A surgical case report of an epiploic hernia — A mobile right colon herniating through the foramen of Winslow

Abstract

Introduction

An Epiploic Hernia is an extremely rare type of abdominal hernia with <0.1 % incidence where the bowel or other intra-abdominal contents herniate through the Foramen of Winslow. A case of an Epiploic hernia in a middle-aged female is presented here.

Presentation of case

A woman in her 60s was admitted to a tertiary level hospital with severe right sided intermittent upper abdominal pain associated with nausea, bloating and constipation. The symptoms were thought to be due to biliary colic and managed conservatively. Since the symptoms persisted and a computed tomography scan of abdomen was organized. CT scan showed that the caecum was in the upper left quadrant. A laparoscopy was performed and demonstrated that her right colon was mobile herniating through the Foramen of Winslow into the lesser sac. The hernia was reduced, and the bowel was viable. The patient was discharged with no complications.

Discussion

There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon, gall bladder, omentum, or Meckel's diverticulum. A caecal herniation through the Foramen of Winslow is reported only with an incidence of 0.02 %. <10 % of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50 %.

Conclusion

A high index of suspicion is needed for the diagnosis of this internal hernia and radiological investigation is fundamental in making this diagnosis for allowing prompt surgical treatment.

Highlights

• •Epiploic hernia is an extremely rare type of abdominal hernia with an incidence of <0.1 %.
• •A caecal herniation through the Foramen of Winslow is reported only at an incidence of 0.02 %.
• •High index of suspicion is needed for the diagnosis of internal hernia.
• •Radiological investigation plays an elemental role in diagnosis and timely management.
• •A delay in diagnosis and management of the hernia could lead to significant morbidity and mortality.

1. Introduction

An Epiploic hernia, also known as Blandin's Hernia through the Foramen of Winslow, is an extremely rare type of abdominal hernia with an incidence of <0.1 % and < 8 % of the internal hernias [1]. The most common content of this type of hernia is the small intestine, less commonly Omentum and Caecum [2]. Owing to the anatomy of the foramen of Winslow, there is a very high risk of strangulation of the contents. A delay in diagnosis and management of the hernia could lead to significant morbidity and mortality. Here a case is reported in line with the SCARE criteria 2023 [3] of an epiploic hernia with terminal ileum, caecum and a mobile right colon up to the hepatic flexure as the content of the hernia through the Foramen of Winslow into the lesser sac.

2. Presentation of case

A woman in her 60s was admitted to our hospital with a 12-h history of sudden onset of severe right sided crampy upper abdominal pain with waxing and waning nature associated with nausea, bloating and constipation. She had no significant comorbidities and no previous abdominal surgeries. On examination she had a soft abdomen, tenderness in the upper abdomen with negative Murphy's sign. There were no palpable masses in the abdomen. On admission she was well controlled on analgesics and her laboratory investigations and urine dip were normal. An initial impression of biliary colic was suggested. An abdominal ultrasound scan showed gallstones but no features of cholecystitis. Hence, she was treated for biliary colic.

However, overnight the pain worsened and was not controllable with analgesics. Inflammatory markers remained normal. A static picture of partial bowel obstruction was persistent as well. A computed tomography (CT) scan with IV contrast of abdomen and pelvis was organized to rule out any common bile duct stones, gastrointestinal perforation and/or bowel obstruction. The scan showed that there was an abnormally positioned caecum with its pole situated closer to the greater curvature of the stomach in the left gastric space without any volvulus or strangulation features. A part of the small bowel could also be seen in the lesser sac (Fig. 1a–d).

Fig. 1.

a. Axial CT representation showing caecum lying in the lesser sac.

Fig. 1b. Axial Representation of the Epiploic Hernia.

Fig. 1c. Coronal view of CT scan showing the caecum sitting in the lesser sac.

Fig. 1d. Coronal oblique view showing the caecum and terminal ileum herniating into the lesser sac through the epiploic foramen.

Her symptoms resolved completely after she had CT scan raising the possibility of spontaneous reduction of internal hernia. She was observed and a repeat scan was considered to confirm reduction of internal hernia. A plan was discussed with the patient to manage this condition conservatively for now and for further review to consider laparotomy and/or bowel resection and anastomosis if symptoms recurred since there was no overt features of bowel obstruction. She remained stable for the next 48 h after which the pain recurred with heightened intensity, and she was taken to theatre for a laparoscopic exploration.

Intraoperatively, there was an internal hernia where the caecum, ascending colon till the hepatic flexure and a part of the terminal ileum had herniated through the foramen of Winslow into the lesser sac. A colorectal surgeon's opinion was sought, and the hernia reduced laparoscopically with the entire mobile right hemi colon and terminal ileum reduced without any bowel fixation surgery or any bowel resection in the view that the incidence of recurrence was minimal with no current features of bowel ischemia.

The patient was observed in the ward post-operatively and discharged home 2 days later after having bowels opened successfully and no further recurrence of symptoms reported till date of writing of the report.

3. Discussion

The Foramen of Winslow is the only natural opening communicating between the peritoneal cavity and the lesser sac bounded superiorly by caudate lobe of the liver, dorsally by the inferior vena cava, ventrally by the hepatoduodenal ligament and inferiorly by the duodenum [4].

