Spigelian hernia (SH) occurs due to the protrusion through a congenital or acquired defect or weakness in the Spigelian aponeurosis. SH accounts for only 0.1-0.4% of occurrence and a 17-24% risk of strangulation. We hereby report a case of a 34-year-old gentleman presented with concomitant incarceration of the omentum with small intestine and testis in Spigelian hernia sac. We have successfully operated on this patient via a transperitoneal approach with a small incision over the hernia site. This incision could be an alternative to midline laparotomy as a safe and effective method in managing incarcerated SH in an emergency setting.
Inguinal scrotal swelling is a common presentation to surgical clinic with various differential diagnoses. In most circumstances, a good clinical assessment is sufficient to identify the diagnosis. Imaging is necessary when diagnostic difficulty was encountered. The choice of imaging study could affect the management and outcome. A 60-year-old male presented with an enlarging right inguinal scrotal swelling for 5 years. Clinical examination showed a swelling extended from the right inguinal region down to the right scrotum, firm, not reducible, and not separable from the right testis. Differential diagnoses range from the malignant testicular tumor, irreducible inguinal hernia to the soft-tissue tumor. Ultrasonography and computed tomography scan were unable to conclude the origin of the tumor and involvement of the right testis. Inguinal exploration with potential radical orchiectomy was planned and caused much distress to the patient, resulted in delay in surgery. Intraoperatively, the mass was separated from the testis and spermatic cord, and thus, excision biopsy was performed sparing the testis and spermatic cord. Histopathological examination showed cellular angiofibroma. The right choice of imaging modality is important to provide a precise diagnosis and better treatment plan. This could avoid the unnecessary distress to the patient for potential organ lost. A review through the literature showed the ability of magnetic resonance imaging to better delineate the anatomy of inguinal scrotal soft-tissue mass and thus should have been the imaging modality of choice.
Abdominal sacrocolpopexy is a well-established procedure for the reconstruction of apical support in pelvic organ prolapse. Its long-term efficacy is well known; however, it is also associated with higher perioperative morbidity when compared with the less invasive transvaginal approach. Long-term risk of bowel-related complication from abdominal sacrocolpopexy is rare, but can be significant as it is often serious and requires major surgical intervention. Here we highlight an unusual case of strangulated small bowel (in this instance complicated with sepsis secondary to peritonitis), 14 years after an abdominal sacrocolpopexy procedure. This example amplifies the need for proper preoperative counseling; also, life-long follow-up is necessary for patients undergoing this procedure.
OBJECTIVE: Conventional laparoscopic cholecystectomy (LC) involves the use of four ports, but the number of ports has gradually been reduced to one for cosmetic reasons. however, single-incision LC is technically demanding, and there is a substantial learning curve associated with its successful application. The aim of this clinical study was to evaluate the safety and feasibility of a less demanding alternative LC technique with a faster learning curve.
METHODS: This prospective descriptive study was performed from September 2009 to February 2011 at Sultanah Bahiyah hospital in Kedah, Malaysia. A total of 58 patients underwent two-incision threeport laparoscopic cholecystectomy (TILC), which was performed by the senior consultant hepato-pancreato-biliary surgeon and two hepato-pancreato-biliary trainees. Study end points included operative time, postoperative pain, length of hospital stay and early postoperative complications. The follow-up period was 4 weeks.
RESULTS: The overall operative time taken was 44 ± 18 minutes. none of the patients had major complication or incisional hernia postoperatively. All but one of the patients were discharged within 24 h. nonsteroidal anti-inflammatory drugs were the main postoperative analgesic used.
CONCLUSION: TILC is feasible and safe cholecystectomy technique.
Congenital internal herniation is a rare condition presenting as recurrent abdominal pain or acute intestinal obstruction. In cases in which bowel incarceration or strangulation develop, rapid progression to bowel ischemia, necrosis or perforation is inevitable. Mortality in such cases has been reported to be as high as 50%. Despite advances in imaging modalities, arriving at a pre-operative diagnosis of a congenital internal herniation remains a challenge. We report such a case where imaging was unsuccessful in determining the cause of intestinal obstruction in a 3 year old child. Congenital internal herniation may result in disastrous consequences if not addressed in a timely fashion due to its rarity. Hence a high index of clinical suspicion is needed to avoid missing this diagnosis in a child presenting with recurrent abdominal pain or acute intestinal obstruction.
The occurrence of congenital diaphragmatic hernia in a pregnant adult is rare. In contrast to neonatal diaphragmatic hernias, most of the adult patients present with vague gastrointestinal symptoms mimicking other diseases hence the importance of high index of suspicion. We report a case of a young pregnant lady with congenital diaphragmatic hernia presenting with symptoms and clinical signs suggestive of acute pancreatitis. The patient had a laparotomy performed to reduce the hernial content and the diaphragmatic defect was successfully repaired.
Focal eventration of the diaphragm with transthoracic kidney is a very rare condition. It is usually asymptomatic and often revealed as an incidental finding on imaging studies. We presented a case of previously undiagnosed focal eventration of left hemidiaphragm with transthoracic left kidney confused with traumatic diaphragmatic hernia. Differentiation of these two conditions is important as each were managed differently. A traumatic diaphragmatic hernia needs early surgical intervention whereas no treatment was required for focal diaphragmatic eventration in most cases. Diagnostic laparoscopy confirmed the findings in this case and the patient was managed conservatively.
