Omental Torsion

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Overview

Torsion of the omentum is a condition in which the organ twists on its long axis to such an extent that its vascularity is compromised. This is illustrated in the image below.


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This is an example of primary torsion of the omentum. A normal-appearing omentum can be seen above the torsion point. The omentum below that point is ....

Although omental torsion is rarely diagnosed preoperatively, knowledge of the entity is important to the surgeon because it mimics the common causes of acute surgical abdomen.

Eitel first described omental torsion in 1899; since then, fewer than 250 cases have been reported.

Etiology

Torsion of the omentum may be primary or secondary. In primary torsion, a mobile segment of omentum rotates around a proximal fixed point in the absence of any associated intra-abdominal pathology. Although the precise cause is unknown, both predisposing and precipitating factors in the pathogenesis of the condition can be identified.[1, 2, 3, 4]

Factors that predispose a patient to torsion include anatomic variations of the omentum itself, such as accessory omentum, bifid omentum, irregular accumulations of omental fat (in patients who are obese), and narrowed omentum pedicle. Any redundancy of omental veins may lead to kinking and twisting around the shorter and tenser arteries. The higher incidence of torsion on the right side of the omentum is related to the greater size and mobility of that side.

Precipitating factors are those causing displacement of the omentum, including trauma, violent exercise, and hyperperistalsis with resultant increased passive movement of the omentum.

Secondary torsion

Secondary torsion is more common than primary torsion and is associated with preexisting abdominal pathology, including cysts, tumors, foci of intra-abdominal inflammation, postsurgical wounds or scarring, and hernial sacs. Most cases of secondary torsion occur in patients with inguinal hernias.[5]

Pathophysiology

In omental torsion, the omentum twists around a pivotal point, usually in a clockwise direction. Venous return is compromised, and the distal omentum becomes congested and edematous. Resultant hemorrhagic extravasation creates a characteristic serosanguineous fluid in the peritoneal cavity.

As the torsion progresses, arterial occlusion leads to acute hemorrhagic infarction and eventual necrosis of the omentum occurs. Spontaneous derotation may be possible and may explain omental adhesions in the right lower quadrant, which are often found during laparotomy and have no clear cause.

Clinical Findings

Torsion of the omentum is difficult to clinically diagnose preoperatively. Accurate preoperative diagnosis was reported in the range of 0.6-4.8%. In a report from Greece, for example, a 14-year-old boy who was admitted to the hospital for acute appendicitis was found during surgery to be suffering from omental torsion on the long axis.[6]

Omental torsion usually occurs in adults (of either sex). The twisted portion of the omentum tends to be localized to a right-sided segment, thereby giving rise to the sudden onset of pain and signs of peritoneal irritation on the right side of the abdomen. The condition may be associated with nausea, vomiting, or low-grade fever. An abdominal mass may be palpable in half of the patients.

This right-sided acute pain and rebound tenderness is often mistaken for acute appendicitis, acute cholecystitis, or twisted ovarian cysts. At laparotomy, the finding of free serosanguineous fluid in association with a normal appendix, gallbladder, or pelvic organs should alert the surgeon to the possibility of omental torsion.

Diagnostic Studies

CBC counts may reveal moderate leukocytosis, which occurs in two thirds of cases.

Reports suggest that ultrasonography and computed tomography (CT) scanning may show a characteristic appearance of twisted omentum; however, because the disease may mimic other surgical emergencies, extensive radiologic studies are usually not indicated.

CT scanning may show a concentric distribution of fibrous and fatty folds converging radially toward the torsion.[7, 8] Ultrasonography, on the other hand, may show a complex mass and mixture of solid material and hypoechoic zones.

Laparoscopy is a safe diagnostic and therapeutic modality.[9, 10] In a report from Italy, for example, ultrasonographic and radiologic findings in 3 patients who presented with acute abdominal symptoms were unclear, prompting the use of diagnostic laparoscopy.[11] Because laparoscopic examination allowed exploration of the entire peritoneal cavity, an accurate diagnosis of omental torsion, and laparoscopic resection of necrotic omentum, was achieved in each patient, according to the report.[12]

Treatment & Management

Preoperative differential diagnosis includes acute appendicitis, acute cholecystitis, and twisted ovarian cysts. Torsion of the omentum is usually discovered during laparotomy or laparoscopy for an acute abdomen.[9]

Consider omental torsion if preoperatively diagnosed acute appendicitis is not found and if the gallbladder and ovaries reveal no disease. In addition, the presence of serosanguineous fluid in the peritoneal cavity mandates inspection of the omentum to exclude torsion.

