Laparoscopic management of foramen of Winslow incarcerated hernia

Abstract

Foramen of Winslow hernia (FWH) is a rare and often overlooked diagnosis with a high mortality rate. Widespread availability of cross-sectional imaging allows early diagnosis and prompt management. In this setting, before ischemia occurs, explorative laparoscopy would be the most suitable approach. Experience, however, remains sparse, and technical difficulties may be encountered. This is the case of a 38-year-old Caucasian woman who presented to the emergency department for a sudden epigastric pain. Physical exam was unremarkable, and routine blood tests were within normal range. An abdominal computed tomography (CT) scan confirmed the diagnosis of ileocaecal herniation through the foramen of Winslow. Under urgent laparoscopy, the caecum appeared viable but incarcerated in the lesser sac. Caecal puncture was the key to achieving atraumatic reduction of the hernia and bowel salvage.

Keywords: Caecopexy; Incarcerated hernia; Laparoscopy; Puncture; Winslow.

Fig. 1

Abdominal contrast-enhanced computed tomography. a Axial section shows caecal herniation (C) in the lesser sac causing anterior and lateral displacement of the stomach (S). Edematous infiltration seen along the portal pedicles (arrow heads). b Coronal reconstruction demonstrates the ileocaecal pedicle (¤), the terminal ileum (I) and the transverse colon (T) trapped within the foramen of Winslow. Ileal loops in the lower right quadrant present with the “faeces sign’ (§) in the absence of the caecum

Fig. 2

Attempts of hernia reduction. Intraoperative view shows incarcerated but viable caecum (C). Concomitant push-pull manoeuver with right and left instruments failed to reduce the herniated bowel. Transverse colon (T), terminal ileum (I), pylorus (P), gallbladder (GB), edematous infiltration along the porta hepatis (arrow heads)

Fig. 3

Caecal decompression. a Caecal puncture using a Veress needle. b Deflated bowel allowing atraumatic reduction of the hernia