Ali, SM

Kukreja, N

Sollei, T

Tse, G

BJR|case reports

Internal hernia is the protrusion of an abdominal viscus through the peritoneum or mesentery into a compartment within the abdominal cavity. We present a case of internal herniation through the foramen of Winslow that was identified by CT imaging. It was treated with reduction at laparotomy and subsequent right hemicolectomy.published_or_final_versio

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Title Caecal herniation through the foramen of WinslowAuthor(s) Tse, G; Sollei, T; Ali, SM; Kukreja, NCitation BJR case reports, 2016, article no. 20150330Issued Date 2016URL http://hdl.handle.net/10722/223186Rights This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Received:25 August 2015Revised:11 January 2016Accepted:13 January 2016Cite this article as:Tse G, Sollei T, Ali SM, Kukreja N. Caecal herniation through the foramen of Winslow. BJR Case Rep 2016; 2: 20150330.CASE REPORTCaecal herniation through the foramen of Winslow1GARY TSE, MA, PhD, 2TAMAS SOLLEI, MD, MRCS, 2SYED MOHAMMED ALI, MBBS, MRCS and 2NEIL KUKREJA, MSc, FRCS1School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China2Department of General Surgery, Medway Maritime Hospital, Kent, UKAddress correspondence to: Neil KukrejaE-mail: n.kukreja@nhs.netABSTRACTInternal hernia is the protrusion of an abdominal viscus through the peritoneum or mesentery into a compartment withinthe abdominal cavity. We present a case of internal herniation through the foramen of Winslow that was identified by CTimaging. It was treated with reduction at laparotomy and subsequent right hemicolectomy.SUMMARYInternal hernia refers to the protrusion of an abdominalviscus through the peritoneum or mesentery into a com-partment within the abdominal cavity and represents anuncommon cause of bowel obstruction. Six main types ofinternal herniation have been described, which are para-duodenal, foramen of Winslow, transmesenteric, paracae-cal, intersigmoid and paravesical. Of these, protrusionthrough the foramen of Winslow is rare and accountsonly for approximately 8% of all internal herniae.1 Variousorgans have hitherto been found to herniate through thisforamen. Here, we report a case of caecal herniation thatwas only diagnosed by a CT scan.CLINICAL PRESENTATIONA 57-year-old male presented with a 1-day history of sud-den onset epigastric and chest pain, associated with nau-sea, coffee ground vomiting and rectal bleeding. Onsystemic enquiry of the gastrointestinal system, there wasno history of abdominal distension and the patientreported bowel opening the day prior to admission. Hehad no past history of abdominal surgery but sufferedfrom Type 2 diabetes mellitus and learning difficulties.Clinical examination revealed mild epigastric tendernessin the absence of guarding and rigidity, but was accompa-nied by reduced bowel sounds, with no evidence of ingui-nal or femoral herniation.On admission, he was apyrexial and results of blood testshowed an increased white cell count (16.1, normal range4–11 109 l–1), amylase (279, normal range 30–123U l–1)and alanine transaminase (60, normal range 9–55U l–1),as well as deranged renal function tests (creatinine, 151,normal range 36–107mmol l–1; urea, 15.5, normal range2.5–7.8mmol l–1). Erect chest and abdominal radiographydemonstrated gas collection under the hemidiaphragmwithin a bowel loop but no free air, as well as a distendedstomach. The patient was admitted under the medicalteam with a differential diagnosis of acute coronary syn-drome, but his electrocardiogram and troponin were unre-markable. A surgical opinion was therefore requested. Anurgent CT scan of the abdomen and pelvis demonstratedlarge pockets of gas and faeces in the left hypochondriumadjacent to the stomach. This was suggestive of an abnor-mally lying caecum, secondary to either internal hernia-tion or a volvulus. There was no evidence of free gas inthe abdomen. Figure 1 shows a coronal section of theCT scan. Here, the stomach (S) is lying below the lefthemidiaphragm with the caecum (C) below it and passingthrough the foramen of Winslow. An axial view