A 63-year-old woman with a history of gastroesophageal reflux disease (GERD) associated with a small hiatal hernia presented to the emergency department with severe abdominal pain, nausea, vomiting, and obstructive symptoms that had started 12 hours earlier. The pain was epigastric in nature. She reported no passing of flatus or bowel movement for 24 hours prior to presentation. She also reported a history of intermittent abdominal pain and obstipation that would self-resolve without treatment over the last several years. She had no prior surgical history. Her body mass index was 31. She denied any fever, chills, chest pain, or shortness of breath. Her vitals on presentation included a blood pressure of 110/70 mm Hg, heart rate of 105 beats per minute, and respiratory rate of 22 breathes per minutes. On physical examination, the abdomen was distended with focal tenderness in the epigastric and peri-umbilical regions. No peritoneal signs were noted.\nLaboratory analysis revealed a leukocytosis to 12.9 K/uL (reference range [RR]; 4.0-10.0K/uL) with an elevation in creatinine to 0.8 mg/dL from 0.4 mg/dL (RR; 0.3 -0.6mg/dL). Her blood urea nitrogen level was elevated to 20 mg/dL from 8 mg/dL (RR; 4 – 8 mg/dL). Her lipase, amylase, and liver function tests were within normal limits. Her lactate level was mildly elevated to 3.0 mg/dL (RR; 0.5-1mmol/L).\nA computed tomography (CT) scan of her abdomen and pelvis revealed a right internal hernia containing cecal bascule herniation through the foramen of Winslow into the lesser sac, concerning for a closed-loop obstruction (). There was fecalization with upstream bowel dilation. There was no evidence of pneumoperitoneum, pneumatosis, or bowel wall compromise. A normal appendix was also noted in the right upper quadrant near the gallbladder.\nThe patient’s symptoms including pain, nausea, vomiting, no flatus or bowel movements, along with her leukocytosis and imaging findings were concerning for an internal hernia with a cecal bascule traversing the foramen of Winslow causing a closed-loop obstruction. The patient was taken to the operating room.\nShe underwent an exploratory laparotomy. After fixed retractors were placed, the appendix was noted to be in the right upper quadrant near the gallbladder and liver edge (). The terminal ileum and transverse colon were noted to be tracking behind the portal triad. Upon closer examination, these structures were noted to be involved in an internal hernia with a cecal bascule herniating through the foramen of Winslow. Adhesions were lysed and the hernia sac was partially excised facilitating reduction of the cecal bascule (). The colon was noted to be viable. After reduction, the hernia sac was fully excised. The right colon mesentery was noted to be highly redundant ().\nGiven the viability of the cecum and right colon, the decision was made to perform a cecopexy rather than right hemicolectomy to minimize the risk of a recurrent internal hernia. An appendectomy was also performed. Omentum was placed near the foramen of Winslow to also help prevent future risk of a recurrent internal hernia. No attempt was made at suture closure of the foramen of Winslow space. The abdomen was closed in the standard fashion.\nThe patient’s postoperative course was uncomplicated. Her pain was well-controlled with oral pain medication. Her diet was advanced in a stepwise fashion. She was able to ambulate independently and void spontaneously upon discharge. The patient was discharged 4 days following her operation. She has also been doing well more than 6 months out from surgery.
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.