An 80-year-old female with past medical history of Crohn’s disease (diagnosed in 1998 and managed with Adalimumab) and no prior abdominal surgical history who presented with 1-day history of severe epigastric pain associated with nausea and emesis. Her last colonoscopy was 3 years ago (unremarkable), and last Crohn’s flare was a 1 year beforehand. On examination, patient’s abdomen was soft with severe epigastric tenderness and an appreciable bulge. Labs showed normal lactate (1.1) but mild leukocytosis of 12.5 and no other gross lab abnormalities. Patient underwent computed tomography (CT) scan of abdomen and pelvis which showed a transverse colon herniating through the FOW and causing a closed-loop obstruction (–). Patient was immediately decompressed with a nasogastric tube and was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, the transverse colon was noted to have herniated through the FOW into the lesser sac. The incarcerated transverse colon appeared immensely dilated and hyperemic. With careful traction and gentle counter pressure, the transverse colon was completely reduced from the FOW back into the abdominal cavity. On inspection after reduction, the small and large bowel appeared grossly viable and well-vascularized along with adequate peristalsis. The FOW was closed with 2-0 ethibond running suture by suturing the peritoneum adjacent to the portal triad down to the retroperitoneum just lateral to the inferior vena cava. The patient tolerated the procedure very well and brought to the recovery room in stable condition. Postoperatively, the patient did very well. On postoperative Day 1, the patient was discharged home. Subsequently, the patient was seen in the office on postoperative follow-up Day 7 and was found to be doing well with no complaints.
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.