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 ).
A male patient, 69-years old was presented in our emergency department complaining of severe abdominal pain. The patient described the pain as paroxysmal cramps, which starts at the lower abdomen then radiate to the epigastrium and to the back. The complaint began approximately 24 h before the admission and was associated with distention and mild nausea. Vomiting, fever or altered bowel habits were not reported. The patient suffers from obesity, arterial hypertension, metabolic syndrome and uncomplicated sigmoid diverticulosis. He underwent a laparoscopic Nissen fundoplication 2 years ago. Few weeks after this operation, he suffered a migrated wrap that was surgically repaired. Clinical examination revealed abdominal tenderness without guarding or rigidity. Intestinal sounds were present but weak. Laboratory tests showed no significant abnormalities.\nIn absence of signs of peritonitis, we decided to proceed with further investigations. Abdominal sonography was hindered by distention. Contrast-enhanced computed tomography (CT) of the abdomen showed a single-intestinal loop, which appeared to be distended and trapped behind the stomach. As the possibility of internal herniation rose, we scheduled the patient for an urgent abdominal exploration.\nThe operative findings confirmed the radiological interpretation. The operator could retract the twisted ascending colon and caecum out of the lesser sac through the foramen of Winslow, only after decompression of the strangulated bowel, via suction of gas and fluid content through a small incision. The initially congested herniated colon regains normal appearance soon. In the absence of permanent ischemic changes, the operator opted for minimal intervention. Without colectomy, the abdomen was temporary closed, with a second-look planned after 24 h, which revealed viable intestine with no signs of intestinal obstruction. The patient stayed in the intensive care unit for 2 days and was discharged at the seventh postoperative day after he showed good recovery and uneventful hospital stay.