Current indications for the intrathoracic transposition of the omentum

Abstract

Background: The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications.

Methodology and review: This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery.

Conclusions: OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.

Keywords: Bronchial fistula; Empyema; Eso-gastric anastomosis; Esophagectomy; Infected vascular grafts; Median sternotomy; Mediastinal tracheostomy; Mediastinitis; Omentoplasty; Omentum; Space-filling procedures.

Fig. 1

Intrathoracic eso-gastric anastomosis reinforced by omental wrapping. Note that the OF is mobilized together with the greater curvature gastric tube (a) and then wrapped around the eso-gastric anastomosis (b) which will be completely covered by the OF. (GT – gastric tube, E – esophagus, L – lung)

Fig. 2

Closure of a large bronchial fistula after right pneumonectomy during a space-filling procedure (a). The OF was mobilized through a phrenotomy (b) and fxed with separate stitches over the bronchial fistula (c, d) without performing a supplementary laparotomy (BF – bronchial fistula, D – diaphragm, L - liver)