial in reducing surgical morbidity following radical abdominal hysterectomy and in managing vaginal cuff dehiscence through vaginal approaches. Robotic-assisted omental flap harvesting has enhanced precision and reduced complications in reconstructive surgeries, making it a promising minimally invasive approach in regenerative surgery and complex reconstructions, such as for facial skeleton reconstruction. The omentum has also been beneficial in laparoscopic procedures for pudendal nerve decompression and in managing thoracic aortic graft infections, demonstrating its versatility and effectiveness in various clinical settings. These studies collectively highlight the omentum's significant role in improving surgical outcomes, reducing complications, and enhancing the quality of life for patients, solidifying its place as a valuable tool in modern surgical practice. This article provides a comprehensive narrative review of omentum transplantation in oncology, discussing its current applications and future potential as a standard treatment modality.

Treatment of Mild-to-moderate Progressive Hemifacial Atrophy by Acellular Dermal Matrix Combined With Preoperative Digital Evaluation

Background

Progressive hemifacial atrophy (PHA) is a rare condition marked by the gradual degeneration of skin, soft tissues, muscles, and, in advanced stages, bone. The primary approach for managing PHA involves surgical interventions to reconstruct and restore the facial contour. The current treatments each present several limitations. Therefore, there is a critical need for innovative therapeutic methodologies for PHA soft-tissue reconstruction.

Methods

Eight patients diagnosed with Guerrerosantos II and III PHA were included in the study. Preoperative 3-dimensional facial scans were digitally analyzed, and corresponding 3-dimensional-printed models were generated to assess soft-tissue deficiencies. Based on this evaluation, acellular dermal matrix (ADM) was tailored to a stepped, multilayered composite dermis of a specific shape and size. It was then anatomically anchored at precise locations and supplemented with volume filler and ligament-mimicking repairs.

Results

The location, volume, and thickness of the ADM postoperatively were highly compatible with preoperative evaluations, significantly improving the facial contour and morphological and volumetric differences. All patients achieved good healing without other complications and reported improved postoperative scores on the FACE-Q craniofacial modules (P < 0.05).

Conclusions

Structural repair of PHA using ADM, guided by preoperative digital assessments, provides a safe, effective, and relatively stable outcome. This approach is innovative for achieving precise facial reconstruction.

"Soft Tissue Reconstruction in Progressive Hemifacial Atrophy: Current Evidence and Future Directions"

BACKGROUND

Progressive Hemifacial Atrophy (PHA) is a rare disorder characterized by gradual unilateral soft tissue atrophy in the face, which may also include clinically significant degeneration of underlying muscle and bone. In recent years, there has been a growing body of evidence regarding different soft-tissue reconstructive strategies in PHA, and the impact of intervention timing on disease progression. This article provides a comprehensive synthesis of the latest evidence in order to guide optimal management.

METHODS

A comprehensive multi-database search was performed through April 2020 using relevant search terms to identify clinical studies. Outcomes, complications, disease- and patient-related indications pertaining to different soft-tissue reconstructive strategies in PHA were collected and critically appraised.

RESULTS

35 articles reporting on a total of 824 PHA patients were evaluated; 503 (61%) were managed by microvascular free flaps, 302 patients (37%) were managed by autologous fat grafts, and 19 (2%) by pedicled flaps. A detailed synthesis of outcomes is presented herein, as well as a comparative evaluation of different microvascular free-flap options.

CONCLUSION

Soft-tissue reconstruction in PHA remains an evolving field. Operative decision-making is often multifaceted, and guided by specific volumetric, aesthetic and functional deficiencies. Serial fat grafting is the primary modality utilized for patients with mild soft-tissue atrophy, while microvascular free flaps widely remain the treatment of choice for reconstruction of large volume defects. There exists a growing role of graft supplementation to improve fat graft survival, while recent evidence demonstrates that early intervention may help curb disease progression.

[Application of pedicled omentum flap in breast reconstruction of breast cancer patients]

OBJECTIVE

To explore the clinical application of the pedicled omentum flap in breast reconstruction of breast cancer patients.

