Left-sided Hernia Research Articles

CHARGE syndrome in a fetus with a large paraesophageal hernia presenting prenatally as esophageal atresia

We report on the case of a 28-year-old primigravida with polyhydramnios and a fetus with mild bilateral ventriculomegaly, a large cyst in the right lateral ventricle, a fluid-filled structure posterior to a normal heart (Figure 1) and a missing stomach. After delivery, bilateral retinal coloboma, micrognathia, bilateral external ear abnormalities and a submucous cleft palate with excessive salivation were noted. Esophago- and tracheoscopy excluded esophageal atresia and tracheoesophageal fistula, but X-ray of the chest and a barium swallow examination revealed a large left-sided paraesophageal hernia of the stomach (Figure 2). Neonatal echocardiography showed a persistent foramen ovale and, on magnetic resonance imaging, an aberrant right subclavian artery and left-sided choanal atresia could be seen. Other notable findings were dysphonia and hypocalcemia. A diagnosis of CHARGE syndrome was established based on the presence of four major features of the syndrome (bilateral coloboma, choanal atresia, swallowing difficulties and external ear abnormalities)1. CHARGE is a rare congenital anomaly syndrome, with ocular coloboma, congenital heart defects, choanal atresia, retardation of growth and development, genital hypoplasia and ear anomalies associated with deafness. The syndrome was first described in 1979 by B.D. Hall, as referenced by Blake and Prasad1. Its incidence is 0.1–1.2 per 10 000 deliveries1. In most cases, de novo truncating mutations in the gene encoding the chromodomain helicase DNA binding protein 7 (CHD7), located on chromosome 8q12, cause the syndrome2. Mutations in the CHD7 gene have been demonstrated in 42–64% of cases3. The clinical diagnosis is made either if four major features are present, i.e. coloboma of the eyes, choanal atresia or stenosis, cranial nerve anomaly (especially nerve I (missing or decreased sense of smell), nerve IX and nerve X (swallowing difficulties and aspiration) and nerve VII (facial palsy)) as well as ear abnormalities or if three major and three minor features are present, i.e. heart defects, cleft lip and/or palate, esophageal atresia or tracheoesophageal fistula, kidney anomalies, genital anomalies, growth deficiency, typical CHARGE face with asymmetry and ptotic lids, palm crease or CHARGE behavior (perseverative and obsessive compulsive)1. CHARGE syndrome may be associated with the presence of esophageal atresia and/or tracheoesophageal fistula4. In contrast to postnatal features, typical prenatal features on ultrasound are not well established since only a small number of fetuses with this syndrome have been described prenatally. In 2012, Legendre et al. summarized 40 cases of CHARGE syndrome5 and described external ear abnormalities, arhinencephaly and semicircular canal agenesis as typical prenatal ultrasound features. However, arhinencephaly and semicircular canal agenesis are rather difficult to identify. In our case, CHARGE syndrome was prenatally misdiagnosed as esophageal atresia because no stomach was present in typical location; polyhydramnios was visible and we interpreted the herniated stomach in the posterior mediastinum as mediastinal pouch of the atretic esophagus. This case shows that paraesophageal hernia can occur in fetuses with CHARGE syndrome, mimicking esophageal atresia. Based on our observation, paraesophageal hernia and CHARGE syndrome is a potential differential diagnosis in the case of a eutrophic fetus with clinical signs of esophageal atresia. E. Tempfer-Bentz*†, R. B. Troebs‡, C. Sonntag§, G. A. Rezniczek† and C. Tempfer† †Department of Obstetrics and Gynecology, Ruhr University of Bochum, Bochum, Germany; ‡Department of Pediatric Surgery, Ruhr University of Bochum, Bochum, Germany; §Department of Radiology, Ruhr University of Bochum, Bochum, Germany *Correspondence. (e-mail: [email protected])

Successful management of an incarcerated left-sided Amyand's hernia in a 63-year-old male

Successful management of an incarcerated left-sided Amyand's hernia in a 63-year-old male

Transverse testicular ectopia

Described herein are six cases of transverse testicular ectopia. All patients who underwent orchidopexy at the one pediatric surgical unit between October 2001 and January 2008 were evaluated. The medical records of all patients diagnosed with transverse testicular ectopia were evaluated retrospectively. Five patients (84%) were admitted with a symptomatic right inguinal hernia and empty scrotum on the left side. Only one child (16%) had left-sided hernia and right non-palpable testis (age ranged from 1 month to 3 years). Four patients (66%) were diagnosed in the operating theatre and the last two (33%) on inguinal ultrasound preoperatively. Magnetic resonance imaging was also performed in the last patient. Herniorrhaphy with fixation of the ectopic gonad to the opposite hemiscrotum through a transseptal incision was performed in all patients. Postoperative complications were not observed.

