Retroperitoneal cecal volvulus: a complication of a rare internal hernia – a case report

Introduction and importance: The foramen of Winslow hernia (FWH) is a rare type of internal hernia. In one-third of cases, the cecum was found in the lesser sac. More rarely, the herniated cecum might be volvulated, which represents 1–1.5% of the causes of intestinal obstruction. Once diagnosed, surgical reduction and/or resection of the nonviable herniated bowel is crucial for a positive outcome. Case presentation: The authors report a case of retroperitoneal cecal volvulus that complicated FWH in a patient with a history of laparoscopic cholecystectomy. Clinical discussion: A delay in the diagnosis is associated with high morbidity and even higher mortality. Because of lacking a consensus, the treatment of FWH depends on the team’s surgical experience. Conclusion: Reporting this case will help us to keep in mind this differential diagnosis while treating patients in our daily practice.


Case description
The SCARE criteria were followed in reporting this case report [1] .We present the case of an 83-year-old woman, who was admitted through the emergency department few hours after the sudden onset of thoracic and upper abdominal pain associated with vomiting.The pre-existing conditions include: laparoscopic cholecystectomy, history of percutaneous coronary intervention and drug-eluting stent implantation in the right coronary artery, and left anterior descending artery/first diagonal branch (D1), transcatheter aortic valve implantation for high-grade aortic stenosis and mitral/tricuspid valve insufficiency, renal insufficiency (stage G3a), type II diabetes mellitus, arterial hypertension, dyslipoproteinemia, history of basal cell carcinoma, and restless legs syndrome.The physical examination showed a cachectic patient with no jugular vein congestion or peripheral edema on auscultation, a regular heart rhythm with no murmurs, an unremarkable pulmonary examination, and a distended abdomen with no signs of peritonitis.Upon admission, a synthetic opioid, Piritramid 7.5 mg was intravenously (iv) administered.
The patient was initially pain-free but experienced a pain recurrence shortly after that.Computed tomography (CT)-scan of both thorax and abdomen with with iv contrast-enhancement excluded a possible aortic dissection and showed signs of intestinal transit disorder in the left upper abdomen and a distended transverse colon without signs of mesenteric ischemia (Fig. 1).Subileus was diagnosed and conservative treatment was initiated, including gastric and rectal tube installation, fluid therapy, correction of hypokalemia, proton pump inhibitor, analgesic, and antibiotic therapy.Under this treatment, the patient showed no remarkable improvement.Colonoscopy and gastroscopy under fluoroscopy were then performed.Due to stool soiling, only the transverse colon could be reached but was not dilated as suggested in the CT.However, a tumoral stenosis was ruled out and an intestinal decompression tube was inserted.The concomitant

HIGHLIGHTS
• The Foramen of Winslow hernia represents a rare type of internal hernias.• A cecal volvulus is a rare case of intestinal obstruction representing 1-1.5% of all cases.• A radiological exam, usually a computed tomography scan, should be performed.• A high clinical suspicion should be raised once a part of the bowel is found in the lesser sac.• Surgery is the treatment of choice with nowadays no consensus or guideline.• Most of the published cases are case reports.gastroscopy also showed no signs of malignancy or stenosis.After repositioning the nasogastric (NG) tube, water-soluble contrast medium (Peritrast 400 mg, Köhler Pharma) was administered through both tubes and an abdominal radiography was performed.Unexpectedly, neither the contrast via the NG-tube nor the colonic decompression tube stained or reached the the large, air-filled, coffee bean-shaped structure in the upper left abdomen (Fig. 2).In the following hours, the rectal decompression tube was dislocated, the patient's abdomen remained distended and painful.Due to these unclear findings a new interdisciplinary discussion took place.The physical examination showed diffused abdominal pain with signs of local peritonitis in the epigastrium.In the context of the upon mentioned findings and the clinical condition of the patient there was a clear indication for exploratory laparotomy.An informed consent was obtained.A median laparotomy was performed.The intraoperative findings showed ascites with omental adhesions (postcholecystectomy), dilated small bowels and a slim colon transverse and left colon.The small intestine was followed from the Treitz band and surprisingly was fixed in the right upper quadrant.The Lesser sac was widely opened and just then the diagnosis was clear: cecal

