Post-myomectomy omental infarction: a case report

BACKGROUND

Omental Infarction (OI) is uncommon and mimics common causes of acute abdomen. It is important to differentiate it from other abdominal conditions that require emergency management. It was first reported in literature in 1896 and about 400 cases have been reported till date.

CASE PRESENTATION

We reported on a 41 year-old Para 0⁺⁰ Ibo house wife who presented with 10 years history of supra-pubic mass and five months history of excessive menstrual flow. After physical examination, a diagnosis of symptomatic uterine fibroid was made. She had myomectomy and the raw surface created after the excision of the myomas was covered with omentum. Wound infection developed on the 8th post-operative day leading to a wound breakdown and later partial extrusion of infarcted omental tissue through the dehisced wound. During re-exploration, the infarcted omental tissue was extracted and the residual abdominal abscess was drained. Surgical site wound infection occurred on the 3rd day after re-operation and a sub-acute intestinal obstruction developed on the 4th day thereafter which responded to conservative management.

CONCLUSION

Careful surgical technique is imperative when utilizing the omentum for reconstructive abdominal surgery. Torsion of the omentum and creation of excess tension while using the omentum for reconstructive procedures should be avoided and increase awareness of this uncommon disease condition by the surgeon is also important. This case is to report a rare finding of omental infarction following myomectomy.

Intrathoracic transposition of the omentum

Complex chest and lung infections with bronchial fistula are life-threatening situations with a mortality rate of up to 20%. If medical treatment fails, these patients require aggressive procedures to heal. Transposition of the omentum is a valuable, nonstandard option in these complex cases with aggressive infection involving the pleural space, with or without a bronchial fistula, when medical treatment is unsuccessful. We present a 29-year-old female patient diagnosed with primary immunodeficiency and invasive fungal infection with involvement of the left upper lobe and mediastinal and vertebral bodies treated with a lobectomy and intrathoracic transposition of the omentum.

Retrospective Review of Complications of Liver Hydatid Cyst Surgery with Emphasis on Outcomes of Omentoplasty

Background

The outcome and complications of liver hydatid cyst surgeries with new and old techniques are not well determined. We intended to present the results of operations done for patients with hepatic hydatid cyst in an endemic area.

Methods

Data of 112 patients referred and operated for liver hydatid cyst, in Imam Khomeini Hospital complex, Tehran, Iran, from 2015 to 2018, were collected including demographic characteristics, operation parameters and complication related statistics. The variables were presented for different surgical methods including operations with and without omentoplasty.

Results

Patients aged 39. 3 ± 13. 9 yr (70 females; 63. 5%). Most frequent clinical complaint was vague abdominal pain (n=45; 40. 2%). The most prevalent comorbidity was hypertension (18; 16.0%). Conservative methods were chosen more frequently including omentoplasty (44; 39. 3%), cyst drainage (27; 24. 1%), cyst resection (19; 17%) and marsupialization (3; 2. 7%). Overall, 56 patients (50%) were operated with omentoplasty as the single method or in combination with segmentectomy. Complications occurred less in patients operated with omentoplasty (41. 1 vs. 23. 2%; P=0. 043); particularly, biloma was more frequent in surgeries without omentoplasty (7. 1 vs 0. 0%; P=0. 042). Persistence and recurrence rates were 12. 5% and 3. 6% with relative predilection in, respectively, segmentectomy and lobectomy surgical methods compared to Omentoplasty. No mortality was recorded.

Conclusions

In our case series of hepatic hydatid cyst patients, omentoplasty was safe with less complication and similar long-term recurrence rate.

Usefulness of Omentoplasty to Reduce Perineal Wound Complications in Abdominoperineal Resection After Neoadjuvant Chemoradiotherapy

BACKGROUND

Omentoplasty is sometimes used to prevent perineal wound complications after abdominoperineal resection (APR) following neoadjuvant chemoradiotherapy (NACRT). However, recent studies have raised some controversy about its clinical benefit.

