The patient is a 70-year-old woman who presented to the emergency department with acute-onset abdominal pain throughout her epigastrium for approximately 2 hours. The pain was constant and severe, extending across the bilateral upper quadrants. She had experienced pain like this once before within the past year which spontaneously resolved within 4 hours. The patient’s last oral intake was an hour before onset of the pain, and she denied any fevers, chills, nausea or vomiting. She was an otherwise healthy woman who took no medications and had no abdominal surgical history. On admission, vital signs were normal, with a heart rate in the 70’s. Although initially reported as tender by emergency department staff, after pain medication and intravenous fluids, examination by the surgical team revealed resolution of pain and a soft, non-tender abdomen. Lactic acid on presentation was 5.0 mmol/l, and her white blood cell count was 9600 µl−1, with the remainder of her laboratory values within normal limits. She underwent a computed tomography scan which demonstrated herniation of her cecum through the FoW, causing compression of the inferior vena cava (IVC) and portal vein (Figures –).\nThe patient was taken to the operating room for a laparotomy. On exploration, the cecum was found to be free-floating with significant mobility of the right colon mesentery. It appeared to have spontaneously reduced. A right hemicolectomy was performed, resecting all the redundant right-sided colon and creating a primary side-to-side functional end-to-end anastomosis.\nPost-operatively, the patient’s presenting pain had resolved, she tolerated rapid advancement of diet, and was discharged once bowel function was regained. She was seen in the outpatient clinic at 2 weeks post-operatively and was doing well without recurrence of symptoms.
An 80-year-old female with past medical history of Crohn’s disease (diagnosed in 1998 and managed with Adalimumab) and no prior abdominal surgical history who presented with 1-day history of severe epigastric pain associated with nausea and emesis. Her last colonoscopy was 3 years ago (unremarkable), and last Crohn’s flare was a 1 year beforehand. On examination, patient’s abdomen was soft with severe epigastric tenderness and an appreciable bulge. Labs showed normal lactate (1.1) but mild leukocytosis of 12.5 and no other gross lab abnormalities. Patient underwent computed tomography (CT) scan of abdomen and pelvis which showed a transverse colon herniating through the FOW and causing a closed-loop obstruction (–). Patient was immediately decompressed with a nasogastric tube and was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, the transverse colon was noted to have herniated through the FOW into the lesser sac. The incarcerated transverse colon appeared immensely dilated and hyperemic. With careful traction and gentle counter pressure, the transverse colon was completely reduced from the FOW back into the abdominal cavity. On inspection after reduction, the small and large bowel appeared grossly viable and well-vascularized along with adequate peristalsis. The FOW was closed with 2-0 ethibond running suture by suturing the peritoneum adjacent to the portal triad down to the retroperitoneum just lateral to the inferior vena cava. The patient tolerated the procedure very well and brought to the recovery room in stable condition. Postoperatively, the patient did very well. On postoperative Day 1, the patient was discharged home. Subsequently, the patient was seen in the office on postoperative follow-up Day 7 and was found to be doing well with no complaints.