A 63-year-old woman with a history of gastroesophageal reflux disease (GERD) associated with a small hiatal hernia presented to the emergency department with severe abdominal pain, nausea, vomiting, and obstructive symptoms that had started 12 hours earlier. The pain was epigastric in nature. She reported no passing of flatus or bowel movement for 24 hours prior to presentation. She also reported a history of intermittent abdominal pain and obstipation that would self-resolve without treatment over the last several years. She had no prior surgical history. Her body mass index was 31. She denied any fever, chills, chest pain, or shortness of breath. Her vitals on presentation included a blood pressure of 110/70 mm Hg, heart rate of 105 beats per minute, and respiratory rate of 22 breathes per minutes. On physical examination, the abdomen was distended with focal tenderness in the epigastric and peri-umbilical regions. No peritoneal signs were noted.\nLaboratory analysis revealed a leukocytosis to 12.9 K/uL (reference range [RR]; 4.0-10.0K/uL) with an elevation in creatinine to 0.8 mg/dL from 0.4 mg/dL (RR; 0.3 -0.6mg/dL). Her blood urea nitrogen level was elevated to 20 mg/dL from 8 mg/dL (RR; 4 – 8 mg/dL). Her lipase, amylase, and liver function tests were within normal limits. Her lactate level was mildly elevated to 3.0 mg/dL (RR; 0.5-1mmol/L).\nA computed tomography (CT) scan of her abdomen and pelvis revealed a right internal hernia containing cecal bascule herniation through the foramen of Winslow into the lesser sac, concerning for a closed-loop obstruction (). There was fecalization with upstream bowel dilation. There was no evidence of pneumoperitoneum, pneumatosis, or bowel wall compromise. A normal appendix was also noted in the right upper quadrant near the gallbladder.\nThe patient’s symptoms including pain, nausea, vomiting, no flatus or bowel movements, along with her leukocytosis and imaging findings were concerning for an internal hernia with a cecal bascule traversing the foramen of Winslow causing a closed-loop obstruction. The patient was taken to the operating room.\nShe underwent an exploratory laparotomy. After fixed retractors were placed, the appendix was noted to be in the right upper quadrant near the gallbladder and liver edge (). The terminal ileum and transverse colon were noted to be tracking behind the portal triad. Upon closer examination, these structures were noted to be involved in an internal hernia with a cecal bascule herniating through the foramen of Winslow. Adhesions were lysed and the hernia sac was partially excised facilitating reduction of the cecal bascule (). The colon was noted to be viable. After reduction, the hernia sac was fully excised. The right colon mesentery was noted to be highly redundant ().\nGiven the viability of the cecum and right colon, the decision was made to perform a cecopexy rather than right hemicolectomy to minimize the risk of a recurrent internal hernia. An appendectomy was also performed. Omentum was placed near the foramen of Winslow to also help prevent future risk of a recurrent internal hernia. No attempt was made at suture closure of the foramen of Winslow space. The abdomen was closed in the standard fashion.\nThe patient’s postoperative course was uncomplicated. Her pain was well-controlled with oral pain medication. Her diet was advanced in a stepwise fashion. She was able to ambulate independently and void spontaneously upon discharge. The patient was discharged 4 days following her operation. She has also been doing well more than 6 months out from surgery.
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 ).