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.
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.