Wednesday, February 3, 2010

The Watchdog

Have you ever wondered why, in years past, people didn’t always die if they developed appendicitis or intestinal perforations or any of the intra-abdominal maladies that continue to plague us today. I do a large number of surgeries for these and other similar problems; I find it hard to believe that before abdominal surgery became fairly routine everyone died if they developed such surgical emergencies.
Watchdog is defined as “a dog kept to guard a property” or “a watchful guardian.” Our bodies have all been built with such a watchdog. God, in his infinite wisdom, created us with a marvelous, but unsung organ called the omentum. Never heard of it you may say. Most people outside of medical circles are oblivious to the existence of the omentum, but to those of us who make a living rooting around peoples insides this amazing organ keeps us and our patients out of trouble.
What’s the omentum? Almost everyone has this organ, but it is almost never mentioned in high school or college textbooks on anatomy. We all learn about the liver and pancreas and our intestines as part of high school biology, but the omentum is the guardian to all these vital organs. Just inside our abdominal cavity, laying like an apron draping over our intestines is the omentum. Structurally, it is a sheet of fat, blood vessels and lymphatic tissue that literally is an apron, providing a protective cover to our abdominal viscera.
Most of the time all it is called to do is lie dormant, ever vigilant, but quiescent. But, when the need arises it springs into action. There have been numerous times I’ve operated on a patient and followed this remarkable organ to the exact location of the offending process. It seems to have a sixth sense that causes it to move in and seal off diseased areas in our abdominal cavity. Invading bacteria are kept isolated and what could have been a massive infection, becomes a localized and often a very minor annoyance.
Take, for example, diverticulitis which is a very common condition these days. Diverticuli are small protrusions that can develop on our colons where the inner lining of the colon bulges through the outer muscular coat, akin to the inner tube of a bicycle popping out of the outer tire. These diverticuli can become inflamed and rupture, which allows the bacteria inside the colon to leak out into the abdominal cavity. A catastrophe and life threatening emergency one would think. However, here comes the omentum to the rescue. Like the “Blob” of movie legend, this organ will adhere to the area of perforation, sealing the hole and preventing potential life threatening spread of the contaminants. The diverticulitis often is diminished to a minor episode of pain in the lower abdomen, frequently treated successfully with oral antibiotics as an outpatient.
I’ve had patients come to see me with symptoms typical of appendicitis that have been present for nearly a week. Typically, appendicitis that has been ongoing for such a time would have developed an abscess or severe peritonitis. Yet, there is the patient, sitting up, smiling with only minimal discomfort. What do you think is found at surgery? A very nasty, inflamed, gangrenous appendix with the omentum encircling it like a gift wrapped present waiting to be delivered to the proper recipient, in this case, me, the surgeon.
The omentum has been described as an organ that brings new blood supply to areas in need. In fact, it is often utilized for just such a purpose. Plastic surgeons may use it to reconstruct areas damaged by cancer, radiation therapy or severe infections. When I encounter a difficult intestinal problem, a difficult perforation or something similar, I frequently use the omentum to help remedy the situation. And, when it is absent, having been removed or utilized for some other purpose I am often hardpressed to find a suitable substitute to replace this remarkable organ.
It must be true that in the days before surgery the “watchdog” saved many lives. Inflammatory processes leading to abscesses and often death have been described since the time of Hippocrates. Often these patients died of their disease, but many recovered uneventfully. It is almost certain that these recoveries were due to our marvelous omentum. It is no wonder that general surgeons call the omentum their best friend and ally. It has truly earned its title, “The Watchdog”.