THE GREATER OMENTUM: Anatomy, Embryology, and Surgical Applications

doi:10.1016/S0039-6109(05)70406-0

Surgical Clinics of North America

Volume 80, Issue 1, 1 February 2000, Pages 275-293

https://doi.org/10.1016/S0039-6109(05)70406-0 Get rights and content

The greater omentum was once thought of as a useless, large, mesenterial fold, often getting in the way of surgeons during abdominal intervention and forming troublesome intra-abdominal adhesions. Resection of the fold has no consequence. Omentectomy was performed carelessly in the past, but does this Cinderella of anatomic and surgical knowledge have value?

Section snippets

DISCOVERY OF THE PROTECTIVE POWER OF THE GREATER OMENTUM

De Lamballe, a military surgeon during the wars of Napoleon I, was the first to draw attention to the greater omentum as an interesting structure that is useful for protection against infection. In 1829, he recorded his observation that, in preventing bowel injuries through adhesion formation, the greater omentum saved many wounded soldiers from peritonitis, a deadly disease in those days.¹⁵

The concept of using the omentum to rapidly form adhesions was spread in 1880 by the renowned

DISCOVERY OF THE USEFULNESS OF THE OMENTUM IN RECONSTRUCTIVE SURGERY

In 1926, aware of the versatility of the tissue, the surgeon Knazozovicky in Germany was the first to dare exteriorizing the undetached omentum through a tunnel to the body surface, that is, out of the abdominal cavity, to perform an arthroplasty.¹⁵ Thiessen (in 1935) and Walters (in 1937) of the Mayo Clinic introduced their technique of successful cure of intractable vesicovaginal fistulas by interposition of the omentum.¹⁵ Simultaneously, British heart surgeon O'Shaughnessy published in The

Description

The greater omentum is a free-hanging mesenteric tissue apron in the abdominal cavity (Fig. 1). Arising from the greater gastric curvature, it crosses the transverse colon, where it is attached and descends in front of the viscera down to the symphysis.¹⁵ The anterior surface faces the abdominal wall, that is, the parietal peritoneum; the posterior surface faces the visceral peritoneum. The origin of the omental edge varies among individuals. On the right side, it may hang from the pyloric

ORGANOGENESIS

The development of the omentum is closely related to adjacent structures, especially the stomach and spleen.13, 14, 15 This relationship provides the anatomic and biochemical background for the effectiveness of using the omentum in reconstructive and protective surgery and for experimental studies.

CLINICALLY RELEVANT NATURE OF THE OMENTUM

Recent studies have established that, under pathologic conditions, the omentum is endowed with distinct capacities, such as adhesion to traumatized tissue. The activated fibrinogen attaches the omentum immediately on rough, ischemic, and inflamed areas, especially after mechanical trauma to serosal surfaces.¹⁵ With regard to hemostasis, the omentum reduces profuse, uncontrollable hemorrhage by pressure. This has been ascribed to the omental ability of accelerating the activation of prothrombin

USE OF THE OMENTUM IN SURGERY

Because of its plasticity and great volume, the repair of defects using the omentum can be undertaken on the vascular pedicle within and outside of the abdominal cavity. The omentum can be used to repair defects in the abdomen and pelvic floor and tracheal and bronchial defects in the neck and on other surfaces of the body. Repair using the omentum begins with radical local clearance of the recipient side and ends with the substitution of the defect with omentum.

References (28)

R. Cartier et al.
Angiogenic factor: A possible mechanism for neovascularization produced by omental pedicles
J Thorac Cardiovasc Surg
(1990)
L.F.G. Krist et al.
An ultrastructural study of dopamine-immunoreactive nerve fibers in milky spots of the human greater omentum
Neurosci Lett
(1994)
D. Liebermann-Meffert et al.
Vascular anatomy of the gastric tube used for esophageal reconstruction
Ann Thorac Surg
(1992)
B. Patsner et al.
Use of the omental J-flap for prevention of postoperative complications following radical abdominal hysterectomy: Report of 140 cases and literature review
Gynecol Oncol
(1997)
P.G. Arnold et al.
One-stage reconstruction of massive craniofacial defect with gastroomental flap
Ann Plast Surg
(1981)
R.H.J. Beelen
The greater omentum: Physiology and immunological concepts
Neth J Surg
(1991)
F. Braye et al.
Le lambeau gastroépiploïque: Un lambeau muqueux secrétant pour la reconstruction de l'oropharynx et de la cavité buccale
Ann Chir
(1995)
G.L. Clifton et al.
Omental transposition in chronic spinal cord injury
Spinal Cord
(1996)
van GarderenJ.A. et al.
Complications of the pedicled omentoplasty
Neth J Surg
(1991)
van Geel AN, Wiggers TH: The pedicled omentoplasty; technical aspects in reconstructive surgery. Neth J Surg...