Traumatic lumbar hernias: do patient or hernia characteristics predict bowel or mesenteric injury?

Traumatic lumbar hernias are rare but important injuries to diagnose in blunt abdominal trauma, both because of delayed complications of the hernia itself and because of well-documented association with bowel and mesenteric injuries. No study to our knowledge has determined whether specific features of the hernia-size of the wall defect, inferior or superior location, or the side of the hernia-bear any predictive value on the presence of underlying bowel and mesenteric injury. A retrospective query of the radiology information system yielded 21 patients with lumbar hernias which were diagnosed on CT. These were reviewed by three radiologists to confirm the presence of an acute lumbar hernia and to determine the size and location of the hernia. The patients' medical records were reviewed to determine the presence of operatively confirmed bowel and/or mesenteric injuries, which occurred in 52 % of patients. A significant (p < 0.001) difference was found in the frequency of bowel and/or mesenteric injury with hernia defects greater than 4.0 cm (100 %) and those less than 4.0 cm (17 %). Larger hernias also resulted in more procedures (p = 0.042) and a trend towards longer ICU stay, but no difference in injury severity score (ISS) or overall hospital stay. No significant difference was seen in the frequency of bowel and/or mesenteric injuries based on side or location of the hernia, though distal colonic injuries were more commonly seen with left-sided hernias (50 %) compared to right-sided hernias (18 %). Although based on a small patient population, these results suggest that larger traumatic lumbar hernias warrant particularly close evaluation for an underlying bowel and/or mesenteric injury.

Congenital Morgagni's hernia: A national multicenter study

BackgroundCongenital Morgagni's hernia (CMH) is rare and represents less than 5% of all congenital diaphragmatic hernias. This is a national review of our experience with CMH outlining clinical presentation, methods of diagnosis, associated anomalies, treatment, and outcome. Patients and methodsThe medical records of all patients with the diagnosis of CMH treated at four pediatric surgery units in Saudi Arabia were retrospectively reviewed for age at diagnosis, sex, presenting symptoms, associated anomalies, diagnosis, operative findings, treatment, and outcome. ResultsDuring a 20-year period (January 1990–December 2010), 53 infants and children with CMH were treated. There were 38 males and 15 females. Their age at diagnosis ranged from 1month to 9years (mean 22.2months). Forty-three (81%) presented with recurrent chest infection. Twenty-two (44.5%) had right CMH, 15 (28.3%) had left-sided hernia and 16 (30.2%) had bilateral hernia. In 7, the diagnosis of bilaterality was made at the time of surgery. Associated anomalies were seen in 38 (71.7%). Twenty-one (39.6%) had congenital heart disease, 8 (15%) had malrotation, and 15 (28.3%) had Down syndrome. All were operated on. Twenty-nine (54.7%) underwent repair via an open approach. The remaining 24 (45.3%) underwent repair using minimal invasive surgery, laparoscopic-assisted hernia repair (19 patients) or totally laparoscopic approach (5 patients). At the time of surgery, the hernia sac content included the colon in 33 (62.3%), part of the left lobe of the liver in 13 (24.5%), the small intestines in 11 (20.75%), the omentum in 5 (9.4%), and the stomach in 4 (7.5%). In 12 (22.6%), the hernia sac was empty. When compared to the open repair, the laparoscopic-assisted approach was associated with a shorter operative time, an earlier commencement of feeds, less requirement for postoperative analgesia, a shorter hospital stay, and better cosmetic appearance. There was no mortality. On follow-up, 2 (7%) of the open surgical group developed recurrence. ConclusionsCMH is rare and in the pediatric age group commonly presents with recurrent chest infection and has a high incidence of associated anomalies, commonly congenital heart disease and Down syndrome. We advocate a laparoscopic-assisted approach to repair CMH. This is a simple technique that produces a sound repair, and when compared with the open approach it takes less operative time, requires less analgesia, allows earlier commencement of feeds, is associated with a shorter hospital stay, and has a better cosmetic outcome.

