Abstract

Intestinal herniation through the foramen of Winslow into the lesser peritoneal sac is an uncommon variety of internal hernia which causes intestinal obstruction. A total of 80 cases had been reported in the literature by 1965 (1). Males are affected twice as frequently as females. The small bowel alone is contained in the hernia two to three times more often than is the colon. The patient, a 69-year-old white woman, was hospitalized after being ill for a week. Her symptoms began after a meal, with sudden vomiting and cramping abdominal pain. There followed increasing abdominal distension and complete constipation. On physical examination the abdomen was distended and was generally slightly tender. No masses could be palpated. There was muscle guarding but no rebound tenderness. Bowel sounds were heard. The blood pressure, pulse rate, and temperature were within normal limits. Multiple laboratory studies disclosed normal values. A supine roentgenogram of the abdomen showed a huge, “U”-shaped segment of gas-distended bowel traversing the abdomen. A blunt, rounded end was uppermost in the left abdomen. Haustral markings were identified there. No pattern of gas corresponding to the usual position of the right colon could be found. Essentially vertically oriented loops of bowel seen in the right flank were thought to be small bowel (Fig. 1). An erect study of the abdomen demonstrated a long air-fluid level in the largest segment of distended bowel. A barium-enema study showed obstruction to the flow of barium in the proximal transverse colon. The end of the barium column was tapered (Fig. 2). A diagnosis of volvulus of the proximal transverse colon associated with a hypermobile right colon was made. At surgery a distended but thick-walled, faintly engorged cecum presented immediately. Further examination showed that the cecum, a segment of the terminal ileum, and a portion of the ascending colon had herniated into the lesser peritoneal sac through the foramen of Winslow. This mass of bowel had in turn perforated through an atrophic lesser omentum and re-entered the general peritoneal cavity. After decompression of the distended colon, the hernia was reduced through the foramen of Winslow, and the foramen was reduced in size with sutures. The patient recovered without incident. Discussion In intestinal herniation through the foramen of Winslow the roentgen appearance will vary somewhat according to the hernia contents, but, in general, bowel should be identified in the lesser sac medial and posterior to the stomach. When small bowel alone is contained in the hernia, the stomach is likely to be displaced forward and to the left. Multiple air-fluid levels will be seen in the lesser sac. Cimmino (2) stressed the use of the erect lateral view to establish this. Lavarde and Chevret (3) noted that a double obstruction may be produced when a loop of small bowel returning from the hernia stretches tightly across the colon and occludes it.

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