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 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.