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To the Editor,
Due to the technical advances in laparoscopic surgery, we are indeed able to welcome a new dawn for the versatile use of the omentum in reconstructive surgery. The large experience of and excellent documentation by Zaha and Inamine  in laparoscopically harvesting the omental flap, pedicled or free, in 96 patients should not go unnoticed. The description of their dissection technique is so lucid that it could easily be adopted by other endoscopic surgeons, regardless of the indication. We would like to draw your attention to a small, but to our mind significant, technical point.
The laparoscopically harvested omental flap has many uses but is particularly suitable for selected cases that require reconstructive breast surgery and effective for the treatment of mediastinitis or reconstruction of the sternum after deep sternal wound infection (DSWI) or sternal osteomyelitis. Both conditions, albeit a distant second or third choice, also can be managed by transposition of a pedicled rectus abdominis, either as a muscle or as a musculocutaneous (TRAM or VRAM) flap. Direct injury to the rectus muscle or the superior epigastric vessels (SEV), resulting in a muscle hematoma and subsequent fibrosis or interruption of flow, however small the risk, should be avoided. Apart from a few anecdotal reports and a small case series (n = 5)  on the successful transposition of the pedicled rectus muscle to the chest after ligation of the ipsilateral inferior mammary artery (IMA), there have been none where the SEV had been transected. Furthermore, the delay required for the collateral circulation to develop may be too long for some patients to wait. Zaha and Inamine  state that the port in the right upper quadrant was inserted “at the level of a wedge of the rectus muscle.…” We would rather recommend, as we did previously , that the port should be sited lateral to the rectus muscle wherever possible.
Keeping a lifeboat intact should, also in reconstructive surgery, always be a priority; one way is to avoid an unplanned encounter with a vessel!
Disclosures Drs. Van Wingerden and Totte have no conflicts of interest or financial ties to disclose.
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