A 67-year-old male with a past medical history of prostate cancer, hypertension and prior open right inguinal hernia repair presented to the emergency department (ED) with sudden onset nausea, vomiting and abdominal pain for 2 h. The abdomen was non-distended and slightly tender in the epigastrium. A clinical diagnosis of pancreatitis was made based on physical examination, history and a mildly elevated lipase and the patient was discharged home with antiemetic medications by the ED providers. The patient presented back to the ED 2 days later with worsening abdominal pain, nausea, vomiting and obstipation. At this time his abdomen was distended and tender to palpation in the epigastrium without peritoneal irritation. Due to his obstructive clinical picture, a CT scan of the abdomen and pelvis with IV contrast () was obtained in the ED. The scan was read as a possible volvulus versus an internal hernia causing small bowel obstruction. A nasogastric tube was placed after he was admitted to the surgical unit with partial resolution of his abdominal tenderness and distention. A barium enema () was performed to rule out an obstructing distal mass, which showed a transition point at the hepatic flexure.\nDue to the clinical picture of a complete bowel obstruction and subsequent imaging findings, an urgent abdominal exploration was performed. A standard supraumbilical midline laparotomy was made and the peritoneal cavity was entered. Distended loops of bowel were encountered, and the right colon was mobilized from some loose attachments to the abdominal wall. The right colon was followed to identify the cecum and terminal ileum. The cecum was identified to be in the lesser sac, herniated through the foramen of Winslow. The cecum was reduced and was determined to be ischemic and nonviable, so a right hemicolectomy was performed with an isoperistaltic ileocolic anastomosis with the transverse colon. The duodenum was Kocherized to expose the retroperitoneum. The foramen of Winslow was closed by approximating the hepatoduodenal ligament to peritoneum overlying the right kidney with a simple interrupted 3–0 polyglyconate suture, adequately obliterating the foramen. The transverse colon was pexy to the anterior abdominal wall using 3–0 polyglyconate suture.\nHis postoperative course was uncomplicated. His intestinal transit was restored on postoperative Day 3. His diet was advanced as tolerated. He was discharged on Day 5 after surgery with good diet tolerance and having adequate bowel function. Pathology was benign.
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 ).