METHODS

Between May 2013 and October 2017, 205 patients with breast cancer received modified mastectomy. The pedicled omentum flap was used to reconstruct breast at the same time. All patients were female with an average age of 34.9 years (mean, 26-58 years). The tumor located at left breast in 127 cases and right side in 78 cases. The diameter of the tumor was 2-5 cm (mean, 2.9 cm). The 120 cases of breast cancer were at stage Ⅰ and 85 cases were at stage Ⅱ; and 126 cases were invasive ductal carcinoma and 79 cases were invasive lobular carcinoma. The course of disease ranged from 10 to 92 days (mean, 38.5 days). The size of defect after tumor ablation ranged from 9 cm× 6 cm to 18 cm×12 cm; the size of pedicled omentum flap ranged from 18 cm×10 cm to 22 cm×16 cm.

RESULTS

According to the anatomical basis, the omentum was divided into 4 types, including thin type (42 cases, 20.5%), medium type (133 cases, 64.9%), hypertrophy type (24 cases, 11.7%), and absence type (6 cases, 2.9%). All omentum flaps survived successfully and the incisions healed by first intention. All patients were followed up 6-74 months (mean, 24.5 months); 83 cases were followed up more than 5 years. The shape, texture, and elasticity of the reconstructed breast were good and no flap contracture deformation happened. Only linear scar left at the donor sites, and the function of abdomen was not affected. No local recurrence happened.

CONCLUSION

The pedicled omentum flap can be harvested safely and reliable, which is the one of ideal option for breast reconstruction in breast cancer patients.

Challenges in Microsurgical Reconstruction for Craniofacial Osteomyelitis With Resultant Osteonecrosis

INTRODUCTION

Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton.

METHODS/RESULTS

The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop.

CONCLUSIONS

Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels.

Craniofacial Microsomia

Clinicians use different diagnostic terms for patients with underdevelopment of facial features arising from the embryonic first and second pharyngeal arches, including first and second branchial arch syndrome, otomandibular dysostosis, oculoauriculovertebral syndrome, and hemifacial microsomia. Craniofacial microsomia has become the preferred term. Although no diagnostic criteria for craniofacial microsomia exist, most patients have a degree of underdevelopment of the mandible, maxilla, ear, orbit, facial soft tissue, and/or facial nerve. These anomalies can affect feeding, compromise the airway, alter facial movement, disrupt hearing, and alter facial appearance.

Laparoscopic Free Omental Flap for Craniofacial Reconstruction: A Video Article Demonstrating Operative Technique and Surgical Applications

The omental flap is a well described pedicled flap for surgical reconstruction of multiple body locations. As a laparoscopically harvested free flap, the omentum offers a minimally invasive solution to many reconstructive problems including extremity and head and neck wounds. This video article highlights the operative technique involved in flap harvest and inset for a cranial defect. An illustrative case involving a 23-year-old female's traumatic scalp degloving injury that was resurfaced by free omental flap and split-thickness skin graft is presented. This patient had stable long-term wound coverage for a very severe injury. Through video media we demonstrate that the laparoscopically harvested free omental flap is a minimally invasive, 2-team operation that provides soft tissue coverage of severe, remote wounds. This video demonstrates a safe operative technique and nuances specific to laparoscopic harvest of this flap.

The Laparoscopically Harvested Omental Free Flap: A Compelling Option for Craniofacial and Cranial Base Reconstruction

Background Management of craniofacial and cranial base tumors is a challenge due to the anatomic intricacies associated with the calvarium, the pathological diversity of lesions that present, and the potential complications. Clinical outcomes in laparoscopically harvested omentum free flaps for cranial base and craniofacial reconstruction are presented in this paper, in the largest case series to date. Methods A retrospective single-center experience for over 10 years with laparoscopically harvested omentum flaps used to reconstruct craniofacial and cranial base defects. Results A total of 13 patients underwent craniofacial or cranial base reconstruction using laparoscopically harvested omentum free flaps. The mean patient age was 48 years. The anterior skull base represented the most common site of reconstruction. A total of 12 of the flaps survived (92%), with one flap failure due to infection. All patients demonstrated satisfactory aesthetic and functional outcomes. There were no perioperative or intra-abdominal complications. Conclusions The laparoscopically harvested omentum free flap is a safe and effective tool in the armamentarium of the reconstructive surgeon. It is the ideal option to treat complex, three-dimensional subcutaneous defects, such as those encountered in craniofacial and cranial base reconstruction. Its unique angiogenic and immunologic capacity makes it an excellent flap for the previously irradiated and/or infected wound bed.

