Internal Hernia Through the Foramen of Winslow; Is Laparoscopy the New Standard for Management? a Case Presentation

Sepehr Lalezari, MD¹, Scott C Hobler, MD², Amir H Aryaie, MD³. ¹Johns Hopkins Medicine, ²The Jewish Hospital, Cincinnati, ³Texas Tech University Health Sciences Center

INTRODUCTION: Internal hernia through the Foramen of Winslow is a relative rare event comprising only 8% of all internal hernias. In recent years, laparoscopic approach to management appears to be the favored approach indicating a paradigm shift over past years. A standard approach to dealing with this type of hernia has yet to be established. We present a case of this rare hernia which was safely managed laparoscopically.

CASE PRESENTATION: 52 year-old female presented to the emergency department with severe abdominal pain. The pain was described as pressure type in the epigastric region and radiated to her back and across right upper abdomen. Her abdomen was soft, not distended, and tender in the right upper quadrant and epigastric area with voluntary guarding. Intravenous and oral contrast-enhanced?computed tomography?(CT) of the abdomen and pelvis was obtained. A small amount of contrast was noted within non-distended small bowel loops located in the lower abdomen and pelvis. A large structure was visualized within the epigastrium. The structure was exerting a mass effect upon the lesser curvature of the stomach displacing it towards the left and inferiorly. The patient was taken to the operating room for a diagnostic laparoscopy. Once intra-abdominal access was gained, gross examination revealed the colon herniating through the foramen of Winslow into lesser sac. The right colon and cecum appeared incarcerated but not strangulated. The colon was reduced with gentle traction and appeared viable. Given the redundant nature of the colon we elected to perform a laparoscopic right hemi-colectomy to prevent recurrence. The patient tolerated the procedure well and was discharged home on post-operative day three.

CONCLUSION: Foramen of Winslow hernia appears to be more common in middle aged male patients. With mortality rates as high as 50% prompt diagnosis is crucial. Management options vary from resection of herniating structures to organopexy. Some studies report closure of the foramen although given possibly of injury to vital surrounding structures this should be avoided. Placement of omentum into the foramen in another option. All options can be effectively carried out via a minimally invasive approach thus laparoscopy should be strongly considered as the first line option for management of this rare hernia.

Figure 1(A-D): Intraoperative findings