Left Amyand's hernia in children: Method, management and myth

The presence of the appendix within an inguinal hernia is referred to as Amyand's hernia.1 A paediatric surgeon can expect to discover the appendix in one of every 1000 hernia sacs,2 usually at emergency herniotomy. We report an even rarer presentation – left-sided Amyand's hernia discovered unexpectedly at elective surgery in a baby and a toddler. Elective bilateral inguinal herniotomies were performed on a 10-week-old twin boy who had been born at 27 week's gestation. Both hernias were reducible since detection on day 9 of life. The left hernia sac contained small bowel, caecum and appendix. The contents were easily reduced in to the abdomen, and routine inguinal herniotomy was performed. Recovery was uncomplicated. A 13-month-old boy was followed up in clinic having presented at 5 weeks of age with a right communicating hydrocele. The right hydrocoele had resolved, but there was now a reducible right inguinal hernia. He had also developed a tense, non-tender, irreducible left inguino-scrotal swelling thought to be a hydrocoele. A right inguinal herniotomy was subsequently performed in the standard manner. On opening the left inguinal canal to repair the hydrocoele, the inguino-scrotal swelling was actually found to be an incarcerated inguinal hernia. The hernia comprised terminal ileum, caecum and appendix. The bowel was viable and, after further proximal extension of the incision in the peritoneum, was easily reduced in to the abdomen without appendicectomy. The hernia sac was transected distally, preserving the vas and testicular vessels as per routine inguinal herniotomy. Proximally, the edges of the peritoneum were closed with a continuous absorbable suture. An upper gastro-intestinal (GI) contrast study showed normal rotation of the gut. Amyand had a big day on December 6th 1735 at St. George's Hospital, London. Not only did he perform the first appendicectomy, he described finding the appendix, perforated by a pin, in a right inguinal hernia of an 11-year-old boy.3 To unexpectedly find a left Amyand's hernia in two children at elective operation is most unusual. The majority of reported cases of left Amyand's hernia present as emergencies, appendicitis or strangulated hernia, in adults. The largest series of Amyand's hernia in children reports on 30 cases, only three of which were left sided.4 One of the three presented with perforated appendicitis in the hernia, and the other two were detected on axial imaging pre-operatively. We describe the technique of herniotomy in this unusual situation for the first time. By carefully incising the encasing processus vaginalis and extending this incision distally on the spermatic cord and proximally towards the deep inguinal ring, enough exposure was possible to: (i) identify the hernia contents; (ii) inspect the hernia contents for viability; (iii) reduce the hernia to the abdominal cavity; and (iv) repair the hernia by herniotomy. All reports to date suggest that the caecum and appendix herniate through the left inguinal canal because of either high caecal mobility, situs inversus or malrotation of the gut. In one case report, the finding of an appendicitis in the left inguinal canal lead the surgeons to consider malrotation, and a midline laparotomy was performed simultaneously5 – the bowel was rotated normally. Our second patient underwent a post-operative upper GI contrast study which was normal. In the absence of any report of left Amyand's hernia in children or adults associated with situs inversus or malrotation, we suggest that these concerns are unfounded, and certainly, exploratory laparotomy can be avoided. It is generally agreed in all preceding case reports that appendicectomy in Amyand's hernia is not indicated unless it is inflamed or strangulated. However, Johari et al.6 suggest removing a normal appendix when found in the left inguinal canal as this raises the possibility of malrotation and the potential for later atypical presentation with appendicitis. Again, the current authors believe that in the absence of inflammation and any report of associated malrotation with left Amyand's hernia, ‘prophylactic’ appendicectomy is not indicated. Our rare cases allowed us to describe in detail the operative management of left Amyand's hernia in children discovered at elective operation. Rather than repeating old myths, we have outlined the management of these children, specifically advising against prophylactic appendicectomy of a non-inflamed appendix, and the avoidance of unnecessary interventions (laparotomy) or investigations (contrast studies) for malrotation or situs inversus.

