An 80-year-old female with past medical history of Crohn’s disease (diagnosed in 1998 and managed with Adalimumab) and no prior abdominal surgical history who presented with 1-day history of severe epigastric pain associated with nausea and emesis. Her last colonoscopy was 3 years ago (unremarkable), and last Crohn’s flare was a 1 year beforehand. On examination, patient’s abdomen was soft with severe epigastric tenderness and an appreciable bulge. Labs showed normal lactate (1.1) but mild leukocytosis of 12.5 and no other gross lab abnormalities. Patient underwent computed tomography (CT) scan of abdomen and pelvis which showed a transverse colon herniating through the FOW and causing a closed-loop obstruction (–). Patient was immediately decompressed with a nasogastric tube and was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, the transverse colon was noted to have herniated through the FOW into the lesser sac. The incarcerated transverse colon appeared immensely dilated and hyperemic. With careful traction and gentle counter pressure, the transverse colon was completely reduced from the FOW back into the abdominal cavity. On inspection after reduction, the small and large bowel appeared grossly viable and well-vascularized along with adequate peristalsis. The FOW was closed with 2-0 ethibond running suture by suturing the peritoneum adjacent to the portal triad down to the retroperitoneum just lateral to the inferior vena cava. The patient tolerated the procedure very well and brought to the recovery room in stable condition. Postoperatively, the patient did very well. On postoperative Day 1, the patient was discharged home. Subsequently, the patient was seen in the office on postoperative follow-up Day 7 and was found to be doing well with no complaints.
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 ).