Omentoplasty
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Omentoplasty is a surgical procedure in which part of the greater omentum is used to cover or fill a defect, augment arterial or portal venous circulation, absorb effusions, or increase lymphatic drainage. The omentum has been described as the “policeman of the abdomen,” in that it wraps around abdominal structures such as the gallbladder and appendix and can revascularize them when they are deprived of their blood supply. Omentoplasty may be classified into the following two types [1] :
When Casten and Alday introduced omental transposition for treatment of patients with atherosclerosis, [2] they believed that it worked by supplying extra blood to the ischemic limb. However, this explanation is implausible because the diameter of the omental vessels is roughly one tenth that of the popliteal artery. Later studies demonstrated that an increase in local collateral circulation (rather than any significant increase in blood flow) was the likely mechanism of action for omental transfer. [3, 4, 5, 6, 7]
Goldsmith et al showed that the omentum contains a lipid fraction that promotes neovascularization; thus, a local effect on limb musculature with increased local collateral circulation may be a possible mode of action. [8, 9]
Omentum is known to adhere to surrounding structures and develop connections with them. Hoshino et al observed vascular connections between the omentum and the limb vasculature in limbs that had been amputated after omental transplantation. [1] Babu et al noted revascularization of muscle from omental vessels growing into it in limbs that had been amputated after omental transplantation. [10]
Agarwal et al performed postoperative angiography in 50 patients who underwent omental grafting; they observed a greater number of collateral vessels at the graft site, with filling of vessels distal to the block in the limbs. [11]
In an extension of the same study, 20 dogs underwent allograft omental transfer in limbs after ligation of the femoral artery. In 10 cases, exploration of the graft site after 3 weeks revealed an increased number of collateral vessels at the graft site, with filling of vessels distal to the site of the block. The authors’ conclusion stated that even an omental graft that is mismatched with respect to blood group and human leukocyte antigen (HLA) is taken up and revascularizes the ischemic limb. [11]
Subodh et al used postoperative Doppler studies and selective celiac axis angiography to study the circulation in the omental graft and found that, in 18 of 20 cases, the arterial pulsations were heard up to the knee on Doppler study; in the other two cases, symptoms did not improve. [12]
On celiac axis angiography, however, the omental vessels were able to be visualized up to the thigh in only six patients and up to the knee in only four. [12] The authors concluded that omental transposition probably works by promoting local collateralization; similar conclusions were drawn in another study comparing free omental grafts to pedicled omental grafts.
Three randomized controlled trials involving a total of 2296 participants concluded that omentoplasty for esophagogastrostomy after esophagectomy in patients with esophageal cancer may decrease anastomotic leakage without affecting the rate of other complications. [13, 14, 15, 16]
Omentoplasty has been used in various settings involving both intra-abdominal and extra-abdominal conditions. Intra-abdominal settings in which omentoplasty is indicated include the following:
Extra-abdominal settings include the following:
The presence of advanced intra-abdominal malignancies is the only absolute contraindication for omentoplasty.
Omentoplasty has two main relative contraindications. One is unavailability of a sufficient length of omentum for the procedure being planned; this may occur as a consequence of prior intra-abdominal infections or previous surgical procedures. The other relative contraindication is unavailability of acceptable-quality blood vessels; this may occur secondary to atherosclerosis.
Hoshino S, Nakayama K, Igari T, Honda K. Long-term results of omental transplantation for chronic occlusive arterial diseases. Int Surg. 1983 Jan-Mar. 68(1):47-50. [Medline].
Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet. 1971 Feb. 132(2):301-4. [Medline].
Sasajima T, Kubo Y, Izumi Y, Inaba M, Goh K. Plantar or dorsalis pedis artery bypass in Buerger’s disease. Ann Vasc Surg. 1994 May. 8(3):248-57. [Medline].
Van der Stricht J, Goldstein M, Flamand JP, Belenger J. Evolution and prognosis of thromboangeitis obliterans. J Cardiovasc Surg (Torino). 1973 Jan-Feb. 14 (1):9-16. [Medline].
Kunlin J, Lengua F, Testart J, Pajot A. Thromboangiosis or thromboangeitis treated by adrenalectomy and sympathectomy from 1942 to 1962. A follow-up study of 110 cases. J Cardiovasc Surg (Torino). 1973 Jan-Feb. 14(1):21-7. [Medline].
Komori K, Kawasaki K, Okazaki J, Eguchi D, Mawatari K, Okadome K. Thoracoscopic sympathectomy for Buerger’s disease of the upper extremities. J Vasc Surg. 1995 Sep. 22(3):344-6. [Medline].
Nakajima N. The change in concept and surgical treatment on Buerger’s disease–personal experience and review. Int J Cardiol. 1998 Oct 1. 66 Suppl 1:S273-80; discussion S281. [Medline].
Goldsmith HS, Griffith AL, Catsimpoolas N. Increased vascular perfusion after administration of an omental lipid fraction. Surg Gynecol Obstet. 1986 Jun. 162(6):579-83. [Medline].
Goldsmith HS, Griffith AL, Kupferman A, Catsimpoolas N. Lipid angiogenic factor from omentum. JAMA. 1984 Oct 19. 252(15):2034-6. [Medline].
Bronzetti G, Galli A, Della Croce C. Antimutagenic effects of chlorophyllin. Basic Life Sci. 1990. 52:463-8. [Medline].
Agarwal VK, Bajaj S. Salvage of end stage extremity by omentopexy in Buerger’s disease. Indian J Thorac Cardiovasc Surg. 1987. 5:12-17.
Subodh S, Mohan JC, Malik VK. Omentopexy in limb revascularisation in Buerger’s disease. Indian Heart J. 1994 Nov-Dec. 46(6):355-7. [Medline].
Yuan Y, Zeng X, Hu Y, Xie T, Zhao Y. Omentoplasty for oesophagogastrostomy after oesophagectomy. Cochrane Database Syst Rev. 2014 Oct 2. CD008446. [Medline].
Chen L, Liu F, Wang K, Zou W. Omentoplasty in the prevention of anastomotic leakage after oesophagectomy: a meta-analysis. Eur J Surg Oncol. 2014 Dec. 40 (12):1635-40. [Medline].
Wiggins T, Markar SR, Arya S, Hanna GB. Anastomotic reinforcement with omentoplasty following gastrointestinal anastomosis: A systematic review and meta-analysis. Surg Oncol. 2015 Sep. 24 (3):181-6. [Medline].
Nasiri S, Mirminachi B, Taherimehr R, Shadbakhsh R, Hojat M. The Effect of Omentoplasty on the Rate of Anastomotic Leakage after Intestinal Resection: A Randomized Controlled Trial. Am Surg. 2017 Feb 1. 83 (2):157-161. [Medline].
Borham MM. Comparison between omentoplasty and partial cystectomy and drainage (PCD) techenques in surgical management of hydatid cysts liver in endemic area (Yemen). J Egypt Soc Parasitol. 2014 Apr. 44(1):145-50. [Medline].
Killeen S, Mannion M, Devaney A, Winter DC. Omentoplasty to assist perineal defect closure following laparoscopic abdominoperineal resection. Colorectal Dis. 2013 Oct. 15(10):e623-6. [Medline].
Boiskin I, Karna A, Demos TC, Blakeman B. Herniation of the transverse colon: an unusual complication of pedicled omentoplasty. Can Assoc Radiol J. 1995 Jun. 46(3):223-5. [Medline].
Ashwin Pai, MBBS, MS (GenSurg), MRCS Honorary Assistant Medical Officer, Department of Surgery, Kasturba Medical College, India
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Omentoplasty
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