A 67-year-old male with a past medical history of prostate cancer, hypertension and prior open right inguinal hernia repair presented to the emergency department (ED) with sudden onset nausea, vomiting and abdominal pain for 2 h. The abdomen was non-distended and slightly tender in the epigastrium. A clinical diagnosis of pancreatitis was made based on physical examination, history and a mildly elevated lipase and the patient was discharged home with antiemetic medications by the ED providers. The patient presented back to the ED 2 days later with worsening abdominal pain, nausea, vomiting and obstipation. At this time his abdomen was distended and tender to palpation in the epigastrium without peritoneal irritation. Due to his obstructive clinical picture, a CT scan of the abdomen and pelvis with IV contrast () was obtained in the ED. The scan was read as a possible volvulus versus an internal hernia causing small bowel obstruction. A nasogastric tube was placed after he was admitted to the surgical unit with partial resolution of his abdominal tenderness and distention. A barium enema () was performed to rule out an obstructing distal mass, which showed a transition point at the hepatic flexure.\nDue to the clinical picture of a complete bowel obstruction and subsequent imaging findings, an urgent abdominal exploration was performed. A standard supraumbilical midline laparotomy was made and the peritoneal cavity was entered. Distended loops of bowel were encountered, and the right colon was mobilized from some loose attachments to the abdominal wall. The right colon was followed to identify the cecum and terminal ileum. The cecum was identified to be in the lesser sac, herniated through the foramen of Winslow. The cecum was reduced and was determined to be ischemic and nonviable, so a right hemicolectomy was performed with an isoperistaltic ileocolic anastomosis with the transverse colon. The duodenum was Kocherized to expose the retroperitoneum. The foramen of Winslow was closed by approximating the hepatoduodenal ligament to peritoneum overlying the right kidney with a simple interrupted 3–0 polyglyconate suture, adequately obliterating the foramen. The transverse colon was pexy to the anterior abdominal wall using 3–0 polyglyconate suture.\nHis postoperative course was uncomplicated. His intestinal transit was restored on postoperative Day 3. His diet was advanced as tolerated. He was discharged on Day 5 after surgery with good diet tolerance and having adequate bowel function. Pathology was benign.
A male patient, 69-years old was presented in our emergency department complaining of severe abdominal pain. The patient described the pain as paroxysmal cramps, which starts at the lower abdomen then radiate to the epigastrium and to the back. The complaint began approximately 24 h before the admission and was associated with distention and mild nausea. Vomiting, fever or altered bowel habits were not reported. The patient suffers from obesity, arterial hypertension, metabolic syndrome and uncomplicated sigmoid diverticulosis. He underwent a laparoscopic Nissen fundoplication 2 years ago. Few weeks after this operation, he suffered a migrated wrap that was surgically repaired. Clinical examination revealed abdominal tenderness without guarding or rigidity. Intestinal sounds were present but weak. Laboratory tests showed no significant abnormalities.\nIn absence of signs of peritonitis, we decided to proceed with further investigations. Abdominal sonography was hindered by distention. Contrast-enhanced computed tomography (CT) of the abdomen showed a single-intestinal loop, which appeared to be distended and trapped behind the stomach. As the possibility of internal herniation rose, we scheduled the patient for an urgent abdominal exploration.\nThe operative findings confirmed the radiological interpretation. The operator could retract the twisted ascending colon and caecum out of the lesser sac through the foramen of Winslow, only after decompression of the strangulated bowel, via suction of gas and fluid content through a small incision. The initially congested herniated colon regains normal appearance soon. In the absence of permanent ischemic changes, the operator opted for minimal intervention. Without colectomy, the abdomen was temporary closed, with a second-look planned after 24 h, which revealed viable intestine with no signs of intestinal obstruction. The patient stayed in the intensive care unit for 2 days and was discharged at the seventh postoperative day after he showed good recovery and uneventful hospital stay.