Omental torsion is a benign rare cause of acute abdomen, easily misdiagnosed as acute appendicitis, acute cholecystitis or diverticulitis. It is defined as axial twisting along the long axis of the omentum to such an extent that its vascularity is compromised. It most frequently affects the right side because the right side of the omentum is longer than the left side, more mobile and less richly vascularized with poor collateralization [
12,
13]. However, in this case, we found a complete torsion of the greater omentum with necrosis secondary to incarceration in a bilateral inguinal hernia, more evident on the left side. The predisposing factors identified in this case were sex (more frequent in males), a large pedicle and history of untreated inguinal hernia. Given the few clinical signs, the preoperative diagnosis was largely based on radiological findings. CT findings of greater omental torsion include a well circumscribed, oval, or cake-like fatty mass with heterogeneous attenuation, containing strands of soft tissue attenuation [
12] and particularly the presence of concentric linear strands (the “whirl sign”). Of notice, the whirl sign may not be as apparent if the axis of rotation is not perpendicular to the transverse scanning plane [
14]. Although a CT scan is helpful in diagnosing torsion of the omentum and may prevent an unnecessary surgery, the extension of omental torsion may not be clearly visualized through this technique, rendering close vigilance of clinical resolution/deterioration. Segmental omental torsion is usually a benign and self-limiting disease [
15], capable of evolving to resolution within 2 weeks with conservative measures. This fact was taken into consideration since the patient experienced no clinical signs of deterioration in the emergency service. The treatment of complete torsion of the greater omentum with secondary necrosis is usually surgical [
8]. In this case, a laparoscopic approach should be considered because it is less invasive and associated with lower morbidity. Moreover, when preoperative diagnosis is not clear by imaging techniques, laparoscopy is useful for both diagnosis and treatment [
13,
16]. The criticism to this approach is the surgical treatment that was used for the treatment of the hernias, since laparoscopic repair of incarcerated, non-reducible groin hernias has to be done urgently and can be performed with an endoscopic technique, as advised by the European Association for Endoscopic Surgery [
17]. However, a surgeon should not endanger the patient's life. In this perspective, there is controversy regarding the laparoscopic approach to large incarcerated inguinal hernias.
The combination of imaging techniques and minimally invasive surgery were helpful in making a correct diagnosis and avoiding a more invasive surgical approach such as laparotomy.