A surgeon's history of the omentum: From omens to patches to immunity

Modification of the modified Graham patch repair for duodenal perforation using the gastrocolic ligament: Two case reports

INTRODUCTION

Gastroduodenal perforations are relatively common surgical emergencies with mortality rates as high as 40%. The Graham patch repair is one surgical approach but may need to be modified when the patient lacks viable omentum. The gastrocolic ligament can be utilized to repair these perforations for coverage.

PRESENTATION OF CASES

Case 1: A 77-year-old female with a complex history presented with severe abdominal pain and was found to have pneumoperitoneum on CT scan. She was found to have a first segment duodenal perforation. We employed a modified Graham patch omentopexy utilizing the gastrocolic ligament to repair the defect. She recovered well with no complications. Case 2: A 65-year-old male with multiple myeloma presented with chemotherapy intolerance and diffuse abdominal pain. CT scan demonstrated pneumoperitoneum. Upon surgical exploration, he was noted to have a 1 cm anterior duodenal perforation. He had almost no viable omentum and therefore underwent a modified Graham patch repair using the gastrocolic ligament. He recovered well with no complications.

DISCUSSION

There have been reports of patients with gastroduodenal perforation with suboptimal omentum who underwent modified repair with the falciform ligament or a jejunal serosal patch repair. The gastrocolic ligament was found to be an effective alternative for our cases. This approach is an attractive one due to its relative ease and effectiveness.

CONCLUSION

We described the use of the gastrocolic ligament as an alternative approach for gastroduodenal perforation in patients with suboptimal omentum. Further studies are needed to assess long term postoperative outcomes and establish best practices.

Use of omentum during robotic-assisted reconstructive urological surgery: a systematic review of the current literature

PURPOSE

Due to its biological properties, the omentum is a very useful tool in the hands of reconstructive urologists. The purpose of this systematic review is to present all existing evidence regarding the use of omentum during different robotic-assisted reconstructive urological surgeries.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines, three databases (PubMed, Scopus and Cochrane) were systematically screened. The following search string was used: (omentum OR omental) AND robotic. Retrospective studies and case-series were included, while case-reports were not included.

RESULTS

13 studies met all eligibility criteria and were included in final qualitative synthesis. Seven studies reported robotic vesicovaginal fistula repair, two studies reported robotic vesicouterine or vesicocervical fistula repair, one study reported robotic rectovesical fistula repair, one study reported robotic rectourethral fistula repair, one study reported ureterolysis with omental wrap and one study reported robotic repair of long ureteral strictures with omental wrap and autologous onlay flap or graft ureteroplasty. Recurrence rates ranged from 0% to 6.7%. The Grade I-II complications according to Clavien-Dindo Classification ranged from 0 to 40%, while no Grade III-IV were reported.

CONCLUSION

Robotic repair with the use of omentum is potentially a feasible, safe and efficient approach for complicated urological surgeries, such as vesicovaginal, vesicouterine, vaginocervical, rectovesical and rectourethral fistulas, idiopathic retroperitoneal fibrosis and long ureteral strictures. Because the evidence is based on small case series, further publications are needed to enhance confidence in omental harvesting and render it a routine component of reconstructive Urology.

Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases)

Background

To explore the application value of free omental wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).

Methods

The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analysed. In total, 86 cases were divided into Group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases were divided into Group B (control group). The incidences of postoperative pancreatic fistula and other complications were compared between the two groups, and univariate and multivariate logistic regression analyses were used to determine the potential risk factors for postoperative pancreatic fistula. Risk factors associated with postoperative overall survival were identified using Cox regression.

Results

The incidences of grade B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in Group A were lower than those in Group B, and the differences were statistically significant (P < 0.05). Group A had an earlier drainage tube extubation time, earlier return to normal diet time and shorter postoperative hospital stay than the control group (P < 0.05). The levels of C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) inflammatory factors 1, 3 and 7 days after surgery also showed significant. Univariate and multivariate logistic regression analyses showed that a body mass index (BMI) ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P < 0.05). Cox regression analysis showed that age ≥ 65 years old, body mass index ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap isolation and modified pancreaticojejunostomy, and malignant postoperative pathology were independent risk factors associated with postoperative overall survival (P < 0.05).

Conclusions

Wrapping and isolating the modified pancreaticojejunostomy with free greater omentum can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and favourably affect prognosis.

Tertiary peritonitis: considerations for complex team-based care

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key-but not all-elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Primary liposarcoma of the omentum: A case report

RATIONALE

Omental liposarcoma is extremely rare, and only a few reports have been published in the literature. Due to the rarity of the disease, establishing a clear diagnosis and formulating a treatment plan may be challenging for clinicians.

PATIENT CONCERNS

The patient was a 51-year-old woman who presented with a protruding mass and pain in the lower abdomen.

DIAGNOSIS

Magnetic resonance imaging revealed a tumor measuring 15 cm in diameter in the pelvis. Ovarian cancer was suspected based on pre-operative imaging findings.

INTERVENTIONS

An exploratory laparotomy was performed. Intra-operative analysis of the frozen section suggested a benign tumor.

OUTCOMES

Postoperative histopathological analysis confirmed the diagnosis of omental liposarcoma. The patient recovered well after surgery.

LESSON

This case report helps clinical oncologists to develop a comprehensive understanding of this disease and treat it accordingly.

The application of the "omental wrapping" technique with autologous onlay flap/graft ureteroplasty for the management of long ureteral strictures

Background

To present our experience with the "omental wrapping" technique in laparoscopic and robotic ureteroplasty using onlay flaps or grafts for the management of long proximal or middle ureteral strictures.

Methods

This is a retrospective review of 25 patients with long proximal or middle ureteral strictures who underwent laparoscopic and robotic onlay flaps or grafts ureteroplasty using an omental flap to reinforce an anastomosis site between August 2018 and November 2019. Perioperative and follow-up data were collected.

Results

Sixteen laparoscopic procedures and nine robotic procedures were performed successfully. Sixteen patients underwent ureteroplasty with lingual mucosal graft (LMG), and nine patients with appendiceal onlay flap (AOF). The median stricture length was 4 cm (range, 2-6 cm). The mean operative time (OT) was 220.5±50.6 min, the estimated blood loss (EBL) was 66.0±38.9 mL, and the length of hospital stay (LHS) was 8.0±3.6 days. In the LMG group, four patients had tongue numbing and one had an oral ulcer, which relieved itself gradually without intervention. Two patients in the LMG group and four patients in the AOF group experienced urinary tract infection, and all responded well to antibiotic treatment. There were no complications attributed to "omental wrapping". The mean follow-up was 16.3±4.8 months. According to the standards regarding improvement in clinical symptoms, relief of obstruction radiologically and a stable estimate glomerular filtration rate, our surgical success rate was 100%.

Conclusions

The "omental wrapping" technique in laparoscopic and robotic onlay flaps or grafts ureteroplasty for long proximal or middle ureteral strictures is an efficient, safe, reproducible and simple technique.

Traumatic damage to the liver capsule: an unusual cause of small bowel obstruction

A 61-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side while cycling, but had not sought medical attention. On admission, a CT scan showed small bowel obstruction (SBO) and he underwent an emergency open laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis. We believe this is the first reported case of SBO secondary to small bowel herniation into the liver capsule following trauma.