Emergency Laparoscopic Surgery Research Articles

An adult case of large defect of small mesenteric hiatal hernia causing small bowel obstruction

BackgroundSmall mesenteric hiatal hernias (SMHHs) are defined as a small group of internal hernias (IHs) that frequently diagnosed in children. However, SMHHs are relatively rare in adults. Bowel loop herniation via an abnormal mesenteric defect can lead to strangulated intestinal obstruction. Congenital SMHHs are commonly observed in pediatric patients, with some cases involving neonatal death.Case presentationA 24-year-old healthy male patient visited our hospital with a 2-day history of a sudden onset lower abdominal pain. He was initially diagnosed with enteritis. However, his symptoms worsened, and he was brought to our hospital. Contrast-enhanced computed tomography (CT) scan showed formation of a closed loop in the small intestine within the pelvis and signs of ischemia. As the patient was diagnosed with small bowel obstruction (SBO) caused by IH, emergency laparoscopic surgery was performed to loosen the obstruction. The patient was found to have ascites and small-bowel necrosis. A part of the small intestine that measured 30 cm was strangulated via a large-diameter defect (17 × 11 cm) in the ileal mesentery. Via a small abdominal incision, the necrotic bowel was resected, and the mesenteric defect was repaired.ConclusionSMHHs are rare in adults, and they should be considered as potential causes of strangulated intestinal obstruction in adults without a history of laparotomy or trauma.

A case of late-presenting congenital diaphragmatic hernia diagnosed at 5 years with acute abdomen

BackgroundSome congenital diaphragmatic hernias are diagnosed beyond 1 month. A late-presenting congenital diaphragmatic hernia shows a variety of clinical manifestations, and the preoperative clinical course is variable. We herein report a pediatric case of late-presenting congenital diaphragmatic hernia diagnosed as acute abdomen.Case presentationA 5-year-old boy was brought to our hospital because of herniation of the intestine into the left thoracic cavity, which was observed on radiography performed for abdominal pain. Enhanced computed tomography showed herniation of the small intestine and colon into the left thoracic cavity. Emergency laparoscopic surgery was performed based on the diagnosis of left diaphragmatic hernia. The entire small intestine and part of the colon herniated from the posterolateral defect of the diaphragm. We were able to retract the herniated intestine back into the abdomen but confirmed that the diaphragmatic defect and closure of the defect seemed to be technically challenging via laparoscopy; therefore, we converted the procedure to open laparotomy. The diaphragmatic defect was directly closed with interrupted sutures, and the thoracic cavity was degassed. Postoperatively, the left lung was found to be poorly expanded, but pulmonary hypoplasia was not evident in this case.ConclusionsWe herein report a pediatric case of late-presenting congenital diaphragmatic hernia diagnosed as abdominal pain. Late-presenting congenital diaphragmatic hernias present with a wide variety of symptoms; therefore, it is important to be reminded of these conditions and check chest radiographs in children presenting with acute or chronic respiratory or gastrointestinal symptoms of unknown etiology.

Emergency laparoscopic surgery in pregnancy

Introduction: The decision to proceed with surgical intervention is often difficult in pregnant women, particularly in emergency contexts. Opting for laparoscopic surgery in pregnant women is even more challenging. Concerns during laparoscopic procedures include potential fetal injury, reduced uterine blood flow due to pneumoperitoneum, and fetal acidosis. The objective of our study is to evaluate the feasibility and morbidity-mortality of emergency laparoscopy in pregnant women. Materials and Methods: This is a descriptive and prospective study conducted between February 2018 and October 2021, involving 337 patients who underwent laparoscopic surgery for acute non-traumatic abdominal emergencies. Results: Among the 190 female patients operated on, 18 patients (9.47%) were pregnant: 8 (44.5%) had acute appendicitis, 7 (38.9%) had acute lithiasic cholecystitis, 2 (11.2%) had ovarian cyst torsion, and 1 (5.6%) had an appendiceal abscess. This laparoscopic management was performed across different gestational ages. The mean gestational age of our patients was 15 ± 14 weeks of amenorrhea (minimum 7 weeks, maximum 29 weeks). The mean operative time for the surgical interventions in these pregnant women was 61.2 minutes ± 20.16 minutes. No intraoperative complications or incidents, no conversions, and no abortions were recorded. Conclusion: Laparoscopy can be safely used to manage acute non-traumatic abdominal emergencies during pregnancy.

