Correct preoperative diagnosis of herniation through the Foramen of Winslow: two case reports

Abstract

We report two cases of one of the most infrequent types of internal abdominal hernias, i.e. incarcerated herniation through the Foramen of Winslow, with emphasis on appropriate preoperative radiological diagnosis using multidetector row computed tomography (MDCT) in both cases, and their successful surgical treatment.

Difficult diagnosis: internal herniation of the terminal ileum through the foramen of Winslow into the lesser sac

“…The protrusion of intra-abdominal viscera through the foramen of Winslow, a communication between the greater and lesser sac, is a type of herniation, since this peritoneal opening is normally kept shut by intra-abdominal pressure 6. The foramen of Winslow boundaries include the duodenum inferiorly, the caudate lobe of the liver superiorly, vena cava posteriorly and the hepatoduodenal ligament anteriorly, which contains, of note, the portal vein, common bile duct and hepatic artery.…”

“…MDCT scans produce high-quality, multiplanar reconstruction (MPR) images using axial slices, which are able to identify the exact location of an internal hernia. González et al 6 reported two correct preoperative diagnoses of internal herniation through the foramen of Winslow, using MDCT. Furthermore, MDCTs have been shown to identify dead bowel.…”

Internal hernia through the foramen of Winslow: a diagnosis to consider in moderate epigastric pain

“…Foramen of Winslow hernia can be defined as peculiar variant of internal abdominal hernia, since it is a normal peritoneal orifice kept closed by normal intra-abdominal pressure that may be permeated by the intra-abdominal viscera [3]. …”

“…Various, more or less specific findings have been reported, such as an air-fluid collection in the lesser sac or signs of small bowel obstruction associated with the presence of mesenteric vessels stretching anterior to the inferior vena cava and posterior to the portal vein; the absence of the ascending colon in the right gutter and an antero-lateral displacement of the stomach [3]. …”

“…This option can however lead to meaningful complications such as accretions and/or portal vein thrombosis. Thus, leaving the foramen open may be justifiable since the inflammatory post-operative adhesions will most often obliterate the foramen entrance with no evidence of recurrent herniation [3, 6]. …”