A 52-year-old woman with unremarkable medical and surgical history presented to the emergency department with intermittent abdominal pain. Physical examinations revealed a soft abdomen with epigastric tenderness without signs of peritonitis. A gently uplifting mass from above the pubis to below the umbilicus was palpated. The patient’s white blood cell count was slightly increased to 12,220 cells/μL (normal value: 4000–8000 cells/μL), and other serum tests (e.g., C-reactive protein and liver enzymes) were within respective reference ranges. Abdominal contrast-enhanced CT showed the presence of large uterine fibroids in the pelvis and herniation of dilated small bowel loops between the portal vein and the inferior vena cava (Fig. ).\nNo signs of bowel ischemia or peritonitis were observed. Because abdominal pain was refractory to previously administered medications, we performed elective laparoscopic surgery after bowel decompression using a long intestinal tube on the 19th day of hospitalization.\nLaparoscopic surgery was performed using a 12-mm umbilical port and four 5-mm working ports in the bilateral epigastric and hypogastric regions (Figs. .and ). We observed that the small bowel herniated through the foramen of Winslow. Hernia reduction could not be performed simply by pulling out the herniated bowel because of the adhesion between the herniated bowel and intra-omental tissue. Hence, we incised the lesser omentum to open the lesser sac and facilitate adhesiolysis.\nBecause the herniated bowel was observed to be viable, bowel resection was not performed. No intestinal malrotation or long bowel mesentery was observed, and closure of the foramen of Winslow was not performed. Nevertheless, there were no postoperative complications and the patient was discharged on postoperative day 6. No recurrences have occurred after 12 months of follow-up.
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.