A 47-year-old woman presented to the emergency department with generalized abdominal pain for a duration of four days. The pain was intermittent and colicky in nature with a mild response to analgesia. It was associated with vomiting and abdominal distension, with absolute constipation. The patient denied experiencing a similar previous attack. Her medical and surgical histories were unremarkable, and she reported only having an irregular menstrual cycle. She also reported no history of trauma.\nUpon physical examination, the patient was found to have stable vital signs: temperature, 36.7°C; heart rate, 88 beats per minute; and oxygen saturation, 100% room air. An abdominal examination revealed mild abdominal distention with generalized tenderness but no guarding or rigidity; the abdomen was tympanic to percussion, and a digital rectal examination was unremarkable. A provisional diagnosis was made for intestinal obstruction.\nLaboratory investigations, including a complete blood count, urea and analysis, and coagulation profile, were all within normal limits. An abdominal X-ray showed a dilated large bowel with few air fluid levels, no gas in the rectum and no air under the diaphragm (Fig. ). An abdominal CT scan with oral and intravenous contrast showed that the cecum was flipped superiorly and positioned anteriorly to the transverse colon, and it herniated into the foramen of Winslow (opening between the inferior vena cava and portal vein). The cecum occupied the lesser sac, and it was distended with gas and caused a mass effect on the stomach and hepatic root, with associated intrahepatic bile duct dilatation. This was associated with proximal small bowel dilatation and collapsed large bowel loops distally (Fig. ). These findings were consistent with an obstructive internal hernia into the lesser sac through the foramen of Winslow.\nA surgical consultation was requested, and laparoscopic assisted internal hernia reduction with ileocecal resection and side-to-side anastomosis were offered. The cecum and terminal ileum, along with the appendix, had herniated through the foramen of Winslow as evidenced during laparoscopy (Video 1). Both the cecum and terminal ileum were markedly distended and probably less vascularized (Fig. ). Consequently, the cecum and terminal ileum were resected (Fig. ).\nThe patient’s postoperative was uneventful. She was started on a clear liquid diet and then advanced to solid foods by Day 2. The patient was discharged, and she did not show any signs or symptoms suggestive of complications or recurrence during the last follow-up.
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.