MSS855: HAND-ASSISTED LAPAROSCOPIC APPROACH TO A FORAMEN OF WINSLOW HERNIA
Brendan M Flynn, DO1; Virginia P Madey, MD2; Gao L Chen, MD2; Anna K Hindle, MD2; 1Walter Reed National Military Medical Center; 2MidAtlantic Permanente Medical Group (MAPMG), Northern Viriginia
A 68-year-old female presented with acute onset abdominal pain, accompanied by nausea and vomiting that began earlier that morning. She had no prior history of similar symptoms and was in her state of usual good health. Her medical history is notable for obesity, which has been managed with daily 15 mg Phentermine for the past two years, resulting in sustained weight loss. Her only abdominal surgical history was two Caesarean sections.
Computed tomography (CT) imaging revealed a closed-loop bowel obstruction, suggestive of an internal hernia, and there was no radiographic evidence of bowel compromise. A nasogastric tube was placed, and the patient was taken to the operating room for diagnostic laparoscopy. Intraoperatively, the terminal ileum to the ascending colon had herniated through the foramen of Winslow and was incarcerated in the lesser sac. Initial attempts at laparoscopic hernia reduction were unsuccessful, and due to concern for a traction injury, a hand-assist port was placed. Given concern for injury to the appendix during the laparoscopic reduction attempts, an appendectomy was performed. The foramen was closed laparoscopically with permanent barbed suture. The patient recovered well, the nasogastric tube was removed upon the return of bowel function, and her diet was advanced. She was discharged home on postoperative day five.
A foramen of Winslow hernia is a rare cause of internal hernia, accounting for 8% of all internal hernias and less than 0.1% of all hernias. Herniated viscera typically include the small bowel, cecum, and ascending colon. Predisposing factors include increased bowel mobility, an enlarged foramen of Winslow, and changes in intra-abdominal pressure. The clinical presentation can vary depending on the herniated viscera, with atypical presentations such as gastric outlet obstruction, cholecystitis-like symptoms, and obstructive jaundice being reported.
The surgical approach for treating a foramen of Winslow hernia is influenced by the patient's condition, surgeon skill and preference, and available hospital resources. Both open and laparoscopic repairs have been described, though no robot-assisted cases have been reported to date. The surgical approach, including bowel resection, cecopexy, or foramen closure varies based on intraoperative findings. Ischemic bowel should undergo resection as is standard of care. There is currently no consensus on the ideal surgical management of this hernia, but recurrence is rare despite a diversity in approach. Consistent with established surgical management of internal hernias, we advocate for meticulous anatomical closure of the foramen of Winslow to mitigate the risk of recurrence.
