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 44-year-old female patient, without prior abdominal surgery, was admitted to the emergency department with an acute epigastric abdominal pain, without nausea. She presented similar episodes of pain in the past, without having ever requested a medical opinion. Physical examination revealed an acute epigastric pain without signs of peritonitis. Laboratory analyses were within normal limits. A computed tomography showed an internal hernia of the colon in the lesser sac, going back from the liver pedicle (). There were neither occlusion nor ischemia. We performed immediately a diagnostic laparoscopy with one 11-mm umbilical port and two 5-mm ports (one in the left lumbar and one in the hypogastrium). Exploration confirmed that the ascending colon and the right colonic flexure had herniated through the foramen of Winslow (). The colon was reduced with an atraumatic Johann’s graspers and was viable, cecum, ascending colon and the right colonic flexure was mobile due to a misapposition of the right Told fascia. To prevent recurrent herniation we performed the fixation to the lateral wall of the cecum, ascending colon and right colonic flexure with several non-absorbable sutures (). We did not perform the closure of the Winslow’s hiatus. Postoperatively, the patient recovery was uneventful and was discharged home 2 days later. A computed tomography was performed 1 month later for another reason, showing a good result of the right colon fixation on the lateral wall (). Twenty months after surgery, the patient totally recovered and has not experienced any recurrence or occlusion.