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A. Atay et al.
cinoma had omental involvement and the stage of
the disease changed [42]. In a study by Ross etal.
(2018) including 153 patients with endometrium
tumor, microscopic tumors were found in 35% of
patients who underwent omental sampling, and
during patient surveillance, the mean survival was
11.4months in patients with omental tumor and
was 128.7months in those without. In the same
series, the mean survival was 127.7 months in
patients with omental sampling and 71.3months
in those without. Omental involvement is an
important prognostic factor for survival [43]. In
contrast, in 106 patients with serous carcinoma
in the uterus, Luz et al. (2016) detected macroscopic involvement in 6 of 66 patients who
underwent omental biopsy or omentectomy, with
micrometastatic involvement in 2 of them and
omental involvement in 8 (12%). In their study,
they found no signicant difference in survival
advantage between the group with omental biopsy
or omentectomy (evaluation) and the group without. In addition, the authors recommended that the
omentum should undergo a comprehensive intraoperative assessment [44]. Notably, there is no
need for a second operation to perform omentectomy, indicating that the survival period remained
unchanged following the surveillance of cases that
underwent surgery due to prediagnosis of endometrium cancer but had papillary serous carcinoma
that was histopathologically detected [45].
In most cases of tubal ectopic pregnancy, the
omentum has been reported to be able to control
complications due to tubal pregnancy or play a
retarding role by wrapping around the tube [46].
In the literature, cases of primary omental pregnancy have also been reported [47].
Omental involvement in gynecological tumors
occurs in 9–37.5% cases. It is acknowledged that
tumor retention is important for surgical staging
and planning of treatment and it is correlated
with peritoneal involvement [42–44, 48].
Omental involvement is considered an indicator
of poor prognosis. When performing radical surgery, it is necessary to perform omentectomy for
the purpose of removing the tumor load on the
omentum. However, the contribution of omentectomy to survival remains controversial. In earlystage tumors, omental involvement is minimal
and omentectomy has no impact on survival, and
if there is no macroscopic involvement, it is not
recommended to perform omentectomy [49].
Random omental biopsies can be performed in
early stages to contribute to staging.
22.5 Omental Pathologies
Omentum torsion is a very rare entity and can
mimic many clinical pathologies in the abdomen.
Additionally, abdominal CT is very helpful in
differential diagnosis. Surgical removal of ination/necrosis mass is sufcient in patients who do
not recover by clinical follow-up and medical
approach [50]. Omental torsion state can mimic
appendicitis. Laparoscopy should be the rst
option in cases that are thought to undergo exploration for the purpose of diagnosis and treatment.
In laparoscopy as well as resection of the omental
necrosis site, some surgeons recommend performing appendectomy [51, 52].
Moreover, 83.3% of patients with omentum
infarction have more than normal weight according to their average age. Recurrent ultrasound
can be conducted for diagnosis. Clinically,
omentum infarction can mimic appendicitis.
Because conservative treatment is sufcient in
most cases, appendicitis should be excluded in
differential diagnosis (Fig.22.2). In addition to
partial omentectomy, incidental appendectomy
may be performed in patients who underwent
laparotomy/laparoscopy by consulting with the
family [53].
The omentum also plays a role in limiting and
controlling infections that settle in the abdomen.
Depending on the damage caused by the infection to the omentum, it may be necessary to perform omentectomy. There are cases in the
literature with laparotomy for abscesses caused
by melioidosis (Burkholderia pseudomallei)
[54]. Omentectomy may be performed depending on mass image in patients with pelvic
actinomycosis and the appearance of tumor
implant in omental involvement [55]. Omental
involvement is also common in patients with
abdominal tuberculosis and can imitate an ovarian tumor. To avoid unnecessary radical surgical
22 Omentectomy: Whether toPerform Should BeQuestioned
Fig. 22.2 CT image of a patient with omental necrosis (Arrow) detected in the postoperative period
249
resection, laparoscopic expressions and biopsy
are diagnostic. In diagnosed cases, medical treatment is recommended [56].
The omentum captures, limits, and tries to
maintain the contents or materials remaining in the
abdominal cavity after surgeries. Before conducting a radical surgical intervention due to the omental mass, a good anamnesis should be obtained and
the source of the omental mass should be investigated. In many cases wherein the cause can be
determined, follow-up should be sufcient. Spilled
and not removed stones from the gallbladder, perforated during laparoscopic cholecystectomies,
are wrapped by the omentum and can turn into an
inammatory mass [57]. Stones that do not exhibit
clinical symptoms can be traced. However, due to
rarely spilled stones, internal or external stulas
can also develop from abscesses surrounded by the
omentum. In such cases, abscess drainage, irritation, and removal of traction without removing the
omentum may be sufcient.
