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Fat Necrosis of the omentum

Dr. Hema Warrier MD, DGO   Co-operative Hospital, Palakkad.

TOGS, Vol 2 No3,April 2006.

 

Ms.X , a 45 year old patient, presented with a 20 weeks size fibroid . She was morbidly obese ,weighing about 90 kg. She had also undergone 2 previous LSCS. She wanted laparoscopic hysterectomy.

Laparoscopic Assisted Vaginal Hysterectomy was done for the patient. The surgery was difficult, considering the size of the fibroid and the adhesions caused as a result of 2 previous surgeries. The primary trocar was passed through an intra-umbilical incision. The omentum was seen to hang like curtains as soon as the scope was put in. After sufficient adhesiolysis, LAVH was done successfully.

However, post-operatively, the patient had non-specific abdominal symptoms. She did not have vomiting and had passed flatus, but on the whole she was not comfortable. A plain X-ray abdomen did not show multiple fluid levels , putting at rest, any thought of serious obstruction. Ultrasonography showed normal peristalsis and absence of significant fluid in the abdomen. However, after five days, she started passing green discharge vaginally. She did not have any pain, or abdominal distension. As it did not abate, in view of this unusual finding, it was decided to open the patient.

At laparotomy, on the 7th post-operative day, the omentum was seen to have linear focal areas of necrosis. An extensive search through a midline abdominal incision did not reveal any perforation in the intestine whatsoever. Histopathology showed fat-necrosis of the omentum.

A retrospective analysis of the surgery was done. Robie’s grasper, a rotating bipolar cautery was used to cauterize the pedicles. Ordinarily, a bipolar cautery allows current to pass through its prongs only when they are in contact with the tissue. The current is generated only at the level of cauterization. Electric current does not arc to the surrounding tissues as is wont to happen with the use of unipolar current. When unipolar current is used, the electrical circuit is completed when the current passes from the point of cautery to the point where the plate is kept under the skin of the patient through the tissues in between. As a result the high electrical current generated arcs and may pass to adjacent tissues inadvertently. In the case described, the bipolar cautery used may have had leaks somewhere along it’s shaft, allowing electric current to pass through it. The omentum being in touch with the shaft got heated up resulting in necrosis.

To test the fact, a wet mop was kept on the table, and the shafts of all the bipolar instruments in the hospital were placed on it one by one with current being allowed to pass through the prongs on the instrument. It was seen that while the mop did not get heated up when other bipolar graspers where placed on it, it did get heated when the Robie’s grasper was placed on it along it’s shaft.

Conclusion: Retrospectively it is the author’s opinion, that in such cases, where the only symptom was vaginal discharge, laparotomy could be averted. Conservative management could be done, laparotomy being kept as a reserve procedure for a later date, if and when the patient develops any serious abdominal problem. Finally, although a good carpenter does not blame his instruments, a good endoscopic surgeon should be aware of instrument-related problems for prompt detection and management of surgical problems.

 

 



 

 

 

 

 

 

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