Herniation Through the Foramen of Winslow: R e p o r t of a Case ~ HERBERT F. SCHWARZ, M.D. Wayne, New Jersey
epigastric region, and abdominal tenderness was now limited to this area. Some abdominal distention was evident, and the low-grade fever persisted, b u t with temperatures as high as 100.6F. Total bilirubin rose to 4.1 mg/100 ml, with 1.3 mg/100 ml direct. T h e urine was positive for bile. Other liver function tests disclosed no abnormality. A double-dose gallbladder series revealed nonvisualization. On the sixth day a barium-meal study revealed complete obstruction at the mid-ileum. T h e patient under*vent exploratory laparotomy several h o u r s later. T h e p r o x i m a l and mid-ileum were anchored to the posterior peritoneum by a long mesentery, but there was no fixation of the distal ileum or right colon. T h e right iliac fossa was empty. T h e distended small bowel was followed up to the right u p p e r quadrant, where the terminal ileum and the entire cecum were found to be trapped in the lesser omental sac, having herniated t h r o u g h the foramen of Winslow. T h e lesser omental sac was entered t h r o u g h the gastrocolic o m e n t u m and reduction was attempted, b u t could not be accomplished until the cecal contents were aspirated. T h e cecum was subsequently fixed to the right gutter with silk stitches. Exploration of the remainder of the abdomen, including the gallbladder, disclosed no abnormality. T h e patient made an uneventful recovery except for a minimal w o u n d infection, and she has been asymptomatic since her discharge from the hospital.
INTERNAL HERNIATION through the foramen of Winslow is a rare cause of intestinal obstruction, with fewer than 100 cases having been recorded. T h e potentially lethal outcome of internal strangulation warrants the reporting of all such cases to further familiarize the intestinal surgeon with this entity.
Report of a Case A 56-year-old white woman entered the hospital with an 18-hour history of epigastric abdominal pain radiating to the right subscapular region and to the mid-back. T h e pain had been preceded by a usual dinner. T h e r e had been no vomiting and the bowels had moved on the previous day. Rectal bleeding was denied. Past history included intermittent episodes of u p p e r abdominal pain and fatty food intolerance. T h e patient had had no previous surgical operation. She admitted to nmderatc alcoholic intake. On physical examination the temperature was 100.2F and blood pressure was 156/100 m m Hg. Pertinent findings included marked right-upperq u a d r a n t and epigastric tenderness. Bowel sounds were normal. No mass or herniation were found, and brown stool was present on rectal examination. Initial laboratory findings included a leukocyte count of 9,300, total bilirubin 0.75 rag/100 mI; ser u m amylase 160 Hoffman La-Rochc d,,c units, seruln lipase 0.84 ACA International Units/100 mI, and alkaline phosphatase 3.8 Bodansky units/100 ml. Chest x-ray and plain roentgenogram of the abdomen were unremarkable. A diagnosis of acute cholccystitis was made and conservative treatment begun. T h e patient vomited small amounts on several occasions following admission, but a Levine tube was not felt to be necessary. On the second hospital day an enema was given, with good resuhs. By the third hospital day a mass was palpable in the subxyphoid and
Discussion Incidence: Internal hernias comprise less than 1 per cent of all causes of intestinal obstruction, 18 and herniation through the foramen of Winslow is even more unusual, representing only 8 per cent of all internal hernias.S Blandin 2 recorded the first case in 1884, having found all of the small bowel in the lesser omental sac at autopsy. Wreves ~6 described the first case in which the herniation was found at laparotomy in 1888. Neve .2 had the first surviving patient in
* Received for publication April 19, 1976. Address reprint requests to Dr. Schwarz: 1777 H a m b u r g Turnpike, Wayne, New Jersey 07470.