Comment to: First laparoscopic totally extraperitoneal repair of Laugier’s hernia: a case report. Ates M, Dirican A, Kose E, Isik B, Yilmaz S. Hernia 2013; 17:121–123

I read with interest the recent case report of Ates et al. [1] regarding laparoscopic totally extraperitoneal (TEP) repair of Laugier’s hernia and would like to take this opportunity to add few comments. The authors made a very important remark that ‘the surgeon should be alert to the possibility of an atypical femoral hernia when examining patients with inguinal hernias’ and this statement is even more relevant in female patients who carry a significantly higher risk of having a synchronous femoral [2], or less commonly obturator hernia. In a personal prospectively maintained database on 582 patients undergoing TEP repairs for inguinal hernias, out of 540 male patients who had 763 repairs an obturator hernia was incidentally identified in only 3 explored groins (0.4 %), whereas the same combined anomaly was found in 5 out of 52 inguinal hernia repairs (9.6 %) in the remaining 42 female patients. In comparison, I only came across two patients initially consented for a TEP repair of bilateral inguinal hernias that were incidentally found to have an associated Laugier’s hernia at time of surgery. Both repairs were completed laparoscopically and a photographic representation of the first case can be seen in a recently published article [3]. This reinforces the increasing observation that a laparoscopic approach may offer further advantages over traditional inguinal herniorrhaphy as it can also allow simultaneous repair of occult contralateral inguinal [4], synchronous femoral [5] or obturator [6] hernias. It is therefore extremely important to possess a thorough anatomical knowledge of the pelvis and groin regions as viewed through the laparoscope, but also to systematically and carefully expose all potential hernial defects such as the obturator foramen and femoral canal. This only comes at the cost of quite a steep learning curve [7] that will eventually allow the surgeon to master every aspect of this challenging procedure [8]. Once a synchronous groin/pelvic hernia has been identified, it may also become quite convenient to be familiar with few extra technical tricks that could be of significant value for a successful clinical outcome. I would like to illustrate this with the presentation of my second patient, at the time 54 years of age, who was incidentally diagnosed with multiple groin defects. During a standard TEP approach and following reduction of bilateral indirect inguinal hernia sacs and right femoral hernia, a synchronous previously undiagnosed smaller left-sided femoral hernia was identified along with the presence of an additional, quite distinct and substantial defect that had formed through the lacunar ligament on the right side (Laugier’s hernia). The Laugier’s hernia was reduced (Fig. 1a, b) and remaining defect closed using the previously described Endoloop technique (Fig. 1c) [9] in order to minimize the risk of postoperative seroma formation. Similarly, the right femoral canal was plugged using a small size prosthetic mesh (Perfix Plug, Bard, Warwick, RI, USA) that was simply glued in place using fibrin sealant [TISSEEL (Fibrin Sealant), Baxter, Deerfield, IL, USA] (Fig. 1d). Finally, two anatomical meshes of polyester with lateral slit (Parietex Anatomical Mesh 15 9 10 cm, TECT 1510 ADP2, Covidien, Mansfield, MA, USA) were used to cover all defects and also fixed with fibrin sealant as This comment refers to the article available at 10.1007/s10029-011-0820-2.

Prediction of contralateral inguinal hernias in children: a prospective study of 357 unilateral inguinal hernias