GoldsmithH.S.

The Omentum: Research and Clinical Applications

H.S. Goldsmith

Omental transposition to the brain for Alzheimer's disease

Ann N Y Acad Sci

(1997)

KiricutaI.

The Use of the Omentum in Plastic Surgery

I. Kiricuta

L'emploi du grand épiploon dans la chirurgie du sein cancéreux

Press Med

(1963)

Cited by (194)

General Morphological Characteristics of the Results of Experimental Modeling of Aseptic Peritonitis
2023, Annals of Anatomy
Aseptic peritonitis is a reaction of the local immune system aimed at rejection of a foreign body, which, having antigenic properties, does not (unlike a pathogen) counteract the immune system. The suture materials, namely catgut thread, used in intracavitary surgical operations possess xenogenic properties and can be used for antigenic stimulation of the immune system of the peritoneal cavity. Consequently, we decided to use a catgut suture for antigenic stimulation of the immune system of the peritoneal cavity and to study the morphological features of the results of experimental modeling of aseptic peritonitis in albino rats.
The study involved 15 Wistar albino male rats, weighing 286,13 ± 6,26 g. To study the dynamics of destructive changes made by the catgut implant in the peritoneal cavity of the experimental animals, the animals were assigned into three groups in accordance with the time interval of their euthanasia at 3, 7, and 14 days of the experiment.
After modeling an aseptic peritonitis, the investigation the abdominal cavity showed that in four out of five animals of the first group, that is, on day 3 of the experiment, the catgut implant had adhered to the greater omentum. The search for the fifth implant led to an unexpected discovery: we found it conjoined with the second derivative of the visceral peritoneum, similar in structure to the greater omentum, but related to the testes. On day 7, the implant embedded into the peritoneal cavity of the animals, had adhered to the serous formations of the testes in all five cases (100%, three of them – to the left epididymal omentum, and another two – to the right one). On day 14 (n = 5) it was found that in three cases it had adhered to the serous formations of the testes (60%, one of them to the left epididymal omentum, another two – to the right one) and in two cases it had adhered to the greater omentum (40%).
During the experiment on implantation of a xenogenic substrate in the form of flat bundles made from the catgut thread into the peritoneal cavity of sexually mature male rats, it was found for the first time that their acceptors were not only the greater omentum, but also two derivatives of the peritoneum, homeomorphic to it and associated with the epididymides, which we reasonably called epididymal omenta and described in details.
CT and MR imaging of the greater omentum: Pictorial essay
2023, Clinical Imaging
The greater omentum is a unique anatomical structure that serves a critical function in the containment of inflammatory and infectious processes within the abdominal cavity. It is also a common site of involvement by metastases, as well as the primary location for various pathologic lesions of clinical significance. Its fibroadipose composition, large size, and position in the most anterior aspect of abdomen allow accurate visualization of the greater omentum on CT and MR images. Careful evaluation of the greater omentum can provide important clues to the diagnosis of the underlying abdominal disorder.
The aim of this article is to present the normal appearance of the greater omentum, and the wide spectrum of its pathological features as demonstrated on CT and MRI of the abdomen.
The apron of the greater omentum of gastric cancer patients contains various lymphoid structures including lymph nodes
2023, Translational Research in Anatomy
To gain more insight into the pattern of peritoneal cancer dissemination and optimize cancer treatment, it is important to improve our understanding of the omental lymphatic system. Although omental milky spots (OMSs) are considered the only lymphoid structures in the omentum, clinical studies mention the presence of lymph nodes (LNs) as well. This discrepancy may be explained by the fact that OMSs are highly dynamic structures and may erroneously be mistaken for LNs. The aim of this study was to evaluate the lymphoid structures, and mainly the presence of lymph nodes, in the apron of the greater omentum.
In this study, diagnostic samples of the greater omentum of 17 gastric cancer patients that were previously reported to contain LNs were re-evaluated for their presence. Paraffin embedded omental samples were stained with Picrosirius red, smooth muscle actin and CD20 and CD3, and microscopically re-examined according to predefined criteria to distinguish OMSs from LNs.
Pathology records reported 47 LNs in 17 patients. Upon re-evaluation, 20/47 LNs could be classified as true LNs and were located in both the upper and lower quadrants of the greater omentum. The other 27 structures could not be classified as LNs or OMSs and were defined as intermediate lymphoid structures.
