A 38-year-old woman presented to the emergency department with a sudden onset of epigastric pain for 12-h duration. Pain was associated with nausea without vomiting or changes in bowel habit. The pain was unresponsive to auto medications (paracetamol or proton pump inhibitors). There was no history of other drug intake or alcohol abuse. The patient’s past surgical history was unremarkable except for caesarean section that followed a difficult vaginal delivery, 2 years prior to presentation.\nPhysical examination revealed an apyretic hemodynamically stable patient. She was found to have epigastric tenderness on palpation but no guarding or signs of peritoneal irritation. Bowel sounds were present. The remaining physical examination was otherwise unremarkable.\nBlood tests were within normal limits including no leucocytosis, negative C-reactive protein and normal liver and pancreatic enzymes.\nAn abdominal intravenous contrast CT scan demonstrated a herniated caecum through the foramen of Winslow (measured at 3.5-cm of diameter), representing a 7.5-cm faeces-containing collection in the lesser sac displacing the stomach anteriorly and to the left. There was an associated ‘faeces sign’ in the small bowel loops (Fig. ).\nThe patient underwent an urgent exploratory laparoscopy using a 12-mm supra-umbilical port and three 5-mm working ports in the left lumbar, right lumbar and epigastric regions. The caecum and terminal ileum along with the appendix had herniated through the foramen of Winslow. There was free serous intraperitoneal fluid. After division of the gastrohepatic ligament, the caecum was found to be markedly distended but undoubtedly well-vascularized without lacerations. Edematous infiltration was found within the porta hepatis.\nSeveral attempts for hernia reduction have been executed, using one hand for proximal traction of the colon, appendix and even the dilated ileum and the other for applying opposing pressure using a gauze-protected forceps (Fig. ). These manoeuvres had to be stopped because of a minimal tear to the mesoappendix. Thereafter, puncture site on the caecum was prepared with a purse string using Coated VICRYL® 000 (polyglactin 910, Sutures, ETHICON). Decompression of the caecum was performed using a Veress needle introduced through the abdominal wall (Fig. ). Thereafter, the purse string was tight concomitantly with the removal of the needle by the assistant. No leakage was noticed, and consequently no lavage/drainage was performed. Subsequent reduction of the hernia was straightforward, and careful inspection ruled out organ injury. No colonic elongation was noticed; instead, a lack of posterior wall attachment of the ascending colon was present, justifying a caecopexy with a non-absorbable suture along and a prophylactic appendicectomy.\nThe postoperative course was uneventful. Full oral intake was tolerated on postoperative day 1, and the patient was discharged on day 2. At the 6-month follow-up, the patient did not show any suggestive signs or symptoms of complications or recurrence.\nAmong the 200 reported cases of FWH, the laparoscopic approach has been rarely used and solely in the most recent papers [, –]. Among them, hernia reduction was inconstantly associated with caecopexy when the ileocecal portion was involved [–, ]. Right colectomy is indicated for bowel ischemia or systematically achieved by some authors []. Needle bowel decompression has been previously described for reduction of incarcerated hernias but only performed under laparotomy and/or followed by right colectomy [, , ]. This is the first case to report laparoscopic puncture emptying of an otherwise healthy but incarcerated colon in order to achieve hernia reduction and avoid bowel resection.\nHistorically, FWHs have been impinged by a significant mortality rate reported as high as 50 % []. This was the consequence of delayed diagnosis in the setting of a rare disease lacking specific symptoms or peritoneal signs (due to strangulation located in the lesser sac). Abdominal CT scan is presently accepted as the imaging modality of choice allowing preoperative diagnosis of FWHs [, , , ]. Suggestive CT findings such as air-fluid level in the lesser sac which taper toward the foramen, presence of mesentery between the portal vein and inferior vena cava, absence of ascending colon in the right gutter and anterolateral displacement of the stomach have been recognized in our case and allowed timely surgical management.\nIt is now established that urgent abdominal exploration significantly reduces morbidity and mortality rates when performed before irreversible ischemia occurs [, ]. Laparotomy has traditionally been advocated as the preferred approach [, , , ]. Some recent reports, however, showed that laparoscopy offers exploratory possibilities, treatment options and enhanced recovery in this particular setting of prompt management [, , , , ]. For incarcerated but viable hernias, the Kocher manoeuvre has been proposed to enlarge the foramen of Winslow []. This technique, however, is potentially difficult to realize due to distorted anatomy and inflammatory adhesions.\nAlternatively, we advocate puncture decompression of the incarcerated bowel as a feasible and safe technique. We consider that it is preferable to suture a planned puncture before bowel reduction than to repair an irregular tear that would have occurred during excessive trauma. An uncontrolled tear in a weakened hollow organ exposes the risk of faecal contamination and could potentially necessitate organ resection. Planned perforation of a hollow viscus can be safely accomplished under laparoscopy without compromising the postoperative course. In this case, bowel movements recovered soon after surgery allowing full oral intake and discharge on postoperative day 2.\nTreatment of viable non-ischemic FWHs is not standardized []. Some authors limit the procedure to hernia reduction, especially when achieved under laparoscopy [–, ]. Although recommended by some authors [, ], there are no current guidelines for foramen of Winslow closure []. This exposes to the serious risk of injury of the porta hepatis while the inflammatory postoperative adhesions seem to most often close the foramen []. Alternatively, the foramen of Winslow can be packed with omentum [, ]. Systematic right colectomy, even for viable bowel, has been proposed when appropriate peritonization cannot be achieved due to redundant colon [–]. We agree that lack of posterior attachment of the caecum and ascending colon is a confirmed risk factor for FWH and consider that caecopexy to the lateral wall is the most suitable option when the bowel is deemed viable after reduction [, ]. Being easily achieved under laparoscopy, it combines the advantages of avoiding porta hepatis injury, protecting against theoretical recurrence and allowing bowel sparing.
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 ).