Abdominal hernias: Radiological features

Rectus sheath nerve block for analgesia & incarcerated hernia reduction in the emergency department

BACKGROUND

Patients who present to the emergency department (ED) with incarcerated or strangulated ventral hernias are often in significant pain. Furthermore, even with procedural sedation, reduction itself also causes substantial pain. Hernias that cannot be reduced at the bedside with intravenous opioids or procedural sedation will require emergent surgery, which contributes to morbidity and mortality, especially in high-risk populations.

CASE REPORT

We present the case of a 94-year-old man with an incarcerated ventral hernia that was reduced in the ED with the aid of a rectus sheath block, ultimately avoiding the need for emergent surgical intervention.

IMPLICATIONS

Ultrasound can visualize and diagnose an incarcerated hernia, and a bilateral rectus sheath block can be performed in the ED to anesthetize the peritoneal wall, paralyze abdominal musculature, and achieve nearly painless hernia reduction.

The importance of predictive markers in incarcerated abdominal wall hernia

PURPOSE

Emergency abdominal wall hernia repairs play a significant role in general surgical emergencies. In such cases, the time taken to decide on surgery is crucial, as the situation may progress to necrosis, perforation, and organ resection due to strangulation following incarceration. To facilitate the early detection of this condition, studies have been conducted on various predictive markers, most of which are related to similar markers used in acute mesenteric ischemia. This study aims to assess the predictive significance of preoperative laboratory and imaging findings in incarcerated abdominal wall hernia with strangulation.

METHODS

Retrospectively, 122 patients who underwent emergency surgery for incarcerated abdominal wall hernias with a preoperative diagnosis between January 1, 2018, and September 1, 2023, at the General Surgery Clinic of Samsun University Education and Research Hospital were included in the study. According to the examination of the operation notes, Group I was designated for patients who underwent bowel resection, Group II for those who underwent omental resection, and Group III for those without resection. The study investigated the association between patients 'age, gender, hernia type and side, preoperative laboratory parameters (pH, Base Excess (BE), Lactate, White Blood Cell Count (WBC), Neutrophil (N), Lymphocyte (L), Monocyte (M), Platelet (P), C-Reactive Protein (CRP), and pH/BE, pH/Lactate, Lactate/BE, N/L, N/M, L/M, N/CRP, M/P, P/CRP ratios), physical examination (PE), and imaging findings among the resection groups.

RESULTS

Out of the 122 patients operated with a preliminary diagnosis of acute incarcerated abdominal wall hernia, 68 were female, 34 were male, and the median age was found to be 67.16 (30-99). In the conducted statistical analysis, mean values of Lactate (p = 0.007), WBC (White Blood Cell) (p = 0.001), Neutrophil (p < 0.001), and NLR (Neutrophil-to-Lymphocyte Ratio) (p = 0.003) were significantly different based on resection groups. Subsequent pairwise comparisons indicated that these differences were attributed to variations in mean values of Lactate, WBC, Neutrophil, and NLR between the Bowel Resection and Resectionless groups. Mean values of Monocytes were also significantly different among resection groups (p = 0.049), and pairwise comparisons revealed that this difference was due to variations in mean values of Monocytes between the Omental Resection and Resectionless groups. The cut-off values were determined as follows in the ROC analysis: 1.2 mmol/L for Lactate, 18.5 (10^9/L) for WBC, 8.1 (10^9/L) for Neutrophil and 10 mg/L for CRP concerning bowel resection.

CONCLUSION

In cases of abdominal wall hernia operations due to incarceration, bowel and/or intra-abdominal organ resections related to strangulation can lead to significant morbidity and mortality. Beyond the imaging methods available for preoperative assessment, high levels of laboratory parameters, including Lactate, WBC, Neutrophil, and NLR ratio, may primarily indicate the need for bowel resection, considering that omental resection is associated with lower morbidity and mortality compared to bowel resection, elevated levels of monocytes may primarily indicate the requirement for omental resection in emergency abdominal wall hernia surgery. We recommend that this be prioritized in emergency surgery to prevent complications such as bowel perforation and sepsis and improve clinical outcomes. The surgeon is advised to keep this in mind.

Omental Hernia as a Potential Cause of False-Positive GI Bleeding on 99m Tc-RBC Scintigraphy

ABSTRACT

Gastrointestinal bleeding scintigraphy is a noninvasive study used to determine the presence of active bleeding, localize the bleeding site, and estimate the bleeding volume for prognostic purposes in patients with suspected gastrointestinal bleeding. However, it is important to note that false-positive results can occur due to various reasons. In this case, we present the scenario of a middle-aged woman who exhibited symptoms of gastrointestinal bleeding and underwent 99m Tc-RBC scintigraphy. The imaging revealed an accumulation of radiotracer in the hypogastric region, which was later determined to be caused by an omental hernia on SPECT/CT images. The herniated structure caused congestion in the mesenteric vessels, leading to the accumulation of 99m Tc-RBC. This case highlights the significance of considering anatomical anomalies and nonbleeding pathologies when interpreting the 99m Tc-RBC scintigraphy results for gastrointestinal bleeding.

Obesity increases the surgical complexity and risk of recurrence after midline primary ventral hernia repair: results on 2307 patients from the French Society of hernia surgery (SFCP-CH) registry database

PURPOSE

Obesity is a known risk factor of recurrence after hernia surgery, but available data often concern pooled cases of primary and incisional hernia, with short follow-up. We aimed to analyze the impact of severe obesity (BMI ≥ 35 kg/m2) on the results of midline primary ventral hernia repair (mPVHR), in comparison with non-severely obese patients.

METHODS

Data were extracted from a multicentric registry, in which patients' data are consecutively and anonymously collected. We conducted a retrospective comparative study on patients with severe obesity (sOb) versus non-severely obese patients (non-sOb), who underwent surgery, with a minimal 2-year follow-up after their mPVHR.

RESULTS

Among 2307 patients, 267 sOb and 2040 non-sOb matched inclusion criteria. Compared with non-sOb, sOb group gathered all the worse conditions and risk factors: more ASA3-4 (39.3% vs. 10.2%; p < 0.001), symptomatic hernia (15.7% vs. 6.8%; p < 0.001), defect > 4 cm in diameter (24.3% vs. 8.8%; p < 0.001), emergency surgery (6.1% vs. 2.5%; p = 0.003), and Altemeir class > 1 (9.4% vs. 2.9%; p < 0.001). Laparoscopic IPOM was used more often in sOb patients (40% vs. 32%; p = 0.016), but with smaller Hauters' ratio (46 vs. 73; p < 0.001). Compared with the non-sOb, the rate of day-case surgery was lower (48% vs. 68%; p < 0.001), the surgical site occurrences were significantly more frequent (6.4 %vs. 2.5%; p < 0.001). The main outcome, 2-year recurrence, was 5.9% in the sOb vs. 2.1% (p = 0.008), and 2-year reoperations was 3% vs. 0.3% (p = 0.006). In the adjusted analysis, severe obesity was an independent risk factor for recurrence [OR = 2.82, (95%CI, 1.45; 5.22); p = 0.003].

