A 20-year-old male of Middle Eastern descent, with a surgical history of a Ladd's procedure, walked into the emergency room complaining of severe diffuse abdominal pain and multiple episodes of emesis starting 24 prior to admission. The otherwise healthy patient had a Ladd's procedure six years prior due to intestinal malrotation. The patient denies the passing of stool or flatulence in the day prior to his admission and did not have a fever. On physical examination, the vital signs were normal, the abdomen was non-distended, peristalsis was weak on auscultation and pain was noted on palpation in the right upper quadrant. There were no signs of peritonitis.\nAt this stage, the differential diagnosis included small bowel obstruction due to adhesions, a perforated gastrointestinal ulcer and an internal hernia. A nil per os (NPO) laboratory test and an abdominal X-ray were ordered. IV fluids and analgesic were prescribed. Laboratory test showed a white blood cell count of 12 K, Lactate levels were within normal range, and no electrolyte abnormalities were found.\nAt that point, it was decided to order a CT scan and insert a nasogastric (NG) tube. The NG tube subsequently failed entry. The abdominal CT showed mesenteroaxial gastric volvulus and showed the presence of air within the Falciform Ligament (). Clinical and radiological findings led to the decision to proceed to the operating room. Consultation with a radiologist raised suspicions that possible adhesions were present in the upper abdomen. Furthermore, the patient had a midline laparotomy due to a Ladd's procedure. Consequently, the surgeon, a young specialist 2-year post-surgery residency, felt more comfortable with an exploratory laparotomy rather than a laparoscopic approach.\nThe patient was laid supine, and isoflurane was used for inhaled analgesia. During the operation, the cecum was in lower abdominal cavity and a necrotic strangulated small intestine loop was visualized within the Winslow foramen (). An excision and anastomosis procedure was conducted, and the cecum was fixed in the lower left quadrant.\nPostoperatively, the patient felt well and maintained normal vital signs. On the second post-operative day, the abdominal swelling gradually reduced, peristalsis was normal, the abdomen was non-tender and the patient returned to enteral feeding following the ERAS protocol. On post-operative day three, the patient eliminated stool and flatulence. The patient was discharged from the hospital on the fifth post-operative day in good clinical condition with nonrestrictive enteral feeding and minimal abdominal discomfort. The patient was advised to maintain good hydration, avoid weightlifting or straining, use laxatives if required and seek medical attention in case of fever or recurrence of symptoms.\nTwo weeks after the surgery, during a follow-up at the outpatient clinic, the abdominal pain was completely resolved. He consumed a normal diet, had plenty of fluids and felt well without any further complaints.
A 63-year-old woman with a history of gastroesophageal reflux disease (GERD) associated with a small hiatal hernia presented to the emergency department with severe abdominal pain, nausea, vomiting, and obstructive symptoms that had started 12 hours earlier. The pain was epigastric in nature. She reported no passing of flatus or bowel movement for 24 hours prior to presentation. She also reported a history of intermittent abdominal pain and obstipation that would self-resolve without treatment over the last several years. She had no prior surgical history. Her body mass index was 31. She denied any fever, chills, chest pain, or shortness of breath. Her vitals on presentation included a blood pressure of 110/70 mm Hg, heart rate of 105 beats per minute, and respiratory rate of 22 breathes per minutes. On physical examination, the abdomen was distended with focal tenderness in the epigastric and peri-umbilical regions. No peritoneal signs were noted.\nLaboratory analysis revealed a leukocytosis to 12.9 K/uL (reference range [RR]; 4.0-10.0K/uL) with an elevation in creatinine to 0.8 mg/dL from 0.4 mg/dL (RR; 0.3 -0.6mg/dL). Her blood urea nitrogen level was elevated to 20 mg/dL from 8 mg/dL (RR; 4 – 8 mg/dL). Her lipase, amylase, and liver function tests were within normal limits. Her lactate level was mildly elevated to 3.0 mg/dL (RR; 0.5-1mmol/L).\nA computed tomography (CT) scan of her abdomen and pelvis revealed a right internal hernia containing cecal bascule herniation through the foramen of Winslow into the lesser sac, concerning for a closed-loop obstruction (). There was fecalization with upstream bowel dilation. There was no evidence of pneumoperitoneum, pneumatosis, or bowel wall compromise. A normal appendix was also noted in the right upper quadrant near the gallbladder.\nThe patient’s symptoms including pain, nausea, vomiting, no flatus or bowel movements, along with her leukocytosis and imaging findings were concerning for an internal hernia with a cecal bascule traversing the foramen of Winslow causing a closed-loop obstruction. The patient was taken to the operating room.\nShe underwent an exploratory laparotomy. After fixed retractors were placed, the appendix was noted to be in the right upper quadrant near the gallbladder and liver edge (). The terminal ileum and transverse colon were noted to be tracking behind the portal triad. Upon closer examination, these structures were noted to be involved in an internal hernia with a cecal bascule herniating through the foramen of Winslow. Adhesions were lysed and the hernia sac was partially excised facilitating reduction of the cecal bascule (). The colon was noted to be viable. After reduction, the hernia sac was fully excised. The right colon mesentery was noted to be highly redundant ().\nGiven the viability of the cecum and right colon, the decision was made to perform a cecopexy rather than right hemicolectomy to minimize the risk of a recurrent internal hernia. An appendectomy was also performed. Omentum was placed near the foramen of Winslow to also help prevent future risk of a recurrent internal hernia. No attempt was made at suture closure of the foramen of Winslow space. The abdomen was closed in the standard fashion.\nThe patient’s postoperative course was uncomplicated. Her pain was well-controlled with oral pain medication. Her diet was advanced in a stepwise fashion. She was able to ambulate independently and void spontaneously upon discharge. The patient was discharged 4 days following her operation. She has also been doing well more than 6 months out from surgery.