Case of ileal herniation through the foramen of Winslow diagnosed preoperatively by CT and treated with laparoscopic surgery

Abstract

A previously healthy 35-year-old man visited the emergency room complaining of epigastric pain and vomiting. The pain was sudden in onset. His blood tests were within normal limits except for a mild neutrophilia of 14 300/μL. Enhanced abdominal CT scan showed the small intestine dilated into the space between the portal vein and inferior vena cava from the foramen of Winslow. Under the diagnosis of herniation through the foramen of Winslow (HFW), we performed emergency laparoscopic surgery. Laparoscopy revealed an internal herniation of the dilated small intestine through the foramen of Winslow. Because the herniated small intestine was viable, intestinal resection was unnecessary. We released the incarceration under laparoscopy. HFW is very rare and often overlooked, but abdominal CT examination enabled a precise preoperative diagnosis because of characteristic findings. We should consider the possibility of HFW in patients with internal herniation of unknown origin. Laparoscopic surgery for HFW is effective.

Herniation of the hepatic flexure through the foramen of Winslow, and a review of literature describing the minimally invasive technique

“…The foramen is bounded superiorly by the peritoneum of the caudate lobe, inferiorly by first part of the duodenum, anteriorly by the hepatoduodenal ligament and posteriorly by the inferior vena cava 7 13. The anterior boundary formed as by the hepatoduodenal ligament is of importance as it contains the portal vein, common bile duct and hepatic artery 11…”

“…Foramen of Winslow hernia tend to occur most frequently from the third to sixth decade, with increased prevalence in men 5 6 10. Various factors have been identified to predispose patients to such a hernia: an abnormally large foramen of greater than 3 cm2 7 8 10–12; long hypermobile small bowel mesentery2 7 10 11; persistence of ascending colon mesocolon2 7 8 11; non-retroperinteal right colon7 8 11 12; large right hepatic lobe2 7 10 11; gastrohepatic ligament defects8 14; greater omentum atrophy; and bowel malrotations 8 11…”

“…Patients would usually present with upper abdominal pain, typically in the epigastric region, radiating to left hypochondrium, left shoulder or back 2 6–8 11. This may be accompanied by symptoms of acute bowel obstructions, and are relieved by bending forward or lying with trunk flexion as such position widens the foramen 2 8.…”

“…The viscera most commonly involved are the small bowel (63%), ascending colon and caecum (30%), and transverse colon (7%) 2 5 8. Cases of gallbladder, greater omentum, small bowel diverticulum and Meckel’s diverticulum have also been reported 2 4 5 8–11…”

“…Since the first case of herniation through the foramen of Winslow reported by Bladin in 1834, there have been about 200 cases reported 2 4 5 7 8 10 11. Clinical diagnosis is often difficult with non-specific symptoms, and mild peritoneal signs due to pathology located in the lesser sac.…”