Page 68 - ONLINE PROCEEDING BOOK WSAVA 2017
P. 68

An Urban Experience
WSVA7-0416
SOFT TISSUE SURGERY
THE OMENTUM: THE SURGEON’S BEST FRIEND
G. Dupré1
1Dipl. ECVS, Dipl. Human thoracoscopy and interventional pneumology, Clinic for Small animal Surgery, Veterinary Medicine University of Vienna, Veterinaerplatz 1, 1210 Vienna
LEARNING OUTCOMES
• Master the anatomic and physiologic peculiarities of the omentum.
• Understand the great variety of its  eld of application.
• Foresee the potential for unpublished uses in the veterinary  eld.
The omentum is a double peritoneal leaf constituted of 2 parts: the smaller and the greater omentum. The latter spreads down to the bladder where it re ects on itself to reach the dorsal part of the stomach. It forms a cavity called the omental bursa. It is a mesothelium on which lymphoïd spots “milky spots” are dispersed.
The omentum was long thought to be vascularized
in dogs and cats by branches of the right and left gastroepiploic arteries as it is in people. Recent study suggests that the main vascular supply in dogs is not derived from the marginal omental vessels. In dogs, the left marginal omental vessels (both in the super cial and the deep leaf) are directly derived from the splenic artery and its continuation in the omental leaves. The main vascular supply of the right marginal artery is derived directly from the right gastroepiploic artery in the super cial leaf, whereas in the deep leaf the right marginal artery arises directly from the gastroduodenal artery. In the same study, anastomosing arteries between the super cial and deep leaves were weak and inconsistent. The venous system runs parallel to the arterial one. The lymphatic vessels from the milky spots drain into sub-pyloric, splenic and cœliac lymph nodes and then into the thoracic duct or directly from the omental bursa through the visceral surface of the diaphragm.
The omentum is a rich source of angiogenic and neurotrophic factors, acts as a reservoir of peritoneal immune cells, is important for peritoneal lymphatic drainage, and has adhesive properties, contributing
to encapsulation of in ammatory processes and hemostasis. Given the extraordinary features of the omentum and facilitated by its size and plasticity, reconstructive surgery can greatly bene t from its use. In people, new clinical applications such as omental transposition to improve bone healing or to enhance survival of transplanted pluripotent stem cell-derived
cardiomyocytes, are being explored. Its milky spots are rich in lymphocytes that produced antibodies. Through its immune function, the omentum helps to control infection and wound healing of the peritoneal cavity. Not only macrophages, mastocytes and lymphocytes participate in the production of an angiogenetic factor, but also the capillary network at its surface brings a vascular support to the intra-peritoneal organs. Finally, the omentum helps forming adhesions through  brinolytic inhibition. Adhesion of the omentum over a wound allows early revascularization, and isolation of the contaminants.
In small animal surgery the omentum has been used in the following indications:
• Omental wrapping for covering intestinal anastomosis as well as for any vascular and tissue reinforcement (urinary tract) or for hemostasis.
• Omental wrapping to synthetic mesh
• Omental transposition for abdominal or thoracic wall reconstruction
• Drainage of hepatic, prostatic, pancreatic cysts and abscesses.
• Drainage of the thoracic cavity.
• Support to non-healing wounds, exposed bone or  stulous tracts
Omental  ap and graft
In people, surgical lengthening of the omentum is necessary for transposition into the pelvic cavity or exteriorization beyond the peritoneal cavity. This is rarely the case in dogs. However, omental pedicle  aps are described in order to reach extra-abdominal applications as chronic axillary and inguinal lesions. The omentum can be exited through a mini-laparotomy and then tunneled under the skin to reach distant regions. It can also be brought through the diaphragm to reach the chest Most reports on lengthening techniques are based on the omental pedicle extension technique published in dogs by Ross and Pardo.
In the  rst stage of this lengthening technique, the deep leaf is freed from its pancreatic attachment and  ipped caudally. In a subsequent lengthening step, Ross
and Pardo suggested an inverse L-shaped incision, beginning from the left just caudal to the splenic portion of the omentum, across approximately 50% of the omental width, and then continuing caudally parallel
to the remaining omental vessels. The limited width
of the tip of the pedicle and the decrease in available omental tissue is an acknowledged drawback of this lengthening technique. New anatomic knowledge questions the need to mobilize the gastroepiploic arch to allow incorporation in the omental pedicle, reducing the risk of hematoma formation because of ligation of
68
42ND WORLD SMALL ANIMAL VETERINARY ASSOCIATION CONGRESS AND FECAVA 23RD EUROCONGRESS


































































































   66   67   68   69   70