IMAGES FOR SURGEONS ANZJSurg.com
Internal herniation through the foramen of Winslow: a rare cause of bowel obstruction An 80-year-old male patient was admitted with nausea, vomiting and abdominal pain persisting for 1 week. The patient’s medical history showed no malignancies, previous surgery, trauma or weight loss. The physical examination showed peritoneal tenderness and widespread abdominal distention. Laboratory examinations showed no sign of pathologies, except leukocytosis (14 000/mm3). Abdominal computed tomography showed widespread small intestine dilation and intra-abdominal free air, and the patient underwent emergency surgery (Fig. 1). Intra-abdominal exploration showed that the terminal ileum and cecum (in part) were herniated into the bursa omentalis through the foramen of Winslow. Kocher’s manoeuvre was used to reduce herniated loops. Perforation foci secondary to ischaemia were detected in the 10-cm herniated small bowel loop (Fig. 2). Perforated intestinal loops were resected, and right colonic
fixation was performed. The patient did not have any complications in the post-operative period, and was discharged on day 8. Herniation through the foramen of Winslow (HFW) is a rare type of herniation, and is usually not considered in the differential diagnosis in the preoperative period; still, it causes significant morbidity and mortality. HFW constitutes 0.1% of all abdominal hernias, and 8% of all types of internal herniation.1 The rate of preoperative diagnosis is quite low, and the diagnosis is usually made intraoperatively. Because of delays in diagnosis and treatment, mortality rates up to 50% have been reported. HFW was described for the first time in 1834 by Blandin, and is an extremely rare type of internal herniation. To date, approximately 200 cases have been reported.2 Under normal conditions, the foramen of Winslow is closed due to intra-abdominal pressure. The predisposing factors in
Fig. 1. (a) View of axial computed tomography: collapsed bowel loops entering the omental bursa (green arrow) through the foramen of Winslow (white circle) and exiting (blue arrow) are present (bird’s beak finding). Red arrows indicate strained bowel loops that were herniated to the omental bursa. (b) View of sagittal computed tomography: bowel loops herniated to the bursa omentalis (white circle) and mesenteric vascular structures (yellow arrows) that were displaced to the superior due to herniation are present. White stars indicate strained bowel loops. Free air secondary to perforation is seen in the subdiaphragmatic area (curved arrow). (A, aorta; V, vena cava; K, liver; S, gallbladder.)
Fig. 2. (a) Enlarged foramen of Winslow (white arrow). (b) Necrotic small intestine segment after reduction.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
HFW pathophysiology have been described in detail by Erskine.3 These ones are abnormally enlarged foramen, the presence of an unusually long small bowel mesentery or persistence of the ascending mesocolon, an elongated right hepatic lobe, a lack of fusion between caecum or ascending colon to the parietal peritoneum, a defect in the gastrohepatic ligament and incomplete intestinal rotations or malrotation. Although HFW-specific physical examination findings do not exist, laboratory findings are helpful only in the case of intestinal ischaemia development. The common clinical finding is cramp-like abdominal pain in the upper midline, which is seen together with nausea and vomiting. Previous studies have reported patients who are admitted with nausea, vomiting and weight loss secondary to the compression of herniated intestinal loops, as well as obstruction icterus due to hepatic pedicle pressure.4 The small bowel is involved in 58% of the cases of herniation through foramen of Winslow. Still, involvement of the ascending and transverse colon, gallbladder and Meckel’s diverticulum has been described in the literature.5 Abdominal tomography could aid in the diagnosis of HFW. Abdominal Wojtasek have defined abdominal tomography findings of HFW as follows: (i) the presence of mesenteric adipose tissues and intestinal loops behind the hepatic pedicle; (ii) abnormal localization of the cecum; and (iii) gas and/or fluid in the lesser sac with a ‘bird’s beak’ pointing towards the epiploic foramen.6 The surgical approach has priority in HFW treatment due to risk of obstruction and strangulation. Following careful exploration, bowel loops that are entrapped in the hernia sec should be reduced in patients who undergo emergency operations. Gastrohepatic and gastrocolic ligaments should be opened and reduction should be completed with the help of Kocher’s manoeuvre. Resection should be performed when ischaemic bowel loops are detected. Another debated point is the treatment algorithm when intestinal ischaemia cannot be detected after reduction. Some authors suggest using caecopexy or right colonic fixation, whereas others suggest using extended right hemicolectomy to prevent reherniation when the colon intersection is not clear. Another matter of debate is whether foramen of Winslow should be closed or not. Cases of portal venous thrombosis secondary to the closure of the foramen of Winslow are present in the literature. Therefore, most authors suggest not to close the foramen of Winslow due to potential concerns. It is considered that this gap would close secondary to inflammatory reactions
Images for surgeons
during the post-operative period.7,8 In our case, ischaemic and perforated bowel loops were resected after reduction. The cecum and colon were mobile, and therefore fixed to the retroperitoneal area by fixation. Because of similar concerns, we did not close the gap in the foramen of Winslow. In conclusion, HFW should be considered in the differential diagnosis for patients who are admitted with intestinal obstruction and acute abdominal conditions, who have stomach ache (in the form of intermittent cramps) and who do not have any medical history.
