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Hernia of cecum and ascending colon through the foramen of Winslow
CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 4 (2013) 879–881
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Hernia of cecum and ascending colon through the foramen of Winslow夽 Carlos A. Puig ∗ , Joseph B. Lillegard, James E. Fisher, Henry J. Schiller Division of Trauma Critical Care and General Surgery, Mayo Clinic, Rochester, MN, United States
a r t i c l e
i n f o
Article history: Received 8 May 2013 Received in revised form 21 June 2013 Accepted 23 July 2013 Available online 3 August 2013 Keywords: Internal hernia Foramen of Winslow Cecum Ischemia
a b s t r a c t INTRODUCTION: Internal hernias through the foramen of Winslow are rare events and constitute 8% of internal hernias but only 0.1% of all abdominal hernias. PRESENTATION OF CASE: A 62-year-old man presented with upper abdominal pain, distention and vomiting, and was shown on CT scan to have the right colon and cecum herniating into the lesser sac through the foramen of Winslow. This diagnosis was confirmed at laparotomy as well as a midgut volvulus and right hemicolectomy was performed because of ischemic changes of the cecum. DISCUSSION: Six developmental abnormalities may result in internal herniation of bowel contents in the abdomen: (i) abnormal retroperitoneal fixation of the mesentery resulting in anomalous positioning of the intestine; (ii) incomplete mesenteric surfaces with the presence of abnormal opening through which the intestine herniates, (iii) abnormally large internal foramina or fossae (e.g. foramen of Winslow); (iv) abnormally long small-bowel mesentery; (v) an elongated right hepatic lobe thought to guide bowel into the foramen of Winslow, and (vi) persistence of the ascending mesocolon allowing marked mobility of the right colon. CONCLUSION: We believe that hypermobile cecum was responsible for the internal herniation through the foramen of Winslow and that this served as the lead point allowing for the midgut volvulus. There is no consensus on the surgical management of internal hernias through the Foramen of Winslow when the herniated contents are grossly viable. The literature in this regard is scarce and surgical decision making is based on surgeon preference and the viability of the herniated intraabdominal contents. © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved.
1. Introduction
2. Case report
The foramen of Winslow is a normal communication between the greater and lesser peritoneal cavities, located beneath the free edge of the lesser omentum, and the hepatoduodenal ligament. The posterior, superior, and inferior boundaries of this foramen include the inferior vena cava, caudate lobe, and duodenum, respectively.1 Internal hernias through the Foramen of Winslow are rare events and constitute 8% of internal hernias but only 0.1% of all abdominal hernias.2 Two thirds of these hernias contain small bowel alone with the remaining one third containing other structures such as the cecum, ascending and transverse colon, gallbladder and/or omentum.1–10 In addition, internal hernias account for approximately 0.5–5.8% of all cases of intestinal obstructions and are associated with a high mortality rate, exceeding 50% in some series.11
A 62-year-old male presented to the Emergency Department with sharp, crampy abdominal pain in the epigastrium. The pain was progressive, began nearly 24 h before presentation and was associated with nausea, vomiting, and fever. He had no history of malignancy, weight loss, prior abdominal operations or recent trauma. He did have a history of alcohol abuse (6–8 beers/day). His family history was non-contributory. Physical exam revealed tenderness in the epigastrium and mild distension without evidence of peritonitis. Bowel sounds were present. The patient was tachycardic and diaphoretic. The remaining physical examination was otherwise unrevealing. Laboratory studies showed mild elevation of pancreatic enzymes and hyponatremia (Table 1). No significant leukocytosis or metabolic acidosis was present. The patient was admitted to the hospital with a presumptive diagnosis of alcoholic pancreatitis. He was treated with bowel rest, intravenous hydration and given medication to relieve pain and nausea. His pain initially improved although his abdominal distention increased despite the presence of bowel sounds. On hospital day three, he resumed a diet, which lead to nausea, pain and emesis. Computed tomography (CT) scan of the abdomen and pelvis was performed which revealed an internal hernia of the cecum and
夽 This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike License, which permits noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. ∗ Corresponding author at: Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. Tel.: +1 507 255 2245. E-mail address: [email protected] (C.A. Puig).