CONCLUSION

In patients with severe obesity, mPVHR is technically challenging and recurrence rate is three times higher than that of non-severely obese patients.

An antibacterial biologic patch based on bacterial cellulose for repair of infected hernias

Infection-associated complications and repair failures and antibiotic resistance have emerged as a formidable challenge in hernia repair surgery. Consequently, the development of antibiotic-free antibacterial patches for hernia repair has become an exigent clinical necessity. Herein, a GBC/Gel/LL37 biological patch (biopatch) with exceptional antibacterial properties is fabricated by grafting 2-Methacryloyloxyethyl trimethylammonium chloride (METAC), a unique quaternary ammonium salt with vinyl, onto bacterial cellulose (GBC), followed by compounding with gelatin (Gel) and LL37. The GBC/Gel/LL37 biopatch exhibits stable swelling capacity, remarkable mechanical properties, flexibility, and favorable biocompatibility. The synergistic effect of METAC and LL37 confers upon the GBC/Gel/LL37 biopatch excellent antibacterial efficacy against Staphylococcus aureus and Escherichia coli, effectively eliminating invading bacteria without the aid of exogenous antibiotics in vivo while significantly reducing local acute inflammation caused by infection. Furthermore, the practical efficacy of the GBC/Gel/LL37 biopatch is evaluated in an infected ventral hernia model, revealing that the GBC/Gel/LL37 biopatch can prevent the formation of visceral adhesions, facilitate the repair of infected ventral hernia, and effectively mitigate chronic inflammation. The prepared antibacterial GBC/Gel/LL37 biopatch is very effective in dealing with the risk of infection in hernia repair surgery and offers potential clinical opportunities for other soft injuries, exhibiting considerable clinical application prospects.

Richter supraumbilical hernia managed with invagination: a case report

Introduction and importance

Richter's hernia is an incarceration of the anti-mesenteric border of a segment of bowel through an abdominal wall defect. It primarily affects elderly individuals but can occur at any age, with a slightly increased incidence in females. The increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter's hernias.

Case presentation

A 40-year-old male with a history of laparoscopic cholecystectomy and kidney transplantation presented with a 4-day history of supraumbilical swelling and abdominal pain. The swelling was irreducible and accompanied by mild tenderness, and local signs of inflammation were exhibited. Intraoperatively, a 1.5 cm hernia defect was found, with the sac containing omentum and a portion of bowel segment for which invagination with serosal closure with the Mayo double-breasting technique was done.

Clinical discussion

Richter's hernia presents with abdominal discomfort, bloating, nausea, and vomiting, with a notable feature being the delayed onset of symptoms due to its partial involvement of the bowel wall. Diagnosis can be achieved through a computed tomography (CT) scan or intraoperative exploration. Management of Richter hernia is contingent upon the patient's clinical condition, physical examination, and suspicion of strangulation.

Conclusion

Diagnosis of Richter's hernia demands higher suspicion, particularly in patients with predisposing factors like a history of minimally invasive surgery. Prompt surgical intervention is crucial for reducing mortality and enhancing prognosis, with invagination alone being adequate if ischaemia is confined and mesh placement is unnecessary.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia

INTRODUCTION

Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias.

MATERIALS AND METHODS

Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound.

RESULTS

We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05).

CONCLUSION

Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Advanced postoperative tissue antiadhesive membranes enabled with electrospun nanofibers

Tissue adhesion is one of the most common postoperative complications, which is frequently accompanied by inflammation, pain, and even dyskinesia, significantly reducing the quality of life of patients. Thus, to prevent the formation of tissue adhesions, various strategies have been explored. Among these methods, placing anti-adhesion membranes over the injured site to separate the wound from surrounding tissues is a simple and prominently favored method. Recently, electrospun nanofibers have been the most frequently investigated antiadhesive membranes due to their tunable porous structure and high porosities. They not only can act as an essential barrier and functional carrier system but also allow for high permeability and nutrient transport, showing great potential for preventing tissue adhesion. Herein, we provide a short review of the most recent applications of electrospun nanofibrous antiadhesive membranes in tendons, the abdominal cavity, dural sac, pericardium, and meninges. Firstly, each section highlights the most representative examples and they are sorted based on the latest progress of related research. Moreover, the design principles, preparation strategies, overall performances, and existing problems are highlighted and evaluated. Finally, the current challenges and several future ways to develop electrospun nanofibrous antiadhesive membranes are proposed. The systematic discussion and proposed directions can shed light on ideas and guide the reasonable design of electrospun nanofibrous membranes, contributing to the development of exceptional tissue anti-adhesive materials in the foreseeable future.

Multiple Complicated Concurrent Hernias in a Single Patient: A Case Report

Multiple complicated concurrent hernias with obturator hernia and paraesophageal hernia unusually occur in clinical settings. The obturator hernias belong to a rare pelvic hernia that accounts for a minority of all abdominal hernias. Besides, paraesophageal hernias occur commonly in elderly female patients. Clinical manifestations of these hernias are usually unspecific and the diagnosis is based on computed tomography (CT). In this paper, we presented a case of multiple complicated hernias in an 81-year-old woman. She was admitted to our hospital due to intestinal obstruction that was caused by a simultaneous obturator and paraesophageal hernia. She was successfully treated by laparoscopic hernia repair. Postoperative progression was favorable. She was then discharged from the hospital after four hospital days.

Internal Hernia as a Rare Complication of Acute Appendicitis

Appendicitis is a well-known and highly common surgical emergency disease, yet it presents with a wide variety of manifestations. This is a case report of a 47-year-old female who presented with a complaint of having constant crampy right lower abdominal pain for two weeks. The patient reported having a sudden onset of symptoms that went with the typical picture of acute appendicitis that occurred two weeks ago. Our pre-op workup was inconclusive; therefore, we planned to go for a diagnostic laparoscopy, where surprisingly, the appendix was long, inflamed, and attached to the posterior wall of the cecum. Thus, a ring-like structure was developed, in which 8 to 10 cm of the terminal ileum (the last part of the small bowel) was going through and causing an internal hernia. Although blood and radiology workups provide valuable assistance in diagnosing common cases, a highly suspicious sense and skillful surgeons with good clinical experience play a major role in managing such rare presentations.