Emergency laparoscopic surgery in Russia: a current state

To determine the current status and main factors influencing the level of emergency laparoscopic surgery in the Russian Federation. A retrospective nationwide analysis included patients ≥18 years old undergoing surgery for acute cholecystitis (AC), acute appendicitis (AA), perforated ulcer (PU) and ileus. The database of the chief surgeon of the Russian Ministry of Health for 2018 - 2022 was used. To investigate possible reasons influencing the level of emergency laparoscopic surgeries, we performed online survey of medical organizations connected to the electronic reporting system. Over five years, the incidence of laparoscopic surgeries for AC increased from 52.6% to 70.5% (p<0.001), for AA from 25.1% to 41.0% (p<0.001), for PU from 9.4% to 13.2% (p<0.001) and for ileus from 5.9% to 8.5% (p<0.001). The percentage of emergency laparoscopic surgeries in rural hospitals (level I) was 14.8%, level II hospitals - 40.2%, level III - 67.7% (p<0.001). We obtained responses from 1.982 (84.9%) out of 2.335 hospitals included in the database. Significant differences were revealed in equipment of hospitals of different levels with laparoscopic surgical systems and proportion of surgeons proficient in laparoscopic techniques (p<0.001). The same factors influence laparoscopy in different federal districts to a greater extent than their geographic and demographic characteristics. Laparoscopic emergency procedures became more widespread, but vary widely between regions, urban and rural. Availability of laparoscopic surgery is influenced by availability of equipment and trained surgeons, geographic distance and population density, level of hospital and ability to maintain acquired skills and increase experience in appropriate surgeries.

369 Should We Be Group and Save Testing for Laparoscopic General Surgical Procedures? a Retrospective Audit of Transfusion Rates at a District General Hospital

Abstract Introduction The risk of bleeding in surgery makes the requirement for transfusion a pertinent consideration for all clinical staff involved in the care of surgical patients. Group and save testing allow for appropriate blood to be dispensed, but each Group and Save sample costs approximately £20 per sample and 116g of CO2 per test. Historically the reported transfusion rate for laparoscopic surgery has been low. This audit aimed to ascertain the overall transfusion rate in laparoscopic surgery at a District General Hospital and use the data to inform practice regarding group and save requirements before surgery. Method A retrospective audit was undertaken incorporating all elective and emergency laparoscopic procedures undertaken at one trust between January 2020 and October 2021. Colorectal and Gynaecological procedures were excluded. Analysis was then undertaken with records from clinical coding and the hospital blood bank to determine how many patients received transfusion intra-operatively or within 72 hours of their procedure. Results 1794 laparoscopic procedures were included in the data set. Procedures included were laparoscopic cholecystectomy, laparoscopic appendicectomy, diagnostic laparoscopy, and laparoscopic hernia repair. Of these procedures 93.8% were performed on adults. Following analysis, 2 patients in the data set were found to have received transfusion within 72 hours of their procedure (0.11%). Conclusions The low transfusion rate in this study is comparable to other rates reported in the literature. This resulted in a local change in trust policy for elective and emergency laparoscopic surgery, reducing or eliminating the group and save requirement for most procedures.