521 Dis. Col. & Reef. Sept. 1977
Volume 20 Number 6
522
H . F. S C H } V A R Z
1892. T h e earliest correct preoperative diagnosis is credited to Douglas 4 in 1929. Ages of the patients in reported cases range from 15 months to 77 years, 15 with males predominating in a ratio of approximately 2.5 to 1.l0 Pathologic Anatomy: T h e foramen of Winslow is a potential space bounded by the gastrohepatic omentum, containing portal vein, hepatic artery and common duct, anteriorly, the inferior vena cava with its peritoneal covering posteriorly, the caudate lobe of the liver above, and the duodenum below. Only under special circumstances is herniation thought possible. Moynihan 11 lists these as follows: 1) persistence of a common mesentery for the entire intestinal tract; 2) failure of fusion of right colon to the posterior abdominal wall; 3) unusually long small-intestinal mesentery; 4) abnormally large foramen of Winslow. It is thought that a sudden increase in intraabdominal pressure due to muscular effort may cause herniation in patients who are anatomically predisposed. 6 T h e contents of the hernia are small intestine in about 70 per cent of the cases, the cecum and variable amounts of right colon in 25 per cent, and the transverse colon and other viscera in the remaining cases. TM Clinical Picture: T h e clinical history is that of intestinal obstruction, but there are certain subtle differences. T h e abdominal pain is more often felt in the epigastrium and in the right upper quadrant. Vomiting seems to be less prominent due to a compressive effect by the herniated bowel on the pytoroduodenal area. For the same reason there is less swallowed air passing into the small intestine and abdominal distention appears relatively late. T h e obstruction is often incomplete initially, and absolute constipation to feces and flatus may be delayed.
Dis. Col. & Rect. Sept. 1977
Not infrequently, onset of the symptoms is less acute, with pain having been present from several days to a few weeks.7, 17 At times a history of chronic, recurring, selflimiting episodes of pain is elicited prior to the acute attack. Presumably herniation occurs but reduction takes place spontaneously. The physical findings characteristically include a palpable epigastric swelling early during the illness, but later this finding is often obscured by the generalized abdominal distention of advanced obstruction. Laboratory and X-ray Findings: T h e laboratory is of little use in establishing a diagnosis of herniation into the foramen of Winslow. However, in a few cases jaundice has been reported, 1, 13 probably on the basis of extrinsic pressure on the common duct lumen by the herniated mass. Radiographic findings, on the other hand, are extremely helpful, and when accurately interpreted in conjunction with the history and physical findings should suggest the correct diagnosis. Gas in the lesser omental sac is the principle finding. W h e n found, it should suggest one of three possibilities 1) pneumoperitoneum; 2) abscess with gas formation; 3) herniation of gas-containing bowel into the sac. When correlated with the clinical findings of mechanical obstruction, herniation of the lesser omenal sac is the probable cause. Other x-ray findings include a rounded epigastric gas pocket separate from the stomach, a displacement of the stomach to the left, and deformity and compression of the posterior wall of the stomach.3 Contrast studies of the upper and lower gastrointestinal tract will often be needed in doubtful cases for further clarification. Treatment: Delay in carrying out definitive treatment is quite characteristic in these patients and is attributed to such factors as rarity of the condition, the atypi-
Volume 20 Number 6
H E R N I A T I O N TI-|ROU(;H FORAMF, N OF D,'INSLOW
59 --~
cal presentation of the obstruction, and
References
frequent misinterpretation of radiologic studies. Nevertheless gan~ene, necessitating resection of the intestine, has been reported to occur in only a relatively few cases, s In most instances reduction of the herniated mass, and measures to prevent recurrence, comprise the extent of surgical treatment. In early cases this is often quite simple. In late or difficult cases certain technical maneuvers are necessary to accomplish these objectives. These include 1) opening the lesser omental sac and manipulating the contents; 9) emptying the entrapped bowel by aspiration or by enterotomy; 3) enlarging the foramen by kocherization of the second portion of the duodenum; 4) enterectomy in situ, 9 Occluding the foramen by suture and tacking the cecum to the posterior abdominal wall are measures that have been used
