Image of the Month—Diagnosis FREE

In this case, preoperative coronal imaging on an abdominal CT scan demonstrated internal herniation of the small intestine behind the hepatoduodenal ligament, displacing the pancreas caudally as well as the stomach cranially (Figure 1). On the basis of our findings, the diagnosis of an internal hernia through the foramen of Winslow accompanied by bowel incarceration was established. Immediately after this diagnosis was made, the patient underwent laparotomy to confirm a herniated ileal segment with redundant mesentery posterior to the portal triad in the foramen of Winslow (Figure 2). The colonic segment from the ileocecal junction to the right-sided transverse colon was actually movable because of unfixation to the retroperitoneum without bowel malrotation. This situation likely facilitated ileal herniation into this narrow anatomical space. Fortunately, an accurate preoperative diagnosis prompted the rapid surgical treatment for the still uncomplicated internal herniation. Hernia contents were so easily reduced that bowel resection could be avoided because of the lack of evidence of bowel necrosis. The foramen of Winslow was closed and fixed with sutures to the retroperitoneum. The patient's postoperative course was uneventful.

An internal hernia is a protrusion of a viscus into a natural orifice of the abdominal cavity. Hernias through the foramen of Winslow are generally associated with bowel obstruction and strangulation because the small intestine is most often involved, followed by the colon and gallbladder.¹ This type of hernia is more prevalent among men, with the highest incidence between the second and sixth decades of life.² Nonspecific clinical features of this type of hernia lead to delaying the decision to perform surgery and make preoperative diagnosis difficult. Abdominal CT has now become the accepted modality to provide a correct diagnosis during symptomatic periods. Furthermore, new methods of imaging technology have increased interest in viewing abdominal anatomy and abnormality. Reformatting helical CT scans such as multidetector CT can provide a new perspective for the specific diagnosis and preoperative evaluation.³ They may help surgeons to better understand the confusing laparotomy findings. In any incarcerated hernia, emergency operative repair is indicated, followed by reduction of intestine with gentle traction. A strangulated, necrotic bowel should be resected. Closing the foramen is a controversial issue. Some reports recommend not closing the foramen because of incidental injury of the portal triad by operative procedures,⁴ whereas others suggest closing to prevent recurrence of the hernia.^1,4

In summary, an internal hernia through the foramen of Winslow is a rare cause of bowel obstruction and is a diagnostic challenge. A delay in treatment is responsible for high mortality.^1,4 Successful management requires early diagnosis followed by prompt surgical intervention. We conclude that multidetector CT is the best diagnostic method for an internal hernia through the foramen of Winslow.

Return to Quiz Case.

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.