WTP4.9 Use of the American Association for Surgery and Trauma (AAST) Scale as a Predictive Tool in the Laparoscopic Approach to Adhesive Small Bowel Obstruction in a Tertiary Hospital

Abstract Aims The laparoscopic approach (LA) in treating adhesive small bowel obstruction (ASBO) has been shown to be a beneficial technique. Despite being a minimally invasive procedure, it is still not a widespread technique. Tools to identify which patients with ASBO may benefit from LA are needed. The AAST scale classifies ASBO into five grades of obstruction, differentiated by radiological, intraoperative, and pathological findings. The correlation between AAST-radiological and AAST-intraoperative is evaluated, as well as the association between the AAST scale and the rate of conversion to open surgery. Methods Observational, descriptive, retrospective, single-center, retrospective study from January 2011 to April 2022 of patients undergoing emergency laparoscopic surgery for suspected ASBO. Results 43 patients were analyzed. By CT scan 13.5% of patients had AAST-I, 43.2% AAST-II, and 43.2% AAST-III. Intraoperatively 11.6% of patients had AAST-I, 46.5% AAST-II, 25.5% AAST-III, 13.9% AAST-IV, and 2.3% AAST-V. The overall conversion rate was 27.9%. Using the univariate logistic regression model, an association was found between conversion rate and intraoperative AAST, as patients with an AAST≤II were less likely to convert to open surgery (OR 0.03, 95%, CI 0.00-0.26, p=0.03). This association was not observed between conversion rate and AAST-radiological. The degree of agreement between radiological-AAST vs intraoperative-AAST was moderate (Kappa coefficient 0.532). Conclusions Although radiological AAST is a guiding tool in selecting patients in whom the entire LA can be performed, it is the intraoperative findings that increase conversion, which encourages a laparoscopic approach in these cases.

SP1.11 Hospitals offering emergency laparoscopic surgery have improved outcomes

Abstract Aims Only 20% of patients requiring emergency surgery in the UK are offered laparoscopic surgery; there is wide variability in uptake of laparoscopic emergency surgery between hospitals, ranging from 0% to over 80% of cases. This study investigated whether hospitals with an advanced laparoscopic culture had improved outcomes. Methods The national NELA database was interrogated to identify patients requiring surgery for adhesional small bowel obstruction; this was selected because it is common (around 25% of cases in NELA) and often amenable to laparoscopic surgery. Hospitals were grouped into quintiles, according to the number of cases attempted by the laparoscopic approach; each group was assessed for length of stay and mortality. Results In 176 acute hospitals, 20597 operations were performed for adhesional SBO. Overall mortality was 6.2%. In the quintile with the lowest rate of laparoscopy, 4% of cases were started laparoscopically, compared with 44% in the highest quintile. In the lowest quintile, 4.8% of patients were discharged within 3 days, compared to 13.8% in the highest quintile; discharge at 7 days was 26% versus 37%. Overall, 30-day mortality in the group with the lowest rate of laparoscopy was 6.9%, compared with 5.4% in hospitals with the highest rate of laparoscopy (p&amp;lt;0.001). Conclusions Hospitals where patients with adhesional SBO are offered laparoscopic emergency surgery demonstrate shorter lengths of stay and a significantly reduced mortality. This may be due to the benefits of the laparoscopic approach; it could also be a surrogate marker for an advanced culture of emergency surgery.

Prediction of Treatment Option by Human Chorionic Gonadotropin (hCG) Levels in Ectopic Pregnancy using Machine Learning

Aim: The objective of this study is to construct a model using a random forest to predict the treatment option of ectopic pregnancy based on hCG levels, as well as to confirm the model’s accuracy. Methods: We selected 17 variables related to ectopic pregnancy and extracted data from our records for cases of possible ectopic pregnancy. We then divided the cases into two groups: 1) laparoscopic surgery and 2) MTX or conservative treatment. We created a model for predicting the prognosis of ectopic pregnancy. Afterward, we confirmed the model’s accuracy using the test data. Additionally, we compared the model’s accuracy with that of two specialized obstetriciangynecologists (OB/GYNs) specialists who judged the same data. This study was approved by our ethics committee. Results: One hundred and twenty-eight patients were eligible for this research, of whom 52.3% (67) underwent laparoscopic surgery and 7.0% (9) had emergent laparoscopic surgery. MTX and conservative treatment, including normal pregnancies or miscarriages, were 25.0% (32) and 25.0% (32), respectively. The model’s accuracy using a random forest was 87.3%, and the area under curve (AUC) was 0.784. The two OB/GYNs judged the same data with respective accuracies of 77.3% and 79.7%. Conclusion: In conclusion, this model using a random forest was superior to the judgment of specialists. Moreover, this research is new in the fact that it has presented a numerical model involving multiple risks that, until now, have been judged empirically by humans. In the future, it may help develop and elucidate a more extensive prediction system for ectopic pregnancy.