1. Allcock E: Hernia through the foramen of Winslow. Med J Aust 1:621, 1963 2. Blandin PF: Traitd' d'anatomie topographique, ou anatomic des rdgions du corps h u m a i n . Eel 2, Paris, Germer-Baillidre, 1834, p 680 3. Dillard DH, Hodges FJ III: Successful surgical correction of hernia of the foramen of Winslow: W i t h comments on the roentgen diagnosis. Am Surg 23:26, 1957 4. Douglas J: Hernia through the foramen of Winslow. Ann Surg 90:806, 1929 5. Erskine JM: Hernia through the foramen of }Vinslow. Surg Gynecol Obstet 125:1093, 1967 6. C,illis L: Hernia through foramen of \.Vinslow: Report of a case. Lancet 2:48, 1946 7. Green EK: Strangulated hernia through the foramcn of ~Vinslow: Report oE case. Minn Med 10:451, 1927 8. H a n s m a n n GH, Morton SA: Intra-abdominal hernia: Report of a case and review of the literature. Arch Su,g 39:973, 1939 9. Lewis JN: Hernia throt, gh foramen of Winslow. Br Med J 2:1511, 1949 10. McKail RA: Hernia through the foramen of Winslow, hernia traversing the lesser sac, and allied conditions: T h e radiologieal diagnosis and differential diagnosis. Br J Radiol 84:611, 1961 11. Moynihan BG: On Retroperitoneal Hernia. London, Bailliere, Tindall and Cox, 1899, 170 pp 12, Neve A: Hernia into the foramen of Winslow; laparotomy; recovery. Lancet 1:1175, 1892 13. Rene L, Garcia-Moran M: Triade symptomatique pour le diagnostic de l'dtranglement herniaire ~ travers l'hiatus de Winslow. H e m Acad Chir Paris 90:878, 1964 14. Roberts PA: Hernia through the foramen of Winslow. Guy's Hosp Rep 102:253, 1958 15. St. John EG: Herniation through the foramen of Winslow. Anl Roentgenol Radium T h e r N u d Med 72:222, 1954 16. Treves F: Clinical lecture on hernia into the foramen of Winslow. Lancet 9:701, 1888 17. Venner B: Hernia through the foramen of Winslow. Med J Aust 2:678, 1949 18. Wangensteen OH: Intestinal Obstructions: A Physiological and Clinical Consideration With Emphasis on Therapy, Including Description of Operative Procedures. Springfield, II1., Charles C Thomas, 1948, 484 pp
to p r e v e n t
recnrrence. However,
n o recm'-
rence has been reported.
Summary Herniation into the lesser omentaI sac through the foramen of ~Vinslow is a rare cause of intestinai obstruction. A successfully managed case is presented. T h e clinical history and physical findings are reviewed, and radiographic findings are discussed. T h e proper interpretation of these findings should suggest the diagnosis. Treatment is prompt surgical correction, and various technical maneuvers that may be necessary are outlined.
epigastric region, and abdominal tenderness was now limited to this area. Some abdominal distention was evident, and the low-grade fever persisted, b u t with temperatures as high as 100.6F. Total bilirubin rose to 4.1 mg/100 ml, with 1.3 mg/100 ml direct. T h e urine was positive for bile. Other liver function tests disclosed no abnormality. A double-dose gallbladder series revealed nonvisualization. On the sixth day a barium-meal study revealed complete obstruction at the mid-ileum. T h e patient under*vent exploratory laparotomy several h o u r s later. T h e p r o x i m a l and mid-ileum were anchored to the posterior peritoneum by a long mesentery, but there was no fixation of the distal ileum or right colon. T h e right iliac fossa was empty. T h e distended small bowel was followed up to the right u p p e r quadrant, where the terminal ileum and the entire cecum were found to be trapped in the lesser omental sac, having herniated t h r o u g h the foramen of Winslow. T h e lesser omental sac was entered t h r o u g h the gastrocolic o m e n t u m and reduction was attempted, b u t could not be accomplished until the cecal contents were aspirated. T h e cecum was subsequently fixed to the right gutter with silk stitches. Exploration of the remainder of the abdomen, including the gallbladder, disclosed no abnormality. T h e patient made an uneventful recovery except for a minimal w o u n d infection, and she has been asymptomatic since her discharge from the hospital.
INTERNAL HERNIATION through the foramen of Winslow is a rare cause of intestinal obstruction, with fewer than 100 cases having been recorded. T h e potentially lethal outcome of internal strangulation warrants the reporting of all such cases to further familiarize the intestinal surgeon with this entity.