22.6 Miscellaneous Conditions
The functions of the omentum to nd, capture,
and surround foreign bodies can lead to undesirable situations in the clinic. Primarily, the omentum faces complications related to hematoma,
ischemic area, incision lines, suture materials,
and defects formed in the abdominal cavity after
surgeries. The contribution of the omentum to the
inammatory process here can occasionally
result in the formation of brides. In the literature,
some studies reported that the omentum prevents
the formation of brides in contrast to what is generally believed. The omentum aims to prevent
adhesions with brinolytic factors secreted from
its surface [19].
In a study by Araike etal. (2015) including 113
patients operated due to intestine obstruction due
to brides, as a result of a 5-year follow-up, the
bride ileus recurred in 18 patients (20.8%). In
multivariate analysis, it was found that 87.9% of
patients underwent omentectomy and 53.8% of
those who did not undergo omentectomy had
brides. It was found that 54.5% of patients who
developed bride ileus underwent omentectomy
and 21.3% did not undergo omentectomy.
Omentectomy is an independent risk factor for
bride formation and bride ileus development [58].
Excessively increasing omental and visceral
adipose tissue in obese patients is a factor that
adversely affects morbidity and mortality. In a
meta-analysis study conducted by Lee et al.
(2018), the addition of omentectomy to bariatric
surgery had no positive impact other than resulting in statistically signicant reduction in BMI,
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A. Atay et al.
although minimal. There was no signicant difference in both groups in terms of metabolism and
cytokines. Only in patients who underwent bariatric procedures, HDL lipoprotein was signicantly
increased [18]. In a similar study by Andersson
etal. (2014), adding omentectomy to Roux en-Y
gastric bypass did not have a positive impact on
reducing insulin resistance and cardiometabolic
risks [59]. Although there are metabolically positive feedbacks in similar cases wherein omentectomy is added to Roux-en-Y gastric bypass in the
literature, extensive and prospective studies are
needed [60]. In the study by Tamboli etal. (2011),
after Roux-en-Y gastric bypass surgery, there was
a decrease in the release of inammatory genes
and inammation in the skeletal muscles and this
was observed more in patients undergoing omentectomy [61]. In patients with metabolic syndrome who underwent partial jejunum resection
in addition to omentectomy, especially intestinal
system surgical procedures to control type 2 DM,
better results have been obtained in terms of
metabolism prole [62].
Peritoneal dialysis catheter obstruction is a
common problem in the clinic (23–36%).
Malposition and development of omental wrap
are the most commonly reported causes. In the
literature, it was noted that some of the patients
with catheter dysfunction underwent partial
omentectomy and the catheters were made functional [63–65]. On the other hand, in a series of
154 pediatric patients with peritoneal dialysis
catheter, it was found that omentectomy did not
contribute to catheter obstruction, mainly due to
technical problems [65]. Currently, catheter types
are more prominent in terms of dysfunction.
Moreover, some authors recommend laparoscopic placement of the catheter, partial omentectomy, and omentoplasty [66].
Idiopathic omental hemorrhage is very rare,
but it can lead to life-threatening hemorrhages.
Trauma, aneurysm, and vasculitis are the main
causes of omental hemorrhage, and signs of
hypovolemia can be dominating. In the differential diagnosis of the disease that mimics the acute
abdomen, abdominal CT may be useful. In addition, with angiography, information about the
location of bleeding and whether it is caused by
tumors can be obtained or laparotomy or laparoscopy may not be required due to embolization. In
laparotomy cases, hemostasis and partial omentum resection can be performed [67].
In inguinal hernia incarceration, the contents
of the hernia are important in the approach to
monitor and for follow-up. Filling the hernia
defect by the omentum will reduce the risk of
strangulation of bowel loops (Fig. 22.3). In a
study by Houben et al. (2015) including 2184
Fig. 22.3 CT view of omental strangulation and necrosis ndings in our patient who underwent laparotomy due to
strangulated incisional hernia and right femoral hernia
22 Omentectomy: Whether toPerform Should BeQuestioned
251
patients with pediatric hernia, irreducible (incarcerated) hernia was detected in 1.6% patients,
whereas hernia was frequently detected in the
intestines in males (62%) and in the hernia sac
and ovary in females (62%); it was determined
that the omentum formed the contents of the
incarcerated hernia at a frequency of 12%. In half
of these cases, partial omentectomy was performed [68].
