Hernia Through Winslow Foramen: A Case Report

Eko Ristiyanto1, TaufikAgung Wibowo2, RidhoSyaiful Ardhi1, Benny Philippi1, Toar JM Lalisang1
1. Digestive Surgery division, Cipto Mangunkusumo Hospital. Facultas Medicine Universitas Indonesia.
2. Radiology Department Cipto Mangunkusumo Hospital. Facultas Medicine Universitas Indonesia

ABSTRACT
Hernias through Winslow foramen are extremely rare, occurred for 0.1% of all abdominal hernias and found during laparotomy due to
strangulated bowel obstruction. We report a case of ileum herniated through Winslow foramen to lesser sac. A 54-year-old man presented
acutely with severe epigastric pain, vomiting, and bowel obstruction signs. Plain abdominal x-ray confirmed the diagnosis but the etiology
was unclear. Emergency laparotomy was performed and a herniated loop of ileum was found entering the lesser sac through the Winslow
foramen. The loop of ileum was reduced and viable, omental patch was put on Winslow foramen as plasty procedure. The patient’s recovery
was uneventful, and after 5 postoperative days, he was discharged. Retrograde analysis on the plain abdominal x-ray showed a closed loop of
small bowel at the projection of lesser sac, suggesting the protrusion of ileum loop. This radiologic finding should be considered as
abdominal internal hernia through Winslow foramen.

KEYWORDS: Hernia, Winslow foramen, Plain Abdominal X rays.

Background
Hernias through Winslow foramen are extremely rare, occurring 0.1% of all abdominal hernias, and 8% of all
internal abdominal hernias. 1Until present there were 11 cases of Winslow foramen hernia reported in the
literatures. Seven out of 9 cases were herniation of ileum, followed by caecum or ascending colon. 2,3 Gallbladder
and omentum herniated through Winslow foramen were the rest. Most patients were admitted with strangulated
small bowel obstruction. If non vital bowel occurred, the mortality rate increased to 36% and 49% 4. All the
diagnosis were confirmed during laparotomy. We present a case of patient with strangulated bowel obstruction
due to herniation of ileal loop through Winslow foramen. We also note the role of plain abdominal x-ray to detect
Winslow foramen hernia.

Case Report
A 54-year-old man came in the emergency room with severe epigastric pain/colic, vomiting and bowel obstruction
symptoms. Similar pain has been frequently experienced in the past, and no previous abdominal surgery. On
admission, the patient looked severe ill and septic, blood pressure was 130/80 mmHg, heart rate was 110 beats per
minute, respiratory rate was 24 times per minute, and temperature was normal. Signs of bowel obstruction were
clearly present, with mild tenderness and distended abdomen, especially at the right upper quadrant. Laboratory
study showed hemoglobin 12.4 gr/dL, hematocrit 34%, white blood cells count 15.400/microliter, with a shift of
white blood cell differential count to the left (increased neutrophils). Base excess of arterial blood gas analysis
was within normal limit. Total bilirubin and direct bilirubin were elevated to 2.8 and 1.8 mg/dL, respectively.
Plain abdominal x-ray revealed small bowel obstruction, free fluid/ascites, and no sign of obturator hernia. There
was a closed-small bowel loop trapped/located in the lesser sac (Fig. 1, arrow).
 Figure 1. Abdominal x-ray showing bowel obstruction. Arrow shows suspectedbowel loop in the lesser sac.

Emergency midline laparotomy was performed after optimal fluid resuscitation and pain management.
Intra operatively, a loop of 50-cm-long ileum was found herniating through Winslow foramen, the strangulated
loop was released. The ileum was considered viable and was returned into the greater sac (Fig. 2). Defect of
foramen was more than three digits wide, mobile caecum/ascending colon and redundant transverse colon were
found. Reducing Winslow foramen diameter was done using a plasty procedure through suturing of duodenal-
hepatic ligament to posterior peritoneal layer and omental probe was put on the opening of the tunnel. The
patient's post-operative recovery was managed according to ERAS protocol and he was discharged after 5 days.

Figure 2. Intraoperative findings and illustration.

Discussion
The reported demographic for bowel herniation through Winslow foramen is usually men working manual
labor, aged between 50 to 60 years old. Some have suggested that cholecystectomy might be a risk factor. 5 Other
postulated risk factors6 include abnormally long bowel mesentery, redundant transverse colon, mobile caecum,
abnormally enlarged Winslow foramen, and a defect in the gastro-hepatic ligament. Wide Winslow foramen,
mobile caecum and redundant transverse colon are the causes of this Internal abdominal Hernia. Herniation
through Winslow foramen is rare because the normal peritoneal orifice is kept closed by normal intra abdominal
pressure. Erskine7 has also postulated that the failure to push the right colon retroperitoneally due to changes in
the intra-abdominal pressure as a contributing factor. Symptoms are often related to small bowel obstruction and
occasionally to gastric outlet obstruction. The presence of jaundice has also been described due to direct
compression of the hepatic pedicle.5 The obstruction in our patient was proximal, rendering minimal nasogastric
drainage. Our patient had no previous abdominal surgery or trauma, and the abdominal x-ray suggested small
bowel obstruction, therefore laparotomy was mandated. There are many more common causes of epigastric
pain; however, these conditions can be excluded quickly. Unfortunately, many cases of this condition have been
identified at autopsy.
Bowel obstruction is usually diagnosed from plain abdominal X-rays in our center. Some have reported that
gas-containing intestinal loops high in the abdomen and medial-posterior to stomach are associated with small
bowel obstruction. An emergency abdominal x-ray is considered the diagnostic modality of choice, 8 largely as a
consequence of clinical diagnostic uncertainty. 9This patient’s case presentation has a lot in common with other
recently published cases. There were no obvious risk factors in this patient, except that he is an average manual
worker. This condition is rare, difficult to diagnose, and does not always present with obvious risk factors.
Management is mainly by surgical reduction, following immediate resuscitation. Reduction can be difficult
especially if there is massive colonic dilatation. A wide Kocher’s maneuver or opening of the gastro-hepatic
ligaments may be required. In cases with diagnostic uncertainty, even with high resolution computed
tomography, open surgery is usually performed. However, this has led some experienced surgeons to perform
initial investigation with laparoscopy. Successful laparoscopic management for Winslow foramen herniation has
now been widely reported.10 The debate continues as to whether Winslow foramen ought to be closed in order to
prevent recurrence. To date, there has not been a report of recurrence, probably due to adhesion obliterating the
foramen,the omental patch, and tethering the remainder of the small bowel. Therehave been warnings of the
potentially significant negative consequences of closing the defect: portal vein thrombosis and obstructive
jaundice.

Conclusion
Internal herniation through Winslow foramenis a difficult clinical diagnosis and must not be missed. Careful
evaluation of clinical symptoms, abdominal x-ray imaging, and surgical intervention are advised.

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