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.
A 42-year-old woman with no relevant medical history, presented at the Emergency Department\nwith epigastric pain, of sudden beginning and progressive worsening, with a few hours of\nevolution. Mild abdominal distension and pain on palpation were noted, but there were no\nsigns of peritoneal irritation. An increase of pancreatic enzymes (amylase: 201 U/L and\nlipase: 880 U/L) was observed and recorded as abnormal finding. As there was diagnostic\nuncertainty and no obvious cause for acute pancreatitis, an abdominal-pelvic CT was\nperformed. It reported the presence of an interposition of the transverse colon between the\nleft lobe of the liver and the stomach, probably related to a foramen of Winslow hernia.\nThere was no pneumoperitoneum. Only a small quantity of free liquid was observed.\nThe patient was submitted to an urgent diagnostic laparoscopy to confirm the imaging\nfindings. The reduction of the hernia contents and the closure of the foramen were carried\nout. There was no need for bowel resection, since there was appropriate viability of the\ncolon (Figs –).\nThe postoperative care progressed favorably without complications. The diet was started on\nthe first postoperative day, being the intestinal transit restored. The patient was\ndischarged on the third day after surgery. After 15 months of follow-up, the patient was\nasymptomatic and there was no evidence of recurrence.