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Special Feature |

Image of the Month—Diagnosis FREE

Arch Surg. 2011;146(11):1330. doi:10.1001/archsurg.2011.279-b.
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At laparoscopy, the colon was quite distended with distortion of the normal anatomy in the epigastrium by mass effect. There was herniation of the ascending colon into the lesser sac, displacing the stomach anteriorly and laterally. Two working 5-mm ports were placed. The patient was placed in reverse Trendelenburg position to further facilitate exposure. Using gentle, persistent traction and countertraction with atraumatic graspers, the colon was reduced from the lesser sac and out of the foramen of Winslow back into its normal anatomic position. After reduction, we noted that our patient had a mobile right colon, as well as a marginally enlarged foramen. The involved segment of colon was pink and viable. No attempt was made to close the defect (Figure 3). The patient was discharged home on postoperative day 2, and to date there has been no recurrence.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Operative view after reduction of the hernia.

Previously, Van Daele and colleagues1 reported what was believed to be the first documented laparoscopic reduction of a foramen of Winslow hernia. On review of the literature, it seems that Webb and Riordan2 may have predated them with their case report of internal herniation of the cecum in 2009. Both groups discuss successful use of minimally invasive techniques for reduction of the hernia. In those cases, as in the one presented herein, the preoperative recognition of the possibility of an internal hernia made radiographically—specifically with CT—followed by prompt exploration afforded the best outcomes.

An internal hernia is a protrusion of a viscus from its normal position through a peritoneal or mesenteric orifice.3 It may be congenital or acquired. Internal hernias may be further subdivided, depending on their location, into paraduodenal, transmesenteric, pelvic, transomental, pericecal, and foramen of Winslow hernias.3,4 Internal hernias constitute 1% to 5% of all hernias, and foramen of Winslow hernias are estimated to make up about 8% of this select group.5

The foramen of Winslow forms a window between the greater and lesser sacs; however, herniation through this location is rare because the hepatic flexure and transverse colon, with its attached greater omentum, normally prevent bowel from migrating near the foramen.6 Historically, this has been an intraoperative diagnosis, with only a handful of cases being diagnosed preoperatively. Nevertheless, the routine use of ever-faster and higher-section CT scans in our emergency department are sure to change this, particularly when the following imaging clues are appreciated: (1) displacement of the stomach laterally and anteriorly, (2) gas in the lesser sac, (3) CT features of mesenteric fat and vessels posterior to the portal triad, or (4) a “bird's beak” pointing toward the foramen.7

The clinical symptoms of a foramen of Winslow hernia are nonspecific and can mimic seemingly benign abdominal complaints that further predispose these internal hernias to an insidiously higher mortality rate, likely due to delay in diagnosis. A laparoscopic approach is reasonable in a stable patient. Operative findings of bowel ischemia or gangrene should prompt one to strongly consider conversion to an open approach because the bowel's architecture will be less forgiving of the shearing forces required for reduction and the risk of perforation or injury to the portal structures increases. Finally, there have been no reports of recurrence, and closure of the defect has been associated with portal vein thrombosis and probably should not be attempted.8,9

Return to Quiz Case.

Correspondence: Andre Grisham, MD, Department of Surgery, Baptist Memorial Hospital, 1500 W Poplar, Memphis, TN 38107 (docag01@aol.com).

Accepted for Publication: March 29, 2011.

Author Contributions:Study concept and design: Javan. Analysis and interpretation of data: Grisham. Drafting of the manuscript: Grisham and Javan. Critical revision of the manuscript for important intellectual content: Grisham. Administrative, technical, and material support: Javan. Study supervision: Grisham.

Financial Disclosure: None reported.

Van Daele E, Poortmans M, Vierendeels T, Polvlieghe P, Rots W. Herniation through the foramen of Winslow: a laparoscopic approach.  Hernia. 2011;15(4):447-449
PubMed  |  Link to Article   |  Link to Article
Webb LH, Riordan WP. Internal herniation of the cecum through the foramen of Winslow.  Am Surg. 2009;75(12):1252-1253
PubMed
Rajeswaran G, Selvakumar S, King C. Internal herniation of the caecum into the lesser sac: an unusual cause of an acute abdomen (2009: 10b).  Eur Radiol. 2010;20(1):249-252
PubMed   |  Link to Article
Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings.  AJR Am J Roentgenol. 2006;186(3):703-717
PubMed   |  Link to Article
Osvaldt AB, Mossmann DF, Bersch VP, Rohde L. Intestinal obstruction caused by a foramen of Winslow hernia.  Am J Surg. 2008;196(2):242-244
PubMed   |  Link to Article
Cohen DJ, Schoolnik ML. Herniation through the foramen of Winslow.  Dis Colon Rectum. 1982;25(8):820-822
PubMed   |  Link to Article
Forbes SS, Stephen WJ. Herniation through the foramen of Winslow: radiographic and intraoperative findings.  Can J Surg. 2006;49(5):362-363
PubMed
Chung CC, Leung KL, Lau WY, Li AK. Spontaneous internal herniation through the foramen of Winslow: a case report.  Can J Surg. 1997;40(1):64-65
PubMed
Evrard V, Vielle G, Buyck A, Merchez M. Herniation through the foramen of Winslow: report of two cases.  Dis Colon Rectum. 1996;39(9):1055-1057
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Operative view after reduction of the hernia.

Tables

References

Van Daele E, Poortmans M, Vierendeels T, Polvlieghe P, Rots W. Herniation through the foramen of Winslow: a laparoscopic approach.  Hernia. 2011;15(4):447-449
PubMed  |  Link to Article   |  Link to Article
Webb LH, Riordan WP. Internal herniation of the cecum through the foramen of Winslow.  Am Surg. 2009;75(12):1252-1253
PubMed
Rajeswaran G, Selvakumar S, King C. Internal herniation of the caecum into the lesser sac: an unusual cause of an acute abdomen (2009: 10b).  Eur Radiol. 2010;20(1):249-252
PubMed   |  Link to Article
Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings.  AJR Am J Roentgenol. 2006;186(3):703-717
PubMed   |  Link to Article
Osvaldt AB, Mossmann DF, Bersch VP, Rohde L. Intestinal obstruction caused by a foramen of Winslow hernia.  Am J Surg. 2008;196(2):242-244
PubMed   |  Link to Article
Cohen DJ, Schoolnik ML. Herniation through the foramen of Winslow.  Dis Colon Rectum. 1982;25(8):820-822
PubMed   |  Link to Article
Forbes SS, Stephen WJ. Herniation through the foramen of Winslow: radiographic and intraoperative findings.  Can J Surg. 2006;49(5):362-363
PubMed
Chung CC, Leung KL, Lau WY, Li AK. Spontaneous internal herniation through the foramen of Winslow: a case report.  Can J Surg. 1997;40(1):64-65
PubMed
Evrard V, Vielle G, Buyck A, Merchez M. Herniation through the foramen of Winslow: report of two cases.  Dis Colon Rectum. 1996;39(9):1055-1057
PubMed   |  Link to Article

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