2210-2612/$ – see front matter © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2013.07.014
CASE REPORT – OPEN ACCESS 880
C.A. Puig et al. / International Journal of Surgery Case Reports 4 (2013) 879–881
Table 1 Laboratory values with normal reference ranges at the time of presentation to the emergency department. Laboratory studies CBC Hemoglobin Hematocrit WBC Platelets Chemistries Sodium Potassium Chloride Bicarbonate Glucose BUN Creatinine Alkaline phosphatase AST (GOT) Lipase Total bilirubin Direct bilirubin Lactate
Results
Reference interval
14.3 39.7 9.7 287
13.5–17.5 g/dl 38.8–50% 3.5–10.5 × 10(9)/L 150–450 × 10(9)/L
128 4.6 93 26 120 9 0.9 53 47 112 0.6 0.1 1.6
135–145 mmol/L 3.6–5.2 × 10(9)/L 100–108 mmol/L 22–29 mmol/L 70–140 mg/dl 8–24 mg/dl 0.8–1.3 mg/dl 45–115 U/L 8–48 U/L 10–73 mg/dl 0.1–1 mg/dl 0.0–0.3 mg/dl 0.6–2.3 mmol/L
right colon through the foramen of Winslow with free intraperitoneal fluid and an area of possible pneumatosis coli (Figs. 1 and 2). There was no evidence of free intraperitoneal air or portal venous gas. A surgical consultation was obtained. Physical exam findings at that time showed focal peritonitis in the epigastrium. At laparotomy, there was turbid ascites without any obvious hollow viscus perforation. The right colon, cecum and terminal ileum had herniated through foramen of Winslow. The cecum was markedly distended with areas of patchy necrosis without frank perforation (Fig. 3). Reduction of the internal hernia revealed a 360◦ twist of the small bowel mesentery consistent with a midgut volvulus. The small bowel was dusky but viable and an incidental Meckel’s diverticulum was found. After reducing the midgut volvulus, the small bowel was seen to be viable and well perfused. Right hemicolectomy with primary anastomosis was performed, due to
Fig. 2. CT abdomen and pelvis with coronal views. The cecum (C) and proximal right colon have herniated into the lesser sac behind the stomach (S) through the foramen of Winslow. Air in the dependent portion of the lumen of cecum (small solid arrow).
patchy necrosis of the cecum. The fascia and skin were closed. The patient did well postoperatively and was discharged on postoperative day four. 3. Discussion There are six developmental abnormalities that may result in internal herniation of bowel contents in the abdomen: (i) abnormal retroperitoneal fixation of the mesentery resulting in anomalous
Fig. 1. CT abdomen and pelvis with axial views. The cecum (C) and proximal right colon have herniated into the lesser sac behind the stomach (S) through the foramen of Winslow. Air in the dependent portion of the lumen of cecum (small solid arrow).
Fig. 3. Intraoperative photo. Cecum herniating into lesser sac through foramen of Winslow. Cecum (C), transverse colon (TC), stomach (S), omentum (O), and small bowel (SB).
CASE REPORT – OPEN ACCESS C.A. Puig et al. / International Journal of Surgery Case Reports 4 (2013) 879–881
positioning of the intestine (e.g. mesocolic or paraduodenal hernias); (ii) incomplete mesenteric surfaces with the presence of abnormal opening through which the intestine herniates (e.g. mesenteric hernias); (iii) abnormally large internal foramina or fossae (e.g. foramen of Winslow and supravesical hernias; (iv) abnormally long small-bowel mesentery; (v) an elongated right hepatic lobe thought to guide bowel into the foramen of Winslow, (vi) persistence of the ascending mesocolon allowing marked mobility of the right colon.11,12 Erskine and colleagues have also postulated that failure of the right colon to retroperitonealize along with changes in intra-abdominal pressure may contribute to the development of an internal hernia through the Foramen of Winslow. [7] This type of hernia was initially described as an operative diagnosis; currently preoperative diagnosis is more common due to better imaging modalities including CT scan. Features of cecal herniation through the foramen of Winslow identified by CT include: (i) mesenteric fat and vessels posterior to the portal structures, (ii) gas and/or fluid in the lesser sac with a “bird’s beak” pointing toward the epiploic foramen and (iii) the cecum absent from its normal anatomic position.10,13
4. Conclusion Our patient had hypermobility of the cecum and ascending colon with an apparently normal sized foramen of Winslow. We believe that cecal hypermobility was the cause of the internal hernia and that midgut volvulus was secondary to the internal herniation. There is no consensus on the surgical management of internal hernias through the Foramen of Winslow when the herniated contents are grossly viable. In our patient the cecum was found to have patchy necrosis, which made the decision of resection straight forward. Surgical options at laparotomy with viable tissue are: reduction of hernia with or without cecopexy, creation of a peritoneal flap to cover herniated right colon and cecum and resection of herniated contents to prevent recurrence. The literature in this regard is scarce due to the rarity of this type of hernia and surgical decision making is based on surgeon preference and the viability of the herniated intraabdominal contents. Conflict of interest None.
