Ausr. N.Z. J . Surg. 1992,62,400-401
CASE REPORTS LAPAROSCOPIC RESECTION FOR PRIMARY OMENTAL TORSION S. C. S. CHUNG, K. W. NG AND A. K. C. LI Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
Introduction Primary omental torsion is a rare cause of acute abdominal pain that may mimic acute appendicitis. A case of omental torsion in which the diagnosis was made by laparoscopy and the infarcted omentum was resected laparoscopically is reported.
Case report
A 35 year old man was admitted to the Prince of Wales Hospital, Hong Kong because of a 3 day history of right-sided abdominal pain. The pain was preceded by a short episode of dull epigastric discomfort which was not associated with other bowel symptoms. On physical examination he was pyrexial (38.3"C). There was marked tenderness and guarding over the right subcostal area. His white blood count was raised to 16 X 109/L. Liver function tests were normal. Abdominal ultrasonography was unremarkable. A diagnosis of high retrocaecal appendicitis was made arid the patient underwent laparoscopy with a view to laparoscopic appendicectomy . There was a small amount of serosanguineous fluid in the peritoneal cavity. The appendix was normal. A piece of infarcted omentum lOcm in size was seen. The torted pedicle was identified on blunt dissection under laparoscopic vision (Fig. I ) . The pedicle was ligated with a 2/0 chromic catgut Endoloop (Ethicon, Edinburgh, UK) and then divided. The resected omentum was too big to be extracted through the lOmm trocar so it was cut up into smaller pieces using laparoscopic scissors and removed piecemeal through a 15 mm trocar (Fig. 2). The total operating time was 3 h. The patient made an uneventful recovery and was discharged on the fourth postoperative day. He returned to work 10 days after the operation.
Correspondence: Prof. A. K. C. Li, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong. Accepted for publication 11 December 1991.
Fig. 1. Omental torsion seen laparoscopically
Fig. 2. The torted omentum was fragmented and removed piecemeal.
Discussion Laparoscopy has been recommended as an alternative to diagnostic laparotomy for patients with acute abdominal pain in whom the diagnosis is uncertain.' It is particularly useful in excluding appendicitis in young females. With recent advances in laparoscopic surgery, not only can the diagnosis be made through the laparoscope, in many cases the definitive surgery can be carried out laparoscopically . Laparoscopic cholecystectomy is fast becoming the treatment of choice for symptomatic In some centres the procedure is
PRIMARY OMENTAL TORSION
extended to patients with acute chole~ystitis.~ Laparoscopic appendicectomy is a relatively simple procedure, and is possible even in cases with severe inflammation. Laparoscopic repair of perforated duodenal ulcers has also been reported.6 Laparoscopy avoids the surgical trauma inherent in a laparotomy. There is less pain, less scarring and a shorter convalescence. It is likely that the approach to patients with acute abdominal pain will soon undergo fundamental changes, with laparoscopic surgery playing an increasing role in their diagnosis and treatment. Torsion of the omentum is a rare cause of acute abdominal pain.’ Patients usually present with acute onset of right lower quadrant pain with signs of peritoneal irritation. The clinical features may closely mimic acute appendicitis. The diagnosis is made at operation, where a moderate amount of serosanguineous peritoneal exudate and a twisted, infarcted piece of omentum is found.’ The recommended treatment is resection of the torted omenturn. The diagnosis is also easily made through the laparoscope. Dissection of the torted omentum and ligation of the pedicle using an Endoloop suture is safely accomplished by a surgeon skilled in laparoscopic surgery. Removal of the rather bulky infarcted omentum posed a technical problem. In this case the omentum had to be cut up into small pieces and removed piecemeal through the laparoscopic trocar. The procedure is tedious and took up more than half of the operating time. A myoma morcellator, designed for laparoscopic removal of uterine myoma, has a mechanism for resecting large punches from the instrument. It would have been suitable in this case. An alternative would be to make a mini-laparotomy
40 I
incision to extract the mass. A mechanisni of fragmenting resected tissue and removing it through the trocar sheath without contaminating the abdominal cavity is one of the problems that need to be solved before laparoscopic techniques can be applied to resectional surgery for intra-abdominal turnours.
Acknowledgement The authors acknowledge the financial support of Ethicon for reproduction of the colour figures.
References 1. PATERSON-BROWN S., ECKERSLEY J. R. T., SIMA. J. W. & DUDLEY H. A. F. (1986) Laparoscopy as an adjunct to decision making in the ‘acute abdomen’. Br. J . Surg. 73, 1022-4.
2. THESOUTHERN SURGEONS CLUB(1991) A prospective analysis of 1518 laparoscopic cholecystectomies. N . Engl. J . Med. 324, 1073-8. 3. NATHANSON L. K., SHIM1 S. & CUSHERl A. (1991) Laparoscopic cholecystectomy: The Dundee technique. Br. J . Surg. 78, 163-6. 4. FLOWERS1. L., BAlLkY R. w., SCOVILL W. A. & ZUCKERK. A. (1991) The Baltimore experience with laparoscopic management of acute cholecystitis, Am. J . Surg. 161, 388-92. 5 . GOTZF., PIER A. & BACHER C. (1990) Modified laparoscopic appendicectomy in surgery. A report of 388 operations. Surg. Endosc. 4, 6-9. 6. MOURETP., FRANCOIS Y . , VICNALJ . , BARTHX. & LOMBARD-PLATET R. (1 990) Laparoscopic treatment of perforated peptic ulcer. B r . J . Surg. 77, 1006. R. A . & SIMOES A. Primary idiopathic tor7 . MAINZER sion of the omentum. Arch. Surg. 88, 974-83. 8 . ADAMS J. T. (1973) Primary torsion of the omentum. Am. J . Surg. 126, 102-5.