Incidence, types, and associated factors of external abdominal hernias among adult patients visiting the surgical outpatient department, eastern Ethiopia: a multicentre cross-sectional study

Background

Abdominal hernia is the most common surgical alignment that affects all age groups and sexes. It is characterized by the protrusion of abdominal contents through the abdominal wall's muscles and fascia. In this study, the incidence, types, and associated factors of external abdominal hernias at Hiwotfana Comprehensive Specialized Hospital and Jugal Regional Hospital, eastern Ethiopia, were ascertained.

Objective

To identify the incidence, types, and associated factors of external abdominal hernia among adult patients who visited the surgical outpatient department of Hiwotfana comprehensive specialized hospital and Jugal regional hospital from 20 October to 5 December 2022.

Methods

A cross-sectional study was conducted from 20 October to 5 December 2022, on adult patients who visited the surgical outpatient department at the Hiwotfana Comprehensive Specialized Hospital and Jugal Regional Hospital in eastern Ethiopia. All adult patients who visited the surgical outpatient department of each hospital were enroled in the study using a stratified random sampling technique. Both descriptive and inferential statistics were conducted, and the results were presented in text, graphs, and tables. Odd ratios for the strength and directions of association were used with a 95% CI, and a P value of less than 0.05 was considered to declare statistical significance.

Result

A total of 403 participants were included in this study from two different governmental hospitals in Harar town, with a 100% response rate. The incidence of the external abdominal wall hernia was 41 (10.2%). The epigastric hernia had the highest prevalence (41.5%, n=17). Constipation [adjusted odds ratio (AOR)=2.91, CI=1.119-7.579), prolonged cough (AOR=3.993, CI=1.358-11.741), history of abdominal surgery (AOR=5.764, CI=1.837-18.083) and heavy lifting (AOR=5.476, CI=2.505-11.969) had statistically significant association (P≤0.05).

Conclusion

The incidence of external abdominal wall hernia in our area is similar to the other existing literature reported from different areas. Epigastric hernia is the most prevalent type of external abdominal hernia and is commonly encountered in female patients. Constipation, a prolonged cough, previous abdominal surgery, and heavy lifting are significantly associated with an external abdominal wall hernia.

Retroperitoneal totally endoscopic prosthetic repair of lumbar hernia

Lumbar hernia is a rare lateral abdominal wall hernia. Various surgical repair strategies have been recorded, but there is currently no unified standard. A Chinese surgeon recently revealed a novel technique for treating primary lumbar hernia called retroperitoneal totally endoscopic prosthetic repair (R-TEP). We have made a further exploration of this method and successfully used it in the treatment of secondary lumbar hernia. We successfully performed R-TEP on three patients with lumbar hernias. All patients were female with an average age of 64 years (51-71 years). Two patients each had a primary upper lumbar hernia, while one patient had a secondary lumbar hernia. With a mean operative time of 77 min (60-105 min), all operations were performed successfully. The average visual analogue scale (VAS) was 1.3 points (1-2 points) on the second day following surgery. The mean postoperative hospital stay was 2.3 days (2-3 days). No postoperative complications occurred. During a mean follow-up period of 19 months (10-24 months), there was no recurrence of the hernia, chronic pain or mesh infection. Therefore, R-TEP is safe and effective for both primary and secondary lumbar hernia. Anti-adhesive coated meshes are not required, making this a cost-effective procedure that is worthy of recommendation.

Aging-Related Findings of the Respiratory System in Chest Imaging: Pearls and Pitfalls

Purpose of Review

The purpose of this review is to describe the main features of the aging chest, studied through different imaging modalities.

Recent Findings

Aging-related changes of the respiratory system are inevitable. Therefore, it is mandatory to be familiar with the para-physiological changes that occurs, in order to avoid inappropriate interpretation of radiological findings that put patients at risk of over or undertreatment.

Summary

The role of the radiologist is fundamental in evaluating aging-related processes affecting the respiratory system and in distinguishing them from frank diseases.

Comparison of Doppler Ultrasound and Clinical Features of Patients With and Without Femoral Hernia in Lower Extremity Venous Insufficiency Patients

ABSTRACT

In this study, we aim to evaluate Doppler ultrasound (US) and clinical features of patients with and without femoral hernia (FH) in lower extremity chronic venous insufficiency (CVI) patients.We retrospectively analyzed prospectively collected data of 1364 limbs with the CVI suspected. Femoral hernia was detected in 32 of the limbs, and the control group was formed with 32 limbs without FH. All limbs were evaluated with Valsalva maneuver and augmentation method to detect venous reflux in FH group. Venous reflux rates in the Doppler US, venous clinical severity scores (VCSSs), and clinical classes of Clinical-Etiology-Anatomy-Pathophysiology classification were compared statistically in both groups.The mean VCSS was 3.87 ± 0.74 in the FH group and 2.68 ± 0.65 in the control group, which was statistically significant ( P = 0.04). In the more severe clinical classes of Clinical-Etiology-Anatomy-Pathophysiology (C4-6), the number of limbs in the FH group was higher than in the control group (8 and 4, respectively). Doppler US examinations showed venous reflux in 22 of 32 limbs in the FH group and 19 of 32 patients in the control group, and there was a statistically significant difference ( P = 0.029). In the FH group, reflux could be shown only by augmentation method in the vast majority of limbs (16 of 22, 73%).In conclusion, VCSS and reflux rates are higher in limbs with CVI accompanied by FH. In addition, FH may cause false negative results in the evaluation of CVI. The use of augmentation method in limbs with FH can help avoid false negatives.

Strangulated Caecum, Appendix, and Terminal Ileum in Paraumbilical Hernia: An Unusual Presentation in the Elderly

A common surgical condition caused by inadequate closure of the embryonic umbilical defect is an umbilical hernia. The paraumbilical hernia sac usually contains the omentum and bowel loop, although the caecum is infrequently present. The rare incidence of the caecum being present in the paraumbilical hernial sac is described in a few case reports in the literature. In this article, we'd like to discuss a case of a 71-year-old woman who presented with a paraumbilical hernia with strangulated caecum, appendix, and terminal ileum. Right hemicolectomy, end ileostomy, and transverse colon mucus fistula have been performed with uneventful recovery achieved.

