Role of omental flaps in thoracic surgery complications: a narrative review

Introduction

Background

The greater omentum is an intraperitoneal apron of adipose tissue, derived from the dorsal mesentery during the seventh week of embryologic development (1,2). By birth it forms a well-developed organ that continues to mature throughout childhood (1). Anatomically, it extends as a double-layered peritoneal fold from the greater curvature of the stomach toward the pelvis and typically weighs 300–2,000 g with an average surface area of approximately 500 cm² (1,3). Its blood supply arises from anastomotic arcades originating mostly from the celiac trunk with some additional indirect branches of the middle colic artery that anastomose with the gastro-epiploic vessels, creating a highly vascularized and well-perfused tissue bed (1,3). These vessels create interloop spiraling capillaries known as omental glomeruli (4,5). Additionally, the vascular system is closely linked to numerous areas of lymphatic in- and out-flow (4,5).

Beyond its anatomic characteristics, the omentum has crucial immunologic and regenerative functions that make it a remarkable organ, uniquely fit for advanced reconstructive techniques (1,3,5).

Clusters of macrophages, lymphocytes, and stromal cells organized into structures known as “milky spots” function similarly to secondary lymphoid tissue and facilitate rapid immune cell trafficking (3). In addition, the omentum contains abundant angiogenic and fibroblast growth factors, as well as pluripotent stem cells that promote neovascularization, infection control, and tissue repair (1,3,5). Through these mechanisms, the omentum can compartmentalize contamination, limit inflammation, and accelerate healing and regenerative processes (3,5).

The combination of vascular, immunologic, and regenerative characteristics of the omentum makes this organ uniquely suited for the management of complex intrathoracic pathology (3-5). Its ability to deliver robust blood supply, control infection, and promote tissue healing has led to its use as a versatile reconstructive option in thoracic surgery, particularly in the setting of contaminated fields, reinforcement of repairs, and treatment of challenging intrathoracic defects (1,3,4).

Rationale and knowledge gap

Given its biological advantages and highly beneficial cellular composition, the omentum is a unique organ with great potential in different surgical fields (1,6). As a regenerative and antimicrobial organ, it acts as the perfect conduit for tissue recomposition and reconstruction in contaminated fields (6). However, despite its versatility, its intrabdominal nature has complicated its use in extra-abdominal locations (6). Recently, with the introduction of minimally invasive techniques such as laparoscopic and robotic surgery, omental harvesting has become possible without undergoing traditional large surgical incisions, associated with typical postoperative complications, leading to a spark of interest in the reconstructive thoracic surgery field, especially in the use of omental flaps for pleural space complications (6,7). Nonetheless, the lack of literature on the topic remains a barrier to practice.

Objective

The goal of this study is to provide a detailed overview of the current literature addressing the role of omental flaps in the management of pleural space complications. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1004/rc).

Methods

Literature search strategy

An extensive literature review was conducted to identify all existing data available on omental flaps in pleural space complications to perform this narrative review. Studies from MEDLINE (via PubMed), Scopus, and Cochrane Central Register of Controlled Trials were systematically searched from inception to February 2026. Search terms included combinations of keywords and Medical Subject Headings (MeSH) related to such terms as “Omental flap”, “pleural space”, and “bronchopleural fistula”, “post lobectomy complications”, “entrapped lung”, and “empyema”. Selected articles were also manually screened for references to identify additional relevant publications. Grey literature was also queried and selected accordingly (Table 1). Although this study was conducted as a narrative review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used as a guide for literature identification, screening, and reporting (Figure 1).

Figure 1 PRISMA diagram identification of studies via databases.

Study selection

All peer-reviewed articles in English and Spanish that described the application of omental flaps in pleural space complications were reviewed. All types of study designs were included. Editorials, conference abstracts, and non-peer-reviewed literature were excluded. Final study selection was performed independently by two reviewers who screened all titles and abstracts. Full texts of potentially eligible studies were then reviewed for final inclusion. Disagreements were resolved by consensus with the senior author. Inclusion criteria consisted of published studies that described the use of omental flaps in pleural space complications in humans in English or Spanish. Exclusion criteria included studies in other species or another language, as well as editorials, abstracts, non-peer-reviewed literature and other omental flap applications outside pleural disease management.

Data extraction and synthesis

Data extraction was carried out on a supplemental electronic form, collecting study design, patient population, size of the tissue flap, indication for flap use, surgical technique, and outcomes. The findings were synthesized using a narrative approach and organized thematically according to clinical indications, technical considerations, advantages and limitations of omental flaps, and, finally, reported outcomes. Areas of agreement, controversy, and gaps in the literature were highlighted to provide an overview of current knowledge and to identify directions for future research.