Craniofacial microsomia

Craniofacial microsomia (CFM) is one of the most common congenital conditions treated in craniofacial centers worldwide. This condition is variably associated with anomalies of the jaws, ears, facial soft tissue, orbits, and facial nerve function and can be associated with extracranial anomalies. The cause of this condition is unknown, though CFM has been associated withprenatalexposures and genetic abnormalities. Diagnosis, treatment, and outcome assessment in CFM is challenging due to the wide phenotypic spectrum observed in this condition. Surgical treatment requires a coordinated team approach involving multiple specialties, which can include plastic surgery, craniofacial surgery, orthognathic surgery, and microsurgery. A wide variety of surgical options exist, and individual treatment plans should be based on the patient's needs. Although CFM can be challenging to treat, successful outcomes are rewarding. We provide a review of the common craniofacial surgical treatments for individuals with CFM.

Novel role for mast cells in omental tissue remodeling and cell recruitment in experimental peritoneal dialysis

Because of its dynamic structure, the omentum plays a key role in the immunity of the peritoneal cavity by orchestrating peritoneal cell recruitment. Because mast cells accumulate in the omentum upon experimental peritoneal dialysis (PD) and may produce angiogenic/profibrotic factors, it was hypothesized that mast cells mediate omental tissue remodeling during PD. Daily treatment with conventional PD fluid (PDF) for 5 wk resulted in a strong omental remodeling response, characterized by an approximately 10-fold increase in mast cell density (P < 0.01), an approximately 20-fold increase in vessel density (P < 0.02), an approximately 20-fold increase in the number of milky spots (P < 0.01), and a four-fold increase in submesothelial matrix thickness (P < 0.0003) in wild-type rats. In contrast, all PDF-induced omental changes were significantly reduced in mast cell-deficient Ws/Ws rats or in wild-type rats that were treated orally with a mast cell stabilizer cromoglycate. A time-course experiment showed mast cell accumulation immediately before the formation of blood vessels and milky spots. Functionally, PDF evoked a peritoneal cell influx, which was significantly reduced in Ws/Ws rats (P < 0.04) and in wild-type rats that were treated with cromoglycate (P < 0.03). Cromoglycate treatment also completely prevented PDF-induced omental adhesions to the catheter tip (P = 0.0002). Mesothelial damage, angiogenesis, and fibrosis of mesentery and parietal peritoneum as well as glucose absorption rate and ultrafiltration capacity proved to be mast cell independent. Data strongly support the hypothesis that mast cells mediate PDF-induced omental tissue remodeling and, subsequently, peritoneal cell influx and adhesion formation, providing therapeutic possibilities of modulating omental function.

Free anterolateral thigh adipofascial flap for hemifacial atrophy

Though the etiology of hemifacial atrophy is still unknown, the aim of its reconstruction is cosmetic amelioration of the defect. Among many techniques introduced, microsurgical reconstruction has become the gold standard to restore the symmetry of the face. Seven free anterolateral thigh adipofascial flaps were used to reconstruct hemifacial atrophy between September 1999 and May 2005. There were 1 male and 6 females in the series. All the patients had unilateral disease (6 right and 1 left). The average age of onset of disease was 11.9 years. The average duration of atrophy was 6.7 years. The patients' average age was 25 years (range, 21 to 32 years), and the average follow-up period was 12.6 months (range, 6 to 36). The size of the transferred flap ranged from 8 x 6 cm to 12 x 13 cm. All adipofascial flaps survived completely. No complications occurred. The result is stable, and no recurrence of facial atrophy was seen in the patients after follow-up. One patient received minor revision because of the bulky reconstructed face. The esthetic appearance of the reconstructed face was acceptable. Despite a variable vascular anatomy that can give rise to some surgical challenge in raising the anterolateral thigh adipofascial flap, the authors conclude that this is a safe and reliable adipofascial flap for hemifacial atrophy.

