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Foramen of Winslow Hernia: a Review of the Literature Highlighting the Role of Laparoscopy

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Foramen of Winslow hernia (FWH) is an extremely rare entity accounting for up to 8% of internal hernias and 0.08% of all hernias. Only 150 cases of FWH have been described in the literature to date with a peak incidence between the third and sixth decades of life. Three main mechanisms seem to be implicated in the FWH pathogenesis: (a) excessive viscera mobility, (b) abnormal enlargement of the foramen of Winslow, and (c) changes in the intra-abdominal pressure. The presence of an abnormally long bowel, enlargement of the right liver lobe or cholecystectomy, a “wandering cecum,” and defects of the gastrohepatic ligaments are some reported predisposing factors. Timely diagnosis through computed tomography facilitates the appropriate treatment before complications are evident. Although open repair has been mostly utilized, recently laparoscopic approach seems to gain ground due to the encouraging preliminary results. To date, the debate continues as to whether prophylactic measures to prevent recurrence of the FWH need to be undertaken: closure of the foramen, fixation of the highly mobilized viscera, or both.

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Author information

Authors and Affiliations

  1. Department of Surgery, Duke University, Durham, NC, USA

    Demetrios Moris, Babatunde Yerokun, Keri A. Seymour, Alfredo D. Guerron, Philip A. Fong & Ranjan Sudan

  2. Laboratory of Experimental Surgery and Surgical Research, Medical School, University of Athens, Athens, Greece

    Diamantis I. Tsilimigras & Eleftherios Spartalis

Authors
  1. Demetrios Moris
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Contributions

Study conception and design: DM

Data acquisition: DM, DIT

Analysis and data interpretation: DM, DIT

Drafting of the manuscript: DM, DIT, BY, KAS

Critical revision: DM, DIT, BY, KAS, ADG, PAF, ES, RS

Supervision: DM, RS

Corresponding author

Correspondence to Ranjan Sudan.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Additional information

Disclosure Information

Authors: Demetrios Moris, MD has nothing to disclose; Diamantis I. Tsilimigras has nothing to disclose; Babatunde Yerokun has nothing to disclose; Keri A. Seymour has nothing to disclose; Alfredo D. Guerron has nothing to disclose; Phillip A. Fong has nothing to disclose; Eleftherios Spartalis has nothing to disclose; Ranjan Sudan has nothing to disclose. Editors-in-Chief: Richard A. Hodin, M.D., Timothy M. Pawlik, M.D., MPH, PhD has nothing to disclose. CME Overseers: Arbiter: Timothy M. Pawlik, M.D., MPH, PhD has nothing to disclose; Vice-Arbiter: Melanie Morris, M.D., has nothing to disclose. Question Reviewers: Ron G. Landmann, M.D. is a Consultant / Advisor for Intuitive Surgical and Johnson & Johnson; Joseph Kim, M.D., is a lecturer for Genentech.

CME questions for this article available to SSAT members at http://ssat.com/jogscme/

Learning Objectives for patients with Foramen of Winslow Hernia (FWH)

1. To define its epidemiology and pathogenesis

2. To describe the diagnostic approach including classification, symptoms and imaging algorithms

3. To describe current practices in its surgical treatment

4. To describe the role of laparoscopy in the treatment armamentarium of such patients

CME/MOC Questions:

1. Foramen of Winslow is an anatomic space which is defined by all the below EXCEPT:

A) hepatoduodenal ligament anteriorly

B) inferior vena cava

C) caudate lobe of the liver

D) Second portion of duodenum

2. Which is the most common organ involved in FWH?

A) Cecum

B) Greater omentum

C) Small bowel

D) Stomach

3. Which of the below is not a risk factor for FWH?

A) excessive viscera mobility

B) abnormal enlargement of the foramen of Winslow

C) changes in the intra-abdominal pressure

D) Female gender

4. Which of the therapeutic options below should not be considered in the majority of patients with FWH?

A) Laparoscopic repair

B) Open repair

C) Watchful waiting and conservative management

D) Bowel resection and cecopexy

5. Which of the following best represents the prevalence of FWH?

A) 0.1-0.5%

B) 5-10%

C) 15-20%

D) more than 20%

6. Which of the following is NOT a CT finding indicative of FWH?

A) Abnormal localization of cecum

B) Gas and/or fluid in the lesser sac

C) Mesenteric adipose tissue & intestinal loops behind hepatic pedicle

D) Presence of intestinal loop in the greater sac

7. What is the most sensitive imaging modality for the detection of FWH-related acute abdomen?

A) CT-scan

B) Ultrasound

C) Barium enema

D) Abdominal X-ray

8. Which age period is associated with the peak incidence of FWH?

A) <20 years

B) 20-60 years

C) 60-80 years

D) >80 years

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Moris, D., Tsilimigras, D.I., Yerokun, B. et al. Foramen of Winslow Hernia: a Review of the Literature Highlighting the Role of Laparoscopy. J Gastrointest Surg 23, 2093–2099 (2019). https://doi.org/10.1007/s11605-019-04353-3

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