Results

Clinical indications

The central anatomical position of the omentum makes it an ideal donor for soft-tissue reconstruction within the thoracic and abdominal cavity when used as a pedicled flap and for distal defects when employed as a free flap (6,8). Additionally, it can be used as an adjunct or in combination with other flap based reconstruction procedures (7). In most cases, it is large enough to fill significant thoracic defects without requiring additional tissue transposition (9). This makes it an ideal option for complex chest wall reconstruction and mediastinal reconstruction, including sternal, pericardial and pleural cavity procedures (6,7). Coupled with its reliable vasculature and intricate lymphatic system, cases with high risk of failure due to vascular strain or infection can benefit from this donor tissue selection (7).

While indications for the specific use of omental flaps have not been definitively established, existing literature advocates their use in large defects requiring bulk reconstruction, intrathoracic open wounds, high-risk infectious environments, reconstructions associated with high failure rates, and salvage surgeries (1,6,7,9,10). Given the limited literature, the indications, techniques and patient populations for omental flap use in thoracic surgery remain heterogeneous. In the case of bronchopleural fistula (BPF), indications for the use of omental flap include cases of post-pneumonectomy BPF, refractory BPF after failed muscle flap or drainage procedures, BPF associated with infected prosthetic material and reinforcement of BPF repair (1,6,7,9,10). Regarding empyema, indications include empyema associated with BPF and chronic empyema in the setting of entrapped lung and persistent pleural space refractory to other medical and surgical management. Lastly, the indications for prophylactic use are bronchial stump reinforcement post-pneumonectomy, coverage of high-risk anastomoses during lung transplant, reinforcement after airway resection, and prevention of fistula formation in radiated or infected fields (1,6,7,9,10) (Table 2).

Relative contraindications to omental flap harvest include portal hypertension given concerns for bleeding, history of multiple major intrabdominal surgeries due to risk of extensive intraabdominal adhesions or previous resection of the omentum and vascular injuries and patients with extremely low body mass index given the limited size and volume of the omental flap itself (9).

In practical thoracic surgical decision-making, the omentum should not be considered a routine first-line reconstructive option, but rather a highly valuable flap reserved for complex pleural space pathology in which conventional muscle transposition may be inadequate or has already failed (Figure 2). Omental transposition is particularly useful in patients with large residual pleural dead space, chronic empyema, post-pneumonectomy BPF, irradiated tissue, resistant infection, or poor-quality local tissue that limits the use of regional muscle flaps (Figure 3). Smaller fistulas with limited contamination and preserved chest wall musculature may often be managed with local muscle flap bronchoplasty alone, whereas larger fistulas, recurrent empyema, and salvage situations generally require a more aggressive reconstructive strategy combining durable fistula closure with vascularized tissue capable of obliterating residual dead space. In most chronic empyema cases, reconstruction is best performed in a staged fashion with initial open window thoracostomy, serial debridement, infection control, nutritional optimization, and, when appropriate, vacuum-assisted closure therapy before definitive flap transposition. Definitive omental transposition should be considered once the pleural cavity demonstrates healthy granulation tissue and satisfactory control of infection.

Figure 2 Initial management algorithm. BPF, bronchopleural fistula; OWT, open window thoracostomy; VAC, vacuum-assisted closure.

Figure 3 Advanced management algorithm. BPF, bronchopleural fistula; MRSA, methicillin-resistance Staphylococcus aureus; NPWT, negative pressure wound therapy; OWT, open window thoracostomy; VAC, vacuum-assisted closure; VATS, video-assisted thoracoscopic surgery.

Technical considerations

Seven articles described specific details regarding flap harvest for thoracic reconstruction procedures (6,7,11-15). Access to the omental flap was obtained through open or minimally invasive approach (laparoscopic or robotic) (9). While the traditional method was via midline laparotomy, minimally invasive techniques have been associated with less postoperative pain and smaller incision size (6). The transdiaphragmatic approach is reserved only for minor defects because of challenging harvest due to the limited exposure and the proximity to the phrenic nerve branches (6,7,11-15).