PATIENTS AND METHODS

Outcomes for rectal cancer patients who received APR after NACRT were retrospectively compared between the groups with omentoplasty (n=28) and without omentoplasty (n=14).

RESULTS

The operative time was significantly longer in the omentoplasty group (575 vs. 404 min, p<0.001). Laparoscopic surgery was performed more frequently in the omentoplasty group. Perineal wound problems including dehiscence and infection were significantly reduced in the omentoplasty group (46.4% vs. 78.6%, p<0.001). Univariate and multivariate analyses revealed that omentoplasty was the most important factor in reducing perineal wound complications (odds ratio=0.020, 95% confidence intervaI=0.001-0.393; p=0.001).

CONCLUSION

Omentoplasty was useful in reducing perineal wound complications after APR following NACRT.

Laparoscopic Sleeve Gastrectomy with T-Shaped Omentoplasty: Impact on the Early Postoperative Outcomes

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure, yet can be followed by complications such as staple line leak and bleeding, vomiting, and gastroesophageal reflux disease (GERD). Various attempts have been described in the literature to improve the early outcome of LSG through various measures. This study aimed to assess the impact of adding T-shaped omentoplasty to LSG on the short-term outcome of the procedure.

METHODS

This was a retrospective cohort study on patients with morbid obesity who underwent LSG in the period of November 2015 to November 2018. The outcome of patients with morbid obesity who underwent LSG combined with T-shaped omentoplasty (group I) was compared with that of a similar number of patients who underwent classical LSG without staple line fixation (group II). The main outcome measures were the rates of staple line bleeding and leak, postoperative nausea and vomiting (PONV), GERD, gastric axial rotation, other complications, and weight loss.

RESULTS

The study included 106 patients of a mean BMI of 49.8 kg/m². Group II had significantly higher PONV) scale at 1 week and 1 month than group I. Group I had significantly lower rates of staple line bleeding (0 vs 9.6%, p = 0.02) and GERD (3.7% vs 17.3%, p = 0.02) than group II. Both groups had similar rates of staple line leak and comparable operation time.

CONCLUSION

Staple line fixation using the T-shaped omentoplasty technique was associated with lower incidence of significant PONV, staple line bleeding, and GERD as compared with classical LSG.

Omentoplasty Decreases Leak Rate After Esophagectomy: a Meta-analysis

OBJECTIVE

To compare the efficacy of omentoplasty with non-omentoplasty in the prevention of postoperative anastomotic leakage, and to investigate the safety of omentoplasty.

METHODS

Literature searches were performed of the Medline, EMBASE, and Cochrane Library databases. Studies that compared the efficacy of omentoplasty and non-omentoplasty after esophagectomy were selected. A meta-analysis was performed on anastomotic leakage, anastomotic stenosis, hospital mortality, and length of hospital stay. Results were reported as odds ratio (OR), weighted mean difference (WMD), or relative risk (RR), with 95% confidence intervals.

RESULTS

Six studies involving a total of 1608 patients met inclusion criteria. Compared with the non-omentoplasty group, the incidence of anastomotic leakage in the omentoplasty group (OR, 0.37; 95% CI, 0.23-0.60; P < 0.0001) was significantly reduced and the length of hospital stay (WMD, 2.13; 95% CI, 3.57-0.69; P = 0.004) was significantly shortened. However, there was no significant difference in the incidence of anastomotic strictures (OR, 0.82; 95% CI, 0.37-1.80; P = 0.61) or in-hospital mortality (OR, 0.61; 95% CI, 0.25-1.51; P = 0.29).

CONCLUSIONS

Omentoplasty after esophagectomy is a safe and effective method to prevent anastomotic leakage.

Plicated Sleeve Gastrectomy with Combined Mesocolon and Greater Omentum Fixation After T-Shaped Omentoplasty: How to Do it?

INTRODUCTION

This technique aims to evaluate fixation of the sleeved distal part of the stomach to the root of the transverse mesocolon and greater omentum after its shortening in a T-shaped design.