Timely identification of specific injuries in a polytrauma case is of paramount importance in order to reduce morbidity and mortality. Unfortunately, some of these injuries are subtle and can be missed on initial primary and secondary assessments. In this paper, we report one such injury in a case of a 16-year old motorcyclist who complained of abdominal pain over the right lumbar region after the motorcycle handlebar hit his abdomen. Although initial assessment was uneventful, he was subsequently diagnosed to have a traumatic abdominal wall herniation on abdominal computed tomography after more than 24 hours of observation in the ward.
Laparoscopic repair of ventral and incisional hernia has become increasingly popular as compared to open repair. The procedure has the advantages of minimal access surgery, reduction of post operative pain and the recurrence rate. A prospective study of laparoscopic incisional hernia repair was performed in our center from August 2002 to April 2004. Eighteen cases (n: 18) were performed during the study period. Fifteen cases (n: 15) had open hernia repair previously. Sixteen patients (n: 16) had successful repair of the hernia with the laparoscopic approach and two cases were converted to open repair. The mean hernia defect size was 156cm2. There was no intraoperative or immediate postoperative complication. The mean operating time was 100 +/- 34 minutes (75 - 180 minutes). The postoperative pain was graded as mild to moderate according to visual analogue score. The mean day of discharge after surgery was two days (1 - 3 days). During follow up, three patients (16.7%) developed seroma at the hernia sac which was resolved with conservative management after three weeks. One (5.6%) patient developed recurrence six months after surgery. In conclusion, laparoscopic repair of incisional hernia particularly recurrent hernia has been shown to be safe and effective in our centre. However, careful patient selection and acquiring the necessary advanced laparoscopic surgical skills coupled with the proper use of equipment are mandatory before embarking on this procedure.
Mesocolic hernia is a rare cause of intestinal obstruction in children. The diagnosis involves a high index of suspicion and prompt intervention to prevent strangulation and a high morbidity. The embryological basis of the condition is of paramount importance to assist the eventual surgical correction.
A study was conducted to investigate the effectiveness of freeze-dried bovine pericardium (FDBP) as a biomaterial in diaphragmatic herniorrhapy in dogs. Eight adult dogs were randomly selected and divided into two equal groups. In FDBP group, a diaphragmatic defect was induced and repaired with an identical size of FDBP. In the control group, a diaphragmatic wall was incised at three-side border creating a flap and sutured. Grossly, only mild intrathoracic adhesion was observed for most of the animals, and no herniation occured. Microscopically, the biomaterial incorporated into the host's tissue by ingrowth of young muscle fiber and massive new blood vessel formation in between the fibrous tissue.
Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach.
We present a case of a young man with a 5-year history of testicular swelling which was initially thought to be inguinoscrotal hernia. Intra-operatively it was found to be a testicular tumour and histopathological examination confirmed a mixed germ cell tumour. He had an orchidectomy and later underwent chemotherapy. It is interesting to note that the patient had kept the tumour for 5 years with no evidence of distant metastasis at diagnosis. This is probably the longest presentation of a testicular tumour.
Congenital diaphragmatic hernia (CDH) is rare in adults. We report a 24 year old woman presenting with shortness of breath, chest pain and nausea after the birth of her first baby. Clinical examination, plain radiography and a CT scan revealed herniation of abdominal contents into her left chest. Via a midline laparotomy, the contents were reduced and the defect repaired, using a mesh. She remains symptom-free three years since her surgery and even after a second childbirth. A brief review of the literature reporting adult diaphragmatic hernia of congenital origin accompanies this case report. We conclude that symptomatic CDH in adults usually presents as an emergency with gastrointestinal and occasionally respiratory complications. Early diagnosis and repair is essential to avoid subsequent morbidity and mortality.
Pericardial rupture after blunt chest trauma is described in the literature. This case report summarises our experience with a 22-year old male patient who suffered blunt chest trauma during a motor vehicle accident. On admission no serious injuries could be detected, but 3 hours later, displacement of the heart to the right hemithorax combined with sudden cardiac failure appeared. Emergency thoracotomy revealed a right-sided rupture of the pericardium with complete herniation of the heart into the right pleural cavity and consequent strangulation by the margins of the pericardial defect.
A case of classical congenital diaphragmatic hernia is discussed. The rare right-sided classical type - incidence of 1 in 30,000 to 1 in 81,000 live births - and diaphragmatic eventration are often grouped together as Congenital Diaphragmatic Herniae. We had nine in 57,783 live births in ten years.
Obturator hernia is a rare clinical entity usually presenting with strangulation. Preoperative diagnosis is seldom made and this has contributed to a high. mortality. One should suspect a strangulated obturator hernia in an elderly thin female patient presenting with vague abdominal symptoms or intestinal obstruction associated with a positive Howship-Romberg sign. Urgent laparotomy is indicated to establish the diagnosis and for resection of bowel if indicated.
Two cases of enteroumbilical fistula presenting in the neonatal period are reported. Both developed complications which required surgical intervention. A brief discussion on clinical features and management follows.