Based on the techniques described, the vascular supply of the omentum primarily derives from the right or left gastroepiploic arteries and its extensive collateral circulation (9). One of these arteries becomes the base for pedicle flaps. Generally, the artery selected for the flap perfusion is ipsilateral to the defect, while the contralateral arterial branch is divided (9). For instance, if the flap is based on the right gastroepiploic artery, then the left gastroepiploic vessel is ligated proximally to the takeoff from the splenic artery. On the contrary, if the left gastroepiploic artery is used, then the right gastroepiploic is divided distal to the takeoff from the pancreatoduodenal artery (6,9). In rare instances, the flap can be harvested from both vessels (7). Subsequently, the omentum is to be mobilized until enough length is obtained for the tissue transposition and to fill the defect (9,11).

Flap mobilization is usually performed along the greater curvature and adjacent tissues (6,7). An important technical consideration described by Boulton et al. was to ensure that no structures were tethered to the omental pedicle once it was rotated cephalad because it could cause complications such as gastric outlet obstruction or compromise the vascular pedicle (9). Once fully mobilized, the flap can be transferred to the final location by an upper midline incision into the subxiphoid space, thoracoabdominal, subcostal and transdiaphragmatic incisions or by using an existing direct defect as described in some case reports found in the literature (6,9,11).

Final inset depends on the location and the size of the defect as well as the purpose of the flap, whether it is a prophylactic procedure, primary treatment for a defect with high risk of failure, or salvage surgery (7,11). Techniques described include suture closure with different materials and patterns, muscle buttressing, circumferential placement around anastomosis sites or other delicate locations of interest and skin grafting (6,7,11).

Outcomes

The data regarding omental flap use in pleural disease is scarce. While there are multiple studies describing the use of this tissue in different surgical scenarios, those pertaining to specific thoracic surgery pathologies are small and mostly limited to case reports (6,7,11-15). This search yielded four larger case series and few other case reports that met the inclusion criteria. Nonetheless, the reported outcomes report a flap survival rate and successful defect closure in 80–100% of cases (6,7,11-15) (Table 2). Indications for the use of omental flaps can be divided into the treatment of BPF, empyema, or prophylactic use during high-risk surgical procedures.

BPF

Shrager et al. described the outcomes of 15 patients with post-pneumonectomy BPF who were treated with omental flaps. Success rate in fistula closure was obtained in 87% (13/15) of cases (11). While two patients had recurrent BPF, one recurrence was attributed to a persistent fungal infection and the other one was the result of foregoing primary fistula closure during index surgery because the patient suffered intraoperative cardiac arrest (11). Of note, most patients in this study had a history of previous high-dose radiation (11). Guerrero et al. depicted a case report where an omental flap was successfully used for post-pneumonectomy BPF closure with no associated adverse events (15) (Table 2).

Another study by Kreutz-Rodrigues et al. shared the experience of use of the omental flap in a small subgroup of six patients being treated for BPF. Based on their findings, there was a 100% (6/6) flap survival rate for these patients in a 24-month follow-up time period (7). Complications of omental flap harvest were divided into donor site issues such as incisional hernia, injury to adjacent structures, bleeding and postoperative ileus, and flap-specific problems like necrosis, infection and dehiscence (7,8,16). In this study, pooled complications included postoperative bleeding in 15% (6/40 cases) of patients, 50% of whom were on anticoagulation medication. Incisional hernia was seen in 20% (8/40) cases, half of which had undergone anterior chest wall translocation of the omentum and the other half had undergone transabdominal or subxiphoid mediastinal translocation (7). Overall perioperative mortality was 2.5% (1/40) in this series (7). It is worth noting that the rate of complications was not reported by subgroup analysis at any point, so it is unknown if any morbidity corresponded to patients in the BPF subgroup specifically (7).

Several other case reports and case series have yielded similar outcomes when omental flaps are used for bronchopleural fistula in high-risk infectious or immunocompromised scenarios (6,13,15). Even in the setting of reinforcement of BPF and concomitant coverage of prosthetic aortic material, the omental flap had successful healing of the BPF without complications reported (13).

Empyema

The first large case series that evaluated the use of omental flap in thoracic surgery was published in 1990 by Shirakusa et al. (14). This study depicted two groups of patients, the first composed of 5 patients who presented with acute postoperative empyema from bronchial stump dehiscence. The second group included 7 patients with chronic empyema in the setting of fistulous disease secondary to aspergillus or tuberculosis infection (14). All but two patients from the latter group had complete resolution of the empyema, with a 100% success rate for group one (5/5) and 71% for group two (5/7) (14). There was a recurrence of empyema in two cases despite omental plombage in 29% (2/7) (14). Authors concluded that omental flaps were successful in controlling bronchopleural fistulas, yet have limited effectiveness in cases of resistant microorganism infection causing empyema or abscess (14).