METHODS

Sleeve gastrectomy is done in a standard five-port technique. Then, we fix the distal end of the staple line using an inverting interrupted 2/0 Ticron suture. We plicate the anterior and posterior walls to invert the staple line and then fix it to the mesocolic fat below the pancreas and to the edge of the disconnected distal omentum close to the antrum. Proceeding caudally, we shorten the greater omentum in the form of a T-shaped suture that forms an omental window between the two edges of the omentum. Plication and fixation are continued upwards until the lower border of the pancreas. Then, we plicate the sleeved stomach using a 2/0 Ticron suture starting cranially near the angle of His.

RESULTS

All patients are discharged from the hospital the next day and followed-up at the clinic after the end of first and second weeks, then after 3, 6, and 12 months postoperatively.

CONCLUSION

Plicated sleeve gastrectomy combined with mesocolon and greater omentum fixation after T-Shaped omentoplasty is safe and feasible. Long-term follow-up study is required to validate our results.

CT assessment of the quality of omentoplasty and its implications for perineal wound healing

PURPOSE

This study was designed to examine the impact of an omentoplasty and its quality on pelviperineal morbidity after abdominoperineal resection (APR) for rectal cancer.

METHODS

This was a retrospective single-centre study of consecutive patients undergoing APR for primary or recurrent rectal cancer between 2000 and 2018. Quality of omentoplasty was categorised (sufficient vs insufficient) based on postoperative CT scans. Main study endpoints were perineal wound healing and perineal hernia.

RESULTS

This study included 100 patients: 16 with a sufficient omentoplasty, 16 with an insufficient omentoplasty, and 68 without omentoplasty. Rate of pelviperineal complications within 30 days was 44%, 69% and 64% (P = 0.283), and delayed wound healing at 3 months was 19%, 54% and 27%, respectively (P = 0.109). Sufficient omentoplasty was not significantly associated with less delayed healing in multivariable analysis (OR 0.597; 95% CI 0.149-2.397). An insufficient omentoplasty demonstrated significantly higher rates of delayed healing at 6 months (46% vs 14%; P = 0.016) and chronic perineal sinus at 12 months (31% vs 3%; P = 0.008) compared with no omentoplasty.

CONCLUSION

This relatively small series suggest that even a sufficient omentoplasty, as determined by postoperative imaging, does not reduce pelviperineal morbidity after APR for rectal cancer. The methodology of CT-based assessment of an omentoplasty as well as the correlation with postoperative outcomes has to be validated in future studies.

Near-infrared fluorescence angiography for intra-operative assessment of pedicled omentoplasty for filling of a pelvic cavity: a pilot study

BACKGROUND

During creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion.

METHODS

All consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018-October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification).

RESULTS

Fifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12-198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3-39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9-37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2-29.7) in well perfused and 2.5 (interquartile range 1.7-4.0) in poorly perfused tissue.

CONCLUSIONS

FA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting.

Current indications for the intrathoracic transposition of the omentum

Background

The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications.

Methodology and review

This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery.

Conclusions

OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.

Surgical repair of perforated peptic ulcers: laparoscopic versus open approach

INTRODUCTION

Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality.

RESULTS

Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6 min, OS versus 86.9 ± 57.5 min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2 days, OS versus 7.8 ± 5.9 days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009).

CONCLUSION

Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.

Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database

PURPOSE

The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30 days were compared between the groups.

RESULTS

A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0 years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21-2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91-4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22).

CONCLUSIONS

Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.

Laparoscopic approach to colo-renal fistula with renal preservation and omentoplasty: A case report

•

Percutaneous ablation is being increasingly used to treat renal masses.

•

A colo-renal fistula can result as a potential complication.

•

Initial treatment should focus on conservative management involving antibiotics and ureteral stent placement.

•

If failed, fistula can be resected laparoscopically safely without the need for nephrectomy.