References 1. Orseck MJ, Ross PJ, Morrow CE. Herniation of the hepatic flexure through the foramen of Winslow: a case report. Am. Surg. 2000; 66: 602–3. 2. Osvald AB, Mossman DF, Bersch VP, Rohde L. Intestinal obstruction caused by a foramen of Winslow hernia. Am. J. Surg. 2008; 196: 242–4. 3. Erskine JM. Hernia through the foramen of Winslow. Surg. Gynecol. Obstet. 1967; 125: 1093–109. 4. Armstrong O, Hamel A, Grignon A et al. Internal hernias: anatomical basis and clinical relevance. Surg. Radiol. Anat. 2007; 29: 333–7. 5. Hoeffel JC, Zimberger J, Pocard B, Hoeffel C. Demonstration by computer tomography of a case of internal small bowel herniation. Br. J. Radiol. 1992; 66: 1045–6. 6. Wojtasek DA, Codner MA, Nowak EJ. CT Diagnosis of cecal herniation through the foramen of Winslow. Gastrointest. Radiol. 1991; 16: 77–9. 7. Farthouat P, Platel JP. Hernie du hiatus de Winslow: diagnostic tomodensitométrique préopératoire et traitement par coelioscopie. Ann. Chir. 1998; 52: 387–9. 8. Kotobi H, Echaieb A, Gallot D. Traitement Chirurgical des Hernies Rares. Techniques Chirurgicales-Appareil Digestive EMC. Paris: Elsevier SAS, 2005; 40–5.
Mustafa Ozsoy,* MD Taner Ozkececi,* MD Murat Akici,* MD Mustafa Kalkan,* MD Ahmet Katirag˘,† MD Sezgin Yilmaz,* MD Departments of *General Surgery and †Radiology, Afyon Kocatepe University, Afyon, Turkey doi: 10.1111/ans.13124
© 2015 Royal Australasian College of Surgeons
Internal herniation through the foramen of Winslow: a rare cause of bowel obstruction An 80-year-old male patient was admitted with nausea, vomiting and abdominal pain persisting for 1 week. The patient’s medical history showed no malignancies, previous surgery, trauma or weight loss. The physical examination showed peritoneal tenderness and widespread abdominal distention. Laboratory examinations showed no sign of pathologies, except leukocytosis (14 000/mm3). Abdominal computed tomography showed widespread small intestine dilation and intra-abdominal free air, and the patient underwent emergency surgery (Fig. 1). Intra-abdominal exploration showed that the terminal ileum and cecum (in part) were herniated into the bursa omentalis through the foramen of Winslow. Kocher’s manoeuvre was used to reduce herniated loops. Perforation foci secondary to ischaemia were detected in the 10-cm herniated small bowel loop (Fig. 2). Perforated intestinal loops were resected, and right colonic
fixation was performed. The patient did not have any complications in the post-operative period, and was discharged on day 8. Herniation through the foramen of Winslow (HFW) is a rare type of herniation, and is usually not considered in the differential diagnosis in the preoperative period; still, it causes significant morbidity and mortality. HFW constitutes 0.1% of all abdominal hernias, and 8% of all types of internal herniation.1 The rate of preoperative diagnosis is quite low, and the diagnosis is usually made intraoperatively. Because of delays in diagnosis and treatment, mortality rates up to 50% have been reported. HFW was described for the first time in 1834 by Blandin, and is an extremely rare type of internal herniation. To date, approximately 200 cases have been reported.2 Under normal conditions, the foramen of Winslow is closed due to intra-abdominal pressure. The predisposing factors in
Fig. 1. (a) View of axial computed tomography: collapsed bowel loops entering the omental bursa (green arrow) through the foramen of Winslow (white circle) and exiting (blue arrow) are present (bird’s beak finding). Red arrows indicate strained bowel loops that were herniated to the omental bursa. (b) View of sagittal computed tomography: bowel loops herniated to the bursa omentalis (white circle) and mesenteric vascular structures (yellow arrows) that were displaced to the superior due to herniation are present. White stars indicate strained bowel loops. Free air secondary to perforation is seen in the subdiaphragmatic area (curved arrow). (A, aorta; V, vena cava; K, liver; S, gallbladder.)
