Treatment of idiopathic segmental infarction of the greater omentum in children via transumbilical single-port laparoscopy
Highlight box
Key findings
• This study reports 8 pediatric cases of idiopathic segmental infarction of the greater omentum (ISIGO) treated via transumbilical single-port laparoscopy.
• All patients achieved successful resection with no conversions to open surgery, a mean operative time of 90.6±8.6 minutes, and a mean hospital stay of 4.88±1.55 days.
• No complications (intestinal obstruction or incisional hernia) occurred during a mean follow-up of 21 months.
• Seven of the eight patients were overweight or obese, supporting obesity as a major risk factor.
What is known and what is new?
• ISIGO represents a rare etiology of acute abdominal pain in pediatric patients and is frequently misdiagnosed as appendicitis. Obesity has been identified as a significant risk factor.
• This study demonstrates that transumbilical single-port laparoscopy is a safe, effective, and feasible surgical approach for pediatric ISIGO.
What is the implication, and what should change now?
• ISIGO should be considered as a differential diagnosis in obese pediatric patients who present with right-sided abdominal pain and prolonged symptoms.
• Transumbilical single-port laparoscopy can serve as another alternative approach for the treatment of pediatric ISIGO.
• Larger multicenter studies with extended follow-up are necessary to further validate these findings.
Introduction
Segmental infarction of the greater omentum (SIGO) is a rare acute abdominal disease in children, resulting from acute circulatory disorders of the greater omentum. According to the literature, SIGO occurs more frequently in adults, with only 15% of cases reported in children (1). SIGO can be classified as either idiopathic or secondary based on etiology (2). Idiopathic segmental infarction of the greater omentum (ISIGO) is primarily associated with obesity, abnormal fat accumulation, vascular abnormalities, and sudden changes in body position, with obesity identified as the predominant factor. Secondary SIGO is commonly linked to trauma, abdominal lesions, or surgical adhesions. Few reports have addressed pediatric ISIGO. This study presents a preliminary summary of treatment experiences with pediatric ISIGO, based on cases managed at this institution from September 2023 to September 2025. We present this article in accordance with the STROBE and SURGE reporting checklists (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0430/rc).
Methods
Clinical information
A retrospective analysis of the clinical information (Tables 1,2) of eight children with ISIGO at Quanzhou Maternal and Children’s Hospital (Quanzhou Children’s Hospital) from September 2023 to September 2025 was conducted. The cohort included one girl and seven boys, aged 7 to 11 years (mean age 9.1±1.2 years). The body mass index (BMI) of these pediatric patients ranged from 18.35 to 24.00 kg/m2 (mean BMI 21.95±2.11 kg/m2). Nutritional risk assessment revealed five cases of obesity, two cases of overweight, and one case of normal weight. The initial symptom was abdominal pain for 2–4 days, with no other accompanying symptoms. Blood tests revealed elevated white blood cell count in three patients, an increased percentage of neutrophils in six patients, and elevated C-reactive protein (CRP) in eight patients. Preoperative ultrasound showed an abdominal hyperechoic mass without obvious blood flow signals (Figure 1A), indicating the possibility of infarction of the omentum. Computed tomography (CT) identified an abdominal mixed-density shadow mass without significant enhancement (Figure 1B), indicating the presence of infarction of the omentum. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Ethics Committee of Quanzhou Maternal and Children’s Hospital (Quanzhou Children’s Hospital) (No. 121 of 2025). Informed consent was obtained from the parents of the participants.
Table 1
| Case | Sex | Age (years) | BMI (kg/m2) | Abdominal pain site | Duration of symptoms (days) | White blood cell count (×109/L) | Neutrophils (%) | CRP (mg/L) |
|---|---|---|---|---|---|---|---|---|
| 1 | Girl | 8 | 21.20 (obese) | Right | 4 | 10.6 | 58.8 | 13.08 |
| 2 | Boy | 9 | 23.06 (obese) | Right | 4 | 12.9 | 70.5 | 9.73 |
| 3 | Boy | 9 | 18.35 (normal) | Right middle | 4 | 9.3 | 79.0 | 35.10 |
| 4 | Boy | 9 | 23.67 (obese) | Right upper | 3 | 8.9 | 70.6 | 56.74 |
| 5 | Boy | 11 | 24.00 (obese) | Right upper | 4 | 14.2 | 70.1 | 69.35 |
| 6 | Boy | 10 | 22.12 (overweight) | Right middle | 3 | 13.2 | 71.1 | 15.20 |
| 7 | Boy | 7 | 23.70 (obese) | Right upper | 4 | 9.9 | 68.8 | 39.80 |
| 8 | Boy | 10 | 19.48 (overweight) | Right | 2 | 13.9 | 77.8 | 70.32 |
BMI, body mass index; CRP, C-reactive protein; ISIGO, idiopathic segmental infarction of the greater omentum.
