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Title Omentopexy
Author(s) Tomita, Masao; Ayabe, Hiroyoshi; Kawahara, Katsunobu; Tagawa, Yutaka
Citation Acta Medica Nagasakiensia. 1992, 37(1-4), p.183-186
Issue Date 1992-12-25
URL http://hdl.handle.net/10069/17585
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Acta Med. Nagasaki 37:183-186
Omentopexy
Masao Tomita, Hiroyoshi Ayabe, Katsunobu Kawahara, and Yutaka Tagawa
The First Department of Surgery, Nagasaki University School of Medicine
The operative procedure of bronchial anastomosis is of
great use to prevent major complication in relation to anastomosis insufficiency as well as to reduce the inci-dence of anastomosis insufficiency.
In particular, omentopexy is indispensable for tracheo-bronchial anastomosis in combination with esophagectomy, which means a loss of supporting tissue and a reduction of collateral blood flow through the wall of the trachea.
Furthermore, the application of omentopexy is limited in case of a history of abdominal surgery and the diseases of the spleen and/or the omentum.
Introduction
The omentum is well adaptable for tissue defect of various
sizes and shapes and poses sufficient blood supply. The use of the omentum offers some advantage that it
has rich tissue volume and is able to preserve the long
pedicle by gastroepiploid artery. Moreover, neovascularity is facilitated, lymphedema is eliminated, providing rich
fibroblast. As a consequence, wound healing is satisfied.
In addition, it is of great value to prevent spreading of
infection and to wrap the infectious tissue by contracting
the infected deadspace.
Mobilization of The Omentum
The omentum is nourished by supply of the blood from bilateral gastroepiploic arteries and their branches form the vascular arcade. The size of the omentum measured 14 to 36 cm long, 23 to 46 cm wide and it was possible to draw up to the level of the breast gland (Fig. 1) and to draw down to the site of the inguinal ligamentum. Furthermore, the addition of the procedure of mobilization by making free of the attachment of the stomach makes it possible to draw up to the neck in 88%, to the Axilla in 70%, to the upper arm in 25% and the middle of the thigh in 10%. respectively.
Fig. 1. Mobilization of the omentum A) a line between the omentum and the transverse colon B) a line between the omentum and the stomach, preserving the gastroepiploic artery C) mobilized by division of the middleo mental artery D) dividing between D, and D2 to make it elongation
Indication of Omentopexy
Omentopexy is usually applied for prevention of major complication when expecting the impairment of wound healing, for promotion of severely impaired wound healing when occurring complication and for supplement of tissue defect.
Validity of Omentopexy for tracheobronchial anastomosis
When occurring impairment of wound healing of tracheo-bronchial anastomosis, respiratory function was severely affected by spreading infection to the pleural cavity and the
1 84
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M. Tomita et al: Omentopexy
Fig. 2. Microangiogram The bronchial arterial flow was interrupted at bronchial anastomosis on day 3 after bronchial anastomosis
The bronchial flow was appearently seen aross the bronchial anastomosis on day 14
mediastinum. In consequence, it takes a rapid fatal course.
It is indispensable that bronchial arteries are interrupted
at anastomosis so that nutritional blood flow should be
remarkable reduced. As a result, wound healing at anasto-
mosis is impaired.
After anastomosis of tracheobronchial tree, the time of
regeneration of the bronchial artery was investigated by the
grades of developing recannalization on microangiography.
According to our study as shown in Fig. I , recannal-
ization of the bronchial artery was initiated at day 5 to 7
and completed at day 10 to 14. When wrapping of the omentum was applied, the start of regeneration was seen at
day 3 to 4 and the completion was observed at day 5 to 7 as
shown in Fig. 3.
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3 4 5 7 10 12 14day * Control:14dogs(Group-1) a Omental wrapping:12dogs (Group-II) A Pericardial wrapping:13dogs(Group-III)
Fig. 3. The degree of the newly developmental bronchial arteries
around the anastomotic sites
On day 14, it was corroborated that the blood from the
omentum was supplying to the bronchus-reconstructed lung
aross at bronchial anastomosis by microangiography in
which the contrast medium was infused from the omental
artery as shown in Fig. 4.
It is substantiated that omental wrapping plays a promot-
ing role in recannalizaiton of interrupted bronchial artery.
Fig. 4. Angiogram: contrast medium was infused from the omental artery, showing a perfused lung via the communicating blood vessels across the bronchial anstomosis
When carcinoma of the esophagus is invading the tra-
chea, a combined resection with the trachea is mandated.
However, it offers a detrimental effect of bronchial anasto-
mosis on wound healing.
