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A 67-year-old woman came to the emergency department with worsening epigastric pain, bilious emesis, and obstipation during the previous 3 days. She denied having had similar symptoms in the past. She was otherwise healthy and had no history of previous abdominal operations. Physical examination revealed a soft, distended abdomen with mild epigastric tenderness. No abdominal wall hernias were noted. Laboratory studies showed leukocytosis (white blood cell count, 26.4/μL [to convert to ×109/L, multiply by 0.001]). Abdominal radiographs were significant for gastric dilatation only. Findings from computed tomography of the abdomen were suggestive of an internal hernia (Figure 1). After intravenous fluid resuscitation and nasogastric tube decompression, the patient underwent laparoscopic exploration. An internal hernia was diagnosed and repaired laparoscopically (Figure 2).
Abdominal computed tomography demonstrated gastric and duodenal dilatation and a saclike cluster of small-bowel loops interposed between the stomach and the pancreatic tail. The distal small bowel and colon were decompressed.
Intraoperative view of the internal hernia orifice lateral to the duodenojejunal flexure after reduction of 90 cm of viable herniated jejunum.
A. Foramen of Winslow hernia
B. Right paraduodenal hernia
C. Left paraduodenal hernia
D. Transmesocolic hernia
Poultsides GA, Zani S, Bloom GP, Tishler DS. Image of the Month–Quiz Case. Arch Surg. 2009;144(3):287-288. doi:10.1001/archsurg.2008.551-a