A 41-year-old woman presented with a 2-day history of severe, central, cramping abdominal pain of gradual onset, which progressively radiated to the right side of her abdomen. It was relieved by lying on her right side, assuming the foetal position or by bending forwards on the floor. Conversely straightening or stretching her abdomen exacerbated the pain. The patient had not opened her bowels (although she was still passing small amounts of flatus) in 3 days and had been vomiting for 48 h.\nHer laboratory results showed leukocytosis of 14.4 × 109, her other results were unremarkable.\nPlain abdominal radiography (Fig. ) displayed a dilated viscus in the left upper quadrant with absence of colonic shadow on the right side of the abdomen. Initially this was reported as a large distended stomach, but in retrospect was thought to be the caecum.\nAn ultrasound scan of her gall bladder was performed to rule out the possibility of acute cholecystitis; this showed a small amount of free fluid and a known ovarian dermoid cyst.\nComputed tomography was used for diagnosis. Although initially reported as caecal volvulus, in hindsight there were features indicative of the herniation. (Figs and ).\nOn the basis of the computed tomography findings, the patient was taken to theatre for her presumed caecal volvulus. At laparotomy however, the caecum was noted to be herniating through the foramen of Winslow causing closed loop obstruction. It could not be reduced by gentle traction, so the lesser sac was opened up and the caecum decompressed with a small enterotomy and suction to allow reduction. A right hemicolectomy with stapled side-to-side anastomosis was then performed to remove the compromised bowel and the foramen was left open. The patient had an uneventful postoperative recovery and was discharged 4 days later (Figs and ).
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.