Subsequently, Okumura et al. described 25 years of experience utilizing omental flap for chronic empyema in the setting of BPF (12). In authors experience, 23 patients underwent omental pedicle flap with or without muscle flap (12). All surgeries were performed via midline laparotomy for tissue harvest and the graft was delivered via a transdiaphragmatic approach. A proportion of 82.6% (19/23) cases were successful with obliteration of dead space and absence of infectious process during 6-month follow-up (12). There was 1 death (4.3%) secondary to postoperative sepsis due to flap infection, 3 cases (13%) of postoperative ileus and 1 case (4.3%) of gastrointestinal bleed (12).

Prophylaxis

One of the manuscripts categorized the use of omentum based on the indication for surgery (11). They described the course of 47 patients in whom the omentum was used prophylactically to promote healing of high-risk closures of bronchial or visceral structures such as bronchial anastomoses for lung transplant, airway resections, pneumonectomies and cervical exenterations (11). The success rate, characterized by healing of the anastomosis, was 89% (42/47) in this patient population (11). Complications included two deaths unrelated to the procedure and an anastomotic stricture secondary to the usage of a pericardial fat pad instead of omentum in a patient with a prior omentectomy (11) (Table 2).

Discussion

Omental flaps possess several unique biologic and reconstructive advantages that make them particularly valuable in thoracic surgery. Their intrinsic immunologic and antimicrobial properties, supported by a rich vascular and lymphatic network, enhance antibiotic delivery, angiogenesis, and infection clearance, which is especially beneficial in contaminated operative fields, salvage procedures, and immunocompromised patients (1-3,5). In addition, the large size and pliability of the omentum allow it to conform effectively to irregular intrathoracic spaces and obliterate pleural or mediastinal dead space, reducing persistent infection and fluid collections (1,6,7,9,10,14,15).

Other well-established modalities of pleural complication management after anatomic pulmonary resections are intrathoracic transposition of the extra thoracic muscles and thoracoplasty. Compared with muscle flaps, the omentum demonstrates greater tolerance to hostile environments, including enhanced resistance to infection (Figures 4,5). Furthermore, its intrinsic pliability allows for superior conformability to irregular cavities and complex three-dimensional spaces, thereby reducing the risk of contour deformity and disfigurement while successfully obliterating dead space (1,5-8,11,13). Unlike muscle, the omentum has the ability to revascularize and promote lymphatic drainage, which plays a potential role in edema management (1,5). Additional advantages include lower donor site morbidity and its versatility in reconstruction (1,6,7,9). Thoracoplasty has historically fallen out of favor nowadays, especially with the rise of other reconstructive techniques due to its higher morbidity and substantial impact on the body contour and cosmesis. Nevertheless, thoracoplasty remains relevant for the practice of thoracic surgery as an end-of-the-line reconstructive option (Table 3). While thoracoplasty has been the traditional historical procedure for these patients, the resection of multiple ribs is considered an aggressive procedure associated with respiratory compromise, long-term deformity and severe pain (17,18). Thus, when both techniques are compared, the advantages of omental flap are significant over the thoracoplasty from the functional and cosmetic standpoint (17-19) (Table 3).

Figure 4 Example case 1 (postoperative pleural space reconstruction with muscle and omental flap transposition in chronic empyema and bronchopleural fistula) (6). Preoperative (A) and postoperative (B) CT chest in patient with chronic interstitial lung disease, chronic parenchymal opacities, and chronic scarring throughout both lungs after undergoing muscular and omental flap transposition with thoracoplasty for persistent bronchopleural fistula, complicated by entrapped lung and empyema (6). This figure was reused from an Open Access article (6) under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/). CT, computed tomography.

Figure 5 Example case 2 (chest wall reconstruction and pleural space obliteration after omental flap transposition) (6). (A) Preoperative physical exam findings of patient with 18 cm × 5 cm chest wall defect after previous thoracostomy for entrapped lung complicated by bronchopleural fistula (6). (B) Postoperative image depicting complete closure of chest wall defect (6). (C) CT thorax with IV contrast obliteration of the pleural space with intrathoracic omental flap transposition. This figure was reused from an Open Access article (6) under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/). CT, computed tomography; IV, intravenous.

