Laparoscopic management of foramen of Winslow incarcerated hernia

Abstract

Foramen of Winslow hernia (FWH) is a rare and often overlooked diagnosis with a high mortality rate. Widespread availability of cross-sectional imaging allows early diagnosis and prompt management. In this setting, before ischemia occurs, explorative laparoscopy would be the most suitable approach. Experience, however, remains sparse, and technical difficulties may be encountered. This is the case of a 38-year-old Caucasian woman who presented to the emergency department for a sudden epigastric pain. Physical exam was unremarkable, and routine blood tests were within normal range. An abdominal computed tomography (CT) scan confirmed the diagnosis of ileocaecal herniation through the foramen of Winslow. Under urgent laparoscopy, the caecum appeared viable but incarcerated in the lesser sac. Caecal puncture was the key to achieving atraumatic reduction of the hernia and bowel salvage.

Meckel’s Diverticulum in Foramen of Winslow Hernia – A Rare Cause of Bowel Obstruction

“…FOWH accounts for 0.08% of all visceral hernias and 8% of bowel obstruction secondary to internal hernias [1,2]. Historically FOWH was considered difficult to diagnose, often resulting in strangulated bowel contents at the time of presentation [3,4]. This was associated with a high mortality rate of up to 50% before the advent of more reliable imaging resources [2].…”

Case of ileal herniation through the foramen of Winslow diagnosed preoperatively by CT and treated with laparoscopic surgery

“…Therefore, the key to diagnosis relies on prompt radiological findings, especially CT scans, because of characteristic findings. Classical CT scan findings are as follows: (i) mesenteric fat and vessels anterior to the inferior vena cava and posterior to the hepatoduodenal ligament; (ii) gas and/or fluid collection in the lesser sac with a “bird's beak” pointing toward the foramen of Winslow; (iii) the presence of a dilated small intestine posterior to the lesser omentum and compressing the stomach; (iv) two or more bowel loops in the subhepatic spaces; and (v) absence of the ascending colon in the right iliac fossa (if the ascending colon and cecum are involved) . So we should consider HFW in patients with internal herniation of unknown origin for precise and early diagnosis.…”

“…This is especially true when there is a lack of fusion between the parietal peritoneum and the cecum or ascending colon, and the ascending colon and cecum are involved. Instead of foramen closure, packing it with omentum is an option . It has been suggested that closure of the foramen may damage hepatoduodenal ligaments, leading to portal vein thrombosis.…”

“…In our case, the foramen of Winslow was enlarged, and we decided to leave it open. In the past, the treatment has been laparotomy, but some recent reports showed that laparoscopy offers exploratory possibilities, improved treatment options, and enhanced recovery when promptly managed . Reports of HFW diagnosed preoperatively and treated with laparoscopic surgery are likely to increase.…”

Laparoscopic treatment of ileocaecal herniation through the foramen of Winslow – a video vignette

“…Hernia through the foramen of Winslow is an unusual condition, representing 8% of all internal hernias . A growing number of cases of herniation through de foramen of Winslow treated by a laparoscopic approach have been described in the literature, although there are no guidelines for treatment of viable herniated content or for foramen closure .…”