The omental apron of gastric cancer patients contains LNs and intermediate lymphoid structures, the latter most likely representing activated OMSs. These observations underline that our understanding of the lymphatic system of the greater omentum is incomplete and requires additional studies to gain further insight in its structure and function in both health and disease.
A 3D multi-cellular tissue model of the human omentum to study the formation of ovarian cancer metastasis
2023, Biomaterials
Reliable and predictive experimental models are urgently needed to study metastatic mechanisms of ovarian cancer cells in the omentum. Although models for ovarian cancer cell adhesion and invasion were previously investigated, the lack of certain omental cell types, which influence the metastatic behavior of cancer cells, limits the application of these tissue models. Here, we describe a 3D multi-cellular human omentum tissue model, which considers the spatial arrangement of five omental cell types. Reproducible tissue models were fabricated combining permeable cell culture inserts and bioprinting technology to mimic metastatic processes of immortalized and patient-derived ovarian cancer cells. The implementation of an endothelial barrier further allowed studying the interaction between cancer and endothelial cells during hematogenous dissemination and the impact of chemotherapeutic drugs. This proof-of-concept study may serve as a platform for patient-specific investigations in personalized oncology in the future.
Cardio-omentopexy requires a cardioprotective innate immune response to promote myocardial angiogenesis in mice
2022, JTCVS Open
The pedicled greater omentum, when applied onto stressed hearts using omentopexy, has been shown to be protective in humans and animals. The mechanisms underlying cardioprotection using omentopexy remain elusive. This study examined whether macrophage-mediated angiogenesis accounts for the cardioprotective effect of omentopexy in mice.
C57BL/6 mice were subjected to minimally invasive transverse aortic constriction for 6 weeks and subsequent cardio-omentopexy for 8 weeks. Control mice underwent the same surgical procedures without aortic constriction or cardio-omentopexy.
Transverse aortic constriction led to left ventricular concentric hypertrophy, reduced mitral E/A ratio, increased cardiomyocyte size, and myocardial fibrosis in the mice that underwent sham cardio-omentopexy surgery. The negative effects of transverse aortic constriction were prevented by cardio-omentopexy. Myocardial microvessel density was elevated in the mice that underwent aortic constriction and sham cardio-omentopexy surgery, and cardio-omentopexy further enhanced angiogenesis. Nanostring gene array analysis uncovered the activation of angiogenesis gene networks by cardio-omentopexy. Flow cytometric analysis revealed that cardio-omentopexy triggered the accumulation of cardiac MHCII^loLyve1+TimD4+ (Major histocompatibility complex class II^low lymphatic vessel endothelial hyaluronan receptor 1+ T cell immunoglobulin and mucin domain conataining 4+) resident macrophages at the omental–cardiac interface. Intriguingly, the depletion of macrophages with clodronate-liposome resulted in the failure of cardio-omentopexy to protect the heart and promote angiogenesis.
Cardio-omentopexy protects the heart from pressure overload-elicited left ventricular hypertrophy and dysfunction by promoting myocardial angiogenesis. Cardiac MHCII^loLyve1+TimD4+ resident macrophages play a critical role in the cardioprotective effect and angiogenesis of cardio-omentopexy.
A long-term follow up of the laparoscopically harvested free omental flap for breast reconstruction
2024, Microsurgery

View all citing articles on Scopus

: Address reprint requests to Dorothea Liebermann-Meffert, Prof. Dr., MD, Nelkenweg 4, D79112 Freiburg, Germany

^*: Department of Surgery, Kantonsspital, University Hospital Basel, Basel, Switzerland

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THE GREATER OMENTUM: Anatomy, Embryology, and Surgical Applications

Section snippets

DISCOVERY OF THE PROTECTIVE POWER OF THE GREATER OMENTUM

DISCOVERY OF THE USEFULNESS OF THE OMENTUM IN RECONSTRUCTIVE SURGERY

Description

ORGANOGENESIS

CLINICALLY RELEVANT NATURE OF THE OMENTUM

USE OF THE OMENTUM IN SURGERY

J Thorac Cardiovasc Surg

Neurosci Lett

Ann Thorac Surg

Gynecol Oncol

One-stage reconstruction of massive craniofacial defect with gastroomental flap

Ann Plast Surg

The greater omentum: Physiology and immunological concepts

Neth J Surg

Le lambeau gastroépiploïque: Un lambeau muqueux secrétant pour la reconstruction de l'oropharynx et de la cavité buccale

Ann Chir

Omental transposition in chronic spinal cord injury

Spinal Cord

Complications of the pedicled omentoplasty