PurposePreviously, we established a pre-operative risk scoring system to predict contralateral inguinal hernia in children with unilateral inguinal hernias. The current study aimed to verify the usefulness of our pre-operative scoring system.MethodsThis was a prospective study of patients undergoing unilateral inguinal hernia repair from 2006 to 2009 at a single institution. Gender, age at initial operation, birth weight, initial operation side, and the pre-operative risk score were recorded. We analyzed the incidence of contralateral inguinal hernia, risk factors, and the usefulness of our pre-operative risk scoring system. The follow-up period was 36 months. We used forward multiple logistic regression analysis to predict contralateral hernia.ResultsOf the 372 patients who underwent unilateral hernia repair, 357 (96.0 %) were completely followed-up for 36 months, and 23 patients (6.4 %) developed a contralateral hernia. Left-sided hernia (OR = 5.5, 95 %, CI = 1.3–24.3, p = 0.023) was associated with an increased risk of contralateral hernia. The following covariates were not associated with contralateral hernia development: gender (p = 0.702), age (p = 0.215), and birth weight (p = 0.301). The pre-operative risk score (cut-off point = 4.5) of the patients with a contralateral hernia was significantly higher, compared with the patients without a contralateral hernia using the area under the receiver operating characteristic curve (p = 0.024).ConclusionsUsing multivariate analysis, we confirmed usefulness of our pre-operative scoring system and initial side of the inguinal hernia, together, for the prediction of contralateral inguinal hernia in children.

Recurrence and complications of pediatric inguinal hernia repair over 5 years

Introduction and aim Inguinal hernia is one of the most common pediatric diseases in children and it presents most commonly during the first year of life. The aim of this study was to determine epidemiologic indexes and complications of inguinal hernia repair in pediatric patients who underwent inguinal hernia surgery. Patients and methods This retrospective study was carried out in the Imam Khomeini and the Abuzar hospitals. All inpatients who underwent surgery for inguinal hernia from 2003 to 2004 were included in this study. Their hospital records were reviewed till 2007 for age, sex, wound infection, recurrence, and other complications. The v2-test was used for analysis using SPSS, version 13.0. Results In this study, 269 children were included. Of all the patients, 237 (88.1%) were boys and 32 (11.9%) were girls (P < 0.001). The median age at the first reference to the surgeon was 2.93 years. Right-side and left-side inguinal hernia was observed in 136 (50.55%) and 92 (34.20%) cases, respectively. Bilateral inguinal hernia was observed in 41 (15.25%) cases. The frequency of recurrence was 2.2%, and was observed only in boys. Postoperative complications were observed in 5.2% of the cases. The most common of them was anesthetic complication. Conclusion Most of the cases involved male patients. All of the recurrences were in male patients. Postoperative complications were observed in 5.2% of the cases. Keywords : complication, inguinal hernia, pediatric, recurrence

English

A nine months old male baby presented with swelling in left groin. It turns out to be a rare presentation of where the appendix was found within the left hernial sac during surgery for an obstructed inguinal hernia. Herniotomy and appendectomy was carried out since the appendix was inflamed. INTRODUCTION: A vermiform appendix in an inguinal hernia sac, with or without appendicitis, is called Hernia. Claudius Amyand (1660-1740), a French surgeon working at St.George's and Westminster hospitals in London, performed the first successful appendicectomy in 1735, on an 11year-old boy who presented with an inflamed, perforated appendix in his inguinal sac. Since then, the presence of the appendix within an inguinal hernia has been referred to as Amyand's hernia, and still remains a rare occurrence. The case was published in the Philosophical Transactions of the Royal Society of London. We present such a case of hernia discovered at surgery for a left-sided obstructed inguinal hernia in a nine month old baby. Whether or not an appendectomy should be performed at the same times as the hernia repair is debatable. The aim of this study is to present the experience of our Institute surgical department with hernia along with a review of the literature on this subject.

Fetal Umbilical Vein Deviation in Congenital Diaphragmatic Hernia

Deviation of the intra-abdominal umbilical vein has been described as a marker of congenital diaphragmatic hernia (CDH) and has been shown to help identify liver herniation into the fetal chest. The purpose of this study was to quantify the degree of deviation in affected fetuses and to determine the accuracy of measurements for diagnosing liver herniation. In patients undergoing prenatal sonography for CDH, the midhepatic portion of the umbilical vein was identified, and the distance between the lateral edge of the vein and the inner rib margin was measured. The same was done on the right, and the ratio of the left to right measurement was termed the "umbilical vein ratio." The accuracy of the umbilical vein ratio for predicting the presence and side of the hernia and for diagnosing liver herniation was determined. All but 1 of the cases with right-sided hernias had an umbilical vein ratio above the normal range, and all had liver herniation. Of those with a left-sided hernia, only 2 had a ratio within the normal range. Of those with a left-sided hernia, an umbilical vein ratio less than 0.4 was shown by receiver operating characteristic curve analysis to be the best predictor of liver herniation. This cutoff had sensitivity of 89% for predicting herniation, with a false-positive rate of 14%. Ninety-three percent of right-sided CDH lesions and 98% of left-sided lesions have an umbilical vein ratio outside the normal range. This finding shows that deviation may a useful indicator of CDH in screening ultrasound examinations. An umbilical vein ratio less than 0.4 is predictive of liver herniation.