M. Tomita et al: Omentopexy
Esophagectomy directly causes the impairment of wound healing of tracheo-bronchial anastomosis because
of removal of support of the trachea and damage to a
collateral blood flow via the esophagus. An experimental
result shows that recannalization of interrupted bronchial
arteries is delayed on day 7 to 10 in its initiation and on day
14 at the time of development of vascular net formation.
On the contrary, when applying omental wrapping recan-nalization is fastened on day 5 to 7 in its initiation and on
day 10 at vascular net formation. This shows that ornen-
topexy play an important role in development of recannal-
ization of interrupted bronchial artery.
The indications of omentopexy are either in case of
expected impairment of wound healing or in case of risk of
occurring bronchovascular fistula.
The former indicates a tension at anastomosis and de-
nuded adventitia off the wall of the tracheobronchus by
node dissection. The latter included prevention of mechan-
ical injury to the wall of the pulmonary artery by tracheo-
bronchial anastomosis.
Discussion
It has long been recognized that the omentum is of great
use to wrap the tissue and plombage for the dead space,
Williams*) reported that the omentum has an excellent
ability of wrapping, that is, 1) wide surface 2) excellent
capacity of recanalization 3) immunoresistance to infection
4). absorption of blood and lymphatic fluid 5) Iarge volume
6) flexibility 7) hemostatic ability.
The preparation of the omentum has been reported in detail by Alday') and Kitano.') It is reported') that sufficient
volume and flexibility of the omentum is for wrapping of
the tissue and packing of dead space.
It is accepted that wrapping of the omentum prevent
grave and fatal postoperative complications, in particular,
tracheo-bronchial anastomosis provides a detrimental situa-
tion of wound healing by interrupted bronchial arteries.
It is reported by Maeda5) that the incidence of anasto-
mosis insufficiency is 33.3% and the mortality rates are
47.79;~o. Morgan also emphasized that wrapping procedure
by pedicled omentum is of great value for the experimental
result of hepatic transplnatation as well as lung transplan-
tation with the use of the immunodepressive drugs." ')
It is reasoned that omentopexy is attributable to neovas-
cularity at anastomosis.') And also metastasis into mobi-
lized omentum from intraabdominal malignancy is very rare. The occurrence of pyothorax with bronchial fistula is
one of the most ominous complications of post-pulmonary
resection. Therefore, satisfact,ory treatments have been
devised such as thoracic drainage, resuturing and suple-
ment of bronchial stump and thoracoplasty to improve the
surgical outcome by eliminating the occurrence of postop-
erative bronchial fistula.')
185
The use of the omentum for bronchial fistula makes it
possible to ensure closure of the fistula with less operative
stress regardless the presence and/or the amount of myco-
bacterium tuberculosis. However, surgeons should be aware that in case of positive mycobacterium tuberculosis,
even application of omentupexy fail to yield satisfactory
surgical outcome.
When perforating the esophagus, omentopexy should be
applied for a repair. The omentum is characteristic of
eliminating inflammatory process under existing infection
and of promoting wound healing process under unfavor-
able conditions.
lversonrs) reported the validity of omentopexy that the
use of the omentum is effective to have bronchial fistulas
closed in eight out of nine patients with infection of various
drug resistance.
When using artificial material in infectious lesion, it is
recommended that artificial organ should be wrapped by the omentum. It is beneficial to expect absorption of exsu-
date, adaptation to any sizes and forms.
A few side effects have been reported that there is a
slight degree of ileus and a loss of appetite. On the other
hand, Lieb-ermann-Meffert20) reported that contra-indications of omentopexy are as follows, malacia, portal
hypertension, Iiver cirrhosis, active gastric ulcer, splenic
abnormality such as Hodgkin' disease, history of abdom-
inal surgery and diseases of the omentum.
Attention should be paid that poridoneiodine, potent
cytocydal effect of desinfection, is usually used for wash-
ing of infectious sites. However, it is needless to say that
when jod-containing detergent is absorbed into the blood,
an ill-events would be reported, for example, Iiver dysfunc-
tion*~) renal failurel2) suppression of thyroid function.~3)
metabolic acidosis*') hypernatremial5) and hyperchloremia.16)
Ref erences
l) Williams R et al: The great omentum: Its applicability to cancer
therapy. Current problems in surgery pp. 789-865, YeaR Book. Medical P Ublishers Inc. Chicago 1986.
2) Alday Es et al: surgical technique for omental lengthening based on
arterial anatomy. Surg Gynecol obset 135: 103-107, 1972.
3) Kitano T. Tatsumi A, Matsui T et al: Clinical significance of pedicled
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pedcle flap. Am J Surg 152: 40-42, 1986.
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186 M. Tomita et al: Omentopexy
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