Table 1
Summary of all the previous published cases volvulus after herniation through the foramen of Winslow (Fig. 3).The cecum was then decompressed by a purse-string suture and appendectomy.The cecal wall was ischemic (Fig. 4), and as a consequence a right hemicolectomy with side-to-side anastomosis was performed.The postoperative course was uneventful.A regular diet was tolerated and the patient was discharged on the ninth postoperative day in good condition.

Discussion
The first reported case of the foramen of Winslow hernia (FWH) was published in 1834 through Philippe-Frederic Bladin as an incidental postmortem finding.Since then, ~200 such cases have been reported worldwide (Table 1).FWH accounts for 8% of internal hernias and 0.08% of all hernias [37] .In one-third of the T Makarawo et al. [61] Case report 2014 1 No Cecum 61 J Ryan et al. [62] Case report 2014 1 No Right colon 62 CL Tee et al. [63] Case report 2014 1 No Small bowel 63 S Nazarian et al. [64] Case report 2015 1 No Small bowel 64 CR Harnsberger et al. [65] Case report 2015 1 No Cecum and Ileum 65 M Ozsoy et al. [66] Case report 2015 1 No Cecum and Ileum 66 PN Brandao et al. [67] Case report 2016 1 No Transverse colon 67 LE Duinhouwer et al. [68] Case report 2016 1 No Ascending colon 68 R Daher et al. [69] Case report 2016 1 No Cecum and Ileum 69 S Garg et al. [70] Case report 2016 1 No Cecum and Ileum 70 LS Kirigin et al. [71] Case report 2016 1 No Small bowel 71 V Sobek et al. [72] Case report 2016 1 No Cecum 72 E Leung et al. [73] Case report 2016 1 No Small bowel 73 G Tse et al. [74] Case report 2016 1 No Cecum 74 HG Cho et al. [75] Case report 2017 1 No Small bowel 75 Y Ichikawa et al. [76] Case report 2017 1 No Small bowel 76 J Nguyen et al. [77] Case report 2017 1 No Cecum 77 J Patel et al. [78] Case report 2017 1 No Cecum 78 BW Deschner et al. [79] Case report 2018 1 No Cecum 79 A Haddad et al. [80] Case report 2018 1 No Small bowel 80 YJL Jansen et al. [81] Case report 2018 1 No Cecum 81 K Shek et al. [82] Case report 2018 1 No Cecum 82 P Downs et al. [83] Case report 2018 1 No Ileum, right and transverse colon 83 S Fujihata et al. [84] Case report 2018 1 No Small bowel 84 F Ayoob et al. [85] Case report 2019 1 No Ileum and Cecum 85 P Charters et al. [86] Case report 2019 1 No Cecum 86 D Moris et al. [87] Review 2019 15 No -87 YA Mahnashi et al. [88] Case report 2019 1 No Right colon 88 M Azer et al. [89] Case report 2020 1 No Right colon 89 C Buisset et al. [90] Case report 2020 1 No Right colon 92 YM Cho et al. [91] Case report 2020 1 No Cecum 93 E Ristiyanto et al. [92] Case report 2020 1 No Small bowel 94 M Sammut et al. [93] Case report 2020 1 No Cecum 95 I Sravya et al. [94] Case report 2020 1 No Small bowel 96 S Akhtar et al. [95] Case report 2021 1 No Cecum 97 PKBSC Bandara et al. [96] Case report 2021 1 No Small bowel 98 EA Karlsen [97] Case report 2021 1 No Small bowel 99 AM.Williams et al. [98] Case report 2021 1 No Cecum 101 N Naqeeb et al. [99] Case report 2021 1 Yes Cecum 102 S Honma et al. [100] Case report 2021 1 No Small bowel 103 D Chandhrasekhar et al. [101] Case report 2022 1 No Ileum, right colon 104 SL Carpenter et al. [102] Case report 2022 1 No Cecum 105 AL Titan et al. [103] Case report 2022 1 No Small bowel 106 A Kharkhash et al. [104] Case report 2022 1 No Cecum 107 EL Monteiro et al. [105] Case report 2022 1 No Ileum, right colon 108 H Honda et al. [106] Case report 2022 1 No Right colon 109 Y Huang et al. [107] Case report 2022 1 No Small bowel 110 SM Mansoor et al. [108] Case report 2022 1 No Cecum 111 A Perabo et al. [109] Case report 2022 1 No Cecum 112 V Tatagari et al. [110] Case report 2022 1 No Ascending colon 113 E Mulkey et al. [111] Case report 2022 1 No