Fig. 2. (a) Enlarged foramen of Winslow (white arrow). (b) Necrotic small intestine segment after reduction.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
HFW pathophysiology have been described in detail by Erskine.3 These ones are abnormally enlarged foramen, the presence of an unusually long small bowel mesentery or persistence of the ascending mesocolon, an elongated right hepatic lobe, a lack of fusion between caecum or ascending colon to the parietal peritoneum, a defect in the gastrohepatic ligament and incomplete intestinal rotations or malrotation. Although HFW-specific physical examination findings do not exist, laboratory findings are helpful only in the case of intestinal ischaemia development. The common clinical finding is cramp-like abdominal pain in the upper midline, which is seen together with nausea and vomiting. Previous studies have reported patients who are admitted with nausea, vomiting and weight loss secondary to the compression of herniated intestinal loops, as well as obstruction icterus due to hepatic pedicle pressure.4 The small bowel is involved in 58% of the cases of herniation through foramen of Winslow. Still, involvement of the ascending and transverse colon, gallbladder and Meckel’s diverticulum has been described in the literature.5 Abdominal tomography could aid in the diagnosis of HFW. Abdominal Wojtasek have defined abdominal tomography findings of HFW as follows: (i) the presence of mesenteric adipose tissues and intestinal loops behind the hepatic pedicle; (ii) abnormal localization of the cecum; and (iii) gas and/or fluid in the lesser sac with a ‘bird’s beak’ pointing towards the epiploic foramen.6 The surgical approach has priority in HFW treatment due to risk of obstruction and strangulation. Following careful exploration, bowel loops that are entrapped in the hernia sec should be reduced in patients who undergo emergency operations. Gastrohepatic and gastrocolic ligaments should be opened and reduction should be completed with the help of Kocher’s manoeuvre. Resection should be performed when ischaemic bowel loops are detected. Another debated point is the treatment algorithm when intestinal ischaemia cannot be detected after reduction. Some authors suggest using caecopexy or right colonic fixation, whereas others suggest using extended right hemicolectomy to prevent reherniation when the colon intersection is not clear. Another matter of debate is whether foramen of Winslow should be closed or not. Cases of portal venous thrombosis secondary to the closure of the foramen of Winslow are present in the literature. Therefore, most authors suggest not to close the foramen of Winslow due to potential concerns. It is considered that this gap would close secondary to inflammatory reactions
Images for surgeons
during the post-operative period.7,8 In our case, ischaemic and perforated bowel loops were resected after reduction. The cecum and colon were mobile, and therefore fixed to the retroperitoneal area by fixation. Because of similar concerns, we did not close the gap in the foramen of Winslow. In conclusion, HFW should be considered in the differential diagnosis for patients who are admitted with intestinal obstruction and acute abdominal conditions, who have stomach ache (in the form of intermittent cramps) and who do not have any medical history.
References 1. Orseck MJ, Ross PJ, Morrow CE. Herniation of the hepatic flexure through the foramen of Winslow: a case report. Am. Surg. 2000; 66: 602–3. 2. Osvald AB, Mossman DF, Bersch VP, Rohde L. Intestinal obstruction caused by a foramen of Winslow hernia. Am. J. Surg. 2008; 196: 242–4. 3. Erskine JM. Hernia through the foramen of Winslow. Surg. Gynecol. Obstet. 1967; 125: 1093–109. 4. Armstrong O, Hamel A, Grignon A et al. Internal hernias: anatomical basis and clinical relevance. Surg. Radiol. Anat. 2007; 29: 333–7. 5. Hoeffel JC, Zimberger J, Pocard B, Hoeffel C. Demonstration by computer tomography of a case of internal small bowel herniation. Br. J. Radiol. 1992; 66: 1045–6. 6. Wojtasek DA, Codner MA, Nowak EJ. CT Diagnosis of cecal herniation through the foramen of Winslow. Gastrointest. Radiol. 1991; 16: 77–9. 7. Farthouat P, Platel JP. Hernie du hiatus de Winslow: diagnostic tomodensitométrique préopératoire et traitement par coelioscopie. Ann. Chir. 1998; 52: 387–9. 8. Kotobi H, Echaieb A, Gallot D. Traitement Chirurgical des Hernies Rares. Techniques Chirurgicales-Appareil Digestive EMC. Paris: Elsevier SAS, 2005; 40–5.
Mustafa Ozsoy,* MD Taner Ozkececi,* MD Murat Akici,* MD Mustafa Kalkan,* MD Ahmet Katirag˘,† MD Sezgin Yilmaz,* MD Departments of *General Surgery and †Radiology, Afyon Kocatepe University, Afyon, Turkey doi: 10.1111/ans.13124
© 2015 Royal Australasian College of Surgeons