Ventral Hernia Repair Using Ventralex® ST Patch: A Single-Center Study of Clinical Outcomes and Complications

Background

Ventralex® ST (Bard Davol Inc, Warwick, RI) patch is a composite self-expanding and non-absorbable mesh used to reinforce ventral hernia repair. This study was conducted to assess the efficacy, post-operative clinical outcomes, the duration of operation, and complications deciding the post-operative duration/need of hospitalization in patients of small ventral hernia after their open surgical repair using Ventralex ST hernia patch.

Materials and methods

We included 36 patients diagnosed with a small (<2 cm defect size) ventral hernia who underwent open mesh repair following strict surgical methodology using Ventralex® ST hernia patch between September 2018 and April 2020. It was a prospective observational study. Clinically relevant characteristics, along with operative and post-operative data collected through direct interview, clinical examination, and a pretested proforma, were analyzed prospectively.

Results

Thirty-four patients (94.5%) were observed to have an operative time of fewer than 60 minutes, with an average duration of 30-40 minutes. Thirty-one patients (86%) were discharged within 48 hours of surgery, out of which 17 patients (47.2%) were discharged within 24 hours of surgery and 14 patients (38.8%) within 48 hours. Only five patients (13.88%) had a prolonged hospital stay for more than 48 hours due to post-operative complications. Three patients (8.33%) acquired post-surgical wound infection, whereas two (5.55%) developed seroma. Nevertheless, just one patient (2.7%) reportedly developed both infection and seroma after surgery. No cases of mesh infection or recurrences were noted.

Conclusion

This study demonstrates that open repair of small (<2 cm defect size) ventral hernia using the Ventralex® ST hernia patch can be an extremely safe and effective method. Furthermore, it has excellent clinical outcomes when meticulously used with an easily reproducible surgical technique, which requires less intra-operative time, has minimal post-operative complications and negligible recurrence rate, along with reduced post-op hospital stay (86% of patients being discharged within 48 hours).

Positive predictive value of ultrasound in correctly identifying an inguinal hernia: a single-centered retrospective pilot study

Objectives

To determine the clinical utility of preoperative ultrasound imaging for predicting an inguinal hernia in need of surgery. In addition, we aimed to identify factors associated with false positive (FP) ultrasound examinations.

Methods

In this retrospective pilot study, we included all 175 patients who underwent inguinal hernia surgery in our hospital in 2019 and of whom a positive preoperative ultrasound examination of the groin area was available. The positive predictive value (PPV) of the ultrasound examination was determined using inguinal hernia detected during surgery (yes/no) as golden standard. To identify possible predictive factors, we compared the characteristics of patients with a FP ultrasound with patients with a true positive (TP) ultrasound.

Results

PPV of ultrasound examinations to identify an inguinal hernia in need of surgery correctly was 90.9% (159/175). The patients with a FP ultrasound examination had a significantly higher body mass index (BMI) than the patients with a TP ultrasound examination (27.6 ± 4.2 vs 25.8 ± 2.3, p = 0.043).

Conclusions

With a false positive percentage of 9.1%, there is still room for improvement of preoperative diagnostic imaging. Studies with larger cohorts are necessary to establish prediction models that have the potential to reduce FP ultrasound results.

Tailor-Made 3D Printed Meshes of Alginate-Waterborne Polyurethane as Suitable Implants for Hernia Repair

Hernia injuries are the main condition where mesh implants are needed to provide a suitable reinforcement of the damaged tissue. Mesh implants made of polypropylene (PP) are widely used for this application, however complications related to lack of flexibility, elasticity, and mesh infection have been reported. The development of mesh implants from safer materials adaptable to patient necessities can suppose an alternative for conventional PP meshes. In this work, personalized mesh implants made of alginate and waterborne-polyurethane (A-WBPU) are developed using 3D printing technology. For that purpose, five waterborne polyurethane ink formulations with different amounts of alginate are developed and rheologically characterized. All ink formulations are 3D printed showing good printability, manufacturing surgical mesh implants with suitable morphological characteristics customizable to patient injury through computer-aided design (CAD) mesh model adaptation. A calcium chloride (CaCl₂ ) coating is applied after 3D printing as mesh reinforcement. Mechanical analysis revealed that CaCl₂ coated meshes containing 6 wt % of alginate in their formulation are the most suitable to be used as implants for small and groin hernias under physiological tensile strength value of 16 N cm^-1 , and presenting proper elasticity to cover physiological corporal movements (42.57 %). Moreover, an antibiotic-loaded A-WBPU formulation suitable for 3D printing of meshes are developed as strategy to avoid possible mesh infection.

Difficulties in Diagnosing Extraperitoneal Ureteroinguinal Hernias: A Review of the Literature and Clinical Experience of a Rare Encounter in Acute Surgical Care Settings

Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely.

Latest Trends on the Attenuation of Systemic Foreign Body Response and Infectious Complications of Synthetic Hernia Meshes

Throughout the past few years, hernia incidence has remained at a high level worldwide, with more than 20 million people requiring hernia surgery each year. Synthetic hernia meshes play an important role, providing a microenvironment that attracts and harbors host cells and acting as a permanent roadmap for intact abdominal wall reconstruction. Nevertheless, it is still inevitable to cause not-so-trivial complications, especially chronic pain and adhesion. In long-term studies, it was found that the complications are mainly caused by excessive fibrosis from the foreign body reaction (FBR) and infection resulting from bacterial colonization. For a thorough understanding of their complex mechanism and providing a richer background for mesh development, herein, we discuss different clinical mesh products and explore the interactions between their structure and complications. We further explored progress in reducing mesh complications to provide varied strategies that are informative and instructive for mesh modification in different research directions. We hope that this work will spur hernia mesh designers to step up their efforts to develop more practical and accessible meshes by improving the physical structure and chemical properties of meshes to combat the increasing risk of adhesions, infections, and inflammatory reactions. We conclude that further work is needed to solve this pressing problem, especially in the analysis and functionalization of mesh materials, provided of course that the initial performance of the mesh is guaranteed.

Traumatic abdominal wall hernia caused by a low fall

Background

Traumatic abdominal wall hernias (TAWH) are uncommon injuries classically associated with high-energy blunt traumatic mechanisms. Motor vehicle collisions cause the highest proportion of all TAWH. Literature is currently limited, with some debate existing over surgical management strategies.

Case presentation

A 67-year-old man presented after falling from a short step stool while landscaping his yard. On exam, an exquisitely tender lateral flank mass was present with peristaltic movement. CT imaging revealed a TAWH with incarcerated large and small bowel. He was taken to the OR for exploratory laparotomy and mesh hernia repair. The patient was discharged on the third postoperative day with no untoward complications.

