Secondary omental torsion as a cause of acute abdomen in a patient with long-standing right-sided inguinal hernia.

A 43 yr old man presented to the Emergency Department of the Clinical Hospital Centre Zagreb, Zagreb, Croatia, on April 30, 2013 with a history of increasing abdominal pain. Diffuse abdominal tenderness and a right-sided inguinal hernia were found on physical examination. Computed tomography (CT) scan of abdomen revealed characteristic ‘whirl sign’ suggestive of omental torsion (Fig. A).

Figure

(A) Abdominal CT scan showing concentric mesenterial fat stranding at the right abdominal cavity (white arrow). (B) Operative picture demonstrating torsioned and necrotic omentum that was twisted several times around its long axis (black arrow).

Exploratory laparoscopy revealed necrosis of almost the entire greater omentum with torsion at its base and an indirect inguinal hernia with affected omentum and small bowel inside the hernia sac. The procedure was converted to a middle median laparotomy, and the omentum was ligated and resected at its base, ensuring that the entire necrotic part was removed (Fig. B). At the end, a Lichtenstein hernia repair was performed. The postoperative period was uneventful. The patient was examined every six months for two years, and there were no signs of incisional or inguinal hernia.

Omental torsion is a rare disease entity and in most cases it requires an emergent surgical procedure. The possible mechanism is a sudden body rotational movement that provokes torsion of the omentum between two fixed points, insertion point along transversal colon and inguinal canal where the end of the omentum is adherently fixed.