Case Report: Laparoscopic Treatment of a Right-Sided Paraduodenal Hernia

Abstract Introduction: Internal hernia is a rare cause of intestinal obstruction, with paraduodenal hernias accounting for more than 50% of them. Two types of paraduodenal hernias are distinguished: left-sided paraduodenal hernias and the rarest (25% of cases) right-sided paraduodenal hernias.1,2 The reported treatment is by a laparotomy. We report the case of a right-sided paraduodenal hernia that was treated by a laparoscopy. Case Report: A 28-year-old woman had complained about right upper abdominal pain for 2 years. The patient was previously operated on spec of a left upper abdominal wall hernia. On this occasion, no pathological findings appeared. Otherwise, the patient had no relevant pre-existing conditions. The discomfort appeared as acute colicky at intervals of several weeks and suspended in most cases spontaneously within hours. Within the scope of an intertemporal uncomplicated pregnancy, the discomfort appeared less frequent. During the pregnancy, the patient sought treatment twice in foreig...

Prospective comparative assessment of ultrasonography and laparoscopy for contralateral patent processus vaginalis in inguinal hernia presented in the first year of life

Background and purpose Contralateral inguinal exploration in children with unilateral inguinal hernia is still a controversial topic. The aim of this study was to present an evidence-based justification for contralateral inguinal exploration in our population after comparing the results of ultrasonography (US) and laparoscopy. Methods Over a period of 3 years, 246 patients (207 boys and 39 girls) with unilateral inguinal hernia who were presented in the first year of life underwent an US using a 10MHz linear transducer. Operative transinguinal contralateral laparoscopic exploration was carried out in all of them. The results were compared prospectively for the sensitivity and specificity of US and laparoscopy. Results Our results showed a predominant left-side incidence in boys (50.7%) and a right-side incidence in girls (69.2%). With respect to prematurity, 24.6% of boys and 30.8% of patients with left-sided hernia were found to be premature. In all, 64.6% of patients were diagnosed in the neonatal period. We considered positive patent processus vaginalis (PPV) on US when types I–III according to the criteria of Toki and colleagues were reported. Positive PPV was confirmed by US in 30.5% of patients and by laparoscopy in 85.2%. Sonographic assessment of contralateral PPV gave a sensitivity of 91.7% and a specificity of 87.7%. Of the patients, the laparoscopic exploration yielded positive results in 35.8%. The cost of a negative laparoscopy is 50$ and that of a positive laparoscopy is 100$, which on second admission costs 500$. Conclusion As in our community there is a high incidence of consanguinity, preoperative assessment of contralateral hernia should be considered in patients who are presented in the first year of life and in premature infants. In experienced hands US is a highly sensitive tool for the diagnosis of contralateral hernia. Laparoscopic exploration is safe, rapid, and a proven method for diagnosis, even in infants. We recommend laparoscopic exploration for all patients who are presented in the first year of life in order to avoid second admission, which can lower costs significantly. Keywords : hernia, laparoscopy, pediatric surgery

A rare presentation of Bochdalek’s hernia containing duodenum and pancreas

Symptomatic cases of Bochdalek's hernia are uncommon in adults; symptoms arise only due to complications. Most of symptomatic cases are related to a left-sided hernia. We describe the case of a 50-year-old woman with Bochdalek's hernia containing duodenum and pancreas. The patient was successfully treated by a surgical approach.

An Adult Right-sided Bochdalek Hernia Accompanied with Hepatic Hypoplasia and Inguinal Hernia

We herein report a very rare case of adult right-sided Bochdalek hernia accompanied with hepatic hypoplasia and inguinal hernia. A 29-year-old man was admitted with right-sided pneumothorax. A computed tomography was performed and revealed large right sided Bochdalek hernia with hepatic hypoplasia. Under thoracolaparotomy, the defect was closed with Gore-Tex soft tissue patch. After the operation, left-sided inguinal hernia was found. However, it turned out that it had been present during infancy and spontaneously resolved during adolescence. This is the first report of right-sided Bochdalek hernia with hepatic hypoplasia and inguinal hernia in an adult.

