Intestinal obstruction due to small bowel herniation through foramen of Winslow: a case report 

Abstract

Background Intestinal obstruction due to internal herniation of the bowel is a rare clinical entity which is often overlooked in the differential diagnosis of patients with abdominal pain who have no previous history of abdominal surgery. Several sites of bowel internal herniation have been described, amongst which internal herniation through the foramen of Winslow accounts for about 8% of cases. These patients present with nonspecific abdominal pain associated with symptoms of gastroesophageal reflux disease, and hence the diagnosis is often overlooked. The usual symptoms of intestinal obstruction can be delayed, which results in a delay in diagnosis and gangrene of the herniated bowel segment. Abdominal radiographs and computed tomography are helpful in the diagnosis. Open reduction is the management of choice; however, laparoscopic reduction has also been attempted, with good results. Case presentation We report a case of a middle-aged Sri Lankan man who presented with features of gastroesophageal reflux disease, developed features of intestinal obstruction and was found to have a gangrenous small bowel loop which had herniated through the foramen of Winslow. Following needle aspiration and reduction of the herniated small bowel loop, the gangrenous part of the small bowel was resected and an ileoileal anastomosis performed. The large foramen of Winslow was partially closed with interrupted stitches. The patient made an uneventful recovery. Conclusion Since delayed diagnosis of bowel obstruction is detrimental, it is of utmost importance to diagnose it early. Because internal herniation of the small bowel through the foramen of Winslow presents with nonspecific symptoms including features of gastroesophageal reflux disease, as documented in several cases worldwide and also presented by our patient, there should be a high degree of suspicion of internal herniation of the bowel causing bowel obstruction and low threshold for extensive investigation of patients presenting with symptoms of gastroesophageal reflux disease which does not resolve with usual medication.

Lesser sac hernia through the gastrocolic ligament 20 years post subtotal colectomy

“…Lesser sac hernia risk factors include common intestinal mesentery, long small bowel mesentery and an enlarged foramen of Winslow, which all commonly predispose to foramen of Winslow lesser sac hernias 7 . Other risk factors postulated include underlying congenital malformations, extreme weight loss, inflammatory conditions and previous small or large bowel surgery as seen in this case 2,3,5,8 .…”

A rare case of internal hernia through the foramen of Winslow

“…This predisposes to herniation of the cecum and ascending colon, as described in some previous case reports [ 3–7 ]. Similarly, isolated parts of the small intestine [ 8 , 9 ] or parts of the transverse colon [ 10 ] can also herniate into the foramen of Winslow. An early diagnosis is crucial for prognosis.…”

A case of abdominal internal hernia through the foramen of Winslow in a pediatric emergency department

“…Las hernias internas abdominales son un una patología muy poco frecuente, especialmente durante la edad pediátrica, causando el 0,5-6% de los casos 1 . Solo el 8% corresponden a hernias por el hiato de Winslow 2 , con menos de 200 casos publicados. El hiato de Winslow, o foramen epiploico, representa la única comunicación entre la cavidad peritoneal mayor y la transcavidad de los epiplones.…”