A 32-year-old female with no previous operation history, presented to the Emergency Department with acutely developed epigastric and right upper quadrant pain with a 5-hour duration. The patient was transferred from a local clinic for proper management of bowel herniation. The abdominal pain was associated with nausea and vomiting. The character of abdominal pain was continuously sharp and squeezing.\nPhysical examination showed direct tenderness without guarding or peritoneal irritation. Bowel sounds were normal with no bowel distention. Laboratory examination was unremarkable except leukocytosis (16,000/µL).\nAbdominal CT performed in a local hospital had revealed a small bowel herniation through the foramen of Winslow (). The patient underwent an urgent exploratory laparoscopy using one 12-mm umbilical port and two 5-mm working ports in the left lateral and right lateral abdominal walls. After pneumoperitoneam was established, we traced the small bowel from the terminal ileum to the Treitz ligament. There was a moderate amount of hemorrhagic fluid in the intraperitoneal cavity. The previously indicated small bowel herniation site by the abdominal CT was not detected. However, severe congestion consisting of about 30 cm of the small bowel was noted in the mid jejunum, suspected to be the impacted lesion. Injured segments of small bowel were extracted through a mini laparotomy made using the extended umbilical port. Segmental resection of the small bowel with side to side anastomosis was performed. After a hemovac was inserted in the perihepatic space, the abdominal wall was closed, and the operation was completed.\nNo complications occurred during the postoperative period. The patient started on a clear liquid diet on postoperative day 4, and was discharged on postoperative day 6. Mucosal ischemic change with submucosal edema was shown on pathologic findings of the resected small bowel. At the first follow-up, the patient reported no complication.
A 47-year-old woman presented to the emergency department with generalized abdominal pain for a duration of four days. The pain was intermittent and colicky in nature with a mild response to analgesia. It was associated with vomiting and abdominal distension, with absolute constipation. The patient denied experiencing a similar previous attack. Her medical and surgical histories were unremarkable, and she reported only having an irregular menstrual cycle. She also reported no history of trauma.\nUpon physical examination, the patient was found to have stable vital signs: temperature, 36.7°C; heart rate, 88 beats per minute; and oxygen saturation, 100% room air. An abdominal examination revealed mild abdominal distention with generalized tenderness but no guarding or rigidity; the abdomen was tympanic to percussion, and a digital rectal examination was unremarkable. A provisional diagnosis was made for intestinal obstruction.\nLaboratory investigations, including a complete blood count, urea and analysis, and coagulation profile, were all within normal limits. An abdominal X-ray showed a dilated large bowel with few air fluid levels, no gas in the rectum and no air under the diaphragm (Fig. ). An abdominal CT scan with oral and intravenous contrast showed that the cecum was flipped superiorly and positioned anteriorly to the transverse colon, and it herniated into the foramen of Winslow (opening between the inferior vena cava and portal vein). The cecum occupied the lesser sac, and it was distended with gas and caused a mass effect on the stomach and hepatic root, with associated intrahepatic bile duct dilatation. This was associated with proximal small bowel dilatation and collapsed large bowel loops distally (Fig. ). These findings were consistent with an obstructive internal hernia into the lesser sac through the foramen of Winslow.\nA surgical consultation was requested, and laparoscopic assisted internal hernia reduction with ileocecal resection and side-to-side anastomosis were offered. The cecum and terminal ileum, along with the appendix, had herniated through the foramen of Winslow as evidenced during laparoscopy (Video 1). Both the cecum and terminal ileum were markedly distended and probably less vascularized (Fig. ). Consequently, the cecum and terminal ileum were resected (Fig. ).\nThe patient’s postoperative was uneventful. She was started on a clear liquid diet and then advanced to solid foods by Day 2. The patient was discharged, and she did not show any signs or symptoms suggestive of complications or recurrence during the last follow-up.