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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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NAOSITE: Nagasaki University's Academic Output SITE

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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

omental plombage for fistulous pyothorax. Jap J Ass Thorac Surg

36:1225-1263, 1988.

4) Iverson LIG et al: Closure of bronchopleural fistulas by an omental

pedcle flap. Am J Surg 152: 40-42, 1986.

5) Maeda M, Nanjo S, Nakamura K et al: Nationwide analysis of tracheo-bronchoplasty. Broncholog 8:346-355, 1986.

6) Morgan E et al: Successful revascularization of totally ischemic

bronchial autografts with omental pedicle flaps in dogs. J Thorac

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7) Dubois P et al: Bronchial omentopexy in canine lung transplantation. J

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atherosclerosis and thrombosis. Washington DC: American Heart Association 1985.

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186 M. Tomita et al: Omentopexy

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struction of the chest wall. Plast Reconstr Surg 49:263-267, 1972.

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17) Eschapass H et al: Repair of large chest wall defects: Experience with

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20) Liebermann-Meffert D et al: The greater omentum anatomy, physi-

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Belin. Heidelberg New york, 1983.