Discussion

This patient’s mechanism and injury pattern are together a rare combination. Exam findings and radiologic technologies are used to hone the clinical index of suspicion for TAWH. Traumatic abdominal wall defects can have unusual anatomic borders, not always obeying well-known hernia patterns. In this case, the potential space for visceral herniation was created by an 11th rib fracture with associated avulsion of the oblique musculature. Operative approach can be open or laparoscopic, however concomitant injuries directly influence surgical management. Evidence for mesh versus primary repair for TAWH is conflicted by the current literature.

Conclusions

Nearly any amount of blunt abdominal force can cause TAWH. For wall defects with bowel herniation caused directly by trauma, the safest approach may involve exploratory laparotomy. Future multi-center studies may be able to distinguish TAWH repair strategies based on herniation through old defects versus newly-created abdominal wall injuries.

Role of Neurectomy in Inguinodynia Following Hernioplasty: A Randomized Controlled Trial

Introduction

To date, Lichtenstein tension-free mesh hernioplasty is being adopted widely for inguinal hernia repair in adults, although it is accompanied by procedural complications such as recurrences, infection, testicular atrophy, post-operative pain, and nerve injury. As the recurrence rate decreased after Lichtenstein's tension-free hernioplasty, surgeons’ point of focus shifted more toward postoperative groin pain (inguinodynia) after inguinal hernia repair, as it has become a quite significant problem. The nerves of interest in the inguinal region are ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves. Out of all the nerves, the ilioinguinal nerve is at the greatest risk of entrapment during meshplasty. Chronic groin pain is quite significant following hernia repair, and irrespective of the severity, it can interfere with normal daily activity. The traditional surgical technique recommends the preservation of the ilioinguinal nerve to avoid the morbidity associated with the cutaneous sensory loss supplied by the nerve. One popular belief is that if we excise the ilioinguinal nerve, then the chance of getting post-operative neuralgia due to entrapment, inflammation, neuroma, or fibrotic reactions will almost become zero. Hence, this study was conducted to evaluate the effect of prophylactic excision of the ilioinguinal nerve in the patients undergoing Lichtenstein hernioplasty for inguinal hernias.

Methods

All consecutive male patients presenting to the Department of Surgery with inguinal hernia and age above 18 years were included in the study. All the patients were operated on under spinal anesthesia. Lichtenstein tension-free hernia repair was taken as the standard procedure for hernia repair. Patients in whom the nerve was preserved were kept in group A, whereas group B comprised patients who had undergone neurectomy. Patients were followed up regarding pain at first, third, and sixth months, at rest, and after exercise. The pain was graded according to the VAS (visual analog scale) scoring.

Results

In the present study, out of a total of 92 patients, 80 patients were included. In the first month, 15% of the patients in group A had mild pain, while 5% in group B had experienced a moderate degree of pain at rest. After exercise, the result was 30% in group B. Similarly, in the third month of follow-up, it was found that 25% of the patients in group A experienced mild pain, while 12.5% complained about a moderate degree of pain who had to take analgesics for a longer period. After putting them to exercise and then grading the pain, it was found that 32.5% in group A and 15% in group B experienced pain. After follow-up for six months in both groups, it was revealed that there was no significant difference in post-operative pain at rest (10% and 7.5% in groups A and B, respectively). After exercise, 20% of patients in group A complained of pain, while in group B, only 10% experienced pain. There was no significant difference between both the groups while comparing chronic groin pain at rest and after exercise, and after different time intervals in follow-up (p = 0.4513 and 0.548, respectively).

Conclusion

Prophylactic excision of the ilioinguinal nerve in Lichtenstein tension-free meshplasty decreased the incidence of chronic groin pain after surgery but it was statistically insignificant. Furthermore, this procedure did not affect the quality of life after surgery.

Small Bowel Obstruction Due to Incarcerated Obturator Hernia: Successfull Surgical Management with Modified Mesh-Plug Hernioplasty

BACKGROUND Obturator hernia is an uncommon (0.07-1% incidence rate) subtype of hernia of the abdominal wall, with its incarceration being a rare cause of bowel obstruction. Obturator hernia has a higher incidence in elderly women and in malnourished people. This type of hernia has the highest morbidity and mortality rates of all abdominal wall hernias. This article reports a case of an emaciated 93-year-old woman who presented with small bowel obstruction due to incarcerated obturator hernia, successfully managed surgically with a modified mesh-plug hernioplasty. CASE REPORT An emaciated 93-year-old woman presented with diffuse abdominal pain, more intense on the right iliac fossa, radiating to the right thigh, with 8-h evolution and associated with dark-colored vomiting but normal bowel transit. This patient had a surgical history of right Richter´s femoral hernia, strangulated, with previous intestinal resection and a right femoral hernioplasty. A computed tomography (CT) scan revealed an incarcerated obturator hernia on the right side containing a short segment of small intestine. The patient underwent an exploratory laparotomy and a mesh-plug hernioplasty. During follow-up, there was no evidence of recurrence or complications. CONCLUSIONS Obturator hernia diagnosis is challenging due to its rarity and its signs and symptoms being often unspecific. CT scan has the highest sensitivity and is the best diagnostic tool. Surgical management is the only possible treatment for obturator hernia. Awareness of this condition is essential to allow an earlier approach and attempt to mitigate the associated high morbidity and mortality rates.

Internal hernia caused by the appendix adhering to the right ovary: a case report

Internal hernias are a rare condition and sometimes life-threatening, and they need an emergency exploratory laparotomy. Appendicectomy for chronic appendicitis is controversial. Without timely treatment, chronic appendicitis may develop into a ruptured appendix and an infection that spreads to other parts of the body, and other serious complications. Here we report the case of 48-year-old female who had intestinal ischemia secondary to internal hernia caused by the appendix adhering to the right ovary. Her medical history indicated a chronic, right lower abdominal pain for three years.

Interstitial incisional hernia of greater omentum: An incidental finding during routine cadaveric dissection

Omental herniation, located between the rectus abdominis muscle and the anterior blade of the rectus sheath, can be triggered after a transverse suprapubic incision. It causes the development of an incisional interstitial hernia (IIH), which is an extremely rare and poorly understood condition. Based on this information, our work presents the first anatomical description of incisional interstitial hernia found during routine dissection at the Human Anatomy Laboratory of the Federal University of Ceará in a formalized female corpse.