881
Funding Department of General Surgery (Mayo Clinic, Rochester) intramural funding. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Authors’ contributions Case report writing, data collection, and discussion writing were done by Carlos A. Puig. Discussion writing was carried by Joseph B. Lillegard, James E. Fisher and Henry J. Schiller. Henry J. Schiller also reviewed. References 1. Orseck MJ, Ross PJ, Morrow CE. Herniation of the hepatic flexure through the foramen of Winslow: a case report. American Surgeon 2000;66:602–3. 2. Valenziano CP, Howard WB, Criado FJ. Hernia through the foramen of Winslow: a complication of cholecystectomy. A case report. American Surgeon 1987;53:254–7. 3. Meyers MA. Dynamic radiology of the abdomen: normal and pathologic anatomy. 4th ed. New York, NY: Springer-Verlag; 1994. 4. Ghahremani GG. Abdominal and pelvic hernias. In: Gore RM, Levine MS, editors. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia, PA: Saunders; 2000. p. 1993–2009. 5. Blachar A, Federle MP. Internal hernia: an increasingly common cause of small bowel obstruction. Seminars in Ultrasound, CT and MR 2002;23:174–83. 6. Mathieu D, Luciani A. Internal abdominal herniations. American Journal of Roentgenology 2004;83:397–404. 7. Erskine JM. Hernia through the foramen of Winslow: a case report of the cecum incarcerated in the lesseromental cavity. American Journal of Surgery 1967;114:941–7. 8. Erskine JM. Hernia through the foramen of Winslow. Surgery, Gynecology and Obstetrics 1967;125:1093–109. 9. Goldberger LE, Berk RN. Cecal hernia into the lesser sac. Gastrointestinal Radiology 1980;5:169–72. 10. Wojtasek DA, Codner MA, Nowak EJ. CT diagnosis of cecal herniation through the foramen of Winslow. Gastrointestinal Radiology 1991;16:77–9. 11. Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. American Journal of Roentgenology 2006;186(3):703–17. 12. Townsend Jr CM, Beauchamp DB, Evers BE, Mattox KL. Towsend: Sabiston textbook of surgery. 17th ed. Philadelphia, PA: WB Saunders/Elsevier; 2004. p. 1190. 13. Schuster MR, Tu RK, Scanlan KA. Cecal herniation through the foramen of Winslow: diagnosis by computed tomography. British Journal of Radiology 1992;65:1047–8.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Hernia of cecum and ascending colon through the foramen of Winslow夽 Carlos A. Puig ∗ , Joseph B. Lillegard, James E. Fisher, Henry J. Schiller Division of Trauma Critical Care and General Surgery, Mayo Clinic, Rochester, MN, United States
a r t i c l e
i n f o
Article history: Received 8 May 2013 Received in revised form 21 June 2013 Accepted 23 July 2013 Available online 3 August 2013 Keywords: Internal hernia Foramen of Winslow Cecum Ischemia
a b s t r a c t INTRODUCTION: Internal hernias through the foramen of Winslow are rare events and constitute 8% of internal hernias but only 0.1% of all abdominal hernias. PRESENTATION OF CASE: A 62-year-old man presented with upper abdominal pain, distention and vomiting, and was shown on CT scan to have the right colon and cecum herniating into the lesser sac through the foramen of Winslow. This diagnosis was confirmed at laparotomy as well as a midgut volvulus and right hemicolectomy was performed because of ischemic changes of the cecum. DISCUSSION: Six developmental abnormalities may result in internal herniation of bowel contents in the abdomen: (i) abnormal retroperitoneal fixation of the mesentery resulting in anomalous positioning of the intestine; (ii) incomplete mesenteric surfaces with the presence of abnormal opening through which the intestine herniates, (iii) abnormally large internal foramina or fossae (e.g. foramen of Winslow); (iv) abnormally long small-bowel mesentery; (v) an elongated right hepatic lobe thought to guide bowel into the foramen of Winslow, and (vi) persistence of the ascending mesocolon allowing marked mobility of the right colon. CONCLUSION: We believe that hypermobile cecum was responsible for the internal herniation through the foramen of Winslow and that this served as the lead point allowing for the midgut volvulus. There is no consensus on the surgical management of internal hernias through the Foramen of Winslow when the herniated contents are grossly viable. The literature in this regard is scarce and surgical decision making is based on surgeon preference and the viability of the herniated intraabdominal contents. © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved.