Cecum 114 HWL de beaufort et al. [112] Case report 2023 1 No Small bowel cases, the hernia included the cecum and ascending colon [113] .Among the possible causes of predisposition are: an enlarged foramen of Winslow, an abnormally long small bowel mesentery, persistence of the ascending mesocolon that allows marked mobility of the bowel, and an elongated right hepatic lobe [4,57,114] .On the other hand, cecal volvulus accounts for 1% of large bowel obstruction causes [113] .This manifestation has two forms with the more common one involving an axial twist of the ileum, cecum, and proximal ascending colon around its mesentery.The other form, called cecal bascule, accounts for 10% of the cases and involves the folding of the cecum upward toward the hepatic [115] .Cecal volvulus, once untreated, is usually associated with a high mortality rate that reaches 48% [109] .This happens usually due to vascular involvement and delayed diagnosis [45,114] .The initial symptoms of FWH are usually nonspecific and can include both upper abdominal and chest pain [86] .The diagnosis should be expected once on radiological examinations an airfilled structure is seen in the left upper quadrant.However, this is achieved preoperatively in only 10% of cases [116] .An urgent surgical management involves reduction of the herniated bowel and might be followed by cecopexy and/or closure of the foramen of Winslow.Once bowel ischemia is present, resection should be performed [57,60] .Both open and minimal invasive surgeries have been reported [65,74] .
In our case, after ruling out cardiorespiratory distress, the patient was treated conservatively for subileus.Failure of this therapy and the persisting presence of the air-filled coffee bean structure between both stomach and colon on the fluoroscopy with the developing signs of local peritonitis led to the surgical intervention.The initial clinical examination showed no signs of peritonitis and the CT-scan interpreted the dilated colon in the left upper quadrant as transverse colon and excluded mesenteric ischemia.We began a conservative therapy and the surgical treatment was delayed for 48 h.Ferguson et al. in 2008 reviewed the literature for cases of intestinal volvulus as a possible postcholecystectomy complication.Among the 12 published cases, three involved an intraperitoneal cecal volvulus [117] .Interestingly, retroperitoneal cecal volvulus (in the lesser sac through FWH) was also reported twice as a possible complication of laparoscopic cholecystectomy [16,99] .Although it is just speculation, to our knowledge, this case is the third reported case of the rare cecal volvulus after herniation through the foramen of Winslow and a history of cholecystectomy.

Conclusion
This case demonstrates that even with suitable diagnostic imaging, the initial diagnosis of FWH is not always easy.It also proves the significance of maintaining a strong level of clinical suspicion, especially for the rarest cases.A consensus on the management of this rare clinical manifestation is lacking.However, good clinical suspicion and prompt surgical management are essential for a positive outcome.

Ethical approval
An ethical approval was not required.A written informed consent was obtained from the patient for publication of this case report with any accompanying images.

Figure 1 .
Figure 1.Contrast-enhanced computed tomography scan in the portalvenous phase of the upper abdomen showing the dilated colon next to the stomach.

Figure 2 .
Figure 2. Fluoroscopy after colposcopy and contrast administration through the NGT: neither the NG-tube nor the colonic decompression tube stain or reach the large gas filled lumen arguing against it being the transverse colon or the stomach.