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Spiderweb Omentum: A Rare Cause of Small Bowel Obstruction

The patient is a 27-year-old healthy female, who presented to the ED with complaints of abdominal pain and bloating for four days as well as multiple episodes of bilious vomiting persisting for two days. Her initial workup consisted of abdominal X-rays, which revealed dilated small bowel loops on the left side of the abdomen. Vital signs and laboratory tests were within normal limits. She then underwent a CT scan with oral and intravenous contrast, which showed numerous dilated loops of small bowel in the left abdomen containing fecalized contents and a likely transition point in the mid-abdomen (Fig. 1). The patient’s history, physical exam, and imaging were consistent with the diagnosis of a small bowel obstruction (SBO). Pertinent past surgical history consisted of a diagnostic laparoscopy with biopsies of endometriosis implants; as such, her obstruction was preoperatively presumed to be due to intraabdominal adhesions. A nasogastric tube was placed for gastric decompression, and a large amount of bilious fluid was evacuated. Despite this, the patient continued to have projectile bilious emesis and increasing abdominal pain. Due to symptom severity and imaging suggestive of a transition point, she was taken to the operating room for an exploratory laparotomy. Upon entering the abdomen, multiple loops of distended small bowel were immediately encountered. The terminal ileum was identified and found to be decompressed. We followed this proximally until the transition point was identified. At this point, the omentum was found to be extremely thin with nearly complete adipose atrophy. It did, however, contain robust vessels creating a spiderweb-like pattern with large and small openings between the vessels (Fig. 2). The small bowel was found to be coursing through several of these openings. Multiple bands of omental vessels had a constricting effect on the small bowel, resulting in the obstruction. After carefully untangling the omentum from the small bowel, the omentum was divided within 5 cm from its origin at the transverse colon in order to prevent future similar obstructions. SBO is one of the most common causes of admission to surgical services, accounting for approximately one in six emergency admissions. The most common cause of SBO is adhesions from prior surgery (approximately 75%).1 Internal herniation is a less common cause of SBO, with incidence ranging from 0.6 to 5.8 per cent.2 The herniation can be paraduodenal (30–53%), transmesenteric (5–10%), due to Winslow’s foramen (8%), paracecal (6%), involve the sigmoid colon (5%) or broad ligament (4–7%), or, as in this patient, can be due to an omental defect (1–4%).3 Most omental hernias have a congenital origin that results in a slit-like opening in the greater omentum.4 These can be diagnosed radiographically