Incidence of pediatric metachronous contralateral inguinal hernia in children aged ≥1 year

The management of the contralateral asymptomatic side when a child with initial unilateral inguinal hernia undergoes herniorrhaphy continues to be controversial. Age less than 6 months at initial herniorrhaphy is considered as a high risk factor of the occurrence of metachronous contralateral inguinal hernia (MCIH). We performed herniorraphy for patients ≥1 year with initial unilateral hernia at one-day-set outpatient-surgery department without any intervention of contralateral groin. In this study, we reviewed the characteristics of development of MCIH in this condition and discuss the management strategies of MCIH. The subjects of this study were children who were treated at our outpatient-surgery department from January 2006 to December 2006. A total of 2129 patients with initial unilateral hernia and aged ≥1 year underwent an ipsilateral herniorhhaphy only. Patients were followed up for the development of MCIH to 60 months. The Chi-square test was used for intergroup comparison, a level of P<0.05 was considered as statistically significant. Among these children 1341 (63.0%) were obtained 60 months follow-up data, 1146 (85.5%) were boys and 195 (14.5%) were girls. MCIH developed in 70 (5.2%) patients, 61 were boys and 9 were girls. In 570 patients aged 12-23 months, 43 developed MCIH (7.5%); in 564 patients aged 24-59 months, 21 developed MCIH (3.7%); and in 207 patients ≥60 months, 6 patients developed MCIH (2.9%), the difference between these groups was highly significant (P=0.004). In male patients, 30 right-sided MCIHs occurred after 423 initial left-sided herniorrhaphies (7.1%) and 31 left-sided MCIHs occurred after 723 initial right-sided herniorrhaphies (4.3%), difference between these two groups was significant (P=0.041). Seventy-seven percent of the MCIHs occurred within 1 year, 94% occurred within 2 years after initial herniorraphy. As the overall incidence of MCIH in patients aged ≥1 year was 5.2%, routine contralateral groin exploration is not suggested. Transinguinal laparoscopy could be considered as an alternative of conventional "wait and see" policy, especially in patients less than 2 years or left-sided initial unilateral inguinal hernia. If "wait and see" policy is adopted, patients should be closely followed up for 2 years.

Omental torsion with left-sided inguinal hernia: a rare preoperative diagnosis

Omental torsion is a rare disease. It can be difficult to identify if it is not clinically considered in the preoperative period, and this pathology may lead to an acute abdomen. We present the characteristic computed tomography findings and clinical particulars in a 34-year-old male patient with longstanding left inguinal hernia associated with an extraordinary diagnosis.

447: Quantification of ultrasound umbilical vein changes in fetal diaphragmatic hernia

changes in fetal diaphragmatic hernia Douglas Richards, David Kays Intermountain Medical Center and the University of Utah, Maternal Fetal Medicine, Murray, UT, University of Florida, Pediatric Surgery, Gainesville, FL OBJECTIVE: Deviation of the intraabdominal umbilical vein has been described as a marker of congenital diaphragmatic hernia and has been shown to help identify liver prolapse into the fetal chest. Deviation has previously been described only as a subjective finding. The purpose of this study is to quantify the degree of deviation in affected fetuses and to determine the accuracy of measurements for determining liver prolapse. STUDY DESIGN: In patients undergoing prenatal sonography for CDH the mid-hepatic portion of the umbilical vein was identified, and the distance between the lateral edge of the vein and the inner rib margin was measured. The same was done on the right, and the ratio of left to right measurement was termed the umbilical vein ratio (UVR). For this analysis, deviation of the UV, as quantified by the UVR, was used to predict the presence and side of the hernia, as well as to diagnose liver prolapse. The 5th and 95th confidence limits for the normal UVR were determined from 80 unaffected fetuses. Of 160 cases of CDH seen at our center between 11/1995 and 9/2010, 56 fetuses were studied prospectively, and 76 had adequate images available for retrospective measurements. The first sonogram at our center was used for analysis. RESULTS: The gestational age at the time of the ultrasound was 29.4 / 6.2 weeks. Of the 132 patients, 14 had a right-sided and 118 had a left-side hernia. All but one of the cases with right-sided hernias had an UVR above the normal range, and all had liver prolapse. Of those with a left-sided hernia, only 2 had a ratio within the normal range. Of those with a left-sided hernia, an UVR of 0.4 was shown by ROC analysis to be the best predictor of liver prolapse. This cut off had a sensitivity of 0.89 for predicting prolapse, with a false positive rate of 0.14. CONCLUSION: 93% of right-sided CDH and 98% of left-sided lesions have an UVR outside of the normal range. This demonstrates that deviation may a useful indicator of CDH in screening ultrasound examinations. A UVR less 0.4 is predictive of liver prolapse.

