Herniation through both Winslow's foramen and a lesser omental defect: report of a case

Retroperitoneal cecal volvulus: a complication of a rare internal hernia - a case report

Introduction and importance

The foramen of Winslow hernia (FWH) is a rare type of internal hernia. In one-third of cases, the cecum was found in the lesser sac. More rarely, the herniated cecum might be volvulated, which represents 1-1.5% of the causes of intestinal obstruction. Once diagnosed, surgical reduction and/or resection of the nonviable herniated bowel is crucial for a positive outcome.

Case presentation

The authors report a case of retroperitoneal cecal volvulus that complicated FWH in a patient with a history of laparoscopic cholecystectomy.

Clinical discussion

A delay in the diagnosis is associated with high morbidity and even higher mortality. Because of lacking a consensus, the treatment of FWH depends on the team's surgical experience.

Conclusion

Reporting this case will help us to keep in mind this differential diagnosis while treating patients in our daily practice.

Spontaneous lesser omental herniation resolved by laparoscopic surgery: case report and systematic literature review

BACKGROUND

Despite its extremely low incidence, intra-abdominal herniation through the lesser omentum is associated with a high mortality rate and must be recognized early and treated urgently. To overcome a lack of data on the management of this condition, we collected and reviewed all the reported cases of operated lesser omental hernia and presented the case of a patient treated by laparoscopy for an isolated lesser omental hernia.

METHODS

According to PRISMA guidelines and using PubMed, Cochrane Library, and Web of Science, a systematic literature review of cases of lesser omental hernia treated by surgery was performed on February 12, 2023.

RESULTS

Of 482 articles, 30 were included for analysis and only 9 articles presented an isolated hernia through the lesser omentum. Among these, 4 patients were female and the median age was 38. Upper abdominal pain and vomiting were reported in 7 out of 9 patients. The small bowel was responsible for 78% (7/9) of all lesser omental herniations. All of them were treated by laparotomy. In addition, we describe the case of a 65-year-old woman without prior surgical history who was treated by laparoscopy for a spontaneous closed loop hernia through the lesser omentum without any other associated hernias.

CONCLUSION

Mostly associated with prior surgery or trauma, this type of herniation could sometimes occur spontaneously without any sign of peritonitis. Due to the high mortality rate, internal abdominal hernias should always be ruled out with a CT scan in front of patients presenting with persisting acute abdominal pain and no alternative diagnosis.

A review of internal hernias related to congenital peritoneal fossae and apertures

Congenital-type internal hernias have the potential to cause small bowel obstruction well into adulthood. Congenital-type internal hernias include left paraduodenal, right paraduodenal, foramen of Winslow, pericecal, sigmoid mesocolon, transomental, small bowel mesentery, and broad ligament hernias. This review summarizes CT imaging features and complications of congenital internal hernias using a systematic approach based on abdominopelvic quadrants and key anatomic features. CT imaging will continue to be commonly used to evaluate abdominal pain. Anatomical landmarks and characteristic CT findings can help identify congenital internal hernias as a potential cause of abdominal pain.

Internal Hernias in the Era of Multidetector CT: Correlation of Imaging and Surgical Findings

Clinical diagnosis of internal hernias is challenging because of their nonspecific signs and symptoms. Many types of internal hernias have been defined: paraduodenal, small bowel mesentery-related, greater omentum-related, lesser sac, transverse mesocolon-related, pericecal, sigmoid mesocolon-related, falciform ligament, pelvic internal, and Roux-en-Y anastomosis-related. An internal hernia is a surgical emergency that can develop into intestinal strangulation and ischemia. Accurate preoperative diagnosis is crucial for appropriate management. Multidetector computed tomography (CT), with its thin-section axial images, high-quality multiplanar reformations, and three-dimensional images, currently plays an essential role in preoperative diagnosis of internal hernias. The diagnostic approach to internal hernias at multidetector CT includes detecting an intestinal closed loop, identifying the hernia orifice, and analyzing abnormal displacement of surrounding structures and key vessels around the hernia orifice and hernia sac. At each step, multidetector CT can depict pathognomonic findings. A saclike appearance suggests an intestinal closed loop in several types of internal hernias. Convergence, engorgement, and twisting of mesenteric vessels in the hernia orifice can be seen clearly at multidetector CT, especially with use of multiplanar reformations. For definitive diagnosis of an internal hernia, analysis of displacement of anatomic landmarks around the hernia orifice is particularly important, and thin-section images provide the required information. Detailed knowledge of the anatomy, etiology, and imaging landmarks of the various hernia types is also necessary. Familiarity with the appearances of internal hernias at multidetector CT allows accurate and specific preoperative diagnosis. (©)RSNA, 2015.

Internal hernia: complex diagnostic and therapeutic problem

INTRODUCTION

Internal hernias are neglected, life threatening and generally mismanaged surgical pathologies. They may be either acquired or congenital. The mortality and morbidity rates differ between the types and unfortunately reports investigating them are very rare, with limited number of patients, and mostly case reports. In this one of the largest series of the literature, we aimed to evaluate the resemblances and the differences between these two types.

METHODS

From January 2001 to April 2008, 25 patients who underwent surgery for an internal hernia were evaluated. Patients were divided into two groups; group I consisted of patients with acquired internal hernia, and group II with congenital internal hernia. The patients' records, imaging modalities, and operative findings were recorded and analyzed statistically.

RESULTS

Group I consisted of 16 patients whilst group II consisted of nine patients. There were no significant differences between the groups with regard to gender, patients' complaints, clinical and laboratory findings, imaging modalities, types of surgical procedures, and laparotomy time. Group I was significantly older, had significantly longer length of hospital stay (13.6+/-2.3 days versus 7.2+/-1.4 days) and had significantly higher postoperative mortality rate (43.8% in group I and 22.2% in group II, p<0.01).