[Head and neck reconstruction using laparoscopically harvested omentum]

Since the need for laparotomy in harvesting the omentum is the most significant drawback, the omentum has not been the tissue of choice for reconstructive surgery. To compensate for this drawback, we started laparoscopic harvesting of the omentum and clarified the advantages and disadvantages of this procedure. Ten patients underwent laparoscopic harvesting of the omentum by abdominal surgeons, followed by reconstruction of head and neck defects. Surgery was conducted in 5 cases of defect reconstructions for parotid gland tumor surgery and 5 of oropharyngeal defect after cancer surgery. The average harvesting time was 107 minutes (55-140 minutes) and used the omentum and different amounts and length of the vascular pedicle. Although the omentum was successfully transplanted in 9 of 10 cases, 2 cases showed partial peripheral necrosis and 1 total necrosis. With the advantage of laparoscopic harvesting of the omentum, we could obtain appropriate omental size for the defect size. Especially after total parotidecomy, the omentum was useful to fill in the defect, reducing the patients' worries about postoperative deformity. In one case, the omentum was used to treat Frey syndrome, successfully relieving the symptoms. In oropharyngeal reconstruction, the omentum is used to fill dead space and prevented postoperative infection. Although mild abdominal pain was observed a few days after surgery, no major abdominal complications such as intestinal perforation or ileus occurred in the 8 to 39 months following laparoscopic harvest of the omentum. Since the omentum is pliable and easily fills a complicated defect, the omentum is considered satisfactory for reconstructing defects of the lateral face after parotid tumor surgery and small defects after oropharyngeal tumor surgery.

Omental free-tissue transfer: indications and results from personal experience

Between 1987-2002, omental free-tissue transfer was used in 11 patients, aged 6-65 years (mean age, 37.6). The omentum was used for the treatment of brachial plexus injury pain (3 cases), Romberg's disease (1 case), defects of the extremities occurring with chronic obstructive arterial disease (2 cases), posttraumatic lesions (3 cases), and following oncological resections (2 cases). In 2 cases, omental tissue represented the secondary option, after the failure of muscular tissue transfer. In 2 patients, the omental tissue transfer helped to preserve the knee. There was 1 failure, followed by amputation of the thigh. Two patients died from their underlying disease 10 and 36 months, respectively, after the operation.

Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects: donor-site complications in 135 patients from 1975 to 2000

OBJECTIVE

To examine donor-site complications after omental harvest for the reconstruction of extraperitoneal wounds and defects.

SUMMARY BACKGROUND DATA

The omentum, with its immunologic and angiogenic properties, is a versatile organ with well-documented utility in the reconstruction of complex wounds and defects. However, the need for laparotomy and the potential for intraabdominal complications have been cited as relative contraindications to the use of the omentum as a reconstructive flap. Further, few series have assessed long-term results, and no reports have focused on donor-site complications.

METHODS

Patients who underwent reconstruction of extraperitoneal defects with the omentum at a single university healthcare system were identified by searching discharge databases and office records. Charts were reviewed to determine patient demographics, surgical indications and technique, postoperative complications, and outpatient follow-up. Patients with donor-site complications were compared with patients who had no complications using the Student t test and chi-square analysis. Statistical significance was defined at P <.05.

RESULTS

From 1975 to 2000, the authors successfully harvested 135 omental flaps (64 pedicled, 71 free transfer) for reconstruction of the following defects: scalp (n = 16), intracranial (n = 1), orbitofacial (n = 33), neck (n = 8), upper extremity (n = 7), lower extremity (n = 4), intrathoracic (n = 3), sternal (n = 34), breast (n = 3), chest wall (n = 18), abdominal wall (n = 1), and perineal (n = 7). Donor-site complications in 25 patients (18.5%) included abdominal wall infection (n = 9), fascial dehiscence (n = 8), symptomatic hernia (n = 8), unplanned reexploration (n = 6), postoperative ileus (n = 3), gastrointestinal hemorrhage (n = 2), delayed splenic rupture (n = 1), gastric outlet obstruction (n = 1), and late partial small bowel obstruction (n = 1). Factors associated with increased donor-site complications included the use of pedicled flaps (compared with free tissue transfer), mediastinitis, advanced age, and pulmonary failure. Of note, 53 patients had undergone previous abdominal surgery; of these, 26 patients required extensive adhesiolysis and 4 patients sustained enterotomies. Eleven patients (8.1%) had partial flap loss and three patients (2.2%) had total flap loss. Mean length of stay was 28 days. Average follow-up was 2.4 years. The death rate was 5.9%.