is shownin Figure 2, where the caecum is located behindthe stomach.The patient underwent urgent laparotomy that confirmedan internal hernia of the caecum through the foramen ofWinslow, lying behind the stomach in the lesser sac caus-ing small bowel obstruction. The caecum showed evidenceof ischaemia and necrosis, but there was no abdominalcontamination (Figure 3). During surgery, after gainingaccess via the lesser sac, the caecum was decompressed andsubsequently reduced through the foramen. A right hemi-colectomy was performed with a side-to-side stapled anas-tomosis. Postoperatively, the patient was transferred to thehigh dependency unit, went on to have an uneventfulrecovery and was discharged home a week later.DISCUSSIONInternal hernia refers to the protrusion of an abdominalviscus through the peritoneum or mesentery into a com-partment within the abdominal cavity.2 It is an uncommoncause of small bowel obstruction, accounting for around5% of all cases.3 Timely diagnosis is crucial becauseBJR|case reports http://dx.doi.org/10.1259/bjrcr.20150330© 2016 The Authors. Published by the British Institute of Radiology. This is an open access article under the terms of the Creative Commons Attribution4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source arecredited.internal herniae are associated with a high mortality rate.3 Vari-ous types have hitherto been described, including paraduodenal,foramen of Winslow, transmesenteric, paracaecal, intersigmoidand paravesical.4 Of these, protrusion through the foramen ofWinslow represents 8% of internal herniae1 and only 0.1% of allabdominal herniae.5 This foramen forms the communicationbetween the greater peritoneal cavity and the lesser sac. Its ante-rior border is the hepatoduodenal ligament and posterior borderis the inferior vena cava. Its superior border is the caudate lobeof the liver and inferior border is the start of the duodenum andthe hepatic artery. Several organs have been reported to herniatethrough the foramen of Winslow, including the small bowel,caecum, and ascending and transverse colon.6 Involvement ofthe gallbladder,7 small bowel diverticulum8 or Meckel’s divertic-ulum9 has rarely been reported. Predisposing factors include anenlarged foramen of Winslow, failed retroperitonealization ofthe right colon, a long small bowel mesentery and a commonintestinal mesentery.6 Additional factors are a suddenincrease in intra-abdominal pressure10 and an atrophic greateromentum.11 This disease has a male preponderance, affectingmales 2.5 times more frequently than females,12 with the greatestincidence between 20 and 60 years of age and a reduced likeli-hood at extremes of age.13Caecal herniation is a rare event. A caecal volvulus contained ina giant ventral hernia has previously been described in a patientwith an extensive history of intra-abdominal surgeries andrecurrent ventral hernia.14 There was another case involving agiant left-sided Amyand's hernia, where a mobile caecum wasentrapped with the appendix within an inguinoscrotal hernia.15Caecal herniation through the foramen of Winslow into thelesser sac has been reported. One case involving not only thecaecum but also the proximal ascending colon and terminalileum has been described.16 A different case described herniationof a caecal bascule, where the caecum folded anteriorly andsuperiorly.17 Interestingly, in our case, there was isolatedinvolvement of the caecum in the absence of a bascule.Accurate diagnosis of internal herniation is challenging. Symp-toms can vary greatly, depending on the severity.2 It may startwith non-specific abdominal pain. If the herniae are spontane-ously reducible, intermittent obstructive symptoms can occur.In cases where these are irreducible, acute obstruction ensuesand finally strangulation causes peritonism.18 In addition, it hasbeen pointed out that unique symptoms are specific for certaintypes of hernia, correlating with their anatomical variations.2For example, post-prandial pain occurs in paraduodenal her-niae.3 Haemorrhoids occur in left-sided paraduodenal herniaeowing to portosystemic shunting with compression of