In an obese patient who was followed by ventilator support due to multiple fractures of bones,
abdominal lipectomy and omentectomy performed to lower intra-abdominal pressure and
prevent lung complications. On postoperative
day 1, the tidal volume signicantly increased,
and the patient was removed from mechanical
ventilator support on postoperative day 14 [69].
22.6.1 Omentectomy/Omentoplasty
The omentum majus can be partially and totally
removed. In the clinic, infracolic omentectomy is
preferred due to gynecological tumors and total
omentectomy (major and lower) is performed in
stomach cancer and patients who underwent
HIPEC procedure. When performing lesser
omentectomy and bursectomy, dissection of the
part with the extension of the ligamentum
venosum should be performed after binding.
Otherwise, bleeding may occur from the cranial
side due to its connection with the left hepatic
vein [70]. Omentectomy can be performed with
open, laparoscopic, or robotic surgery.
Omental aps are often used in gastrointestinal tract surgery and are mainly used as patches
for peptic ulcer perforations (Graham technique),
as omental wrap in colon anastomoses, and as a
lling material for liver hydatid cysts. Omental
transposition scan protect it from pelvic radiation
and radiation enteritis, especially by covering the
small intestines and ensuring by enveloping
them. The omentum is also used in a large number of procedures related to plastic surgery.
Omental grafts (aps) can also be used for procedures such as revascularization of ischemic legs,
enclosing, reconstruction, stula revision, llers,
or protective shielding [71, 72].
22.7 Conclusion
The omentum is one of the rst organs affected
by inammatory and pathological events in the
abdomen. It is a unique organ with its mobility
and physiological tasks. Its main characteristic is
closely monitoring and controlling the pathological processes developing in the abdomen.
Moreover, the omentum is considered the
“abdominal policeman.” With the function of
limiting and controlling inammatory and infectious pathologies, it somewhat provides the
patient’s survival. While trying to perform the
same function in tumors as well, the stage of the
disease changes as a result of its inability to cope
with the increased tumor load, and thus, it is considered an indicator of poor prognosis. Due to
this feature, it is one of the rst sacriced organs
in radical surgeries. However, whether resection
of the omentum is necessary should be questioned according to each pathological process.
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Open Access inLaparoscopic
Surgery toPrevent Entry
Complications
ViktorJustin, DilettaDi Miceli,
andSelmanUranues
23
23.1 Introduction
To reduce complication rates in surgery, rening
of techniques is a mainstay and starts as early as
preoperative preparation and pre-habilitation of
the patient. Concerning laparoscopic surgery, the
rst complication may arise when access to the
abdominal cavity is performed and pneumoperitoneum is established. While adverse events must
be reduced by any means in all kinds of surgery,
this especially holds true in preventive surgery.
Imagining the sequelae that could arise from a
laparoscopic access injury, e.g., to a major vessel
such as the pelvic vessels in a case of elective or
opportunistic appendectomy, must be one of the
worst nightmares for every surgeon.
V. Justin
Department of Surgery, Section for Surgical
Research, Medical University of Graz, Graz, Austria
Department of Surgery, Klinik Donaustadt, Vienna
Healthcare Group, Vienna, Austria
e-mail: viktor.justin@gesundheitsverbund.at
D. Di Miceli
Department of Surgery, Section for Surgical
Research, Medical University of Graz, Graz, Austria
Department of Surgery, Oncology and
Gastroenterology Sciences, University of Padova,
Padova, Italy
e-mail: diletta.dimiceli@aopd.veneto.it
S. Uranues (*)
Department of Surgery, Section for Surgical Research,
Medical University of Graz, Graz, Steiermark, Austria
More than 50% of accidental bowel and
(major) vascular injuries in laparoscopy are associated with entry techniques. Major entry-related
complications occur in up to 0.6% of patients,
with about 70% related to the rst trocar placement [1–6].
