2024/10/30 by María Sánchez‐Rodríguez, Patricia Tejedor, José Manuel Asencio +4 · 1 voice
Medicine · #Diagnosis and Treatment of Venous Diseases #Lymphatic Disorders and Treatments #Lymphatic System and Diseases
paper · doi:10.1093/bjs/znae276
openalex publication_date 2024/10/30 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
Lymphoedema is a chronic and progressive condition caused by the disruption of lymphatic drainage that significantly impacts a patient’s quality of life1. Omentum flap transposition is a well-established technique that can restore lymphatic flow, without the need for anastomosis, and it has been shown to be effective in treating lower limb lymphoedema in several studies1–4. Robotic surgery offers key advantages, particularly in procedures requiring high precision, such as vascular dissection. The Xi robotic system is especially useful, allowing for operations in multiple quadrants, without repositioning the robot or changing ports. The aims of the video accompanying this article are: to demonstrate the combined technique of pedicled omentum flap transposition to the iliac vessels and free omentum flap to the ankle region as a treatment option for chronic lower limb lymphoedema caused by prior pelvic lymphadenectomy; and to highlight the Xi robotic system as an effective approach for procedures requiring supracolic and inframesocolic dissection, as well as lateral pelvic wall dissection in patients who have previously undergone abdominopelvic surgery. See Video 1. The case of a 57-year-old woman is presented. She had right lower limb lymphoedema, which developed after a hysterectomy and bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and adjuvant brachytherapy for cervical cancer in 2011. The lymphoedema was correlated with increased circumferential measurements of the right limb and pathological lymphatic drainage seen using Lympho-SPECT. A multidisciplinary board recommended reconstructive surgery, involving a pedicled omentum flap and a free omentum flap for the right iliac vessels and the right posterior tibial vessels respectively. All procedures were in accordance with the ethical standards of the Institutional Research Committee and the 1964 Helsinki declaration and its later amendments. In addition, this study was approved by the Medical Research Ethics Committee of the General University Hospital Gregorio Marañón. Informed consent was obtained from the participant included in this study. A robotic approach was used for the abdominal procedure, utilizing four 8 mm ports placed in an infraumbilical transverse line. The procedure involved: first docking for dissection of both flaps and removal of the free flap; identification of the right gastroepiploic vessels as the pedicle for both flaps at the greater curvature of the stomach; dissection of the vessels and greater omentum for the free flap (Video Still Image 1); entry into the lesser sac for mobilization of the pedicled flap; ligation of the gastroepiploic vessels and removal of the free flap; second docking for pedicled omentum flap transposition; dissection of the right iliac vessels and placement of the pedicled flap (Video Still Image 2); and pedicled omentum flap placement to surround and protect the iliac vessels once the vessels were exposed. Simultaneously, the right gastroepiploic vessels, serving as the pedicle of the free flap, were anastomosed to the posterior tibial vessels using 9/0 non-absorbable monofilament sutures (Video Still Image 3). The patient was discharged on the fourth postoperative day, without complications, and at the 6-month follow-up the patient showed clinical improvement, with reduced lymphoedema symptoms and a progressive reduction in limb circumference. The authors have no funding to declare. María Sánchez-Rodríguez (Conceptualization, Formal analysis, Investigation, Methodology, Resources, Software, Writing—original draft, Writing—review & editing), Patricia Tejedor (Data curation, Supervision, Validation, Writing—review & editing), Jose Manuel Asencio (Resources, Validation), Adnan Alsourani (Resources, Validation), Álvaro García-Cañal (Resources, Visualization), Yue Chen (Visualization), and Jose María Lasso-Vázquez (Conceptualization, Data curation, Resources, Supervision, Validation) The authors declare no conflict of interest. Data sharing is not applicable to this article as no data sets were generated or analysed during the present study.