A 32-year-old female with no previous operation history, presented to the Emergency Department with acutely developed epigastric and right upper quadrant pain with a 5-hour duration. The patient was transferred from a local clinic for proper management of bowel herniation. The abdominal pain was associated with nausea and vomiting. The character of abdominal pain was continuously sharp and squeezing.\nPhysical examination showed direct tenderness without guarding or peritoneal irritation. Bowel sounds were normal with no bowel distention. Laboratory examination was unremarkable except leukocytosis (16,000/µL).\nAbdominal CT performed in a local hospital had revealed a small bowel herniation through the foramen of Winslow (). The patient underwent an urgent exploratory laparoscopy using one 12-mm umbilical port and two 5-mm working ports in the left lateral and right lateral abdominal walls. After pneumoperitoneam was established, we traced the small bowel from the terminal ileum to the Treitz ligament. There was a moderate amount of hemorrhagic fluid in the intraperitoneal cavity. The previously indicated small bowel herniation site by the abdominal CT was not detected. However, severe congestion consisting of about 30 cm of the small bowel was noted in the mid jejunum, suspected to be the impacted lesion. Injured segments of small bowel were extracted through a mini laparotomy made using the extended umbilical port. Segmental resection of the small bowel with side to side anastomosis was performed. After a hemovac was inserted in the perihepatic space, the abdominal wall was closed, and the operation was completed.\nNo complications occurred during the postoperative period. The patient started on a clear liquid diet on postoperative day 4, and was discharged on postoperative day 6. Mucosal ischemic change with submucosal edema was shown on pathologic findings of the resected small bowel. At the first follow-up, the patient reported no complication.
A 42-year-old woman with no relevant medical history, presented at the Emergency Department\nwith epigastric pain, of sudden beginning and progressive worsening, with a few hours of\nevolution. Mild abdominal distension and pain on palpation were noted, but there were no\nsigns of peritoneal irritation. An increase of pancreatic enzymes (amylase: 201 U/L and\nlipase: 880 U/L) was observed and recorded as abnormal finding. As there was diagnostic\nuncertainty and no obvious cause for acute pancreatitis, an abdominal-pelvic CT was\nperformed. It reported the presence of an interposition of the transverse colon between the\nleft lobe of the liver and the stomach, probably related to a foramen of Winslow hernia.\nThere was no pneumoperitoneum. Only a small quantity of free liquid was observed.\nThe patient was submitted to an urgent diagnostic laparoscopy to confirm the imaging\nfindings. The reduction of the hernia contents and the closure of the foramen were carried\nout. There was no need for bowel resection, since there was appropriate viability of the\ncolon (Figs –).\nThe postoperative care progressed favorably without complications. The diet was started on\nthe first postoperative day, being the intestinal transit restored. The patient was\ndischarged on the third day after surgery. After 15 months of follow-up, the patient was\nasymptomatic and there was no evidence of recurrence.