Omental Pedicle "J" Flap

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Omental Pedicle "J" Flap

An omental "J" flap provides (1) a nonirradiated vascular pedicle flap to cover intestinal anastomoses and (2) vesicovaginal-rectovaginal fistula repairs to form a lid on the inlet of the true pelvis after exenteration and to form a cylinder for a neovagina.

The purpose of this operation is to create a flap from the omentum by transecting the omentum from its attachments to the stomach, leaving enough branches of the left gastroepiploic vessels to provide an adequate blood supply for the flap.

Physiologic Changes. Irradiation produces obliterative endarteritis, ischemia, and fibrosis, all of which retard healing. By applying a vascular pedicle that has not been irradiated, the surgeon attempts to reverse some of the ischemia present in the irradiated tissue by promoting capillary and arterial ingrowth from the pedicle flap's blood supply. In addition, when the inlet to the true pelvis has been blocked by an omental lid, the small bowel is prevented from dropping into the denuded true pelvis after an extensive operation. Therefore, the possibility of intestinal obstruction and fistula formation is reduced. The omentum has a copious blood supply. Therefore, it is an excellent recipient of a skin graft for a neovagina.

Points of Caution. The short gastric vascular arcades to the omentum must be identified on the greater curvature of the stomach prior to initiating the procedure to ensure an adequate blood supply from the gastroepiploic artery remains for the proposed omental flap. The flap should be designed so the stomach is not pulled into the lower abdomen. The flap should not be placed on tension.

Technique

This operation is performed in conjunction with other radical pelvic surgery. Therefore, the appropriate incision for the initial procedure is adequate for the omental "J" flap. It is extremely difficult to perform the omental J flap through a transverse or Pfannenstiel incision, so a midline incision extended around the umbilicus is preferred.

The design of the flap prior to transecting the omentum is essential. A centimeter ruler and unfolded sponge are helpful in determining the appropriate length needed for the flap to reach the pelvis without tension. A check of the vascular arcades should be made to ensure that an ample blood supply is entering the base of the flap. Generally, the transection of the omentum is started at the hepatic flexure of the colon and proceeds from the patient's right to her left.

The omentum is opened in avascular areas with a small Kelly or Metzenbaum scissors. The vascular bridges between these openings can be doubly clamped with Kelly clamps, incised, and tied with 2-0 suture.

An alternative to Kelly clamps is the automatic LDS (linear dissecting) stapler (United States Surgical Corp.). This device clamps the vascular bridges between the openings in the omentum with the jaws of the stapler, applies two stainless steel clips, and activates a scalpel within the stapler to cut between the steel clips. It is a valuable, and time-saving device.

The omental flap is completed. It can be moved into the pelvis as a cover for a suture line or a pelvic lid.