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 20-year-old male of Middle Eastern descent, with a surgical history of a Ladd's procedure, walked into the emergency room complaining of severe diffuse abdominal pain and multiple episodes of emesis starting 24 prior to admission. The otherwise healthy patient had a Ladd's procedure six years prior due to intestinal malrotation. The patient denies the passing of stool or flatulence in the day prior to his admission and did not have a fever. On physical examination, the vital signs were normal, the abdomen was non-distended, peristalsis was weak on auscultation and pain was noted on palpation in the right upper quadrant. There were no signs of peritonitis.\nAt this stage, the differential diagnosis included small bowel obstruction due to adhesions, a perforated gastrointestinal ulcer and an internal hernia. A nil per os (NPO) laboratory test and an abdominal X-ray were ordered. IV fluids and analgesic were prescribed. Laboratory test showed a white blood cell count of 12 K, Lactate levels were within normal range, and no electrolyte abnormalities were found.\nAt that point, it was decided to order a CT scan and insert a nasogastric (NG) tube. The NG tube subsequently failed entry. The abdominal CT showed mesenteroaxial gastric volvulus and showed the presence of air within the Falciform Ligament (). Clinical and radiological findings led to the decision to proceed to the operating room. Consultation with a radiologist raised suspicions that possible adhesions were present in the upper abdomen. Furthermore, the patient had a midline laparotomy due to a Ladd's procedure. Consequently, the surgeon, a young specialist 2-year post-surgery residency, felt more comfortable with an exploratory laparotomy rather than a laparoscopic approach.\nThe patient was laid supine, and isoflurane was used for inhaled analgesia. During the operation, the cecum was in lower abdominal cavity and a necrotic strangulated small intestine loop was visualized within the Winslow foramen (). An excision and anastomosis procedure was conducted, and the cecum was fixed in the lower left quadrant.\nPostoperatively, the patient felt well and maintained normal vital signs. On the second post-operative day, the abdominal swelling gradually reduced, peristalsis was normal, the abdomen was non-tender and the patient returned to enteral feeding following the ERAS protocol. On post-operative day three, the patient eliminated stool and flatulence. The patient was discharged from the hospital on the fifth post-operative day in good clinical condition with nonrestrictive enteral feeding and minimal abdominal discomfort. The patient was advised to maintain good hydration, avoid weightlifting or straining, use laxatives if required and seek medical attention in case of fever or recurrence of symptoms.\nTwo weeks after the surgery, during a follow-up at the outpatient clinic, the abdominal pain was completely resolved. He consumed a normal diet, had plenty of fluids and felt well without any further complaints.