1. Introduction
2. Case report
The foramen of Winslow is a normal communication between the greater and lesser peritoneal cavities, located beneath the free edge of the lesser omentum, and the hepatoduodenal ligament. The posterior, superior, and inferior boundaries of this foramen include the inferior vena cava, caudate lobe, and duodenum, respectively.1 Internal hernias through the Foramen of Winslow are rare events and constitute 8% of internal hernias but only 0.1% of all abdominal hernias.2 Two thirds of these hernias contain small bowel alone with the remaining one third containing other structures such as the cecum, ascending and transverse colon, gallbladder and/or omentum.1–10 In addition, internal hernias account for approximately 0.5–5.8% of all cases of intestinal obstructions and are associated with a high mortality rate, exceeding 50% in some series.11
A 62-year-old male presented to the Emergency Department with sharp, crampy abdominal pain in the epigastrium. The pain was progressive, began nearly 24 h before presentation and was associated with nausea, vomiting, and fever. He had no history of malignancy, weight loss, prior abdominal operations or recent trauma. He did have a history of alcohol abuse (6–8 beers/day). His family history was non-contributory. Physical exam revealed tenderness in the epigastrium and mild distension without evidence of peritonitis. Bowel sounds were present. The patient was tachycardic and diaphoretic. The remaining physical examination was otherwise unrevealing. Laboratory studies showed mild elevation of pancreatic enzymes and hyponatremia (Table 1). No significant leukocytosis or metabolic acidosis was present. The patient was admitted to the hospital with a presumptive diagnosis of alcoholic pancreatitis. He was treated with bowel rest, intravenous hydration and given medication to relieve pain and nausea. His pain initially improved although his abdominal distention increased despite the presence of bowel sounds. On hospital day three, he resumed a diet, which lead to nausea, pain and emesis. Computed tomography (CT) scan of the abdomen and pelvis was performed which revealed an internal hernia of the cecum and
夽 This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike License, which permits noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. ∗ Corresponding author at: Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. Tel.: +1 507 255 2245. E-mail address: [email protected] (C.A. Puig).
2210-2612/$ – see front matter © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2013.07.014
CASE REPORT – OPEN ACCESS 880
C.A. Puig et al. / International Journal of Surgery Case Reports 4 (2013) 879–881
Table 1 Laboratory values with normal reference ranges at the time of presentation to the emergency department. Laboratory studies CBC Hemoglobin Hematocrit WBC Platelets Chemistries Sodium Potassium Chloride Bicarbonate Glucose BUN Creatinine Alkaline phosphatase AST (GOT) Lipase Total bilirubin Direct bilirubin Lactate
Results
Reference interval
14.3 39.7 9.7 287
13.5–17.5 g/dl 38.8–50% 3.5–10.5 × 10(9)/L 150–450 × 10(9)/L
128 4.6 93 26 120 9 0.9 53 47 112 0.6 0.1 1.6
135–145 mmol/L 3.6–5.2 × 10(9)/L 100–108 mmol/L 22–29 mmol/L 70–140 mg/dl 8–24 mg/dl 0.8–1.3 mg/dl 45–115 U/L 8–48 U/L 10–73 mg/dl 0.1–1 mg/dl 0.0–0.3 mg/dl 0.6–2.3 mmol/L
right colon through the foramen of Winslow with free intraperitoneal fluid and an area of possible pneumatosis coli (Figs. 1 and 2). There was no evidence of free intraperitoneal air or portal venous gas. A surgical consultation was obtained. Physical exam findings at that time showed focal peritonitis in the epigastrium. At laparotomy, there was turbid ascites without any obvious hollow viscus perforation. The right colon, cecum and terminal ileum had herniated through foramen of Winslow. The cecum was markedly distended with areas of patchy necrosis without frank perforation (Fig. 3). Reduction of the internal hernia revealed a 360◦ twist of the small bowel mesentery consistent with a midgut volvulus. The small bowel was dusky but viable and an incidental Meckel’s diverticulum was found. After reducing the midgut volvulus, the small bowel was seen to be viable and well perfused. Right hemicolectomy with primary anastomosis was performed, due to
Fig. 2. CT abdomen and pelvis with coronal views. The cecum (C) and proximal right colon have herniated into the lesser sac behind the stomach (S) through the foramen of Winslow. Air in the dependent portion of the lumen of cecum (small solid arrow).
patchy necrosis of the cecum. The fascia and skin were closed. The patient did well postoperatively and was discharged on postoperative day four. 3. Discussion There are six developmental abnormalities that may result in internal herniation of bowel contents in the abdomen: (i) abnormal retroperitoneal fixation of the mesentery resulting in anomalous
Fig. 1. CT abdomen and pelvis with axial views. The cecum (C) and proximal right colon have herniated into the lesser sac behind the stomach (S) through the foramen of Winslow. Air in the dependent portion of the lumen of cecum (small solid arrow).