Therapeutic strategy for acute appendicitis based on laparoscopic surgery

PurposeThe treatment strategies for acute appendicitis differ depending on the facility, and various studies have investigated the usefulness of conservative treatment with antibiotics, laparoscopic surgery, and interval appendectomy (IA). However, although laparoscopic surgery is widely used, the clinical strategy for acute appendicitis, especially complicated cases, remains controversial. We assessed a laparoscopic surgery-based treatment strategy for all patients diagnosed with appendicitis, including those with complicated appendicitis (CA).MethodsWe retrospectively analysed patients with acute appendicitis treated in our institution between January 2013 and December 2021. Patients were classified into uncomplicated appendicitis (UA) and CA groups based on computed tomography (CT) findings on the first visit, and the treatment course was subsequently compared.ResultsOf 305 participants, 218 were diagnosed with UA and 87 with CA, with surgery performed in 159 cases. Laparoscopic surgery was attempted in 153 cases and had a completion rate of 94.8% (145/153). All open laparotomy transition cases (n = 8) were emergency CA surgery cases. No significant differences were found in the incidence of postoperative complications in successful emergency laparoscopic surgeries. In univariate and multivariate analyses for the conversion to open laparotomy in CA, only the number of days from onset to surgery ≥ 6 days was an independent risk factor (odds ratio: 11.80; P < 0.01).ConclusionLaparoscopic surgery is preferred in all appendicitis cases, including CA. Since laparoscopic surgery is difficult for CA when several days from the onset have passed, it is necessary that surgeons make an early decision on whether to operate.

Incarcerated Larrey hernia with small bowel obstruction: A case report

Morgagni-Larrey hernias (MLHs) are rare diaphragmatic hernias that can cause incarceration or strangulation of the hernia contents in some cases. Here we report a case of incarcerated Larrey hernia with small bowel obstruction, which was successfully treated with emergent laparoscopic surgery. An 87-year-old woman presented to our hospital with abdominal pain and nausea. Computed tomography scan revealed an MLH comprising an obstructed intestinal loop. The patient underwent emergency laparoscopic surgery. Surgical findings showed incarceration of the small bowel on the left side of the falciform ligament. The small bowel was laparoscopically reduced and does not show signs of intestinal ischemia or perforation. The hernia orifice, which was approximately 15mm in diameter, was closed with a surgical suture without the need for sac excision. The patient was discharged on postoperative day 7 without postoperative complications. There are no established surgical techniques for the treatment of MLH due to its rarity. Our experience in the present case suggests that the laparoscopic approach might be considered as a feasible method even for incarcerated MLH. Surgical techniques for MLH should be selected on a case-by-case basis.

Outcomes of Open Versus Laparoscopic Surgery for Colorectal Cancer in the Emergency Setting

Aim: The study aim is to do the comparison of oncological and short-term results of open and laparoscopic surgery for colorectal cancer in emergency setting. Study Design: This retrospective cohort research was held in the Department of Surgery, Civil Hospital, Karachi and Sheikh Zayed Medical College/ Hospital, Rahim Yar Khan for two-years duration from January 2020 to December 2021. Patients and Methods: after approval of this study and an informed consent agreement was signed by each participant. We performed an emergency analysis on 55 consecutive patients who received emergency open (n=40) or laparoscopic (n=15) resection for colorectal cancer. Results: The gender, age, BMI, American Society of Anesthesiologists (ASA) score, tumor location and prior abdominal surgery history were not significantly different between the laparoscopic and open groups. The T4 pathological tumors were more frequent in the open surgery group (50% vs. 13.3%; p=0.031) than in the laparoscopic group. The open surgery group also experienced high proportion of perforation (42.5% vs. 33.3%) and obstruction (47.5% vs. 26.7%) cases. In the laparoscopic group, bleeding or anemia were much common (33.3% vs. 7.5%; p=0.032). The laparoscopic group did not experience any open conversions. The open surgery group had a high pervasiveness of Hartmann's surgery (35%), whereas the laparoscopic group had high pervasiveness of low anterior resection (26.7%; p=0.064). The complication ration at 30-days for laparoscopy (37.5%) and open surgery (33.3%) was comparable (p=0.900). Conclusions: In some individuals with colorectal cancer, emergency laparoscopic surgery has advantages in relation of short-term and oncologic outcomes. As a result, skilled laparoscopic surgeons may actively consider using laparoscopy in life-threatening situations. Keywords: Laparoscopy, colorectal cancer, and emergency.