CONCLUSION

Acquired IH is becoming the most prevalent type of IH. They usually have rapid progression to bowel ischemia, so they have bad outcome. High index of suspicion is mandatory since the main factors that may influence the prognosis of affected patients are early diagnosis and therapy.

Clinical spectrum of internal hernia: a surgical emergency

PURPOSE

To define the indicators of bowel ischemia caused by congenital or acquired internal hernia, based on our 10-year experience in one center.

METHODS

We reviewed the medical records, imaging studies, and operative findings of 20 patients who underwent surgery for an internal hernia at our medical center between 1995 and 2005. The clinical characteristics and related indicators of the patients with, and those without bowel ischemia were compared and analyzed statistically.

RESULTS

The subtypes of congenital internal hernia (CIH) included transmesenteric (n = 6, 60%), paraduodenal (n = 2, 20%), and pericecal (n = 2, 20%) hernia. The abdominal surgical procedures preceding acquired internal hernia (AIH) were Roux-en-Y anastomosis (n = 6, 60%) and appendectomy (n = 3, 30%). Transmesenteric hernia was the most prevalent type of CIH in children. Abdominal rebound tenderness, advanced leukocytosis (>18 000/mm(3)), or a high level of manual band form (>6%) were the positive predictive factors for bowel ischemia, whereas a history of chronic intermittent abdominal pain was a negative indicator. No recurrence was noted during the 10-year study period. The overall mortality rate was 20%, attributable to enteral bacteria sepsis in all cases.

CONCLUSION

Internal hernia is a rare but lethal condition. Early diagnosis and prompt surgical intervention provide the only chance of a successful outcome.

Rare cause of acute pain in the left upper abdominal quadrant

We report a case of a 45-year-old man with acute pain in the left upper abdominal quadrant. Extensive diagnostic workup remained inconclusive. An exploratory laparotomy revealed herniation of the entire ascending colon, together with a part of the terminal ileum through the foramen of Winslow into the bursa omentalis. The internal hernia was further complicated by a perforated appendicitis within the bursa, explaining the acuteness of the symptoms. Reduction of the hernia, appendectomy and colopexy were performed consequently. This would be the first reported case of a perforated appendicitis within the lesser sack.

Internal hernias: anatomical basis and clinical relevance

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.

Left-sided paraduodenal hernia: report of a case

Paraduodenal hernias are rare congenital malformations consisting of incomplete rotation of the midgut, which may lead to intestinal obstruction or simply be detected as an incidental finding at autopsy or laparotomy. We report a case of left paraduodenal hernia diagnosed preoperatively by computed tomography and operated on in an emergency setting for signs of peritoneal irritation. A misdiagnosis had been made when the patient suffered his first attack 6 months earlier and he had been treated for familial Mediterranean fever. We reduced the small bowel loops from the left paraduodenal hernia sac with ligation and transection of the inferior mesenteric vessels. The patient was discharged from hospital on postoperative day 4 after an uneventful recovery.

Rare cause of ileus in the mesenteric cavity of terminal ileum: A report of three cases

Internal herniation is one of the rare reasons of intestine clog, which is hard to diagnose and usually needs an urgent surgical treatment. We report 3 patients with internal herniation in the mesenteric cavity of the terminal ileum. Besides intestinal congestion, they also had peritoneal irritation. Laparotomy revealed that herniation caused disorder in nutrition of the intestine and necrosis. The patients underwent subtotal small intestine resection and were discharged 10, 12 and 14 d after operation.

Laparoscopic management of an internal double omental hernia: A rare cause of intestinal obstruction

INTRODUCTION

Internal hernia is a very rare cause of intestinal obstruction (0.2-0.9% of cases), associated with 45% mortality. A review of the literature revealed just eight reported cases of double omental hernia since 1950 of which our patient is the first case successfully treated laparoscopically.

CASE PRESENTATION

We report on a 29-year-old man who presented with signs and symptoms of intestinal obstruction. The patient underwent emergent exploratory laparoscopy. This revealed herniation of a 20-cm jejunal loop through the gastrocolic ligament and reemergence through a defect in the gastrohepatic ligament. The strangulated loop was reduced with slight traction, and the defect was repaired. The patient was discharged from hospital in just 5 days' time, and after 6 months of follow-up, the general condition of the patient was normal.

CONCLUSIONS

Laparoscopy is a good technique with minimal complications compared with laparotomy. As many cases are missed due to nonspecific signs and symptoms, an urgent laparoscopy or laparotomy is highly recommended in such a situation.

Strangulated internal hernia through the lesser omentum with intestinal necrosis: a case report

CONTEXT

Internal hernias account for only 0.2 to 0.9% of the cases of intestinal obstruction. They do not have specific clinical manifestations, and are usually diagnosed during laparotomy for acute intestinal obstruction. Internal hernias through the lesser omentum are extremely rare.

CASE REPORT

We report here the case of a 36-year-old patient who underwent exploratory laparotomy for acute intestinal obstruction. An internal hernia through the lesser omentum was found, with a strangulated ileal segment passing through the perforation into an abscess within the lesser sac. The surgical procedures included ileal resection, primary anastomosis, abscess removal, and placement of a drain in the lesser sac. The patient was reoperated 6 days later for abdominal sepsis; a lesser sac abscess was removed and the abdominal incision was left open. The patient stayed in the Intensive Care Unit for 15 days, and eventually left the hospital on the 28th post-admission day, with complete recovery thereafter.

CONCLUSION

The early diagnosis of acute intestinal obstruction and immediate indication for laparotomy is the main task of the surgeon when faced with a case of acute abdomen with a hypothesis of internal hernia, so as to minimize severe postoperative complications, as illustrated by the present case.