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RARE CASE OF SIMULTANEOUS FIBROID &
OMENTAL TORSIONS PRESENTING AS
ACUTE ABDOMEN
DR. TALAL AHMAD, SENIOR SPECIALIST SURGEON
DR. IBRAHIM IRSHAID, CONSULTANT GYNAECOLOGIST
DR. MOHAMAD AL-GAILANI, CHIEF OF SURGERY
THE 3RD AHH SCIENTIFIC CONFERENCE
23/2/2024
CLINICAL PRESENTATION
 39-YEAR-OLD EGYPTIAN FEMALE
 PRESENTED TO ER WITH ONE DAY HISTORY OF ACUTE RIGHT SIDED &
RIGHT ILIAC FOSSA ABDOMINAL PAIN AND ANOREXIA.
 NO NAUSEA, NO VOMITING. MENSTRUAL PERIODS REGULAR.
PREVIOUS LAPAROSCOPIC CHOLECYSTECTOMY, HAS IUCD.
 O/E:
 T 36.3, PR 60, BP 106/71
 RIGHT ILIAC FOSSA TENDERNESS & REBOUND TENDERNESS ON DEEP
PALPATION. NO MASSES FELT.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
2
INVESTIGATIONS
 HB 11.8, WCC 3.63, PLAT 185, CRP 19.5, LFT NORMAL, AMYLASE
& LIPASE BOTH NORMAL
 BHCG NEGATIVE
 US: RIGHT ILIAC FOSSA INFLAMMATORY PROCESS WITH
POSSIBILITY OF APPENDICITIS. RIGHT PELVIC MASS LIKELY
OVARIAN TERATOMA.
 CT: RIGHT OVARIAN MASS WITH ADJACENT VASCULAR
MALFORMATION, IUCD IN SITU & POSSIBLE EARLY BORDERLINE
RETROCAECAL APPENDICITIS.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
3
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
CT SCAN
4
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
IUCD IN SITU
PELVIC MASS
5
EMERGENCY DIAGNOSTIC
LAPAROSCOPY
SUSPECTED ACUTE APPENDICITIS
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
6
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
EMERGENCY LAPAROSCOPY
7
OPERATIVE FINDINGS
OMENTAL
TORSION
EMERGENCY LAPAROSCOPY
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
8
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
EMERGENCY LAPAROSCOPY
9
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
TORSION
SUBSEROSAL
FIBROID
OMENTAL
TORSION
SITE OF
ADHESION
EMERGENCY LAPAROSCOPY
10
OPERATIVE PROCEDURE
 LAPAROSCOPIC OMENTECTOMY
 LAPAROSCOPIC MYOMECTOMY
 PFANNENSTIEL INCISION TO DELIVER SPECIMEN
 DECISION TO LEAVE THE NORMAL APPENDIX
 NO JUSTIFICATION FOR APPENDECTOMY
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
11
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
12
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
SUBSEROSAL FIBROID TORSION
13
OMENTAL TORSION
 Torsion of the greater omentum is a rare disease, and it
occurs in <0.4% of the population
 Since the first description of omental torsion by Eitel in 1899,
only a few hundred cases have been reported.
 It is rarely diagnosed preoperatively therefore knowledge of
this entity is important because it mimics common causes of
the acute abdomen.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
14
OMENTAL TORSION:
INCIDENCE
 It is an uncommon cause of acute abdominal pain
 It accounts for approximately 1.1% of all acute abdominal
cases.
 Accounting for less than 4 in 1000 cases of acute
appendicitis.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
15
OMENTAL TORSION:
PATHOPHYSIOLOGY
 Omental torsion usually occurs in adults.
 Sudden onset of pain and signs of peritoneal irritation.
 The condition may be associated with nausea, vomiting or low-
grade fever.
 An abdominal mass may be palpable.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
16
OMENTAL TORSION:
ETIOLOGY
 Torsion of the omentum may be either 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.
 Secondary torsion is more common and is associated with
pre-existing abdominal pathology including:
 Cysts, tumours, foci of intra-abdominal inflammation,
postsurgical wounds or scarring and hernial sacs
(commonest).
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
17
OMENTAL TORSION:
DIFFERENTIAL DIAGNOSIS
 The presentation with acute abdominal pain, tenderness +/-
rebound tenderness is often mistaken for:
1. Acute appendicitis
2. Acute cholecystitis
3. Twisted ovarian cysts
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
18
OMENTAL TORSION:
DIAGNOSIS & TREATMENT
 Ultra Sonography (US) and Computed Tomography (CT) may
show a characteristic appearance of twisted omentum.
