Laparoscopic Management of Primary Omental Torsion

Abstract

Primary omental torsion is an unusual condition, known for its rarity and for the particularity of being intraoperatively diagnosed, in nearly all cases. At the clinical evaluation, this pathology commonly mimics other etiologies of acute abdomen. Hemoperitoneum and necrosis of the omentum are rarely associated with the omental torsion, but when the association is found, then it means that the vascular injuries are irreversible and the required surgical procedure may be far more complex than simple devolvulus. In search of the treatment of choice, laparoscopy proved its effectiveness as a diagnostic and therapeutic tool, while the open surgery approach can be described in many cases as being too invasive. A 37-year-old female patient presented with the generic symptoms of acute appendicitis. Surgical treatment was initiated. During laparoscopy, the abdomen was attentively explored, highlighting the presence of a twisted omentum with hemoperitoneum and necrosis. Omental excision and peritoneal drainage were performed. The evolution was favorable. Another check-up was done at 6 months postoperatively, displaying no signs or symptoms of relapse.

Omental torsion; an unusual case of acute abdomen. Case report

“… Pinwheel sign: cloudy mass of fat with concentric lines, with twisting of blood vessels within the greater omentum. This turns around the central vascular line, this last sign confirms the torsion of the greater omentum [3] , [4] , [7] , [8] . …”

“…Omental torsion occurs when a segment of it is rotated about its axial axis, becoming strangulated; thus, compromising arterial blood flow, causing necrosis, production of serosanguineous fluid and finally, peritonitis [2] , [3] , [6] , [7] . In most cases, omental torsion occurs between the fourth and fifth decades of life.…”

“…This indicates that both ends of the omentum are fixed, both distally and proximally. The distal end of the omentum is associated with scars from previous surgeries or trauma, as well as with inflammation, cysts, tumors, hernias, and other intra-abdominal pathologies that can lead to adhesion formation [6] , [7] , [8] , [9] .…”

Torsion of the omentum: A rare cause of acute abdomen.

“…This procedure can be performed either an open laparotomy or laparoscopically; and involves the resection of the affected part of omentum. 18,19 Exploratory laparotomy serves as diagnostic and therapeutic procedure as the torsion is diagnosed during exploratory laparotomy performed for acute abdomen therefore surgical treatment is still procedure of choice. 12,14 It further gives advantage over conservative approach by preventing possible complications such as sepsis, intraabdominal abscess or adhesion formation.…”

“…12,14 It further gives advantage over conservative approach by preventing possible complications such as sepsis, intraabdominal abscess or adhesion formation. 14,16,17,19 Minimally Invasive approaches like diagnostic and therapeutic laparoscopy however is preferred over exploratory laparotomy, as it result in faster recovery, shorter hospital stay, less scarring, minimally incision and earliest discharge as day case patient with an excellent outcome.…”