Fig. 3. Intraoperative photo. Cecum herniating into lesser sac through foramen of Winslow. Cecum (C), transverse colon (TC), stomach (S), omentum (O), and small bowel (SB).
CASE REPORT – OPEN ACCESS C.A. Puig et al. / International Journal of Surgery Case Reports 4 (2013) 879–881
positioning of the intestine (e.g. mesocolic or paraduodenal hernias); (ii) incomplete mesenteric surfaces with the presence of abnormal opening through which the intestine herniates (e.g. mesenteric hernias); (iii) abnormally large internal foramina or fossae (e.g. foramen of Winslow and supravesical hernias; (iv) abnormally long small-bowel mesentery; (v) an elongated right hepatic lobe thought to guide bowel into the foramen of Winslow, (vi) persistence of the ascending mesocolon allowing marked mobility of the right colon.11,12 Erskine and colleagues have also postulated that failure of the right colon to retroperitonealize along with changes in intra-abdominal pressure may contribute to the development of an internal hernia through the Foramen of Winslow. [7] This type of hernia was initially described as an operative diagnosis; currently preoperative diagnosis is more common due to better imaging modalities including CT scan. Features of cecal herniation through the foramen of Winslow identified by CT include: (i) mesenteric fat and vessels posterior to the portal structures, (ii) gas and/or fluid in the lesser sac with a “bird’s beak” pointing toward the epiploic foramen and (iii) the cecum absent from its normal anatomic position.10,13
4. Conclusion Our patient had hypermobility of the cecum and ascending colon with an apparently normal sized foramen of Winslow. We believe that cecal hypermobility was the cause of the internal hernia and that midgut volvulus was secondary to the internal herniation. There is no consensus on the surgical management of internal hernias through the Foramen of Winslow when the herniated contents are grossly viable. In our patient the cecum was found to have patchy necrosis, which made the decision of resection straight forward. Surgical options at laparotomy with viable tissue are: reduction of hernia with or without cecopexy, creation of a peritoneal flap to cover herniated right colon and cecum and resection of herniated contents to prevent recurrence. The literature in this regard is scarce due to the rarity of this type of hernia and surgical decision making is based on surgeon preference and the viability of the herniated intraabdominal contents. Conflict of interest None.
881
Funding Department of General Surgery (Mayo Clinic, Rochester) intramural funding. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Authors’ contributions Case report writing, data collection, and discussion writing were done by Carlos A. Puig. Discussion writing was carried by Joseph B. Lillegard, James E. Fisher and Henry J. Schiller. Henry J. Schiller also reviewed. References 1. Orseck MJ, Ross PJ, Morrow CE. Herniation of the hepatic flexure through the foramen of Winslow: a case report. American Surgeon 2000;66:602–3. 2. Valenziano CP, Howard WB, Criado FJ. Hernia through the foramen of Winslow: a complication of cholecystectomy. A case report. American Surgeon 1987;53:254–7. 3. Meyers MA. Dynamic radiology of the abdomen: normal and pathologic anatomy. 4th ed. New York, NY: Springer-Verlag; 1994. 4. Ghahremani GG. Abdominal and pelvic hernias. In: Gore RM, Levine MS, editors. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia, PA: Saunders; 2000. p. 1993–2009. 5. Blachar A, Federle MP. Internal hernia: an increasingly common cause of small bowel obstruction. Seminars in Ultrasound, CT and MR 2002;23:174–83. 6. Mathieu D, Luciani A. Internal abdominal herniations. American Journal of Roentgenology 2004;83:397–404. 7. Erskine JM. Hernia through the foramen of Winslow: a case report of the cecum incarcerated in the lesseromental cavity. American Journal of Surgery 1967;114:941–7. 8. Erskine JM. Hernia through the foramen of Winslow. Surgery, Gynecology and Obstetrics 1967;125:1093–109. 9. Goldberger LE, Berk RN. Cecal hernia into the lesser sac. Gastrointestinal Radiology 1980;5:169–72. 10. Wojtasek DA, Codner MA, Nowak EJ. CT diagnosis of cecal herniation through the foramen of Winslow. Gastrointestinal Radiology 1991;16:77–9. 11. Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. American Journal of Roentgenology 2006;186(3):703–17. 12. Townsend Jr CM, Beauchamp DB, Evers BE, Mattox KL. Towsend: Sabiston textbook of surgery. 17th ed. Philadelphia, PA: WB Saunders/Elsevier; 2004. p. 1190. 13. Schuster MR, Tu RK, Scanlan KA. Cecal herniation through the foramen of Winslow: diagnosis by computed tomography. British Journal of Radiology 1992;65:1047–8.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.