A 67-year-old male with a past medical history of prostate cancer, hypertension and prior open right inguinal hernia repair presented to the emergency department (ED) with sudden onset nausea, vomiting and abdominal pain for 2 h. The abdomen was non-distended and slightly tender in the epigastrium. A clinical diagnosis of pancreatitis was made based on physical examination, history and a mildly elevated lipase and the patient was discharged home with antiemetic medications by the ED providers. The patient presented back to the ED 2 days later with worsening abdominal pain, nausea, vomiting and obstipation. At this time his abdomen was distended and tender to palpation in the epigastrium without peritoneal irritation. Due to his obstructive clinical picture, a CT scan of the abdomen and pelvis with IV contrast () was obtained in the ED. The scan was read as a possible volvulus versus an internal hernia causing small bowel obstruction. A nasogastric tube was placed after he was admitted to the surgical unit with partial resolution of his abdominal tenderness and distention. A barium enema () was performed to rule out an obstructing distal mass, which showed a transition point at the hepatic flexure.\nDue to the clinical picture of a complete bowel obstruction and subsequent imaging findings, an urgent abdominal exploration was performed. A standard supraumbilical midline laparotomy was made and the peritoneal cavity was entered. Distended loops of bowel were encountered, and the right colon was mobilized from some loose attachments to the abdominal wall. The right colon was followed to identify the cecum and terminal ileum. The cecum was identified to be in the lesser sac, herniated through the foramen of Winslow. The cecum was reduced and was determined to be ischemic and nonviable, so a right hemicolectomy was performed with an isoperistaltic ileocolic anastomosis with the transverse colon. The duodenum was Kocherized to expose the retroperitoneum. The foramen of Winslow was closed by approximating the hepatoduodenal ligament to peritoneum overlying the right kidney with a simple interrupted 3–0 polyglyconate suture, adequately obliterating the foramen. The transverse colon was pexy to the anterior abdominal wall using 3–0 polyglyconate suture.\nHis postoperative course was uncomplicated. His intestinal transit was restored on postoperative Day 3. His diet was advanced as tolerated. He was discharged on Day 5 after surgery with good diet tolerance and having adequate bowel function. Pathology was benign.
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.