Treatment consists of resection of the affected portion of the omentum. Correct any disease process associated with secondary torsion.[13]

Postoperative recovery is usually rapid, and morbidity is minimal. If left untreated, the natural process of omental torsion is necrosis and fibrosis.

With the advent of diagnostic laparoscopy and the increased demand for laparoscopic appendectomy, omental torsion may become a more frequently recognized clinical entity.

Procedure

An incision centered over the site of maximal tenderness facilitates the operative diagnosis and eases resection of the infarcted omentum. When a healthy appendix is found, search for the cause of the abdominal pain.

First, inspect the cecum for a perforated diverticulum. The terminal ileum is then examined for Meckel diverticulum and regional enteritis, and the pelvic organs are inspected and palpated for disease.

Visualize the gallbladder and duodenum, and evaluate the mesentery for mesenteric lymphadenitis. Continue to explore the abdomen until the cause of acute abdominal symptoms has been identified. This may require extension of the original incision or creation of a new incision.

Author

Alan A Saber, MD, MS, FACS, FASMBS, Director of Bariatric and Metabolic Surgery, University Hospitals Case Medical Center; Surgical Director, Bariatric Surgery, Metabolic and Nutrition Center, University Hospitals Digestive Health Institute; Associate Professor of Surgery, Case Western Reserve University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond D LaRaja, MD, Chairman, Program Director, Clinical Professor, Department of Surgery, Cabrini Medical Center, Mount Sinai School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

Additional Contributors

Amy L Friedman, MD Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, NewYork Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References

  1. Beattie GC, Irwin ST. Torsion of an omental lipoma presenting as an emergency. Int J Clin Pract Suppl. Apr 2005;130-1. [View Abstract]
  2. Young TH, Lee HS, Tang HS. Primary torsion of the greater omentum. Int Surg. Apr-Jun 2004;89(2):72-5. [View Abstract]
  3. Zager JS, Gadaleta D, De Noto G. Primary omental torsion in adults: a small series of cases. Contemp Surg. 1999;55(5):261-63.
  4. Reurings JC, Heikens JT, Roukema JA. [Primary torsion of the omentum majus]. Ned Tijdschr Geneeskd. 2011;155(44):A3776. [View Abstract]
  5. Kayan M, Sabuncuoglu MZ, Çetin M, Çetin R, Benzin MF, Benzin S, et al. Omental torsion with left-sided inguinal hernia: a rare preoperative diagnosis. Clin Imaging. Jan-Feb 2013;37(1):173-5. [View Abstract]
  6. Efthimiou M, Kouritas VK, Fafoulakis F, et al. Primary omental torsion: report of two cases. Surg Today. 2009;39(1):64-7. [View Abstract]
  7. Jeon YS, Lee JW, Cho SG. Is it from the mesentery or the omentum? MDCT features of various pathologic conditions in intraperitoneal fat planes. Surg Radiol Anat. Jan 2009;31(1):3-11. [View Abstract]
  8. Tandon AA, Lim KS. Torsion of the greater omentum: A rare preoperative diagnosis. Indian J Radiol Imaging. Nov 2010;20(4):294-6. [View Abstract]
  9. Peirce C, Martin ST, Hyland JM. The use of minimally invasive surgery in the management of idiopathic omental torsion: The diagnostic and therapeutic role of laparoscopy. Int J Surg Case Rep. 2011;2(6):125-7. [View Abstract]
  10. Sasmal PK, Tantia O, Patle N, Khanna S. Omental torsion and infarction: a diagnostic dilemma and its laparoscopic management. J Laparoendosc Adv Surg Tech A. Apr 2010;20(3):225-9. [View Abstract]
  11. Costi R, Cecchini S, Randone B, et al. Laparoscopic diagnosis and treatment of primary torsion of the greater omentum. Surg Laparosc Endosc Percutan Tech. Feb 2008;18(1):102-5. [View Abstract]
  12. Abe T, Kajiyama K, Harimoto N, Gion T, Nagaie T. Laparoscopic omentectomy for preoperative diagnosis of torsion of the greater omentum. Int J Surg Case Rep. 2012;3(3):100-2. [View Abstract]
  13. Itenberg E, Mariadason J, Khersonsky J, Wallack M. Modern management of omental torsion and omental infarction: a surgeon's perspective. J Surg Educ. Jan-Feb 2010;67(1):44-7. [View Abstract]

This is an example of primary torsion of the omentum. A normal-appearing omentum can be seen above the torsion point. The omentum below that point is edematous and congested.

This is an example of primary torsion of the omentum. A normal-appearing omentum can be seen above the torsion point. The omentum below that point is edematous and congested.