 Treatment consists of resection of the affected portion of the
omentum.
 Any disease process associated with secondary torsion
should be dealt with.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
19
FIBROID TORSION
 Acute abdominal pain caused by torsion of a pedunculated
subserosal leiomyoma (Fibroid) is rare.
 It may be challenging to diagnose preoperatively.
 Failure of diagnosis can lead to ischemia, necrosis and
subsequent peritonitis which may cause significant
morbidity.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
20
FIBROID TORSION:
DIAGNOSIS & TREATMENT
 Ultrasound is the most widely used imaging modality.
 Torsion should be suspected if color Doppler demonstrated a
twisted pedicle or decreased vascular supply.
 The CT findings may include poor contrast enhancement and
congestion of the vascular pedicle at the site of torsion
 Torsion should be recognized as a surgical emergency and
once suspected, early surgical intervention should be
considered.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS
PRESENTING AS ACUTE ABDOMEN
21
HISTOPATHOLOGY & POSTOPERATIVE
COURSE
 HISTOPATHOLOGY: BENIGN NEOPLASM LEIOMYOMA
CONSISTANT WITH FIBROID UTERUS WITH ATTACHED
MARKEDLY CONGESTED MESENTRY.
 UNEVENTFUL POSTOPERATIVE RECOVERY.
 PATIENT DISCHARGED WELL FOLLOWING DAY.
 TELEPHONE FOLLOW UP ON 16/1/2024 PATIENT WELL.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL
TORSIONS PRESENTING AS ACUTE ABDOMEN
22
CONCLUSION
 Rare case of simultaneous Fibroid & Omental Torsions (Both
being rare conditions themselves) presenting as Acute
Abdomen.
 The diagnosis was established upon Laparoscopy.
 Treated by excision of both laparoscopically.
 Patient made an uneventful postoperative recovery and was
discharged well the following day.
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN
23
THANK YOU
RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL
TORSIONS PRESENTING AS ACUTE ABDOMEN
THE THIRD SCIENTIFIC CONFERENCE OF AHH, 23RD OF FEBRUARY 2024
25
DR. MOHAMAD AL-GAILANI FRCS CHIEF OF SURGERY AL HAMMADI HOSPITAL, RIYADH,
KSA

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A rare case of Omental & Fibroid Torsion

  • 1. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN DR. TALAL AHMAD, SENIOR SPECIALIST SURGEON DR. IBRAHIM IRSHAID, CONSULTANT GYNAECOLOGIST DR. MOHAMAD AL-GAILANI, CHIEF OF SURGERY THE 3RD AHH SCIENTIFIC CONFERENCE 23/2/2024
  • 2. CLINICAL PRESENTATION  39-YEAR-OLD EGYPTIAN FEMALE  PRESENTED TO ER WITH ONE DAY HISTORY OF ACUTE RIGHT SIDED & RIGHT ILIAC FOSSA ABDOMINAL PAIN AND ANOREXIA.  NO NAUSEA, NO VOMITING. MENSTRUAL PERIODS REGULAR. PREVIOUS LAPAROSCOPIC CHOLECYSTECTOMY, HAS IUCD.  O/E:  T 36.3, PR 60, BP 106/71  RIGHT ILIAC FOSSA TENDERNESS & REBOUND TENDERNESS ON DEEP PALPATION. NO MASSES FELT. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 2
  • 3. INVESTIGATIONS  HB 11.8, WCC 3.63, PLAT 185, CRP 19.5, LFT NORMAL, AMYLASE & LIPASE BOTH NORMAL  BHCG NEGATIVE  US: RIGHT ILIAC FOSSA INFLAMMATORY PROCESS WITH POSSIBILITY OF APPENDICITIS. RIGHT PELVIC MASS LIKELY OVARIAN TERATOMA.  CT: RIGHT OVARIAN MASS WITH ADJACENT VASCULAR MALFORMATION, IUCD IN SITU & POSSIBLE EARLY BORDERLINE RETROCAECAL APPENDICITIS. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 3
  • 4. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN CT SCAN 4
  • 5. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN IUCD IN SITU PELVIC MASS 5
  • 6. EMERGENCY DIAGNOSTIC LAPAROSCOPY SUSPECTED ACUTE APPENDICITIS RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 6
  • 7. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN EMERGENCY LAPAROSCOPY 7 OPERATIVE FINDINGS
  • 8. OMENTAL TORSION EMERGENCY LAPAROSCOPY RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 8
  • 9. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN EMERGENCY LAPAROSCOPY 9
  • 10. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN TORSION SUBSEROSAL FIBROID OMENTAL TORSION SITE OF ADHESION EMERGENCY LAPAROSCOPY 10
  • 11. OPERATIVE PROCEDURE  LAPAROSCOPIC OMENTECTOMY  LAPAROSCOPIC MYOMECTOMY  PFANNENSTIEL INCISION TO DELIVER SPECIMEN  DECISION TO LEAVE THE NORMAL APPENDIX  NO JUSTIFICATION FOR APPENDECTOMY RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 11