One important limitation of the current literature is the absence of robust long-term functional and volumetric data regarding omental flap behavior after intrathoracic transposition. Unlike muscle flaps, which predictably undergo denervation atrophy, fibrosis, and progressive volume loss over time after transfer into the pleural cavity, the omentum is composed primarily of vascularized adipose tissue and therefore may behave differently in the long term. Available evidence addressing this question is indirect and largely extrapolated from reconstructive and breast surgery literature, where omental flaps generally appear to maintain or even modestly increase volume over time through adipocyte hypertrophy and neoangiogenesis (4,20). In thoracic surgery specifically, Shinohara et al. reported lower local recurrence rates after open window thoracostomy closure with omental flaps compared with muscle flaps, suggesting potentially more durable pleural space obliteration (21). However, no study to date has directly evaluated serial volumetric changes of intrathoracic omental flaps using cross-sectional imaging such as computed tomography (CT) or magnetic resonance imaging (MRI). The behavior of the omentum within the pleural cavity may differ substantially from other reconstructive settings because of unique local conditions, including chronic inflammation, negative intrapleural pressure, persistent bacterial contamination, and absence of external tissue support. Whether these factors ultimately promote adipose tissue preservation, hypertrophy, fibrosis, or progressive shrinkage remains unknown. Accordingly, the long-term volumetric stability and durability of omental flap reconstruction should be recognized as an important knowledge gap in pleural space surgery. Future investigations incorporating serial imaging-based volumetric analysis together with clinical outcomes such as recurrent infection, residual cavity formation, and need for reintervention are needed to better define the long-term behavior of the omentum after intrathoracic transposition.

Limitations

The principal limitation of this study is the paucity of available literature on the topic. No high-quality large-scale investigations exist that allow firm conclusions to be drawn, as the current evidence is derived primarily from a limited number of case reports and small retrospective case series. Furthermore, much of the published data aggregates patients with non-pleural pathologies also managed with omental flaps, which restricts the generalizability of the findings to pleural disease specifically.

In addition, all included studies are observational and neither blinded nor randomized; therefore, the reported outcomes must be interpreted with caution given the substantial risk of bias. Publication bias is also present, as successful or technically novel cases are more likely to be reported than unfavorable outcomes or failed reconstructions. Selection bias further limits interpretation, since omental flaps are often reserved for selected patients with complex or refractory disease, making comparisons across studies difficult. Moreover, there is considerable heterogeneity among reported cases with respect to patient populations, underlying pathology, surgical indications, operative techniques, concomitant procedures, and outcome reporting, which limits the ability to draw standardized conclusions or perform meaningful comparisons across studies.

While the available literature suggests that omental flaps may represent a valuable adjunct in the management of complex thoracic surgical complications, the current evidence base remains limited and largely descriptive. Accordingly, conclusions regarding efficacy and superiority over alternative reconstructive strategies should be interpreted cautiously. Future investigations involving larger patient cohorts, standardized outcome measures, and more rigorous study designs are warranted to better characterize procedure-specific outcomes and define the risk–benefit profile of this intervention.

Conclusions

Omental flap reconstruction represents a valuable and biologically advantageous option for pleural space complications. Its intrinsic immunologic activity, potent antimicrobial properties, and robust lymphatic and vascular networks make it particularly effective in contaminated fields, salvage procedures, and critically ill patients. In addition, its size and pliability allow reliable obliteration of complex intrathoracic dead space problems, while providing durable, well-vascularized coverage of bronchial stumps, prosthetic material, and mediastinal structures.

Although current evidence is largely limited to case reports and small case series, and must be interpreted carefully, reported outcomes demonstrate high rates of flap survival and successful defect closure in bronchopleural fistula and space obliteration in empyema and entrapped lung management. As minimally invasive harvesting techniques continue to evolve, the omentum may become an increasingly popular and preferred reconstructive option in thoracic surgery. Nevertheless, larger and methodologically more rigorous studies are needed to better define patient selection, procedural risks, and long-term outcomes in the management of pleural disease complications specifically.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease for the series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1004/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1004/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1004/coif). The series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” was commissioned by the editorial office without any funding or sponsorship. A.G. and R.V.P. served as the unpaid Guest Editors of the series. R.V.P. was a former expert testimony for Steptoe & Johnson PLL as well as Bolus Law Office. R.V.P. is also a stock owner of Romtec and is part of the Executive Counsel of Eastern Cardiothoracic Surgical Society (ECTSS) and a member of various committers of Thoracic Surgery Directors Association (TSDA), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Society of Thoracic Surgeons (STS) and American College of Surgeons (ACS). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study is a narrative review of previously published literature and did not involve human participants, animals, or identifiable patient data; therefore, institutional review board approval and informed consent were not required.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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