The incarcerated Winslow hernia with cecum ischemia and compression of the hepatoduodenal ligament: a case report

Introduction: Internal hernias through the foramen of Winslow have a very low incidence. This is why they are often not taken into consideration as a differential diagnosis in cases of mechanical ileus. However, rapid diagnosis and treatment are essential for the patient´s outcome. Early surgical intervention is crucial in reducing morbidity and mortality. Presentation of case: A 58-year-old male patient presented with nonspecific abdominal symptoms. Computed tomography (CT) raised suspicion of the cecum herniating through the foramen of Winslow into the lesser sac. Urgent surgical exploration using a laparoscopic approach was planned, and the radiologic suspicion was confirmed intraoperatively. To reposition the incarcerated and dilated cecum to its typical location, conversion to open surgery and colotomy were performed. As it still showed signs of malperfusion, an ileocecal resection was performed, restoring continuity with a side-to-end ileocolic anastomosis at the ascending colon. The postoperative course was uneventful. Discussion: Clinical history and presentation of incarcerated Winslow hernia often remain nonspecific. The key diagnostic tool is the contrast-enhanced CT scan; nevertheless, a diagnosis is often only made intraoperatively. Herniating bowel structures, such as the cecum, suffer from interrupted mesenteric circulation and venous congestion, causing ischemia and dilatation. This can compromise hepatic perfusion and biliary drainage due to the distended bowel compressing the hepatoduodenal ligament. Severe complications, such as perforation, thrombosis, or bleeding, up to and including death, may occur. Conclusion: By reporting this case, awareness of internal hernias should be strengthened so as not to miss this rare but important differential diagnosis.