A 52-year-old woman with unremarkable medical and surgical history presented to the emergency department with intermittent abdominal pain. Physical examinations revealed a soft abdomen with epigastric tenderness without signs of peritonitis. A gently uplifting mass from above the pubis to below the umbilicus was palpated. The patient’s white blood cell count was slightly increased to 12,220 cells/μL (normal value: 4000–8000 cells/μL), and other serum tests (e.g., C-reactive protein and liver enzymes) were within respective reference ranges. Abdominal contrast-enhanced CT showed the presence of large uterine fibroids in the pelvis and herniation of dilated small bowel loops between the portal vein and the inferior vena cava (Fig. ).\nNo signs of bowel ischemia or peritonitis were observed. Because abdominal pain was refractory to previously administered medications, we performed elective laparoscopic surgery after bowel decompression using a long intestinal tube on the 19th day of hospitalization.\nLaparoscopic surgery was performed using a 12-mm umbilical port and four 5-mm working ports in the bilateral epigastric and hypogastric regions (Figs. .and ). We observed that the small bowel herniated through the foramen of Winslow. Hernia reduction could not be performed simply by pulling out the herniated bowel because of the adhesion between the herniated bowel and intra-omental tissue. Hence, we incised the lesser omentum to open the lesser sac and facilitate adhesiolysis.\nBecause the herniated bowel was observed to be viable, bowel resection was not performed. No intestinal malrotation or long bowel mesentery was observed, and closure of the foramen of Winslow was not performed. Nevertheless, there were no postoperative complications and the patient was discharged on postoperative day 6. No recurrences have occurred after 12 months of follow-up.
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.