Report of a Case A 56-year-old white woman entered the hospital with an 18-hour history of epigastric abdominal pain radiating to the right subscapular region and to the mid-back. T h e pain had been preceded by a usual dinner. T h e r e had been no vomiting and the bowels had moved on the previous day. Rectal bleeding was denied. Past history included intermittent episodes of u p p e r abdominal pain and fatty food intolerance. T h e patient had had no previous surgical operation. She admitted to nmderatc alcoholic intake. On physical examination the temperature was 100.2F and blood pressure was 156/100 m m Hg. Pertinent findings included marked right-upperq u a d r a n t and epigastric tenderness. Bowel sounds were normal. No mass or herniation were found, and brown stool was present on rectal examination. Initial laboratory findings included a leukocyte count of 9,300, total bilirubin 0.75 rag/100 mI; ser u m amylase 160 Hoffman La-Rochc d,,c units, seruln lipase 0.84 ACA International Units/100 mI, and alkaline phosphatase 3.8 Bodansky units/100 ml. Chest x-ray and plain roentgenogram of the abdomen were unremarkable. A diagnosis of acute cholccystitis was made and conservative treatment begun. T h e patient vomited small amounts on several occasions following admission, but a Levine tube was not felt to be necessary. On the second hospital day an enema was given, with good resuhs. By the third hospital day a mass was palpable in the subxyphoid and
Discussion Incidence: Internal hernias comprise less than 1 per cent of all causes of intestinal obstruction, 18 and herniation through the foramen of Winslow is even more unusual, representing only 8 per cent of all internal hernias.S Blandin 2 recorded the first case in 1884, having found all of the small bowel in the lesser omental sac at autopsy. Wreves ~6 described the first case in which the herniation was found at laparotomy in 1888. Neve .2 had the first surviving patient in
* Received for publication April 19, 1976. Address reprint requests to Dr. Schwarz: 1777 H a m b u r g Turnpike, Wayne, New Jersey 07470.
521 Dis. Col. & Reef. Sept. 1977
Volume 20 Number 6
522
H . F. S C H } V A R Z
1892. T h e earliest correct preoperative diagnosis is credited to Douglas 4 in 1929. Ages of the patients in reported cases range from 15 months to 77 years, 15 with males predominating in a ratio of approximately 2.5 to 1.l0 Pathologic Anatomy: T h e foramen of Winslow is a potential space bounded by the gastrohepatic omentum, containing portal vein, hepatic artery and common duct, anteriorly, the inferior vena cava with its peritoneal covering posteriorly, the caudate lobe of the liver above, and the duodenum below. Only under special circumstances is herniation thought possible. Moynihan 11 lists these as follows: 1) persistence of a common mesentery for the entire intestinal tract; 2) failure of fusion of right colon to the posterior abdominal wall; 3) unusually long small-intestinal mesentery; 4) abnormally large foramen of Winslow. It is thought that a sudden increase in intraabdominal pressure due to muscular effort may cause herniation in patients who are anatomically predisposed. 6 T h e contents of the hernia are small intestine in about 70 per cent of the cases, the cecum and variable amounts of right colon in 25 per cent, and the transverse colon and other viscera in the remaining cases. TM Clinical Picture: T h e clinical history is that of intestinal obstruction, but there are certain subtle differences. T h e abdominal pain is more often felt in the epigastrium and in the right upper quadrant. Vomiting seems to be less prominent due to a compressive effect by the herniated bowel on the pytoroduodenal area. For the same reason there is less swallowed air passing into the small intestine and abdominal distention appears relatively late. T h e obstruction is often incomplete initially, and absolute constipation to feces and flatus may be delayed.
