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.
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.