Trunk & perineum · Interactive 3D

Omental flap

The pedicled omental flap: the greater omentum freed from the transverse colon and the greater curvature and turned up on the right gastroepiploic vessels to fill a sternal or chest wall wound — a Mathes–Nahai type III flap with two dominant pedicles.

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Technique summary after Janis, Essentials of Plastic Surgery (omentum).

What to look at

1The greater omentum has been lifted off the transverse colon, separated from the greater curvature and turned up on its right gastroepiploic pedicle to reach the lower chest.
2Two dominant pedicles (Mathes–Nahai type III): the right gastroepiploic from the gastroduodenal artery and the left gastroepiploic from the splenic artery, joined along the greater curvature. The flap is based on one; the other is divided.
3Right-based is the usual choice for sternal and mediastinal wounds — the larger vessel and the longer reach. Dividing the arcade between omental branches lengthens the flap further.
4Uses: deep sternal wound infection, chest wall defects, intrathoracic dead space, scalp and limb cover as a free flap, and vascularised omental lymph node transfer for lymphoedema. The price is a laparotomy (or laparoscopic harvest), hernia at the tunnel, and a volume you cannot predict before you look.

Hotspots

1Greater omentum — A double apron of peritoneum and fat hanging from the greater curvature: typically 25 × 35 cm and anything from 300 g to 2 kg, so its size is unknown until the abdomen is opened. Here it has been turned up over the lower chest.
2Right gastroepiploic pedicle — From the gastroduodenal artery (common hepatic), running along the greater curvature from the pylorus. The larger of the two dominant pedicles and the usual basis of a flap for the sternum and mediastinum.
3Gastroepiploic arcade — Right and left gastroepiploic arteries anastomose in the gastrocolic ligament 1–2 cm from the greater curvature. Here the arcade stays with the stomach and the omental branches are clipped; taking the arcade with the flap (dividing the gastric branches instead) gives more length.
4Divided omental branches — The omental (epiploic) branches are divided between clips to free the apron; only the right-sided branch, in continuity with the right gastroepiploic artery, is kept as the pedicle.
5Omental arteries — Right and left omental arteries descend from the arcade and join near the free edge as the arc of Barkow, which keeps the whole apron alive on one pedicle and is what allows the flap to be lengthened by dividing the arcade between branches.
6Stomach — Greater curvature. The short gastric arteries (from the splenic) supply the fundus and take no part in the flap; the right gastric artery runs on the lesser curvature.
7Left gastroepiploic artery — From the splenic artery near the splenic hilum: the smaller pedicle. Divided to release and lengthen a right-based flap; a left-based flap is chosen when the right vessels have been used or the defect is on the left.
8Transverse colon — The first step: separate the posterior layer of the omentum from the transverse colon and mesocolon along the avascular plane, protecting the middle colic vessels. This opens the lesser sac.
9Liver and gallbladder — Orientation: the patient's right. The gastroduodenal artery and the origin of the right gastroepiploic lie just behind the first part of the duodenum, below the liver edge.
10Recipient site — The flap reaches the sternum and anterior mediastinum through an anterior diaphragmatic window or a subcutaneous tunnel over the costal margin (hernia risk). A right-based flap reaches the upper sternum and neck; the omentum is then skin-grafted or the skin closed over it.

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