High-resolution ultrasound of spigelian and groin hernias: a closer look at fascial architecture and aponeurotic passageways

From the clinical point of view, a proper diagnosis of spigelian, inguinal and femoral hernias may be relevant for orienting the patient's management, as these conditions carry a different risk of complications and require specific approaches and treatments. Imaging may play a significant role in the diagnostic work-up of patients with suspected abdominal hernias, as the identification and categorization of these conditions is often unfeasible on clinical ground. Ultrasound imaging is particularly suited for this purpose, owing to its dynamic capabilities, high accuracy, low cost and wide availability. The main limitation of this technique consists of its intrinsic operator dependency, which tends to be higher in difficult-to-scan areas such as the groin because of its intrinsic anatomic complexity. An in-depth knowledge of the anatomy of the lower abdominal wall is, therefore, an essential prerequisite to perform a targeted ultrasound examination and discriminate among different types of regional hernias. The aim of this review is to provide a detailed analysis of the fascial architecture and aponeurotic passageways of the abdominal wall through which spigelian, inguinal and femoral hernias extrude, by means of schematic drawings, ultrasound images and video clips. A reasoned landmark-based ultrasound scanning technique is described to allow a prompt and reliable identification of these pathologic conditions.

"Bulb-like" sign: Small bowel closed loop obstruction in incarcerated Spigelian hernia

A Spigelian hernia is a rare hernia, making up approximately 0.1% of all abdominal wall hernias. This hernia goes through a defect in the Spigelian fascia which is the part of the transversus abdominis aponeurosis lateral to the rectus muscle, often at the level of the arcuate line, where the fascia is widest and weakest. Clinical diagnosis is difficult in patients without obvious abdominal mass but imaging can be a valuable adjunct in diagnosis. We report the case of a 64-year-old male who presented to our hospital with small bowel obstruction secondary to an incarcerated Spigelian hernia who was pre-operatively diagnosed with ultrasound and computed tomography. At ultrasound and computed tomography a closed loop obstruction in a Spigelian Hernia was detected, resembling on both imaging modalities a "bulb-like" appearance.

Unusual Richter's Hernia: Impacted foreign body leading to incarceration and perforation - A rare clinical entity

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The knowledge about this type of hernia has especially gained importance in the context of laparoscopic surgery as majority of the laparoscopic port site hernias are characteristically Richter’s type in configuration.

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Clinical suspicion, prompt radiological diagnosis and timely surgery can lead to an uneventful recovery.

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Surgery is the only treatment, but timely surgery remains the golden opportunity.

Introduction & Importance

Richter’s hernia is a clinically deceiving entity as is particularly associated with high morbidity and mortality which can be can be abated by timely diagnosis and surgery. Direct inguinal hernias having a wide neck have lesser chances of incarceration and strangulation when compared to indirect inguinal hernias. The knowledge about this type of hernia is especially important in the context of laparoscopy as majority of the laparoscopic port site hernias are characteristically Richter’s type in configuration. The objective of this report is to highlight the unusual presentation of the case and sine quo non of prompt diagnosis and timely surgery remains the cornerstone of management.

Case presentation

We report a case of Richter’s hernia incarcerated due to an impacted foreign body (match stick) through a direct inguinal hernia. Patient presented with a painful, non-expansile, tender swelling in left groin. Patient was diagnosed with a complicated inguinal hernia and underwent exploration with resection of involved bowel segment and primary repair of hernia.

Clinical discussion

Richter’s hernia is a rare abdominal wall hernia specifically known for its unusual and delayed presentation leading to high rates of morbidity and mortality. Direct inguinal hernias are less prone to complications like obstruction, strangulation and incarceration owing to presence of a wide neck. Clinical suspicion, prompt radiological diagnosis and timely surgery can lead to an uneventful recovery.

Conclusion

Surgery is the only treatment, but timely surgery remains the golden opportunity. Critical in repair is the evaluation of intestinal viability.

Complicated, Complete, Indirect, Irreducible Right Inguinoscrotal Hernia

Inguinal hernias are the most common of all hernias. A complicated hernia is irreducible, and the contents are obstructed or strangulated. Sonography is considered the imaging modality of choice for the diagnosis of abnormalities of the inguinal area. This case study is about a patient with an inguinal hernia that had not been repaired and progressed into a life-threatening, complicated inguinoscrotal hernia. The patient’s complaints and clinical findings required sonographic examinations of the abdomen, pelvis, inguinal canal, and scrotum. Sonographic findings were corroborated by findings with computed tomography (CT). After the compromised intestine was resected and the hernia was repaired, the patient developed a deep vein thrombosis (DVT), identified sonographically. The patient was successfully treated and discharged.

Superior lumbar hernia after gastrectomy repaired via an open approach in the prone position: A case report

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Lumbar hernia is a rare hernia occurring in the posterolateral abdominal wall and

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suitable for laparoscopic hernioplasty.

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Intraabdominal approach is sometimes difficult for superior lumber hernia after gastrectomy with expected visceral adhesions.

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Open hernioplasty with underlay mesh in prone position is an optional approach to avoid internal visceral adhesion.

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Mesh must be set between Zuckerkandl’s fascia and internal oblique to avoid prolapse of abdominal and retroperitoneal organs.

Introduction

Lumbar hernia is a rare hernia in the posterolateral abdominal wall and only about 310 cases are known to have been reported to date. Laparoscopic hernioplasty is a common surgical approach but is unsuitable for patients who have previously undergone laparotomy and are expected to have extensive visceral adhesions.

Presentation of Case

An 84-year-old woman who had undergone an open distal gastrectomy was referred to our hospital with an enlarging but easily reducible bulge in the right upper back. On computed tomography, the hernial orifice was located in the lateral side of the right quadratus lumborum under the costal arch. The bulge was diagnosed as a superior lumbar hernia. We performed an open hernioplasty in the prone position to avoid internal visceral adhesions. The hernia sac was detected in the latissimus dorsi in the back, and was found to contain the ileocecum, which was rigidly adherent to the sac. Hernioplasty was performed by inserting polypropylene mesh between Zuckerkandl’s fascia and the internal oblique.

Discussion

Mechanical ileus after open distal gastrectomy is common complication and sometimes position was simple procedure without the influence of visceral adhesion and easily reinforced by underlay mesh.

Conclusions

Open hernioplasty in the prone position using a mesh underlay is an optional approach in a patient with a superior lumbar hernia after gastrectomy.