Emergency laparoscopic surgery on a patient who visited the emergency room with lower abdominal pain

Internal hernias account for fewer than 6% of all small intestinal obstructions; of these, hernias caused by defects in the sigmoid colon are particularly challenging to detect. Misdiagnosis may occur if non-surgical symptoms (such as rebound tenderness) are not observed in the emergency room. We report the case of a consent who visited the emergency room with recurrent non-specific lower abdominal pain. She exhibited an internal hernia that had triggered small intestinal ischemia between the mesosigmoid (mesentery) and ovary. A 36-year-old female patient visited the emergency room of our hospital with acute left-lower abdominal pain, nausea, and vomiting that occurred 1 h after meals. We found no palpable mass or enlarged organ. Abdominal computed tomography (CT) revealed segmental small bowel wall thickening with mesenteric congestion in the left-lower quadrant, and small bowel ischemia attributable to internal herniation or adhesion. In addition, a small amount of pelvic ascites and multiple liver cysts were observed. A surgeon was immediately consulted and emergency laparoscopic surgery was performed.

A study of laparoscopic port site complications – A descriptive study in a tertiary care hospital

Background: Minimal access surgery commonly known as laparoscopic surgery among people is gold standard of care for many thoracic, abdominal, urological, and gynecological diseases with proven advantages and outcome over conventional surgeries. Due to recent technological advancement and enhanced surgical skills, more procedures are being done laparoscopically which were previously done conventionally. This rapid rise in magnitude of laparoscopic procedures has led to emergence of newer set of complications which are attributable to both access related and procedure specific. Aims and Objectives: The aims of this study were as follows: (1) To determine the incidence and type of port site complications following laparoscopic surgery. (2) To identify most common complication and possible causes and risk factors associated with these complications. Materials and Methods: It was a prospective observational study carried out in the General Surgery department of C.U. Shah medical college and Hospital after getting the Institutional Ethical Committee approval. Study included 100 patients admitted for planned as well as emergency laparoscopic surgery during February 2019 to December 2020. The patients were observed during early post-operative period and then followed up for 3 months for development of delayed port site complications. Results: It was observed that (63%) patients were male with majority patients in age group of 21–30 years (30%). Laparoscopic appendicectomy was the most common surgery performed (70%) and complications were most commonly associated with laparoscopic appendicectomy. Port site complications were observed in 33% patients (33/100). As an early port site complication, discharge, surgical site infection, port site bleeding, and port site emphysema were observed in 14, 8, 7, and 4 patients, respectively. These complications were more in patients with use of open or Hasson’s method of access, use of large port size (more than 5 mm size), and nonuse of specimen retrieval bag. Umbilical port was the most common site for overall complications. Conclusion: Overall, complications associated with laparoscopic port site are minimal and can be manageable with minimum morbidity.