Dis. Col. & Rect. Sept. 1977
Not infrequently, onset of the symptoms is less acute, with pain having been present from several days to a few weeks.7, 17 At times a history of chronic, recurring, selflimiting episodes of pain is elicited prior to the acute attack. Presumably herniation occurs but reduction takes place spontaneously. The physical findings characteristically include a palpable epigastric swelling early during the illness, but later this finding is often obscured by the generalized abdominal distention of advanced obstruction. Laboratory and X-ray Findings: T h e laboratory is of little use in establishing a diagnosis of herniation into the foramen of Winslow. However, in a few cases jaundice has been reported, 1, 13 probably on the basis of extrinsic pressure on the common duct lumen by the herniated mass. Radiographic findings, on the other hand, are extremely helpful, and when accurately interpreted in conjunction with the history and physical findings should suggest the correct diagnosis. Gas in the lesser omental sac is the principle finding. W h e n found, it should suggest one of three possibilities 1) pneumoperitoneum; 2) abscess with gas formation; 3) herniation of gas-containing bowel into the sac. When correlated with the clinical findings of mechanical obstruction, herniation of the lesser omenal sac is the probable cause. Other x-ray findings include a rounded epigastric gas pocket separate from the stomach, a displacement of the stomach to the left, and deformity and compression of the posterior wall of the stomach.3 Contrast studies of the upper and lower gastrointestinal tract will often be needed in doubtful cases for further clarification. Treatment: Delay in carrying out definitive treatment is quite characteristic in these patients and is attributed to such factors as rarity of the condition, the atypi-
Volume 20 Number 6
H E R N I A T I O N TI-|ROU(;H FORAMF, N OF D,'INSLOW
59 --~
cal presentation of the obstruction, and
References
frequent misinterpretation of radiologic studies. Nevertheless gan~ene, necessitating resection of the intestine, has been reported to occur in only a relatively few cases, s In most instances reduction of the herniated mass, and measures to prevent recurrence, comprise the extent of surgical treatment. In early cases this is often quite simple. In late or difficult cases certain technical maneuvers are necessary to accomplish these objectives. These include 1) opening the lesser omental sac and manipulating the contents; 9) emptying the entrapped bowel by aspiration or by enterotomy; 3) enlarging the foramen by kocherization of the second portion of the duodenum; 4) enterectomy in situ, 9 Occluding the foramen by suture and tacking the cecum to the posterior abdominal wall are measures that have been used
1. Allcock E: Hernia through the foramen of Winslow. Med J Aust 1:621, 1963 2. Blandin PF: Traitd' d'anatomie topographique, ou anatomic des rdgions du corps h u m a i n . Eel 2, Paris, Germer-Baillidre, 1834, p 680 3. Dillard DH, Hodges FJ III: Successful surgical correction of hernia of the foramen of Winslow: W i t h comments on the roentgen diagnosis. Am Surg 23:26, 1957 4. Douglas J: Hernia through the foramen of Winslow. Ann Surg 90:806, 1929 5. Erskine JM: Hernia through the foramen of }Vinslow. Surg Gynecol Obstet 125:1093, 1967 6. C,illis L: Hernia through foramen of \.Vinslow: Report of a case. Lancet 2:48, 1946 7. Green EK: Strangulated hernia through the foramcn of ~Vinslow: Report oE case. Minn Med 10:451, 1927 8. H a n s m a n n GH, Morton SA: Intra-abdominal hernia: Report of a case and review of the literature. Arch Su,g 39:973, 1939 9. Lewis JN: Hernia throt, gh foramen of Winslow. Br Med J 2:1511, 1949 10. McKail RA: Hernia through the foramen of Winslow, hernia traversing the lesser sac, and allied conditions: T h e radiologieal diagnosis and differential diagnosis. Br J Radiol 84:611, 1961 11. Moynihan BG: On Retroperitoneal Hernia. London, Bailliere, Tindall and Cox, 1899, 170 pp 12, Neve A: Hernia into the foramen of Winslow; laparotomy; recovery. Lancet 1:1175, 1892 13. Rene L, Garcia-Moran M: Triade symptomatique pour le diagnostic de l'dtranglement herniaire ~ travers l'hiatus de Winslow. H e m Acad Chir Paris 90:878, 1964 14. Roberts PA: Hernia through the foramen of Winslow. Guy's Hosp Rep 102:253, 1958 15. St. John EG: Herniation through the foramen of Winslow. Anl Roentgenol Radium T h e r N u d Med 72:222, 1954 16. Treves F: Clinical lecture on hernia into the foramen of Winslow. Lancet 9:701, 1888 17. Venner B: Hernia through the foramen of Winslow. Med J Aust 2:678, 1949 18. Wangensteen OH: Intestinal Obstructions: A Physiological and Clinical Consideration With Emphasis on Therapy, Including Description of Operative Procedures. Springfield, II1., Charles C Thomas, 1948, 484 pp
to p r e v e n t
recnrrence. However,
n o recm'-
rence has been reported.
Summary Herniation into the lesser omentaI sac through the foramen of ~Vinslow is a rare cause of intestinai obstruction. A successfully managed case is presented. T h e clinical history and physical findings are reviewed, and radiographic findings are discussed. T h e proper interpretation of these findings should suggest the diagnosis. Treatment is prompt surgical correction, and various technical maneuvers that may be necessary are outlined.
