An 80-year-old female with past medical history of Crohn’s disease (diagnosed in 1998 and managed with Adalimumab) and no prior abdominal surgical history who presented with 1-day history of severe epigastric pain associated with nausea and emesis. Her last colonoscopy was 3 years ago (unremarkable), and last Crohn’s flare was a 1 year beforehand. On examination, patient’s abdomen was soft with severe epigastric tenderness and an appreciable bulge. Labs showed normal lactate (1.1) but mild leukocytosis of 12.5 and no other gross lab abnormalities. Patient underwent computed tomography (CT) scan of abdomen and pelvis which showed a transverse colon herniating through the FOW and causing a closed-loop obstruction (–). Patient was immediately decompressed with a nasogastric tube and was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, the transverse colon was noted to have herniated through the FOW into the lesser sac. The incarcerated transverse colon appeared immensely dilated and hyperemic. With careful traction and gentle counter pressure, the transverse colon was completely reduced from the FOW back into the abdominal cavity. On inspection after reduction, the small and large bowel appeared grossly viable and well-vascularized along with adequate peristalsis. The FOW was closed with 2-0 ethibond running suture by suturing the peritoneum adjacent to the portal triad down to the retroperitoneum just lateral to the inferior vena cava. The patient tolerated the procedure very well and brought to the recovery room in stable condition. Postoperatively, the patient did very well. On postoperative Day 1, the patient was discharged home. Subsequently, the patient was seen in the office on postoperative follow-up Day 7 and was found to be doing well with no complaints.
An 81-year-old female with a medical history of CAD with stents, hyperlipidemia, hypothyroidism, GERD, recent UTI, pancreatic cyst, constipation, anemia and leukopenia presented to the ED with a 1 day history of mild, diffuse and cramping abdominal pain. The patient was unable to give an accurate history, but the son at bedside supplemented this reporting that for several years the patient had been experiencing ill-defined abdominal discomfort. Physical exam showed a soft abdomen with mild tenderness and no evidence of peritonitis. A CT scan of the abdomen and pelvis with IV and PO contrast (Fig. ) showed edematous changes to the mesentery of the small and large bowel with swirling of vessels indicative of internal hernia. The stomach was also noted to be distended with both air and fluid as a consequence of posterior compression by the hernia contents (Fig. ). A surgical consult was obtained, a nasogastric tube and Foley catheter were placed, antibiotics were started, and the patient was taken for an exploratory laparotomy. Upon entering the abdomen through a vertical midline incision, 1.5 l of ascites was drained revealing a diffusely edematous mesentery. A large portion of the small bowel was seen to be herniated through the Foramen of Winslow (Fig. ). A Kocher maneuver and division of the gastrocolic ligament were then performed to allow release of the herniated small bowel. It was at this time that, in addition to small bowel, a large portion of the ascending and transverse colon was noted to be herniated through the foramen of Winslow. The small bowel was also seen to be torsed about its own mesentery. Normal anatomy was restored and the bowel noted to be healthy and viable with peristalsis (Fig. ). Due to the large size of the foramen after reduction and enlargement, it was deemed best to leave it open to prevent any further incarceration or strangulation. The abdomen was closed and the patient tolerated the procedure well. At a follow-up visit 2 months later, the patient had well-healed incisions, was doing well, tolerating a diet, and gaining weight appropriately.