Table 2
| Case | Ascites condition | Size of omental mass (cm3) | Intraoperative finding of greater omentum | Operation time (min) | Hospitalization (days) | Follow-up time (months) |
|---|---|---|---|---|---|---|
| 1 | Bloody | 5.0×2.5×1.5 | Torsion and thrombosis | 85 | 3 | 3 |
| 2 | Bloody | 8.5×7.5×2.0 | Torsion and thrombosis | 80 | 4 | 6 |
| 3 | Yellow | 4.0×2.0×1.5 | Thrombosis without torsion | 95 | 4 | 14 |
| 4 | Bloody | 6.5×3.0×2.0 | Torsion and thrombosis | 85 | 4 | 20 |
| 5 | Yellow | 7.0×4.5×2.0 | Thrombosis without torsion | 105 | 7 | 22 |
| 6 | Bloody | 6.0×3.5×2.5 | Torsion and thrombosis | 100 | 4 | 24 |
| 7 | Bloody | 6.5×5.0×1.5 | Torsion and thrombosis | 85 | 7 | 25 |
| 8 | Bloody | 7.5×4.0×1.5 | Torsion and thrombosis | 90 | 6 | 26 |
ISIGO, idiopathic segmental infarction of the greater omentum.
Treatment course
All patients underwent transumbilical single-port laparoscopic surgery. Following induction of general anesthesia with a laryngeal mask, patients were positioned supine. A longitudinal incision was made along the navel, extending 0.5 cm up and down the umbilical ring, and a disposable multichannel single-hole laparoscopic puncture device was inserted (Figure 2). The pneumoperitoneum was maintained at 10–12 mmHg during surgery.
Intraoperatively, yellow or bloody ascites was identified, and an infarcted mass of the greater omentum adherent to the abdominal wall was observed in the right abdomen. After adhesiolysis, the root of the infarcted omental mass was assessed for signs of torsion and thrombosis (Figure 3A-3D). The gallbladder, appendix, ovary (in the female patient), small intestine, and pelvic cavity were subsequently explored. After confirming the absence of additional intra-abdominal pathologies, the boundaries of the infarcted omentum were delineated. The infarcted omentum was then completely resected via an ultrasonic scalpel, placed in a specimen retrieval bag, and extracted through the umbilical incision. The abdominal cavity was irrigated and cleared of fluid before closure (Figure 4A).
Postoperatively, the patient was given intravenous therapy for hemostasis and prophylactic antibiotics. Upon recovery from anesthesia, the patient could eat. On the second day, postoperatively abdominal ultrasound and blood tests, including complete blood count and CRP, were conducted. As blood test results were within normal limits and no ascites was detected, the patient was discharged from the hospital.
Statistical analysis
The statistical analysis was performed with SPSS Statistics version 24 (IBM Corp., Armonk, NY, USA). The threshold for statistical significance was defined as P<0.05.
Results
All patients underwent transumbilical single-port laparoscopic surgery, with no conversions to open surgery. The operation time ranged from 80 to 105 minutes, with a mean of 90.6±8.6 minutes. Intraoperatively, omental torsion with thrombosis was identified in six patients, whereas thrombosis without torsion was observed in two patients. Hospitalization lasted between 3 and 7 days, with a mean duration of 4.88±1.55 days. Postoperative pathological examination revealed fibrous adipose tissue consistent with infarct changes, congestion, bleeding, and extensive acute and chronic inflammatory cell infiltration in the stroma (Figure 4B). No complications, including intestinal obstruction or incisional hernia, were observed during an average follow-up period of 21 months.
Discussion
Few reports in the literature address SIGO in children, primarily due to its low incidence. The main clinical symptom of SIGO is abdominal pain, and the specific location of abdominal pain is determined by site of torsion and infarction of the greater omentum. Anatomically, the greater omentum is an apron-like structure formed by the peritoneum and is rich in fat, blood vessels, and lymphatic vessels. It extends from the greater curvature of the stomach and drapes over the anterior aspect of the intestines. The greater omentum is attached superiorly to the greater curvature of the stomach and the transverse colon, and the part that descends from the transverse colon is free and can move within the abdominal cavity. The right greater omentum is longer, heavier, and freer than the left, which makes it more prone to torsion, causing greater omentum infarction because of twisting and occlusion of the internal arteries and venous thrombosis (3,4). Therefore, the primary initial symptom of SIGO in children is sudden right-sided abdominal pain without radiating pain, which can worsen with time or changes in position. All eight patients in this study presented with abdominal pain localized to the right abdomen, which correlated to the right greater omentum.