Case of a Large Ruptured Liver Cyst That Was Successfully Treated by Emergency Laparoscopic Surgery

Case of a Large Ruptured Liver Cyst That Was Successfully Treated by Emergency Laparoscopic Surgery

Prospects for development of laparoscopic surgery in the Central Federal District of the Russian Federation

To analyze the achievements of laparoscopic surgery in the Central Federal District of Russia and outline perspective trends for further application. The study included adult patients with abdominal surgical diseases hospitalized in general surgical departments of the Central Federal District between 2014 and 2021. We analyzed the prevalence of elective and emergency laparoscopic surgeries. Incidence and results of laparoscopic interventions between 2018 and 2021 were estimated considering primary statistical data presented in the annual collections of the Chief Surgeon of the Ministry of Health of Russia «Surgical care in the Russian Federation». The absolute number of laparoscopic surgeries in the Central Federal District increased from 23.686 to 80.489 (by 3.4 times) between 2014 and 2021. The annual number of elective laparoscopic surgeries exceeded the number of emergency ones up to 2019. In 2020-2021, this situation changed in favor of emergency abdominal procedures. Laparoscopic surgeries are the most common for in acute cholecystitis (71.06-81.10% of all laparoscopic interventions annually) and acute appendicitis (46.85-55.60%). In 2020 and 2021, the absolute number of laparoscopic appendectomies exceeded the number of laparoscopic cholecystectomies. These values are lower for perforated ulcers (15.44-20.39%) and acute pancreatitis (32.40-36.71%). Laparoscopic operations are rare for acute intestinal obstruction, strangulated hernia and ulcerative gastroduodenal bleeding. In elective surgery, high availability of laparoscopic surgeries was noted in patients with cholelithiasis (89.40-93.78%), hiatal hernia (62.12-77.27%) and adrenal gland diseases (64.23-87.25%). The most intensive increment of availability (by 2.4 times) was noted for inguinal hernia from minimum level (10.98%) in 2018 to 26.00% in 2021. Mortality after some laparoscopic operations decreased in comparison with laparotomy by 12-45 times (2018-2021). However, this aspect and results of laparoscopic surgeries in case of delayed hospitalization require additional study. Analysis of laparoscopic surgery showed the timeliness of beginning and development of this direction In Russia. The prospect of further development of laparoscopic surgery for abdominal diseases is determined by modern trends. These are increase in the number of laparoscopic operations for acute appendicitis, acute cholecystitis and perforated ulcers, as well as higher number of early (after admission) operations.

Immunohistological study of ovarian mature cystic teratoma with extremely elevated SCC antigen level

Squamous cell carcinoma (SCC) antigen is a reliable tumor marker for various cancers, including cervical cancer and lung cancer, and was recently reported to correlate with the severity of inflammatory skin diseases such as atopic dermatitis. Herein, we present a case of a 47-year-old female patient who presented with acute abdomen rupture due to a mature cystic teratoma of the ovary, approximately 11 cm in diameter on imaging examination, prompting emergency laparoscopic surgery. The patient had no symptoms of atopic dermatitis. The operative findings showed no evidence of torsion, but the membrane was partially ruptured, leading to the leakage of the cyst contents. The operation was completed after excising the adnexa and intraperitoneal lavage. The postoperative results revealed a markedly high serum SCC antigen level of 55.3 ng/dL, which was normalized at 2 months postoperatively. Postoperative histopathological examination revealed no squamous cell carcinoma component but a marked lymphocytic infiltrate under the squamous epithelium, suggesting a high degree of inflammation. Additionally, immunostaining demonstrated a cluster of differentiation (CD) 8+ lymphocyte predominance over CD4+ lymphocytes, similar to the histology of atopic dermatitis. Altogether, our findings suggest that the abnormally high SCC antigen levels might be attributed to the presence of severe inflammation in the mature cystic teratoma rather than an underlying malignancy and support the notion that SCC antigen may be a useful marker beyond its established role in cervical and lung cancers.

Successful laparoscopic management of adnexal torsion in early pregnancy: A case report

Ovarian torsion is an urgent gynaecological surgery and can occur during pregnancy. Ovarian torsion during pregnancy carries significant risk to pregnant woman and intrauterine fetus. Diagnosing ovarian torsion during pregnancy can be challenging as most frequently ,patients present with abdominal pain and non specific symptoms. If the diagnosis of ovarian torsion is missed, it can lead to ovarian necrosis and sepsis with subsequent loss of ovarian and tubal function. This condition not only threatens the pregnancy but also has great implications for future fertility. A 26year-old G2P1L1 at 5 weeks gestational age presented to us with right sided lower abdominal abdominal pain radiating to back, burning micturation, and low grade fever. Ultrasound showed an enlarged edematous enlarged right ovary with two hemorrhagic cysts with absent flow on color Doppler. The patient underwent emergency laparoscopic surgery, during which the necrotic adnexa was removed. She was placed on progesterone therapy postoperatively and eventually delivered a healthy baby at term. Ovarian torsion though is extremely rare problem in pregnancy, it should be taken into consideration in differential diagnosis of abdominal pain.

