Robotic Harvest of a Right Gastroepiploic Lymph Node Flap

Lymph node flap (LNF) transfer has proven to be an effective option in the treatment of lymphedema. As a result, much research is presently focused on finding an ideal donor site that results in good clinical outcomes while avoiding iatrogenic lymphedema of the donor area. The omental flap with its lymph nodes based on the right gastroepiploic vessels that has been described for the treatment of lymphedema in the extremities avoids donor site lymphedema of the extremities. Harvesting this flap laparoscopically further reduces the donor site morbidity [1,2]. Robotic surgery has gained popularity in numerous surgical specialties, including plastic surgery [3,4], due to its advantages over laparoscopic and endoscopic techniques. Herein, we report a novel application of robotic surgery for the harvest of a right gastroepiploic lymph node flap (RGE-LNF) for the treatment of lymphedema of the extremities. To the best of our knowledge, the application of a robotic technique for the harvest of this flap has not been reported in the literature. A 55-year-old woman presenting with left lower extremity lymphedema and unsatisfactory outcomes following conservative treatment was offered surgical management with RGE-LNF transfer. All aspects of the various options for flap harvest were explained to her, including the open, laparoscopic, and robot-assisted techniques. The patient was comfortable with the robotic option and gave consent for the Da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) to be used for flap harvest (Supplemental Video S1, which demonstrates the robotic RGELNF harvest). An experienced general surgeon trained in robotic surgery performed the harvest of the flap with guidance from the plastic surgery team. One 12-mm supraumbilical port was created with an optical trocar for camera placement. After abdomen insufflation, two 8-mm ports were inserted at least 8 cm laterally from and 5 cm below the supraumbilical port, one on the right and the other over the left lower abdomen. Finally, a 5-mm assistance port was inserted in the epigastric region slightly cephalad to the camera port and midway between the camera and the right-side port. The RGE-LNF is based on the right gastroepiploic artery and vein (Fig. 1). Exploration was started by identifying the omental attachment to the greater curvature of the stomach and transverse colon, followed by identification of the right gastroepiploic vessels. Flap dissection was initiated by detaching the omentum from the transverse colon. The vertical gastric branches at the cranial aspect of