Nylon-6/chitosan core/shell antimicrobial nanofibers for the prevention of mesh-associated surgical site infection

The state-of-the-art hernia meshes, used in hospitals for hernia repair, are predominantly polymeric textile-based constructs that present high mechanical strength, but lack antimicrobial properties. Consequently, preventing bacterial colonization of implanted prosthetic meshes is of major clinical relevance for patients undergoing hernia repair. In this study, the co-axial electrospinning technique was investigated for the development of a novel mechanically stable structure incorporating dual drug release antimicrobial action. Core/shell structured nanofibers were developed, consisting of Nylon-6 in the core, to provide the appropriate mechanical stability, and Chitosan/Polyethylene oxide in the shell to provide bacteriostatic action. The core/shell structure consisted of a binary antimicrobial system incorporating 5-chloro-8-quinolinol in the chitosan shell, with the sustained release of Poly(hexanide) from the Nylon-6 core of the fibers. Homogeneous nanofibers with a "beads-in-fiber" architecture were observed by TEM, and validated by FTIR and XPS. The composite nanofibrous meshes significantly advance the stress-strain responses in comparison to the counterpart single-polymer electrospun meshes. The antimicrobial effectiveness was evaluated in vitro against two of the most commonly occurring pathogenic bacteria; S. aureus and P. aeruginosa, in surgical site infections. This study illustrates how the tailoring of core/shell nanofibers can be of interest for the development of active antimicrobial surfaces.

Pericecal Hernia Presenting as Acute Appendicitis

We would like to report an unusual case of a pericecal hernia in a 93-year-old female. The patient did not report a history of previous abdominal surgery and presented with acute abdominal pain, constipation, nausea, and vomiting. Diagnosis was made with computerized tomography and laparoscopy was performed, which was significant for loops of small bowel in the pericecal region in a defect of peritoneum. The small bowel loops were mobilized back in the intraperitoneal location and the defect was closed to prevent further herniation. Our case is an extremely rare presentation of a rare condition, as there have only been five reported cases of pericecal hernias that required immediate surgical intervention and outlined explicit details of the surgical procedure. Pericecal hernias are unusual occurrences and occur more frequently in older women. Since the clinical signs and symptoms mimic acute appendicitis, delays in diagnosis are common. Thus, this case highlights the importance of suspecting strangulated internal hernias in patients with signs and symptoms of acute appendicitis to prevent significant morbidity and mortality.

Paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter

BACKGROUND

Paracecal hernias, also known as pericecal hernias, are an exceptionally rare type of internal hernia. We report a unique case of paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter.

CASE PRESENTATION

An 86-year-old female was admitted to our hospital with vomiting and abdominal pain. Laboratory findings showed a slightly elevated C-reactive protein level. Computed tomography scan showed dilated loops of the small intestine in the right paracolic gutter with medial displacement of the cecum and ascending colon. Internal hernia around the cecum due to postoperative adhesion after appendectomy was suspected, and she underwent emergency laparotomy. Intraoperative findings revealed the adhesion between the omentum and right paracolic gutter forming a cavity with the small intestine incarcerated. No abnormal adhesion in the ileocecal region was seen. We transected the omental adhesion from the orifice to the far end of the cavity near the hepatic flexure of the colon to release strangulation and to prevent recurrence. The patient was discharged on postoperative day 14 without complications.

CONCLUSIONS

Paracecal hernias have a type of membranous adhesion of the omentum to the right paracolic gutter. Surgeons should be aware of this paracecal hernia type, when they encounter the internal hernia.

Internal herniation through the falciform ligament of the liver: a case report

Background: An internal abdominal hernia is defined as the protrusion of a viscus through a mesenteric or peritoneal aperture within the peritoneal cavity. A less common type of internal herniation is a small bowel herniation through a defect in the falciform ligament of the liver. This defect can be congenital or iatrogenic after penetration of the falciform ligament with a trocar during laparoscopic surgery. Methods: We present a case report illustrating an internal herniation through an iatrogenic defect in the falciform ligament of the liver. Results: A 78-year-old man comes to the emergency department with severe abdominal pain for several hours. Laparoscopic exploration shows a small bowel herniation through an iatrogenic defect of the falciform ligament after laparoscopic cholecystectomy. Reduction of the internal herniation is performed. Due to subsequently small bowel necrosis, a small bowel resection with primary anastomosis has to be performed too. Conclusion: Small bowel herniation through an iatrogenic defect in the falciform ligament is very rare. However, it can lead to severe complications such as small bowel necrosis. To prevent internal herniation, we strongly suggest immediate repair or division of the falciform ligament when an iatrogenic defect is created during laparoscopic procedures.

Volvulus of the ascending colon due to failure of zygosis: A case report and review of the literature

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The ascending colon has been described as a retroperitoneal organ however it may occasionally have a long mesentery.

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The process of peritoneal zygosis is incompletely understood and is subject to perturbation leading to many abnormalities.

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The excessive mobility may predispose to volvulus of this intestinal segment.

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There is often a long symptomatic prodrome before volvulus occurs during which the observant surgeon may intervene.

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The mesentery has gained new relevance with respect to its role in the contemporary management of surgical diseases.

Introduction

Volvulus of the mobile ascending colon is a serious complication of a subtle embryological abnormality that frequently goes unrecognised. There has been renewed interest in the development of the mesentery because of its relevance to the contemporary management of surgical diseases. This case is presented to illustrate the dire consequences of missing this diagnosis and to review the fascinating embryology of the condition as well as its clinical implications.

Presentation of case

We report on a 23-year-old male who presented with signs and symptoms of distal small bowel obstruction after a long prior history of intermittent right lower quadrant pain. At laparotomy, a 360-degree counter-clockwise volvulus of the entire right colon was noted as the result of an excessively long ascending mesocolon and unattached hepatic flexure. All gangrenous bowel was resected with primary ileocolic anastomosis performed thereafter. The patient did well post-operatively and was subsequently discharged.

Discussion

Interruption of the in-utero events of fixation known as peritoneal zygosis lead to a persistence of the mesocolon in parts of the bowel that ordinarily are retroperitoneal. The events that lead to this anomaly are poorly understood and have been subject to controversy for centuries. New insights have challenged surgical dogma and informed new surgical techniques. Its true incidence is probably underestimated because of its indolent clinical prodrome, and it requires a high index of suspicion.

Conclusion

Failure of peritoneal zygosis is implicated in a myriad of clinical conditions. Expeditious recognition and intervention in the prodromal period can avert potentially disastrous complications.