CONCLUSIONS

The omentum can be safely harvested and reliably used to reconstruct a diverse range of extraperitoneal wounds and defects. Donor-site complications can be significant but are usually limited to abdominal wall infection and hernia. Risk factors associated with complications include the use of pedicled flaps, mediastinitis, and pulmonary failure. This low rate of donor-site complications strongly supports the use of the omentum in the reconstruction of complex wounds and defects.

Thoracic reconstruction with the omentum: indications, complications, and results

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection. The French Associations for Surgical Research

BACKGROUND

Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness.

METHODS

Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI).

RESULTS

Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05).

CONCLUSIONS

OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.

Microvascular transplantation of a free omental graft to the distal extremity in dogs

OBJECTIVE

To assess the survival of a free omental graft applied to an experimentally created wound on the distal extremity in dogs.

STUDY DESIGN

A free omental graft was evaluated as a primary method of treatment for dogs with distal extremity wounds in an experimental model.

ANIMALS OR SAMPLE POPULATION

Five adult intact female mixed breed dogs weighing 21.8 kg to 25.0 kg.

METHODS

A free omental graft was harvested from the abdomen and transferred to a wound bed overlying the medial aspect of the tibia. A microvascular anastomosis was performed between the graft vessels and vessels at the recipient site. Daily clinical assessment of graft viability was performed. Angiography and 99mTechnetium labeled macroaggregated albumin (99mTc MAA) scintigraphic perfusion scans were performed on either day 4, 5, or 7. Postmortem collection of tissues for histopathologic analysis was performed immediately after imaging. Total operative time and graft ischemia time were evaluated for effects on graft survival.

RESULTS

Two of seven grafts survived to the end of the study, three of seven grafts failed because of ischemia, and two of seven grafts failed because of self-trauma. There was no clinically significant morbidity associated with the abdominal portion of the procedure. Because of the small number of surviving grafts, the effects of operative time and graft ischemia time could not be statistically evaluated.

CONCLUSIONS

Microvascular transplantation of a free omental graft can result in a viable tissue covering of a distal extremity wound, however, the failure rate is unacceptably high.

CLINICAL RELEVANCE

A free omental graft may not have sufficient durability to be an acceptable wound covering by itself. Further studies combining omentum with a skin graft or other tissues may result in a clinically useful technique.

Omentoplasty in the prevention of deep abdominal complications after surgery for hydatid disease of the liver: a multicenter, prospective, randomized trial. French Associations for Surgical Research

BACKGROUND

Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant.

STUDY DESIGN

The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42+/-16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay.

RESULTS

Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk < 0.05) and fewer deep abdominal abscesses (0 versus 11%) (p < 0.03). Median duration of hospital stay, however, was similar.

CONCLUSIONS

OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.

High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction

A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high-energy avulsive facial injuries emphasizes the superiority and safety of "ballistic wound" surgical management: (1) immediate stabilization in anatomic position of existing bone, (2) primary closure of existing soft tissue, (3) periodic "second look" serial debridement procedures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotgun wounds, and 15 high-energy avulsive facial injuries. Four general patterns of involvement are noted for both gunshot and shotgun wounds and three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissue. Gunshot wounds are best classified by the location of the exit wound; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complications vary according to four patterns of gunshot wounds and four patterns of shotgun wounds. Avulsive wounds have not been recommended previously for ballistic wound surgical management. The appropriate management of high-energy avulsive and ballistic facial injuries is best approached by an aggressive treatment program emphasizing initial primary repair of existing tissue, serial conservative debridement, and early definitive reconstruction.

Treatment of recurrent cerebrospinal fluid rhinorrhea with a free vascularized omental flap: a case report

Cerebrospinal fluid fistulas after pericranial surgery are a major source of morbidity. A patient who underwent transsphenoidal sinus surgery for a recurrent pituitary adenoma was presented. The patient developed a chronic CSF leak despite standard management, including subarachnoid CSF drainage and transnasal endoscopic closure of the dura. Successful closure of the CSF fistula was obtained using a free omental flap to the sphenoid sinus. This case is the first reported use of a free microvascularized omental flap in an intracranial position for treating chronic CSF rhinorrhea. A description of the indications and the surgical technique for free omental closure of CSF fistulas was provided. The etiology, diagnosis, and management of CSF rhinorrhea are reviewed for the reconstructive surgeon.