SIGO is classified into ISIGO and SIGO based on etiology. SIGO is frequently associated with trauma, abdominal lesions such as tumors, cysts, or inguinal hernias, prior abdominal surgery, and surgical adhesions (5,6). The etiology of ISIGO remains unclear, but potential contributing factors include obesity, abnormal fat accumulation, vascular abnormalities, and sudden changes in body position. Among these factors, obesity is the main risk factor (7). In obese pediatric patients, the accumulation of perivascular fat in the omentum reduces the blood supply to the developing omentum, which leads to relative ischemia. Besides, the increased weight of the omentum may lead to torsion or traction towards its distal parts. Previous reports (8) have shown that obesity can cause venous thrombosis. In obese individuals, increased blood viscosity can promote blood clot formation and subsequent venous stasis and thrombus development. Adipose tissue may contribute to enhanced blood coagulation by producing procoagulant proteins such as plasminogen activator inhibitor-1 or by influencing the hepatic synthesis of coagulation factors, resulting in systemic hypercoagulability. Consequently, in certain cases of omental infarction, only a thrombus is identified during surgery without evidence of omental torsion. In the present study, no secondary causes were identified among the eight children, leading to a diagnosis of ISIGO. Six patients exhibited greater omentum torsion, while two patients presented with only vascular thrombosis of the greater omentum. Notably, seven of the eight children had a BMI consistent with obesity or overweight, suggesting that elevated BMI is a risk factor for ISIGO. Patient 3 exhibited a normal BMI but had a documented history of intense physical activity. Among the eight pediatric patients, the male-to-female ratio was 7:1, close to that reported in the literature. This distribution may be associated with the higher obesity rate observed in boys, who tend to be more physically active than girls, potentially increasing the risk of greater omentum torsion due to sudden changes in body position (9,10).
The symptoms and signs of SIGO are similar to those of acute appendicitis, acute cholecystitis, ovarian torsion, Meckel diverticulitis, and other acute abdominal diseases, but the course of SIGO is longer. This extended duration is attributed to the generally diffuse nature of abdominal pain in SIGO, which, in the early stages, results primarily from blood flow disorder in the greater omentum and often manifests as mild abdominal pain. Furthermore, most patients present with obesity and significant abdominal adiposity, which complicates the detection of peritonitis and impedes early diagnosis. The nonspecific nature of clinical findings, limited availability of relevant Chinese-language literature, and insufficient clinical experience among physicians further contribute to misdiagnosis and delayed treatment of SIGO (1,11-13). With the accumulation of the clinical experience of pediatric surgeons and improvements in medical examination recognition, the accuracy of the preoperative diagnosis of SIGO continues to improve. In this study, all 8 patients were diagnosed with SIGO prior to surgery, and postoperative pathology confirmed omental infarction, consistent with preoperative assessments. Our preoperative diagnosis of SIGO relied on the presence of right-sided abdominal pain and findings from ultrasound and enhanced abdominal CT examinations.
The characteristic ultrasound feature of SIGO is a hyperechoic mass of the greater omentum adhering to the abdominal wall, with no obvious blood flow signal within the mass. Spiral changes at the root of the mass may be observed when torsion of the greater omentum is present (9,14). On abdominal CT, SIGO mainly presents as a mixed-density abdominal mass with no significant enhancement. Vortex-like structures of blood vessels may be observed when torsion of the greater omentum is present (15,16). ISIGO is a noninfectious disease, but the white blood cell count, neutrophil percentage, and CRP levels may increase to varying degrees. These changes are primarily attributable to acute and chronic inflammatory cell infiltration after greater omentum infarction (17).
The treatment of ISIGO is still controversial. Some reports indicate that ISIGO is a self-limiting disease that can be cured through conservative methods such as fasting, the use of antibiotics, and pain relief. However, the condition requires ongoing evaluation throughout conservative treatment (17,18). If the diagnosis remains unclear, or if symptoms worsen or fail to improve significantly after several days, timely surgical exploration is warranted. There are literature reports (19) of abdominal drainage surgery for abdominal abscesses caused by SIGO. With the popularization of laparoscopic technology, an increasing number of scholars believe that laparoscopic exploration should be performed when SIGO cannot be clearly diagnosed or cannot be distinguished from other acute abdominal conditions such as intra-abdominal abscess and acute appendicitis. Retrospective analyses (20) have demonstrated that surgical intervention for SIGO can reduce hospitalization duration. The literature on pediatric SIGO from 2016 to 2026 was reviewed (Table 3). After excluding cases that did not meet the inclusion criteria, 16 patients were included in the final analysis. Of these, 6 patients received conservative management, while 10 underwent surgical intervention; 2 of the surgical cases followed unsuccessful conservative treatment. Hospital stay duration varied considerably among cases, regardless of treatment modality. This variation may be attributable to the rarity of the disease and differences in treatment experience across hospitals. In this study, eight patients underwent transumbilical single-port laparoscopic surgery. Intraoperative assessment excluded other acute abdominal conditions, such as appendicitis, ovarian torsion, and Meckel diverticulitis. All cases were confirmed as ISIGO. Complete excision of the infarcted omentum was performed, leading to favorable postoperative recovery. No complications were reported during the follow-up period.