  • 12. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 12
  • 13. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN SUBSEROSAL FIBROID TORSION 13
  • 14. OMENTAL TORSION  Torsion of the greater omentum is a rare disease, and it occurs in <0.4% of the population  Since the first description of omental torsion by Eitel in 1899, only a few hundred cases have been reported.  It is rarely diagnosed preoperatively therefore knowledge of this entity is important because it mimics common causes of the acute abdomen. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 14
  • 15. OMENTAL TORSION: INCIDENCE  It is an uncommon cause of acute abdominal pain  It accounts for approximately 1.1% of all acute abdominal cases.  Accounting for less than 4 in 1000 cases of acute appendicitis. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 15
  • 16. OMENTAL TORSION: PATHOPHYSIOLOGY  Omental torsion usually occurs in adults.  Sudden onset of pain and signs of peritoneal irritation.  The condition may be associated with nausea, vomiting or low- grade fever.  An abdominal mass may be palpable. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 16
  • 17. OMENTAL TORSION: ETIOLOGY  Torsion of the omentum may be either 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.  Secondary torsion is more common and is associated with pre-existing abdominal pathology including:  Cysts, tumours, foci of intra-abdominal inflammation, postsurgical wounds or scarring and hernial sacs (commonest). RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 17
  • 18. OMENTAL TORSION: DIFFERENTIAL DIAGNOSIS  The presentation with acute abdominal pain, tenderness +/- rebound tenderness is often mistaken for: 1. Acute appendicitis 2. Acute cholecystitis 3. Twisted ovarian cysts RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 18
  • 19. OMENTAL TORSION: DIAGNOSIS & TREATMENT  Ultra Sonography (US) and Computed Tomography (CT) may show a characteristic appearance of twisted omentum.  Treatment consists of resection of the affected portion of the omentum.  Any disease process associated with secondary torsion should be dealt with. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 19
  • 20. FIBROID TORSION  Acute abdominal pain caused by torsion of a pedunculated subserosal leiomyoma (Fibroid) is rare.  It may be challenging to diagnose preoperatively.  Failure of diagnosis can lead to ischemia, necrosis and subsequent peritonitis which may cause significant morbidity. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 20
  • 21. FIBROID TORSION: DIAGNOSIS & TREATMENT  Ultrasound is the most widely used imaging modality.  Torsion should be suspected if color Doppler demonstrated a twisted pedicle or decreased vascular supply.  The CT findings may include poor contrast enhancement and congestion of the vascular pedicle at the site of torsion  Torsion should be recognized as a surgical emergency and once suspected, early surgical intervention should be considered. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 21
  • 22. HISTOPATHOLOGY & POSTOPERATIVE COURSE  HISTOPATHOLOGY: BENIGN NEOPLASM LEIOMYOMA CONSISTANT WITH FIBROID UTERUS WITH ATTACHED MARKEDLY CONGESTED MESENTRY.  UNEVENTFUL POSTOPERATIVE RECOVERY.  PATIENT DISCHARGED WELL FOLLOWING DAY.  TELEPHONE FOLLOW UP ON 16/1/2024 PATIENT WELL. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 22
  • 23. CONCLUSION  Rare case of simultaneous Fibroid & Omental Torsions (Both being rare conditions themselves) presenting as Acute Abdomen.  The diagnosis was established upon Laparoscopy.  Treated by excision of both laparoscopically.  Patient made an uneventful postoperative recovery and was discharged well the following day. RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN 23
  • 24. THANK YOU RARE CASE OF SIMULTANEOUS FIBROID & OMENTAL TORSIONS PRESENTING AS ACUTE ABDOMEN THE THIRD SCIENTIFIC CONFERENCE OF AHH, 23RD OF FEBRUARY 2024
  • 25. 25 DR. MOHAMAD AL-GAILANI FRCS CHIEF OF SURGERY AL HAMMADI HOSPITAL, RIYADH, KSA