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.
A 20-year-old male of Middle Eastern descent, with a surgical history of a Ladd's procedure, walked into the emergency room complaining of severe diffuse abdominal pain and multiple episodes of emesis starting 24 prior to admission. The otherwise healthy patient had a Ladd's procedure six years prior due to intestinal malrotation. The patient denies the passing of stool or flatulence in the day prior to his admission and did not have a fever. On physical examination, the vital signs were normal, the abdomen was non-distended, peristalsis was weak on auscultation and pain was noted on palpation in the right upper quadrant. There were no signs of peritonitis.\nAt this stage, the differential diagnosis included small bowel obstruction due to adhesions, a perforated gastrointestinal ulcer and an internal hernia. A nil per os (NPO) laboratory test and an abdominal X-ray were ordered. IV fluids and analgesic were prescribed. Laboratory test showed a white blood cell count of 12 K, Lactate levels were within normal range, and no electrolyte abnormalities were found.\nAt that point, it was decided to order a CT scan and insert a nasogastric (NG) tube. The NG tube subsequently failed entry. The abdominal CT showed mesenteroaxial gastric volvulus and showed the presence of air within the Falciform Ligament (). Clinical and radiological findings led to the decision to proceed to the operating room. Consultation with a radiologist raised suspicions that possible adhesions were present in the upper abdomen. Furthermore, the patient had a midline laparotomy due to a Ladd's procedure. Consequently, the surgeon, a young specialist 2-year post-surgery residency, felt more comfortable with an exploratory laparotomy rather than a laparoscopic approach.\nThe patient was laid supine, and isoflurane was used for inhaled analgesia. During the operation, the cecum was in lower abdominal cavity and a necrotic strangulated small intestine loop was visualized within the Winslow foramen (). An excision and anastomosis procedure was conducted, and the cecum was fixed in the lower left quadrant.\nPostoperatively, the patient felt well and maintained normal vital signs. On the second post-operative day, the abdominal swelling gradually reduced, peristalsis was normal, the abdomen was non-tender and the patient returned to enteral feeding following the ERAS protocol. On post-operative day three, the patient eliminated stool and flatulence. The patient was discharged from the hospital on the fifth post-operative day in good clinical condition with nonrestrictive enteral feeding and minimal abdominal discomfort. The patient was advised to maintain good hydration, avoid weightlifting or straining, use laxatives if required and seek medical attention in case of fever or recurrence of symptoms.\nTwo weeks after the surgery, during a follow-up at the outpatient clinic, the abdominal pain was completely resolved. He consumed a normal diet, had plenty of fluids and felt well without any further complaints.