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.
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.