The intestines with up to 37.6% of all injuries
are the most affected organs, followed by vascular injuries to major vessels such as the iliac vein/
artery, aorta, and visceral vessels [2]. Depending
on the degree of injury and time of recognition,
substantial morbidity and mortality can arise [7,
8]. Apart from surgeon skill and experience, risk
factors for visceral injury include pre-existing
adhesion due to operations or infection. While
only scarcely present in not operated individuals,
umbilical adhesions have been described in up to
15% of women with previous laparoscopies and
rise up to 60% after previous median laparotomy
[9–12]. In vascular injuries, an underestimation
of the proximity of vascular structures, forceful
thrust, and inadequate pneumoperitoneum
(among other factors) may be fatal [13]. In other
than obese individuals, the distance between the
umbilicus and the retroperitoneal vasculature
may only measure 2cm and thus is easily reached
with either trocar or Veress needle [14, 15].
To address this problem, multiple techniques
have been described over time and can be divided
into closed and open access techniques. Closed
access can be achieved with or without previous
establishment of pneumoperitoneum after puncture with a Veress needle. While the umbilicus is
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_23
255
256
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V. Justin et al.
the usual site for Veress needle insufation, the
so-called Palmers point in the left upper quadrant
can be used in case of expected umbilical adhesions [16]. Alternatively, transvaginal or intercostal approaches have been described [5].
Trocars for closed access can be bladeless or
cutting (with or without shielded blades), blunt or
conically tipped. Optical trocars can provide certain visualization while penetrating the abdominal wall. While several open access techniques
exist, the most known, which requires a special
trocar, has been published by Hasson [17].
Especially in previously operated patients,
blind puncture of the abdomen (either by Veress
needle or gasless introduction of the rst trocar)
carries a higher risk of serious entry injuries,
especially when adhesion of bowel loops cannot
be safely ruled out.
A recently updated Cochrane review [18]
compared 25 entry techniques including results
from 57 RCTs with a total of 9865 patients. The
authors found no evidence of differences in major
complications and generally described the quality of evidence as low or very low with too small
sample sizes to identify differences. Only a
reduced rate of failed entry was observed in open
access techniques. Of note, the majority of studies selected low risk, non-obese patients without
previous abdominal surgery and thus may not
reect real-life clinical data. Consequently, there
is no consensus favoring one access technique
over another, and the methods used vary with surgeons’ preferences being affected by training,
experience, and regional and interdisciplinary
considerations [19].
Operative steps:
1. An approximately 1.5cm vertical incision is
performed from the bottom to the upper edge
of the umbilicus (Fig.23.1).
2. The subcutaneous fatty tissue is dissected, and
the fascia exposed.
3. The fascia is then grasped vertically on both
sides with Kocher clamps creating a fascial
fold (Fig.23.2). This way the risk of accidental injury to the peritoneum and intraabdominal organs can be avoided.
4. The fascia is then carefully incised, thus opening the preperitoneal space (Fig.23.3).
5. When the preperitoneal space is reached, the
Kocher clamps will be turned 90° and will
grasp the fascial edges: this way the fascia
unfolds, and the incision is lengthened
(Fig.23.4).
Fig. 23.1 Umbilical skin incision
23.2 A Safe Technique
We advocate a simple, reproducible technique for
open access that can be employed in all types of
patients. While this technique can be used at any
site of the abdomen, it is preferably done at the
upper edge of the umbilicus, because here the
subcutaneous fat is at its thinnest and the fascia is
easily reached, even in obese patients [14].
Fig. 23.2 Grasping the fascia with Kocher clamps
23 Open Access inLaparoscopic Surgery toPrevent Entry Complications
257
Fig. 23.3 Fascial incision
Fig. 23.4 90° rotation and thus change of the grasper
from longitudinal position to transverse position
Fig. 23.6 Placement of fascial suture
Fig. 23.7 Placement of a tourniquet
Fig. 23.5 Peritoneal incision with peritoneal access
6. The parietal peritoneum now is carefully
grasped and incised (Fig.23.5). The incision
can be digitally enlarged and the
intra- abdominal area around the incision can
be palpated for potential adhesions. Now the
peritoneal cavity can be seen through the
incision.
Fig. 23.8 The fascia is tightened around the trocar to prevent gas leakage
7. Before the rst trocar is introduced, a fascial
suture (#0 or #2-0 usually slowly absorbable
such as Biosyn™) is placed (Fig.23.6). It is
then fed through a tourniquet that is tightened
at the entry site, thus avoiding gas loss
(Figs. 23.7 and 23.8). This way there is no
need for a specially designed, eventually
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