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.
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.