The document discusses the role of omentectomy in early ovarian cancer surgery based on the gross appearance of the omentum. It notes that a healthy fatty omentum can act as a barrier against cancer spread, while a thin omentum with low fat content is more susceptible to early metastasis. Early signs of microscopic metastasis in a thin omentum include omental panniculitis. The document concludes that infracolic omentectomy is usually sufficient for staging early cancers when the omentum appears healthy, while supracolic procedures may be needed if the infracolic region shows signs of panniculitis. The gross appearance of the omentum and signs of invasion or inflammation can help determine the

1. Omentectomy in Early Ovarian Cancer:
Role of the Gross Appearance
of the Omentum in Surgery
Ahmed Samy El-Agwany, MBBCH, MSC, PhD1,2
EDITOR: The omentum is enriched in macrophages, B
and T lymphocytes, dendritic cells, and natural killer
cells. Omentum collect fluids, particulates, bacteria, and
cells from the peritoneal cavity and can induce an immune
response. The omentum helps to restore tissue integrity
in the peritoneum by connecting tissue repair with im-
munological defense. The first goal of ovarian cancer sur-
gery is staging of cancer which includes hysterectomy,
bilateral or unilateral salpingo-oophorectomy or cystect-
omy and omentectomy. The omentum is a layer of fatty
tissue with fuel cells. They feed the cancer cells, enabling
them to multiply rapidly. Once cancer cells reach the
omentum, they reprogram their metabolism to thrive on
lipids acquired from fat cells. Ovarian cancer can convert
the omentum into a solid mass of cells. The omentum
contains stem-like cells, such as adipose stromal cells
(ASCs) that engraft tumor cells and encourage cancer pro-
gression while reducing the response to chemotherapy and
radiation.1,2
A healthy, rich fatty omentum can be a barrier against the
spread of cancer to the peritoneum and serosal surfaces,
while a thin omentum with a low-fat content can be affected
early by early small tumors and this can manifest as omental
panniculitis and develop later into metastatic nodules. And
it can allow early spread of cancer in abdomen and pelvis
because of low barrier effect.
Our observations revealed the following:
On staging cancers, if inspection and palpation reveal a
thin omentum, with low-fat appendices and spaced fat
appendices with a mostly nonfatty double peritoneum
reflection, this is commonly not associated with pan-
niculitis or malignant nodules. And it is a weak barrier
to spread of cancer while a thick rich one of smooth
surface with no adhesions with large appendices and
smooth surface and freely mobile is a barrier against
spread to serial surfaces.
A omentum with a hard-to-visualize nonfatty double
peritoneum areas and densely packed lobules, and that
is easily torn on handling or mobilization, is usually a
sign of early microscopic affection which is Omental
panniculitis.
Omental panniculitis can be an early sign of mi-
croscopic metastasis with initial inflammation as a tis-
sue reaction with fibrosis and tethering (puckering) of
healthy peritoneum between appendices that appears
as a thick abnormal omentum with compact small fat
appendices that can undergo fat necrosis via inflammation
or reduction as used as a fuel by cancer cells. This is
common to see in thin omentum with low fat content that
present early with panniculitis in opposite to thick richy
fatty omentum that acts as a barrier and resists invasion.
FIG. 1. Omental metastasis.
FIG. 2. Unhealthy omentum with omental panniculitis.
1
Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Egypt.
2
El-Shatby Maternity University Hospital, Alexandria, Egypt.
JOURNAL OF GYNECOLOGIC SURGERY
Volume 00, Number 0, 2019
ª Mary Ann Liebert, Inc.
DOI: 10.1089/gyn.2019.0053
1
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2. In advanced cancers, there is small omental cake mass
with a low-fat content that is consumed over time or
invaded with tumor cells especially with thin one.
The omentum acts to engulf malignant cells before they
spread to the peritoneum, especially the infracolic part,
which is mobile. Thus, it is better not to perform a total
omenectony in early stages, as omentum is engulfing cancer
cells delays their spread to the serosal surfaces and upper
abdomen leading to an omental cake. Omentectomy has no
therapeutic role in addressing early cancer; so infracolic or
partial omentectomy is preferable for staging early cancer.
Infracolic omentecotmy is better than total one in staging of
early cancers so as to leave part of omentum to localize the
recurrence in the omentum and not to spread in the abdomen
and pelvis (that is to engulf tumor cells).3,4
Early ovarian cancer in a patient with a thin omentum
with low-fat is usually associated with early peritoneal
and serosal spread. Early cancer and a thick healthy fatty
omentum is usually associated with delayed spread. I can
suggest that infracolic omentectomy is sufficient for early
cancer staging if a patient has a healthy-looking omen-
tum. I also suggest proceeding with a supracolic procedure
if the infracolic is unhealthy as stated above with respect
to panniculitis. Total omentectony, as it indicate invasion
and so better surgery, this needs more evaluation regarding
Omental gross appearance and types of surgery required. We
aimed to raise awareness regarding gross appearance of
omentum in ovarian tumors that can have a role in the type of
surgery (Figs. 1–3)
References
1. Morgan M, Boyd J, Drapkin R, Seiden MV. Cancers arising
in the ovary. In: Abeloff MD, Armitage JO, Lichter AS,
Niederhuber JE, Kastan MB, McKenna WG, eds. Clinical
Oncology, 5th ed. Philadelphia: Elsevier; 2014:1592.
2. Rizi BS, Nagrath D. Linking omentum and ovarian cancer:
NO. Oncoscience. 2015;2:797.
3. El-Agwany AS. Laparoscopy and computed tomography
imaging in advanced ovarian tumors: a roadmap for pre-
diction of optimal cytoreductive surgery. Gynecol Minim
Invasive Ther 2018;7:66–69.
4. Meleis MH, El-Agwany AMS. Peritoneal carcinomatosis in-
dex in advanced ovarian malignancy either by multislice CT
verus laparotomy: A Comparative Study. Indian J Gynecol
Oncolog 2015:13:24.
Address correspondence to:
Ahmed Samy El-Agwany, MBBCH, MSC, PhD
Department of Obstetrics and Gynecology
Faculty of Medicine
Alexandria University
Portsaid Street
beside Bibliotheca Alexandrina
El-Shatby, Alexandria 21526
Egypt, 21526
E-mail: Ahmedsamyagwany@gmail.com
ahmed.elagwany@alexmed.edu.eg
FIG. 3. Left panel shows normal
mesentry; right panel shows nor-
mal omentum. Both panels are
showing smooth healthy fat rich
omentum.
2 LETTER TO THE EDITOR
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