By contusions, lacerations, and punctures various injuries to the omentum may be inflicted, naturally more commonly when it is the anterior abdominal wall which has sustained the traumatism. As result of lacerations, hemorrhages or strangulations may occur. The immediate danger is, then, from hemorrhage. Indications of such lesions of the omentum are not specific, but grave symptoms after any abdominal injury require exploration, and that minute punctures or lacerations should be repaired, while other injuries should be treated according to obvious indications.
TORSION OF THE GREAT OMENTUM.
Torsion of the great omentum was first described by Oberst, in 1882, as a condition found in the sac of a large irreducible hernia. As a distinct and serious condition it has been reported in about sixty instances. The condition occurs within the abdomen as simple torsion, also within hernial sacs, or in both, where the torsion is not limited to the sac, but extends upward into the abdomen. It is more frequent in males, and its onset is usually sudden. Of all its symptoms pain is the most constant and the earliest. This is usually acute and persistent, and in a large proportion of cases is referred to the right iliac fossa. Vomiting is not constant; bowel conditions are not significant. Absolute obstruction is usually rarely noted. In most of the recorded cases some tumor can be felt on examination, which is hard, tender, dull to light percussion, and irregular in shape. Meteorism is not common. Death has occurred in about 15 per cent. of known cases. Diagnosis previous to exploration can be inferential only, but such symptoms as above noted should lead to exploratory laparotomy.
TUMORS OF THE OMENTUM.
The most common of the omental tumors are cysts of inflammatory origin, such as may, for instance, be formed by inclusion between surrounding adhesions or by previous hemorrhage; lymph cysts, often large and multiple, and sometimes of congenital but often of lymphatic origin, are also occasionally seen. The so-called omental dermoids are usually ovarian products. Hydatid cysts have been found in the omentum, but only as secondary products. Omental cysts are difficult or almost impossible of diagnosis previous to operation, which latter should always be performed, and without previous aspiration, as the presence alone of any such tumor requires removal. If large they are most likely to be confused with ovarian cysts. Those which may prove not to be removable should be drained, after being fastened to the abdominal wall—that is, marsupialized. Angioma in the omentum is rare, but has been recorded by Homans and others. Fatty or other benign tumors are also rare. Primary sarcoma is rarely seen here, but most of the sarcomas, and all of the carcinomas which never arise here primarily, but are often seen, are either metastases or direct extensions. In these forms cancer of the omentum is common.
With extensive involvement of the omentum radical operations in these cases are seldom advisable. A circumscribed involvement may, however, be removed, while such operations as anastomoses, enterostomies, and the like are often necessitated.
Omental tumors are difficult of diagnosis, although they are usually superficial and overlie the intestines. They are not affected by respiration. They move laterally and upward, but not downward. If confined to the omentum proper they cause no functional but only mechanical disturbances. Obviously in the presence of extensive adhesions every distinctive feature may be confused.
OMENTOPEXY; OMENTOSPLENOPEXY; TALMA’S OR MORRISON’S OPERATION.
The effect of stasis in the portal circulation is to produce outpour of varying amounts of serous fluid into the pleural cavity. This condition, long known as ascites (dropsy), is the most distressing terminal feature of such diseases as cirrhosis of the liver, cancer, and the like. The osmotic direction of fluid seems to be reversed, and transudation tends to go on until intra-abdominal pressure equals that within the vessels. Absorption is always impeded and finally prevented. Reflecting on the biophysics of this condition Talma and Morrison, independently, and at about the same time, suggested an expedient by which a portion at least of this fluid might be brought back into the general venous circulation. The plan was to attach the epiploön (the omentum) to the peritoneum of the anterior abdominal wall in such a way and over such an area that, by virtue of the adhesions thus produced and the new vascular anastomosis thus established, a new line of vascular connections should be formed, so that fluid not returnable to the vena cava by the usual route should be given a new and artificial direction. To this fundamental proposition much detail has been added.
Thus Schiassi has shown that, so far as the supply of toxins which shall pass through the liver is concerned, there are really two portal veins—the superior mesenteric and the splenic—or he would call what we usually name the portal system the splenoportal. Consequently he would include the spleen in the above mechanical procedure, especially in those cases where it participates in the morbid process—e. g., in the hepatosplenic or pre-ascitic form of Banti’s disease, and the splenomegalic cirrhosis described by Gilbert. In 1904 this problem was studied from its surgical aspects by Monprofit (French Congress of Surgeons), who collected 224 operated cases. Of these 84 died, 129 recovered from the operation, and 11 could not be traced. In 25 cases relapse occurred, in 26 there was improvement, while in 70 there was claimed complete recovery.[64] In other words about one-third of the cases thus reported have recovered. He insists, as would every other surgeon, that with this showing the results would be far better were cases seen and operated earlier. His statistics are not widely variant from those of Zesas, who found that out of 254 cases which he collected 67 recovered and 82 died, while 42 were greatly improved.