CASE REPORTS LAPAROSCOPIC RESECTION FOR PRIMARY OMENTAL TORSION S. C. S. CHUNG, K. W. NG AND A. K. C. LI Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
Introduction Primary omental torsion is a rare cause of acute abdominal pain that may mimic acute appendicitis. A case of omental torsion in which the diagnosis was made by laparoscopy and the infarcted omentum was resected laparoscopically is reported.
Case report
A 35 year old man was admitted to the Prince of Wales Hospital, Hong Kong because of a 3 day history of right-sided abdominal pain. The pain was preceded by a short episode of dull epigastric discomfort which was not associated with other bowel symptoms. On physical examination he was pyrexial (38.3"C). There was marked tenderness and guarding over the right subcostal area. His white blood count was raised to 16 X 109/L. Liver function tests were normal. Abdominal ultrasonography was unremarkable. A diagnosis of high retrocaecal appendicitis was made arid the patient underwent laparoscopy with a view to laparoscopic appendicectomy . There was a small amount of serosanguineous fluid in the peritoneal cavity. The appendix was normal. A piece of infarcted omentum lOcm in size was seen. The torted pedicle was identified on blunt dissection under laparoscopic vision (Fig. I ) . The pedicle was ligated with a 2/0 chromic catgut Endoloop (Ethicon, Edinburgh, UK) and then divided. The resected omentum was too big to be extracted through the lOmm trocar so it was cut up into smaller pieces using laparoscopic scissors and removed piecemeal through a 15 mm trocar (Fig. 2). The total operating time was 3 h. The patient made an uneventful recovery and was discharged on the fourth postoperative day. He returned to work 10 days after the operation.
Correspondence: Prof. A. K. C. Li, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong. Accepted for publication 11 December 1991.
Fig. 1. Omental torsion seen laparoscopically
Fig. 2. The torted omentum was fragmented and removed piecemeal.
Discussion Laparoscopy has been recommended as an alternative to diagnostic laparotomy for patients with acute abdominal pain in whom the diagnosis is uncertain.' It is particularly useful in excluding appendicitis in young females. With recent advances in laparoscopic surgery, not only can the diagnosis be made through the laparoscope, in many cases the definitive surgery can be carried out laparoscopically . Laparoscopic cholecystectomy is fast becoming the treatment of choice for symptomatic In some centres the procedure is
PRIMARY OMENTAL TORSION
extended to patients with acute chole~ystitis.~ Laparoscopic appendicectomy is a relatively simple procedure, and is possible even in cases with severe inflammation. Laparoscopic repair of perforated duodenal ulcers has also been reported.6 Laparoscopy avoids the surgical trauma inherent in a laparotomy. There is less pain, less scarring and a shorter convalescence. It is likely that the approach to patients with acute abdominal pain will soon undergo fundamental changes, with laparoscopic surgery playing an increasing role in their diagnosis and treatment. Torsion of the omentum is a rare cause of acute abdominal pain.’ Patients usually present with acute onset of right lower quadrant pain with signs of peritoneal irritation. The clinical features may closely mimic acute appendicitis. The diagnosis is made at operation, where a moderate amount of serosanguineous peritoneal exudate and a twisted, infarcted piece of omentum is found.’ The recommended treatment is resection of the torted omenturn. The diagnosis is also easily made through the laparoscope. Dissection of the torted omentum and ligation of the pedicle using an Endoloop suture is safely accomplished by a surgeon skilled in laparoscopic surgery. Removal of the rather bulky infarcted omentum posed a technical problem. In this case the omentum had to be cut up into small pieces and removed piecemeal through the laparoscopic trocar. The procedure is tedious and took up more than half of the operating time. A myoma morcellator, designed for laparoscopic removal of uterine myoma, has a mechanism for resecting large punches from the instrument. It would have been suitable in this case. An alternative would be to make a mini-laparotomy
40 I
incision to extract the mass. A mechanisni of fragmenting resected tissue and removing it through the trocar sheath without contaminating the abdominal cavity is one of the problems that need to be solved before laparoscopic techniques can be applied to resectional surgery for intra-abdominal turnours.
Acknowledgement The authors acknowledge the financial support of Ethicon for reproduction of the colour figures.
References 1. PATERSON-BROWN S., ECKERSLEY J. R. T., SIMA. J. W. & DUDLEY H. A. F. (1986) Laparoscopy as an adjunct to decision making in the ‘acute abdomen’. Br. J . Surg. 73, 1022-4.
2. THESOUTHERN SURGEONS CLUB(1991) A prospective analysis of 1518 laparoscopic cholecystectomies. N . Engl. J . Med. 324, 1073-8. 3. NATHANSON L. K., SHIM1 S. & CUSHERl A. (1991) Laparoscopic cholecystectomy: The Dundee technique. Br. J . Surg. 78, 163-6. 4. FLOWERS1. L., BAlLkY R. w., SCOVILL W. A. & ZUCKERK. A. (1991) The Baltimore experience with laparoscopic management of acute cholecystitis, Am. J . Surg. 161, 388-92. 5 . GOTZF., PIER A. & BACHER C. (1990) Modified laparoscopic appendicectomy in surgery. A report of 388 operations. Surg. Endosc. 4, 6-9. 6. MOURETP., FRANCOIS Y . , VICNALJ . , BARTHX. & LOMBARD-PLATET R. (1 990) Laparoscopic treatment of perforated peptic ulcer. B r . J . Surg. 77, 1006. R. A . & SIMOES A. Primary idiopathic tor7 . MAINZER sion of the omentum. Arch. Surg. 88, 974-83. 8 . ADAMS J. T. (1973) Primary torsion of the omentum. Am. J . Surg. 126, 102-5.