the infe-rior mesenteric vein.19 Right iliac fossa pain occurs frequently inpericaecal herniae. Transmesenteric herniation often presents asa painful, palpable abdominal mass.4 Relevant to our case, fora-men of Winslow herniation can cause vomiting owing to gastriccompression. It can also cause jaundice if the common bile ductis compressed, which obstructs bile flow.Different imaging modalities can be used to reach the diagnosis.Radiological signs can vary depending on the organ herniatinginto the lesser sac. Plain abdominal radiography typically showsanterolateral displacement of the gastric bubble by a mass in thelesser sac.11 Evidence of caecal involvement includes absentbowel gas in the right iliac fossa, finding of transverse colon infe-rior to the distended stomach loop and the presence of an ilealloop on the right side of the abdomen towards the Morison’spouch.11 A CT scan may demonstrate mesenteric fat behind theportal vein, common bile duct and hepatic artery. It may revealgas or fluid in the lesser sac with a bird’s beak appearance, withthe beak pointing towards the foramen of Winslow. If the cae-cum is involved, it is absent from the normal anatomical posi-tion.20,21 Narrowing of the portal vein associated with periportaloedema has been described.22Definitive treatment requires prompt surgical correction becauseof the risk of strangulation of the hernia contents.23 SuccessfulFigure 1. A coronal section of the CT scan showing the caecum(C) herniating through the foramen of Winslow (arrow), lyingbelow the stomach (S).Figure 2. An axial section of the CT scan showing the caecum(C) behind the stomach (S).Figure 3. A picture of the resected right colon.BJR|case reports Tse et al2 of 3 birpublications.org/bjrcr BJR Case Rep;2:20150330surgery has been achieved with a laparoscopic approach,24 butopen procedures are frequently needed. During laparotomy,reduction of the hernia contents can be achieved by applicationof gentle pressure.25 If this fails, the foramen of Winslow can beenlarged using a Kocher manoeuvre, in which exposure of theretroperitoneal structures is achieved by incising the peritoneumat the right edge of the duodenum and reflecting the duodenumto the left. Resection of the compromised bowel is needed. Thereis some debate regarding whether the foramen should be closedor not, because attempts at closure may risk damage to the bili-ary ducts, or hepatic artery and portal vein thrombosis.23 Clo-sure has been suggested to be unnecessary as recurrence isunlikely,26 and in our case, the omentum was placed inthe foramen.This case study demonstrates variable clinical signs that apatient with an internal hernia can present with andhighlights the usefulness of CT imaging in correlation withclinical examination.LEARNING POINTS1. Patients with internal herniation can present with chestor epigastric pain.2. CT imaging is important for the assessment ofabnormal anatomy.3. Urgent laparotomy is needed if there are clinical signs ofnecrosis or diagnosis is uncertain.CONSENTWe confirm that informed consent has been obtained from thepatient and we have full permission to publish this case and theimages included herein.REFERENCES1. Takeyama N, Gokan T, Ohgiya Y, Satoh S,Hashizume T, Hataya K, et al. CT of internalhernias. Radiographics 2005; 25: 997–1015.doi: http://dx.doi.org/10.1148/rg.2540450352. Salar O, El-Sharkawy AM, Singh R,Speake W. Internal hernias: a brief review.Hernia 2013; 17: 373–7. doi: http://dx.doi.org/10.1007/s10029-012-1023-13. Martin LC, Merkle EM, ThompsonWM.Review of internal hernias: radiographic andclinical findings. AJR Am J Roentgenol 2006;186: 703–17. doi: http://dx.doi.org/10.2214/AJR.05.06444. Ghahremani GG. Internal abdominalhernias. Surg Clin North Am 1984; 64:393–406.5. 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Dis ColonRectum 1982; 25: 820–2. doi: http://dx.doi.org/10.1007/BF02553325Case report: Caecal herniation through the foramen of Winslow BJR|case reports3 of 3 birpublications.org/bjrcr BJR Case Rep;2:20150330

Caecal herniation through the foramen of Winslow

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