Table 3
| Author | Year | Sex | Age (years) | BMI (kg/m2) | Treatment | Hospitalization (days) |
|---|---|---|---|---|---|---|
| Saad Siddiqui | 2016 | Boy | 7 | 17.50 (normal) | Laparotomy | 3 |
| Laxmikant Gupta | 2016 | Boy | 4 | N/A | Conservative | N/A |
| Fawzia Elgharbawy | 2017 | Girl | 7 | Normal | Laparoscopy | 1 |
| Rahaf J Owedah | 2021 | Girl | 7 | N/A | Conservative | 7 |
| Mateusz Kozłowski | 2021 | Girl | 6 | 20.92 (overweight) | Conservative | 7 |
| Federica Bianchi | 2021 | Boy | 12 | 26.60 (overweight) | Conservative | 5 |
| Ali Javidi | 2021 | Boy | 13 | N/A | Laparoscopy | 1 |
| Elena Porras L | 2022 | Boy | 11 | Overweight | Conservative | 4 |
| Kareem Omran | 2022 | Boy | 6 | 22.22 (obese) | Laparoscopy | 2 |
| Yue Wang | 2022 | Girl | 7 | 18.93 (overweight) | Laparoscopy | 7 |
| Maram Nached | 2023 | Boy | 17 | N/A | Laparoscopy† | 2 |
| Ashok Aralihond | 2023 | Boy | Adolescent boy | 24.40 (overweight) | Conservative | 5 |
| David J McCreary | 2025 | Boy | 12 | N/A | Laparoscopy† | N/A |
| Shohei Maekawa | 2025 | Boy (n=2) | 14, 11 | 21.00 (normal), 22.00 (overweight) | Laparoscopy | 4, 5 |
| Salam Melhem | 2026 | Boy | 8 | 21.40 (obese) | Laparoscopy | 1 |
The list of articles included is presented in Appendix 1. †, pediatric patients with failed conservative treatment. BMI, body mass index; N/A, not available.
Current surgical experience and available evidence (17,20) indicate several potential advantages of transumbilical single-port laparoscopic surgery for the treatment of ISIGO: (I) Compared to traditional laparoscopic surgery, it reduces the number of operation ports, minimizes surgical trauma, decreases postoperative pain, accelerates recovery, and results in a more concealed and aesthetically pleasing incision. (II) The greater omentum exhibits considerable mobility. When protecting abdominal organs during umbilical single-port laparoscopy, it is both safe and feasible to use an ultrasonic scalpel to excise the infarcted omentum along its outer boundary or at the root of the twisted segment. (III) The infarcted omental mass is typically large, and the specimen can be easily removed through the umbilical hole with a larger aperture. (IV) Children with ISIGO generally have a higher BMI and a thicker abdominal fat layer. The relatively large aperture of the single-port laparoscope permits direct visualization during suturing, which facilitates precise closure of the incision and decreases the risk of poor wound healing and incisional hernia following surgery.
Several limitations are present in this study. This was a retrospective, single-center study with a small sample size; the surgical method has not been utilized for an extended period, resulting in a limited number of cases and a short follow-up duration. Future research should include comprehensive, multicenter studies with larger sample sizes.
ISIGO in children is a relatively rare acute abdominal disease characterized by right-sided abdominal pain, a prolonged disease course, and minimal accompanying symptoms. Obesity and overweight status have been identified as risk factors for pediatric ISIGO. The combination of preoperative ultrasound and enhanced abdominal CT demonstrates high predictive value for diagnosis. Based on our preliminary treatment experience with a small sample, we believe that transumbilical single-port laparoscopic surgery is safe, effective, and feasible. It can serve as another surgical approach for the treatment of pediatric ISIGO.
Conclusions
This study reports an initial experience with transumbilical single-port laparoscopy in eight children with ISIGO. In selected cases, this technique may serve as an alternative surgical approach for children with ISIGO.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE and SURGE reporting checklists. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0430/rc
Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0430/dss
Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0430/prf
Funding: This work was supported by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0430/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Ethics Committee of Quanzhou Maternal and Children’s Hospital (Quanzhou Children’s Hospital) (No. 121 of 2025). Informed consent was obtained from the parents of the participants.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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