The use of prosthetic mesh for abdominal wall repairs: A semi-systematic-literature review

Following abdominal wall surgery, incisions are commonly sutured, stapled, or glued together by primary intention. Developments within the field of tissue engineering have led to the use of prosthetic meshes, with over 20 million meshes implanted each year worldwide. The function of the mesh is to hold together abdominal wall incisions and repair abdominal hernias. This has been demonstrated to be highly effective in some individuals; however, some patients have experienced postoperative complications, including dehiscence with further abdominal herniation (viscera protruding through the abdominal wall). Little is currently known about why these complications occur in a subset of patients who have had prosthetic mesh implants in abdominal wall repairs; therefore, this literature review examined existing studies identified via six electronic databases. A total of 463 studies were identified, of which 13 were included in this review. The results identified that the prosthetic mesh is highly successful in a large proportion of patients who have had a had a hernia repair in a range of locations; however, the prosthetic mesh has long-term complications, with rejection being observed in a subset of patients. The reason why the prosthetic is being rejected is still largely unknown, and therefore, further investigation needs to be carried out.

Abdominal hernias in camel (Camelus dromedaries): Clinical findings and treatment outcomes

The present study was designed to describe the clinical presentation of abdominal hernias and to evaluate the efficacy of polypropylene mesh in repair of such affection in camels. Twenty-six dromedary camels were included in this study on the basis of clinical and ultrasonographic evidence of abdominal hernia. Factors associated with prevalence and clinical findings of hernia were presented and hernioplasty using polypropylene mesh was evaluated as a surgical intervention. Out of 26 studied camels, abdominal hernia was prevalent in Wadeh camels than other breeds (17 vs. 9, P<0.01). Camels <6 years of age exhibited more hernias than other age groups (18 vs. 8, P<0.01). Moreover, females showed a significantly higher prevalence (19 vs. 7, P<0.01) of abdominal hernia compared to males (26.9%, n=7). The sensitivity (96.8%) and specificity (93.1%) of ultrasonography (US) for diagnosing hernia were higher in comparison to clinical examination (88.3%). At 3 weeks postoperatively, the clinical index score of 26 operated camels was significantly reduced in comparison with pretreated (22 vs. 4, P<0.005). However, only 2 cases had recurrence of the hernia and 2 camels had slight swelling in situ. By the 6th month post treatment, all treated camels were completely recovered. In conclusion, the polypropylene mesh is a viable and consistent alternative effective treatment for abdominal hernias in camels. In addition, the clinical index scores and US provide a precise paradigm for diagnosis and preoperative planning for abdominal hernias in dromedary camels.

Abdominal wall mass

A 52-year-old man presented to the emergency department due to progressive periumbilical pain for 3 days. Point-of-care ultrasound was performed by using high-frequency linear-array transducer. Point-of-care ultrasound is a useful and non-invasive tool that can be used to evaluate the characteristics of superficial abdominal mass whether it is a hernia, tumor mass, hematoma, abscess, or vascular lesion.

Imaging of Oncologic Emergencies

Oncologic emergencies can be either the result of the primary tumor, its metastasis, a paraneoplastic syndrome or reaction to the chemotherapy. Imaging plays a crucial role in ensuring a prompt diagnosis as well as assisting in the therapeutic management. In this article, we discuss the common thoracic and abdominal oncological emergencies that may be encountered in an emergency department.

Abdominal Hernias, Giant Colon Diverticulum, GIST, Intestinal Pneumatosis, Colon Ischemia, Cold Intussusception, Gallstone Ileus, and Foreign Bodies: Our Experience and Literature Review of Incidental Gastrointestinal MDCT Findings

Incidental gastrointestinal findings are commonly detected on MDCT exams performed for various medical indications. This review describes the radiological MDCT spectrum of appearances already present in the past literature and in today's experience of several gastrointestinal acute conditions such as abdominal hernia, giant colon diverticulum, GIST, intestinal pneumatosis, colon ischemia, cold intussusception, gallstone ileus, and foreign bodies which can require medical and surgical intervention or clinical follow-up. The clinical presentation of this illness is frequently nonspecific: abdominal pain, distension, nausea, fever, rectal bleeding, vomiting, constipation, or a palpable mass, depending on the disease. A proper differential diagnosis is essential in the assessment of treatment and in this case MDCT exam plays a central rule. We wish that this article will familiarize the radiologist in the diagnosis of this kind of incidental MDCT findings for better orientation of the therapy.

Strangulated Richter's incisional hernia presenting as an abdominal mass with necrosis of the overlapping skin. A case report and review of the literature

Although rare, clinicians must be alerted of Richter hernias in patients presenting with innocuous gastrointestinal obstruction symptoms, synchronous with an erythematous hernia. An incarcerated incisional hernia located in a previous laparoscopic insertion site further raises suspicion, while timely surgical management is essential to avoid bowel perforation or resection.

A Rare Type of Primary Internal Hernia Causing Small Intestinal Obstruction

Primary internal hernias are extremely rare in adults. They are an important cause of small intestinal obstruction and lead to high morbidity and mortality if left untreated. Clinical presentation of internal hernia is nonspecific. Imaging has been of limited utility in cases of acute intestinal obstruction; moreover, interpretation of imaging features is operator dependant. Thus, internal hernias are usually detected at laparotomy and preoperative diagnosis in an emergency setting is either difficult or most of the time not suspected. We report herein a case of a 45-year-old male who presented with acute intestinal obstruction which was attributed later to a very rare type of internal hernia on exploratory laparotomy. A loop of ileum was found to enter the retroperitoneum through a hernia gate which was located lateral to the sigmoid colon in the left paracolic gutter. The segment of intestine was reduced and the hernial defect was closed. Our finding represents an extremely rare variant of retroperitoneal hernias.

Rare Hernias Presenting as Acute Abdomen- A Case Series

Hernia is an abnormal protrusion of an organ or tissue through a defect in its surrounding walls. It can be divided into internal, external and diaphragmatic hernias. Most of them can be asymptomatic. If they become symptomatic they can present with features of intestinal obstruction, incarceration or strangulation. In this case series we compare the incidence of these rare presentations of hernias with world literature and to warn surgeons not to cut the obstructing band in cases of internal hernias. In this case series, we review the clinical details of 7 rare presentations of hernia, who presented with various types of hernias to a tertiary care centre in Kerala over a period of one year. Of these 7 cases 6 cases were internal hernias (3 left paraduodenal hernias, 2 transmesentric hernias, and 1 pericaecal hernia) and a case of spigelian hernia above the level of umbilicus. All of them presented as acute abdomen in the emergency department. Among these 7 cases, only one case was diagnosed preoperatively. Three patients had bowel gangrene and had to undergo resection- anastomosis of the bowel. The survival rate among these cases was 100% as compared to 50% in the world literature if they had been left untreated. Even though internal hernias are a rare entity, we need to have it as a differential diagnosis in case of intestinal obstruction, in a previously non-operated abdomen.