Use of Endoscopic Surgical Spacer to Improve Safety During Thoracoscopic Repair of Congenital Diaphragmatic Hernia

Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has recently become more common, and the challenge of managing neonatal cases is increasing. Meanwhile, there have been reported intraoperative complications or conversion to open surgery due to injury of herniated viscera and inability of organ reduction. We used the endoscopic surgical spacer SECUREA™ (Hogy Medical Co., Ltd., Tokyo, Japan), which is an elliptical sponge made of polyurethane with a radiopaque marker, for preventing these complications in three cases of CDH. The first case was a late presentation in a 10-month-old girl, and the second and third cases were prenatally diagnosed female neonates without severe pulmonary hypertension. All cases were left-sided hernias without sacs. At operation, the SECUREA was grasped using forceps, and the viscera were pushed back gently to avoid injuring the spleen or the short gastric vessels in the second and the third case. The SECUREA was intended to prevent intestinal injury during defect repair in all cases, with placement of the SECUREA between the edge of the diaphragm and the reduced intestine. The procedures in all patients were completed with no complications and without the need for conversion.

Male form of persistent Mullerian duct syndrome type I (hernia uteri inguinalis) presenting as an obstructed inguinal hernia: a case report

IntroductionPersistent Mullerian duct syndrome is a rare form of male pseudo-hermaphroditism characterized by the presence of Mullerian duct structures in an otherwise phenotypically, as well as genotypically, normal man; only a few cases have been reported in the worldwide literature. We report the case of a 30-year-old man with unilateral cryptorchidism on the right side and a left-sided obstructed inguinal hernia containing a uterus and fallopian tube (that is, hernia uteri inguinalis; type I male form of persistent Mullerian duct syndrome) coincidentally detected during an operation for an obstructed left inguinal hernia.Case presentationA 30-year-old South Indian man was admitted to our facility with a left-sided obstructed inguinal hernia of one day's duration. He had a 12-year history of inguinal swelling and an absence of the right testis since birth. Our patient had well developed masculine features. Local physical examination revealed a left-sided obstructed inguinal hernia with an absence of the right testis in the scrotum. Exploration of the inguinal canal revealed an indirect inguinal hernia containing omentum, the left corner of the uterus and a left fallopian tube. Extension of the incision revealed a well formed uterus, cervix and upper part of the vagina attached to the prostate by a thick fibrosed band. Total excision of the uterus, bilateral fallopian tubes and right testis was performed. A biopsy was taken from the left testis. The operation was completed by left inguinal herniorraphy. Histopathological examination of the hernial contents was consistent with that of a uterus and fallopian tubes without ovaries. Both testes were atrophied, with complete arrest of spermatogenesis. Post-operative karyotype analyses were negative for 46,XY and Barr bodies on buccal smear. A semen examination revealed azoospermia with a low serum testosterone level.ConclusionsIn cases of unilateral or bilateral cryptorchidism associated with inguinal hernia, as in our patient's case, the possibility of persistent Mullerian duct syndrome should be kept in mind in order to prevent further complications such as infertility and malignant change. Hernia uteri inguinalis is the type I male form of persistent Mullerian duct syndrome, characterized by one descended testis and herniation of the ipsilateral corner of the uterus and fallopian tube into the inguinal canal.