With <0.1 % of abdominal hernias and 8 % of internal hernias, the Epiploic Hernia through the Foramen of Winslow is a rare occurrence [1]. There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon [5], gall bladder [6], Omentum, or Meckel's diverticulum [7]. A caecal herniation through the Foramen of Winslow is reported only at an incidence of 0.02 % [8]. The common risk factors postulated for the occurrence of lesser sac hernias are a large Foramen of Winslow, mobile caecum and right colon due to failed retroperitonealisation as in our case and a raised intra-abdominal pressure [9].

<10 % of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50 % however, prompt diagnosis and treatment reduces this mortality risk to 5 % [10]. Symptoms are mild where the hernia reduces easily resulting in intermittent symptoms and diagnosis can be delayed [11]. The risk of strangulation due to volvulus of the caecum and the ascending colon are significantly high in cases of a hypermobile bowel due to either the retroperitoneal attachments being absent congenitally or acquired lengthening of the attachments [12]. This case is unique in the aspect that there is a congenitally absent retroperitoneal attachment and herniation through the foramen of Winslow. However, there were no features of strangulation or bowel ischemia and hence no bowel resection was needed for this case and the emergency was handled laparoscopically.

Based on the classification of internal hernias through the epiploic foramen this case was a type II hernia (Table 1) [9].

Table 1.

Classification of internal epiploic hernias.

Type of internal epiploic hernia	Contents of the hernia	Incidence
Type I	Small Bowel	65 %
Type II	Terminal Ileum, Caecum, Ascending colon	25 %
Type III	Transverse colon	7 %
Type IV	Gallbladder, Omentum, Other Intraperitoneal structures	3 %

Certain predisposing factors increases the mobility of the caecum. During embryologic development, the ascending colon rotates 270° counter-clockwise from left to right before becoming fixed to the posterior abdominal wall. However, in cases of under/over-rotation, or deficient fixation in the presence of normal rotation, the caecum becomes more mobile and thus is free to twist on its own axis. Furthermore, the caecum can become increasingly mobile over time, secondary to conditions such as chronic constipation and paralytic ileus [3]. Adhesions or congenital bands also predispose to caecal volvulus, as they act as a fulcrum around which the caecum can twist [4]. Other conditions which have been linked to developing caecal volvulus include previous abdominal surgery, pregnancy, acute medical illness, as well as mental illness [4]. There are other rare causes such as neurofibromatosis, with one other case having been reported in literature; however, the mechanism of action is unknown.

The definitive management of this hernia is surgical with laparotomy being more common than laparoscopy. The herniation may be reduced by applying gentle traction to the herniated colon through the foramen squeezing the air back into the distal colon. Reduction of herniated contents can be facilitated by enlarging the foramen by performing a Kocher maneuver, thus lifting the duodenum with its hepatoduodenal ligament away from the IVC. If this proves difficult, the gastrohepatic or gastrocolic ligaments can be opened or a large Kocher maneuver can be performed to help [11]. Bowel resection and anastomosis have been performed more often than not for these hernias due to high risk of volvulus and strangulation [10]. In this instance, the patient had no bowel strangulation or volvulus and hence, a laparoscopic approach with reduction of the hernia without the need for bowel resection and anastomosis was carried out. Considering the risk of surgery the foramen of Winslow was left unrepaired. Literature is scarce regarding recurrences with most literature reporting no recurrence [11]. There is relatively more choices of procedures in cases where caecum is viable after reduction of volvulus. These procedures include untwisting only, caecostomy, caecopexy and right hemicolectomy. Untwisting only carries a significant risk of recurrence, but avoids the morbidities (14 %) associated with bowel resections. Caecostomy has been reported to have a wide range of recurrence (0–25 %), mortality (0–33 %) and morbidities including abdominal wall sepsis, fasciitis and persistent faecal fistula [5]. Caecopexy has been reported to be associated with 13 % recurrence and 10 % mortality [13]. Non-obstructing foramen of Winslow hernia can be repaired operatively on an elective basis to avoid emergent surgery [14]. Closure of the foramen of Winslow to minimize the risk of recurrence may risk damage to the biliary ducts, hepatic artery, or portal vein leading to thrombosis or injury [15].

4. Conclusion

Internal hernias should always be a differential in patients presenting with bowel obstruction. Incidental findings of gall stones is very common in patient with abdominal pain- a high index of suspicion is needed towards the diagnosis of this rare condition of Epiploic hernia and a close liaison with radiologist is fundamental in making this diagnosis and laparoscopic approach can be successfully applied.

Consent

Consent (Written and verbal) has been attained from the patient to use the medical data for this scientific paper.

Ethical approval

The case report is exempt from ethnical approval by Research Governance, University of Aberdeen and NHS Grampian.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Shubham Jain - Study concept or design, data collection, data interpretation, writing the paper.

Ashrafun Nessa - Study concept or design, writing the paper.

Mark Gandhi - Data interpretation, writing the paper.

Radhakrishnan Ganesh - Study concept or design, writing the paper.

Guarantor

Shubham Jain, Ashrafun Nessa, Radhakrishnan Ganesh.

Research registration number

N/A.

Declaration of Generative AI and AI-assisted technologies in the writing process

None.

Declaration of competing interest

None.