Chapt er 141

Omental Procedures: Supracolic Omentectomy,

Infracolic Omentectomy, Omental Biopsy
Kiong K. Chan
City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK

Case history 1: A 42-year-old woman presented with abdominal

distension. CA125 was 458  kU/L. A CT scan revealed ascites, a
Lesser omentum
25-cm pelvic mass, and involvement of the omentum. The liver and
in fissure for
chest were clear so the multidisciplinary team decided that primary ligamentum venosum
debulking surgery should be carried out. Lesser omentum
Pancreas
Case history 2: A 57-year-old woman was found to have an Stomach
asymptomatic mass in the left upper quadrant of the abdomen Duodenum
on a CT scan performed for an unrelated reason. Two and a half Transverse Transverse mesocolon
years previously, she had surgery and adjuvant chemotherapy and colon adherent to posterior
radiotherapy for a leiomyosarcoma of the vagina. Imaging-guided layers of greater
omentum
needle biopsy suggested a gastrointestinal stromal tumor (GIST), so a
Greater omentum
laparotomy was carried out.

Background

The omentum is a common site for metastases from a large variety

of cancers. The commonest causes of omental metastases are
ovarian cancer and primary peritoneal or tubal cancer, through
transperitoneal or transcoelomic spread. Advanced endometrial
and bowel cancers also spread to the omentum. Omentum can also
be affected by distant cancers such as breast cancer.
Although the lesser omentum can be affected, it is usually the
greater omentum that contains the metastases, which often coalesce
to form an omental “cake.” The term “omentectomy” is generally
taken to imply removal of the greater omentum (Figure 141.1).
Omentectomy is subdivided into infracolic, supracolic, and total.
Infracolic omentectomy is the removal of the greater omentum
below the transverse colon. Supracolic omentectomy includes the
part of the greater omentum between the transverse colon and
the greater curvature of the stomach. Total omentectomy includes
removal of the omentum which extends to the hilum of the spleen
in addition to the parts removed by supracolic omentectomy.
The prognosis of patients with advanced epithelial ovarian cancer
is dependent on the completeness of surgical debulking. Although
no randomized study has been undertaken to demonstrate the value
of debulking surgery, there is no doubt that residual disease status
is the single most important prognostic factor in advanced ovarian
cancer. This is the reason why total omentectomy is important in
the surgical management of advanced ovarian cancer.
Figure 141.1  Sagittal section through the abdomen illustrating anatomy of
omentum.
Management
Omentectomy is most often carried out in patients with epithelial
ovarian cancers. A total omentectomy should be performed if there is
obvious involvement of the omentum. Infracolic omentectomy should
be confined to the removal of normal-looking omentum for staging
purposes. Under such circumstances, a large omental biopsy would
also suffice. There is no agreement among gynecologic oncologists
regarding the size of an adequate biopsy [1]. Omentectomy is also
required as part of the staging of uterine papillary serous carcinoma
of the endometrium.
Resolution of the cases
In both patients a midline abdominal incision was made. A Gray
retractor was used to hold the wound apart. In Case history 1,
the ascitic fluid was sent for cytology. The liver and diaphragm

Gynecologic and Obstetric Surgery: Challenges and Management Options, First Edition. Edited by Arri Coomarasamy, Mahmood I. Shafi, G. Willy Davila and Kiong K. Chan.
© 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