Colorenal fistula as a result of percutaneous cryoablation has not been extensively reported. We report a gentleman who presented with urosepsis after percutaneous biopsy of a renal mass complicated by colorenal fistula. After failed attempts at conservative management, he underwent laparoscopic resection of his fistula with renal salvage and omentoplasty highlighting that nephrectomy is not always indicated.

Omentoplasty to assist perineal defect closure following laparoscopic abdominoperineal resection

AIM

This technical note describes laparoscopic production of a well vascularized, omental flap of adequate size to fill the pelvic floor defect in the course of laparoscopic abdominoperineal resection (LAPR).

METHOD

The omentum is laparoscopically mobilized and transposed to the pelvis following full LAPR in three discrete stages.

RESULTS

Laparoscopic omental mobilization, transfer and buttressing of a primary perineal repair reduces pelvic dead space and facilitates closure following LAPR with minimal additional operative time or complications and a potential reduction in perineal wound associated morbidity.

CONCLUSION

Laparoscopic omental mobilization is technically feasible and provides a safe method to aid perineal wound closure.

Omentoplasty in the prevention of anastomotic leakage after oesophagectomy: a meta-analysis

OBJECTIVE

To evaluate the efficacy of omentoplasty for the prevention of anastomotic leakage after oesophagectomy.

METHODS

A systemic review of the Cochrane Library database CENTRAL, MEDLINE and EMBASE from inception to March 2014 was performed. Randomized controlled trials comparing omentoplasty with non-omentoplasty after oesophageal resection for a primary oncological indication were included. Meta-analysis was performed for anastomotic leakage, specific complication rates, in hospital mortality, local recurrence and duration of hospitalization. Data was reported as a Peto odds ratio (Peto OR), odds ratio (OR), weighted mean difference (WMD) or relative risk (RR) with 95% confidence intervals (CI).

RESULTS

Three randomized controlled trials with a total of 633 anastamoses were included. The omentoplasty group demonstrated a significantly lower incidence of postoperative anastomotic leakage (Peto OR: 0.26; 95% CI 0.14 to 0.52), and reduced duration of hospitalization (WMD -2.13; 95% CI -3.57 to -0.69). There was no significant difference between the omentoplasty and non-omentoplasty groups in the incidence of anastomotic strictures (RR: 0.91, 95% CI: 0.33 to 2.57), hospital mortality (RR: 0.86, 95% CI: 0.29 to 2.51), pulmonary complications (RR: 0.90, 95% CI: 0.59 to 1.35) and recurrence after surgery (RR: 1.17, 95% CI: 0.95 to 1.43).

CONCLUSIONS

Omentoplasty may reduce the incidence of anastomotic leakage following oesophagectomy for oesophageal cancer.

Laparoscopic Management of Hydatid Cyst of Liver with Palanivelu Hydatid System over a Period of 3 Years: A Case Series of 32 Patients

The aim of this article is to evaluate the role and safety of laparoscopic management of hydatid disease of liver using Palanivelu hydatid system (PHS)(1) with initial results. A prospective study of hepatic hydatid cyst underwent laparoscopic management using PHS, during the period from June 2008 to October 2010, in department of general surgery in a tertiary care institute. Selective patients were included in our study. Preoperatively 2 weeks and post operatively 6 weeks of Albendazole were given. All patients underwent surgery under general anesthesia. Hydatid cyst evacuation and omentoplasty were done with PHS system to prevent spillage. Cyst was irrigated with 2 % savlon. Drainage tube was kept near the cyst. There were 32 patients with 35 liver hydatid cysts operated. The mean operative time was 93.78 (70-180) min. Intraoperative complications were noted in two patients (6.2 %). Conversion was required in one patient (3.1 %). The mean duration of hospital stay was 3-10 days with an average of 5 days. There was no recurrence in mean follow-up of 3 years. There was no mortality with good subjective and objective cosmetic results. The laparoscopic cyst evacuation and omentoplasty using PHS are feasible and safe for treating the hydatid cyst of liver in selected patients. It aids early recovery with good cosmetic results.