monthly focus

surgical intervention video

This is the case of a 55-year-old man who presented with a locally advanced mid/low rectal cancer with involvement of the vesiculae seminalis. After neoadjuvant treatment, an extended resection was performed. It consisted of an abdominoperineal resection ‘en bloc’ with the vesiculae seminalis. After resection, the dead space in the narrow pelvis was filled up with the omentum. This video focuses on the indications for an omentoplasty and provides a detailed description of the omentoplasty technique.  

The objective of this video is to demonstrate the technical modalities for an omentoplasty. 

In an extralevator abdominoperineal or extended excision for a locally advanced or a recurrent rectal cancer after neoadjuvant radiochemotherapy, an omentum may be useful to fill the dead space in the pelvis. Potential advantages include the avoidance of a large pelvic dead space containing serum and blood as a good medium for the growth of bacteria. In addition, the omentum with its immune regulatory and tissue regenerative properties seems a better candidate than other potential available means such as biological meshes. Other advantages include the presence of an omental buffer in between a potential complicated perineal wound healing and the small bowel and bladder. Repeated trauma from vaccuum wound dressing changes can increase the risk at the formation of small bowel or bladder fistula. In a narrow pelvis, an omentoplasty could contribute to the prevention of a mechanical ileus. 

In some slim patients with a low volume of omentum, an omentoplasty seems unuseful. Potential downsides of an omentoplasty include the additional time required to mobilize the omentum and an omental flap necrosis with persisting presacral abscess formation. However, with new opportunities such as vascularization control with indocyanine green, the risk of such complications can be minimized even in laparoscopic surgery. 

A recent national snapshot study lumped together 477 patients who underwent abdominoperineal resections in 71 hospitals and concluded on the basis of a significant difference in perineal hernia development that an abdominoperineal resection (APR) without omentoplasty can be considered a standard of care. 

However, this snapshot study design was prone to confounding as pinpointed by some of the authors of this film in a letter to the editor. As a result, the resulting induced suggestion that an omentoplasty is not an added value on the basis of these data is not justified. 

Below the links can be opened to the original study and letter to the editor: <a href='https://link.springer.com/article/10.1245/s10434-021-10474-4'>https://link.springer.com/article/10.1245/s10434-021-10474-4</a>.



Omentoplasty during robot-assisted minimally invasive abdominoperineal excision for a locally advanced rectal cancer

Omentoplastie lors d'une excision abdominopérinéale mini-invasive assistée par robot pour cancer rectal localement avancé

This is the case of a 59-year-old woman who presented with a recurrent rectal cancer. A recurrence was identified along with sacral bone involvement. After neoadjuvant treatment, an extended resection was performed after which the defect was closed using a lotus petal flap reconstruction. 

Focus on surgical techniques in locally advanced rectal cancer and recurrent rectal cancer

Lotus petal flap reconstruction of a perineal defect after resection of a recurrent rectal cancer

Omentoplasty during robot-assisted minimally invasive abdominoperineal excision for a locally advanced rectal cancer