423
424    Section 7: Gynecologic Oncology
were normal. The gastrointestinal tract was normal. There was an
omental “cake” measuring 23  ×  5  ×  2.5  cm. There were multiple
metastases on the paracolic peritoneum. There was a 25-cm
diameter right ovarian tumor with metastases on the left ovary,
the uterine serosa, and the pelvic peritoneum including the pouch
of Douglas and the uterovesical fold of peritoneum. The ovarian
tumor and its metastases were removed in the manner described in
Chapter 140. In Case history 2, the uterus, tubes and ovaries were
absent because of her previous surgery. The liver and diaphragm
were normal. The only abnormality was a tumor measuring 10 cm
in diameter involving the left half of the greater omentum. There
were no enlarged retroperitoneal lymph nodes. Omentectomy was
carried out in both cases.
The anterior two leaves of the greater omentum were dissected off
the transverse colon giving access to the lesser sac. No involvement
of the stomach or pancreas was found. The splenic flexure of the
transverse colon was mobilized to avoid traction on the spleen. The
omentum was mobilized from the hepatic flexure. It was then excised
from the greater curve of the stomach inside the gastro-epiploic
arcade of vessels using a combination of diathermy and Autosuture
clips for the small vessels running between the arcade and the greater
curve of the stomach. The short gastric arteries at the cardia of the
Key points
Challenge: Omental procedures.
Background
• The omentum is a site for metastases of ovarian cancer, peritoneal or
tubal cancer, advanced endometrial or bowel cancer, and uncommonly
distant cancers such as breast cancer.
• Omentectomy can be infracolic, supracolic, or total.
Management
• A total omentectomy should be performed if there is obvious involvement
of the omentum.
• Infracolic omentectomy should be confined to the removal of normal-
looking omentum for staging purposes; a large omental biopsy can be an
alternative approach.
Further reading
Gehrig PA, Van Le L, Fowler WC Jr. The role of omentectomy during the surgical
staging of uterine serous carcinoma. Int J Gynecol Cancer 2003;13:212–215.
Hagiwara A, Sawai K, Sakakura C et al. Complete omentectomy and extensive
lymphadenectomy with gastrectomy improves the survival of gastric cancer
stomach were divided between Roberts forceps and ligated with 2-0
Vicryl mounted ties. The omentum was carefully mobilized from the
splenic hilum to complete the total omentectomy. A careful check
was made to ensure complete hemostasis. In this area, any bleeding is
likely to continue and have serious consequences as tamponade does
not occur. For the patient in Case history 2, histology showed the
tumor to be a recurrence of the leiomyosarcoma (illustrating that the
histology from a needle biopsy can be wrong); the patient was treated
with further chemotherapy.
Omentectomy may result in a paralytic ileus, particularly if the
operation is prolonged and there has been significant disturbance of
the bowel (e.g., resection or extensive adhesiolysis). In such cases, it
is wise to request the anesthetist to insert a nasogastric tube at the
time of the operation. This can be guided to an optimal position
by the surgeon and saves the patient an unpleasant experience of
swallowing a nasogastric tube postoperatively. The ileus will resolve
with time provided a careful watch is kept regarding fluid and
electrolyte balance. Potassium supplements are important and must
be given routinely unless a contraindication exists.
Although ileus is the more common complication, bowel obstruction
can occur. This diagnosis must be considered if postoperative vomiting
fails to settle.
• The omentum is intimately related to the transverse colon, the stomach
and the spleen, all of which can be easily injured if care is not taken
during the dissection. In particular, traction on the spleen can tear its
capsule, resulting in an unnecessary splenectomy. This is why the splenic
flexure of the transverse colon must be mobilized when performing a
supracolic or total omentectomy.
• Meticulous hemostasis is important as any bleeding from the omental
vessels may continue due to the absence of tamponade effect.
• Omentectomy may result in paralytic ileus particularly if the operation
is prolonged or if there has been significant disturbance of the bowel;
in such situations, a nasogastric tube can be inserted at the time of the
operation.
• If the patient shows worsening gastrointestinal symptoms, bowel
obstruction should be considered; if this does not settle with conservative
management, it may require surgical correction.
patients with metstases in the adjacent peritoneum. Hepatogastroenterology
1998;45:1922–1929.
Usubütün A, Ozseker HS, Himmetoglu C, Balci S, Ayhan A. Omentectomy for gyneco-
logic cancer: how much sampling is adequate for microscopic examination? Arch
Pathol Lab Med 2007;131:1578–1581.