A 47-year-old woman presented to the emergency department with generalized abdominal pain for a duration of four days. The pain was intermittent and colicky in nature with a mild response to analgesia. It was associated with vomiting and abdominal distension, with absolute constipation. The patient denied experiencing a similar previous attack. Her medical and surgical histories were unremarkable, and she reported only having an irregular menstrual cycle. She also reported no history of trauma.\nUpon physical examination, the patient was found to have stable vital signs: temperature, 36.7°C; heart rate, 88 beats per minute; and oxygen saturation, 100% room air. An abdominal examination revealed mild abdominal distention with generalized tenderness but no guarding or rigidity; the abdomen was tympanic to percussion, and a digital rectal examination was unremarkable. A provisional diagnosis was made for intestinal obstruction.\nLaboratory investigations, including a complete blood count, urea and analysis, and coagulation profile, were all within normal limits. An abdominal X-ray showed a dilated large bowel with few air fluid levels, no gas in the rectum and no air under the diaphragm (Fig. ). An abdominal CT scan with oral and intravenous contrast showed that the cecum was flipped superiorly and positioned anteriorly to the transverse colon, and it herniated into the foramen of Winslow (opening between the inferior vena cava and portal vein). The cecum occupied the lesser sac, and it was distended with gas and caused a mass effect on the stomach and hepatic root, with associated intrahepatic bile duct dilatation. This was associated with proximal small bowel dilatation and collapsed large bowel loops distally (Fig. ). These findings were consistent with an obstructive internal hernia into the lesser sac through the foramen of Winslow.\nA surgical consultation was requested, and laparoscopic assisted internal hernia reduction with ileocecal resection and side-to-side anastomosis were offered. The cecum and terminal ileum, along with the appendix, had herniated through the foramen of Winslow as evidenced during laparoscopy (Video 1). Both the cecum and terminal ileum were markedly distended and probably less vascularized (Fig. ). Consequently, the cecum and terminal ileum were resected (Fig. ).\nThe patient’s postoperative was uneventful. She was started on a clear liquid diet and then advanced to solid foods by Day 2. The patient was discharged, and she did not show any signs or symptoms suggestive of complications or recurrence during the last follow-up.
A 44-year-old female patient, without prior abdominal surgery, was admitted to the emergency department with an acute epigastric abdominal pain, without nausea. She presented similar episodes of pain in the past, without having ever requested a medical opinion. Physical examination revealed an acute epigastric pain without signs of peritonitis. Laboratory analyses were within normal limits. A computed tomography showed an internal hernia of the colon in the lesser sac, going back from the liver pedicle (). There were neither occlusion nor ischemia. We performed immediately a diagnostic laparoscopy with one 11-mm umbilical port and two 5-mm ports (one in the left lumbar and one in the hypogastrium). Exploration confirmed that the ascending colon and the right colonic flexure had herniated through the foramen of Winslow (). The colon was reduced with an atraumatic Johann’s graspers and was viable, cecum, ascending colon and the right colonic flexure was mobile due to a misapposition of the right Told fascia. To prevent recurrent herniation we performed the fixation to the lateral wall of the cecum, ascending colon and right colonic flexure with several non-absorbable sutures (). We did not perform the closure of the Winslow’s hiatus. Postoperatively, the patient recovery was uneventful and was discharged home 2 days later. A computed tomography was performed 1 month later for another reason, showing a good result of the right colon fixation on the lateral wall (). Twenty months after surgery, the patient totally recovered and has not experienced any recurrence or occlusion.