Use of the omentum in chest-wall reconstruction

Increased use of the omentum in chest-wall reconstruction has paralleled the refinement of anatomic knowledge and the development of safe mobilization techniques. Important anatomic points are the omental attachments to surrounding structures, the major blood supply from the left and right gastroepiploic vessels, and the collateral circulation via the gastroepiploic arch and Barkow's marginal artery. Mobilization of the omentum to the thorax involves division of its attachments to the transverse colon and separation from the greater curvature to fabricate a bipedicled flap. Most anterior chest wounds and virtually all mediastinal wounds can be covered with the omentum based on both sets of gastroepiploic vessels. The arc of transposition is increased when the omentum is based on a single pedicle, allowing coverage of virtually all chest-wall defects. The final method of increasing flap length involves division of the gastroepiploic arch and reliance on Barkow's marginal artery as collateral circulation to maintain flap viability. With regard to chest-wall reconstruction, we have included the omentum in the armamentarium of flaps used to cover mediastinal wounds. The omentum is our flap of choice for the reconstruction of most radiation injuries of the chest wall. The omentum may also be used to provide protection to visceral anastomoses, vascular conduits, and damaged structures in the chest, as well as to cover defects secondary to tumor excision or trauma. In brief, the omentum has proved to be a most dependable and versatile flap, particularly applicable to chest-wall reconstruction.

Hepatic trauma revisited

As stated in the introduction to this monograph, much has changed in the management of major hepatic injuries during the past 5 to 10 years. The major changes are summarized as follows: 1. Computed tomographic scanning is now the mainstay of diagnosis for hepatic injuries after blunt trauma and allows for nonoperative therapy in many patients with lacerations, intrahepatic hematomas, or subcapsular hematomas; 2. Realization that the time limit for application of the Pringle maneuver can be extended. 3. Recognition that fibrin glue appears to be a useful topical agent in preliminary clinical studies; 4. Use of hepatotomy with selective vascular ligation instead of mattress sutures for deep lacerations or to control hemorrhage from tracts of penetrating wounds; 5. Use of resectional débridement of devitalized tissue and selective vascular ligation instead of formal anatomical resection; 6. Use of an "omental pack" as a filler of deep cracks or hepatotomy sites instead of closure with mattress sutures; 7. Use of perihepatic packing in selected patients instead of resection when a coagulopathy or major subcapsular hematoma is present; 8. Discontinued use of perihepatic drains for minor or moderate hepatic injuries as long as discrete methods of selective vascular and biliary ligation have been used.

Cerebral shift after lateral craniofacial resection and flap reconstruction

The biomechanical effects on the cranial contents after craniectomy and immediate soft-tissue flap reconstruction are substantial and potentially life threatening. Once the rigid protective covering of the skull is removed, the cerebral component of the cranial contents is vulnerable to rising extrinsic pressure. Intracranial pressure falls, brain compliance rises, and contralateral cerebral shift may occur by virtue of the craniectomy alone. However, if flaps filling the defect should compress by weight or swelling, even greater midline or craniocaudal shift of the brain may occur. We present three cases in which midline cerebral shift was documented by CT scan after flap reconstruction of lateral craniofacial/craniotemporal resection. Three other patients undergoing anterior craniofacial resection during the same time period for skin cancer (one patient) and esthesioneuroblastoma (two patients) had no shift in intracerebral contents. Symptomatic or asymptomatic intracranial shift may occur soon after substantial craniectomy and soft-tissue flap reconstruction. Midline shift from lateral resection and reconstruction is more likely than anteroposterior shift from anterior craniofacial resection. Strategies for minimizing this compression or shift are described.

The contribution of microsurgical reconstruction to craniofacial surgery

Craniofacial surgery has revolutionized the surgical treatment of congenital anomalies affecting the facial and cranial skeleton. Similar techniques have since been used in the reconstruction of patients with extensive craniofacial injuries and following craniofacial resection of tumors involving the midface. The application of microsurgical free flaps to some of these craniofacial problems is another significant advance. Microsurgical transfer of deepithelialized skin flaps or omentum will allow the augmentation of soft tissue contour defects of the face in patients with hemifacial microsomia and Romberg's progressive facial hemiatrophy. Following craniofacial resection of extensive tumors of the midface, microsurgical free flaps and vascularized bone grafts will provide soft tissue coverage and, occasionally, both bone and soft tissue composite reconstruction of the resultant defect. Finally, intracranial infection, following craniofacial surgery and neurosurgical excision of tumors involving the skull base, may be effectively prevented by separation of the dura from the nasopharynx by microsurgical transfer of free muscle flaps and omentum.