Spigelian Hernia and Appendicitis: A Rare Case Report

Introduction: Hernias containing the appendix are well-known entities that preferentially affect the groin. The presence of an appendix within a Spigelian hernia, which is a rare ventral hernia that presents with nonspecific symptoms and location, adds significantly to the complexity and rarity of its diagnosis. Further, only 18 such cases were reported and published in the literature. We report a case of Spigelian hernia and appendicitis within the hernial sac to highlight the diagnostic challenges associated with this type of hernia. Case Presentation: In her late 30s, a female who underwent laparoscopic surgery for a uterine fibroid two and a half years back presented with right lower quadrant abdominal pain for two days. This followed abdominal pain on exertion for the previous nine months. On examination, there was tenderness, guarding, and a positive cough impulse in the right lower quadrant of the abdomen. Her body mass index was 37.53 kg/m2. A contrast-enhanced computed tomography imaging of the abdomen reported a right iliac fossa incisional hernia with omental congestion necessitating an emergency laparoscopic surgery. At surgery, a Spigelian hernia, which was at least 5 cm away from the port site scar of the previous surgery, was found. The hernia contained an inflamed appendix. Thus, a diagnosis of Spigelian hernia and appendicitis within the hernial sac was made. A laparoscopic reduction and repair of the Spigelian hernia and a laparoscopic appendectomy were performed. Conclusion: Whereas Spigelian hernias are considerably rare, the presence of an appendix within a Spigelian hernia sac is yet a more infrequent occurrence. Although the imaging modalities are often inconclusive, careful interpretation of the computed tomography imaging findings may reveal the pathology preoperatively.

TH7.5 De Garengeot hernia: a combination of niche presentation, diagnostic, and anatomical factors

Abstract Background De Garengeot hernias occur in almost 1% of femoral hernias and are diagnosed when the appendix is also present within. They are more commonly observed in post-menopausal women, but their pathogenesis remains controversial. Theories involve abnormalities in bowel rotation during embryological growth, caecum mobility or size, and increased abdominal pressure. Most are diagnosed intra-operatively and are otherwise incidentally discovered on imaging. An advised surgical technique has not been determined due to its rarity; however, most literature suggests laparoscopic hernioplasty and appendicectomy in absence of infection. Case report A 77-year-old female presented with a three-day history of a painless, right groin mass. Blood results were within normal range, and sonography identified a De Garengeot hernia suggesting appendiceal inflammation. She underwent emergency laparoscopic surgery that discovered a strangulated appendiceal tip within an incarcerated femoral hernia, which then unexpectedly divided during manipulation. Additional findings included a broad mesoappendix and lack of appendicitis. The team proceeded with a hernioplasty and appendicectomy, and the patient was discharged two days later without complications. Conclusion This case report highlights a few niche aspects of De Garengeot hernias. Firstly, it is unusual our patient's diagnosis occurred preoperatively via ultrasound; secondly, the ischaemic tip of the appendix unexpectedly self-detached upon mobilisation; and thirdly, the widened mesoappendix likely contributed towards her predisposition to De Garengeot hernias. Overall, our case represents laparoscopic surgery being optimal in treating De Garengeot hernias that are diagnosed preoperatively, and that they should remain a differential diagnosis for non-specific groin lumps, regardless of pain.

A Case of Axial Torsion of an Appendiceal Mucocele Diagnosed Preoperatively and Treated by Emergency Laparoscopic Surgery

A Case of Axial Torsion of an Appendiceal Mucocele Diagnosed Preoperatively and Treated by Emergency Laparoscopic Surgery