Caecal herniation through the foramen of Winslow

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.

Cecal bascule herniation through the foramen of Winslow

Bowel obstructions can have a variety of causes, including impacted feces, adhesions, volvulus, non-internal hernias, and in rare cases internal hernias. We report a 63-year-old woman who presented to the emergency department with severe abdominal pain, nausea, vomiting, and obstructive symptoms that had started 12 hours earlier. A computed tomographic scan of the abdomen and pelvis showed a right internal hernia with a cecal bascule traversing through the foramen of Winslow, concerning for a closed-loop obstruction. The patient underwent an exploratory laparotomy with cecal bascule reduction and cecopexy. Given the increased mortality risk if undiagnosed, it is important to remain aware of internal hernias. Patient outcomes are markedly improved with early diagnosis and surgical intervention.

Laparoscopic management of an ascending colon hernia through the foramen of Winslow

Herniation through the foramen of Winslow is rare, with a non-specific clinical presentation and his diagnosis may be difficult. A 44-year-old female was admitted with an acute epigastric abdominal pain. A computed tomography showed an internal hernia of the colon in the lesser sac. Laparoscopic reduction of the herniated contents and the fixation of the ascending colon with several non-absorbable sutures were performed. Twenty months after surgery, the patient has not experienced any recurrence. Computed tomography helps practitioners to the preoperative diagnosis of herniation through the foramen of Winslow, to the viability of the herniated contents and presence of occlusion. In case of herniation through the foramen of Winslow favored by a mobile ascending colon with a misapposition of the right Told fascia, the fixation of the colon with a non-absorbable suture was safe and may prevent the risk of recurrent internal hernia and colonic volvulus.

Internal herniation of the caecum and the ascending colon through the foramen of Winslow

We are reporting a case of internal herniation of the bowel through the foramen of Winslow. This is a very rare condition that prompts an urgent operative intervention due to its potential fatal complications, as it is usually accompanied by bowel strangulation and ischemia. Due to the vague clinical picture, the diagnosis only reached using imaging techniques such as computed tomography or as a surgical surprise during the operation. Key aspects of surgical interventions are hernia reduction, bowel resection in case of non-viable ischemic bowel and the highly debatable recurrence prevention maneouvres.

Internal hernia with incarceration of the cecum through a loop created by an elongated fallopian tube

We describe a case of a 61-year-old female who presented to the emergency department with a 2-week history of severe right and left lower abdominal quadrant abdominal pain that radiated to the back and was accompanied by nausea and vomiting. An initial computed tomography scan with contrast demonstrated unusual loops of small bowel in the left paracentral pelvis. Follow-up computed tomography scans revealed worsening dilation of the cecum. Exploratory laparotomy was indicated and revealed a mobile right mesenteric stalk, which had migrated to the left lower abdominal quadrant and become incarcerated within a loop formed by a 25 cm long left fallopian tube. The distal end of the fallopian tube was firmly adherent to the parietal peritoneum of the left lower quadrant. A right hemicolectomy and a left salpingo-oophorectomy were performed. This case appears to be the first to document the internal herniation of a mobile cecum and right mesenteric stalk through a highly unusual loop created by an elongated left fallopian tube.