Free omental flap reconstruction of complicated head and neck wounds

Complicated wounds of the head and neck involve a severe deficiency of tissue in a contaminated or irradiated area that is predisposed to infection and necrosis. Reconstruction of these wound areas frequently requires multiple operations and prolonged hospitalization. We have successfully reconstructed complicated head and neck wounds in thirteen patients by means of a single-stage microvascular tissue transfer of the greater omentum with or without an attached segment of the stomach wall. There were 11 complete successes, two partial failures, and no complete failures. We describe four cases to illustrate the basic fundamentals of this reconstructive technique.

Transplantation of tissues and organs. Review of the first 100 years of the Southern Surgical Association

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The use of greater omentum vascularized free flaps for neurosurgical disorders requiring reconstruction

The heterotopic transfer of composite tissue, with microvascular anastomosis of an arterial supply and venous drainage to locally existing vessels, has received considerable attention in the plastic surgical literature. The use of latissimus dorsi musculocutaneous free flaps has been reported in the repair of large defects of the scalp, cranium, and dura following resection of invasive neoplasms or trauma. When the defect involves primarily subcutaneous tissue loss resulting in abnormal contour, omental free flaps provide effective coverage and restoration of contour. In addition, the inherent capability of the omentum to combat infection and form an ideal bed for the establishment of skin or bone grafts provides further indications for its use. The authors have used omental free flaps in nine cases to reconstruct gunshot wounds of the head, orbit, and face, heal chronic cavitating frontal sinus infections, form a base over exposed dura for reconstruction of the skull with rib grafts, and cover large defects after resection of invasive tumors or infected scalp. These wounds of neurosurgical interest were reconstructed with acceptable structural and aesthetic results. The indications, surgical techniques, results, alternative procedures, and potential complications of this procedure are discussed. The authors believe that omental free flaps should be considered an option in the armamentarium of reconstructive approaches for skull, dural, scalp, orbital, and facial wounds.

Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries of the liver

The most important concept emerging from the management of complex hepatic trauma is that direct suture ligation of severed blood vessels and bile ducts is the most effective treatment. Three essential maneuvers are necessary: (1) the use of the finger fracture technique to expose the laceration widely, so that individual ligation of severed blood vessels and bile ducts can be accomplished under direct vision; (2) occluding the portal triad for 20 to 60 minutes; (3) closure of the hepatic incision over a viable omental pedicle. Two hundred consecutive patients with hepatic injuries were treated at the Trauma and Shock Unit of Bellevue Hospital between July 1976 and January 1982. One hundred and twenty-five injuries (63%) could be managed by superficial suture and drainage alone; 75 (37%) more extensive injuries required additional therapy; 47 of the 75 injuries required inflow occlusion for periods of up to 60 minutes, with the mean occlusion time of 30 minutes. All patients were pretreated with 30 to 40 mg/kg of Solu-Medrol prior to cross-clamping the portal triad. In addition, the liver was cooled to 27-32 degrees C topically by pouring 1 liter of iced Ringer's lactate directly on the liver surface, monitoring the temperature with an intra-hepatic probe. Ischemia time exceeded 20 minutes in 70%, 30 minutes in 40% and 60 minutes in 7% of patients. This approach, with complex hepatic trauma, has been dramatically effective. There were only four deaths (5.3%). One (1.3%) patient required reoperation for bleeding; three patients (4%) developed perihepatic abscesses; and two patients (3%) developed biliary fistulae that spontaneously closed. An extended right hepatectomy was necessary in the one patient who required reoperation for bleeding. This represents the only case of a formal hepatic resection in this series. Hepatic artery ligation was not employed in any case. These experiences strongly endorse the direct approach to the treatment of major hepatic lacerations by opening a lacerated liver sufficiently to ligate lacerated blood vessels and bile ducts, followed by closure over an omental pedicle. The wide-spread adoption of this technique will probably lower the mortality from massive liver injuries to 5-10%.