Incisional hernia appendicitis: A unique case report

Vermiform Appendix within Post-Laparoscopic Incisional Hernia: A Unique Case Report and Literature Review

Background: Appendicitis within incisional hernia is an extraordinarily rare postoperative complication with an incidence range from 0.08 to 1%. From the 14 cases that we found in the English literature, only three present appendixes vermiform in incisional hernia followed by laparoscopic surgery. Only two cases are treated minimally invasively by the laparoscopic approach. Case presentation: We introduce a 65-year-old man who had a laparoscopic sigmoid colon resection and had a lump found at the 12 mm trocar site in the right iliac area in the late postoperative phase. There were no complaints from the patient. A vermiform appendix was unexpectedly discovered in the sac of that incisional hernia during control CT scans performed by chemotherapists. Laparoscopic hernia repair without appendectomy was performed. Postoperative outcomes were excellent. Conclusions: Because of low incidence and a lack of distinctive clinical presentation of appendicitis within incisional hernia, there is a risk of delayed perioperative diagnosis and treatment. A CT scan might play an important role in verifying the diagnosis early. For better postoperative outcomes, if possible, laparoscopic surgery should be chosen.

Novel Covert-Inferior Pelvic Approach with a Subpubic Plate for Anterior Pelvic Ring Fractures: Preliminary Results

BACKGROUND

Anterior pelvic ring injuries can be treated via Pfannenstiel, modified Stoppa, or ilioinguinal approaches, but these require exposing the abdominal soft tissues and may damage pelvic organs. The scar on the abdominal wall is also unacceptable for some patients. The minimally invasive anterior pelvic ring internal fixator (INFIX) is not ideal for thin patients with easily irritated skin, and it is associated with complications such as femoral nerve palsy, vascular occlusion, and lateral femoral cutaneous nerve injury. In this study, we designed a new external pelvic approach for the treatment of an anterior pelvic ring fracture.

METHODS

We retrospectively reviewed 28 patients with 36 pubic ramus fractures that had been treated via the covert-inferior pelvic approach. All patients underwent a surgical procedure between August 2019 and January 2021. According to the Nakatani classification, there were 6 cases of type-I fracture, 25 cases of type-II fracture, and 5 cases of type-III fracture. Operative time, blood loss, and postoperative radiographic and computed tomographic (CT) findings were recorded. Patients were followed for fracture healing time, functional status, esthetic satisfaction, and complications.

RESULTS

A total of 27 patients had follow-up for at least 12 months (range, 12 to 29 months). Postoperative radiographs and CT scans showed well-positioned plates and screws. The mean preoperative time was 9.4 ± 3.8 days, the mean operative time was 61.3 ± 22.67 minutes, the mean intraoperative blood loss was 63.6 ± 42.62 mL, the mean fracture healing time was 4.1 ± 1.6 months, and the mean Majeed score was 89.74 ± 8.07. There were no complications of nonunion, internal fixation failure, vascular injury, nerve palsy, or hernia. All of the patients were esthetically satisfied with the scar.

CONCLUSIONS

The covert-inferior pelvic approach combined with a subpubic plate effectively fixed Nakatani type-I, II, and III fractures. The advantages of this method include rapid recovery after the surgical procedure, safety, simplicity, a short learning curve, no damage to abdominal soft tissue, no effect on pubic symphysis micromotion, and esthetic benefits. It may be another option for anterior pelvic ring fractures and can supplement other approaches.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A rare presentation of appendicitis contained within an incisional hernia post loop ileostomy reversal - A case report

INTRODUCTION AND IMPORTANCE

Appendicitis within an incisional hernia is rare, with current literature describing a small number of cases, occurring through a variety of surgical incisions. We describe a case of appendicitis contained within an incisional hernia following reversal of a loop ileostomy, on a background of previous sigmoid cancer resection. This is the second such case we were able to identify on literature review.

CASE PRESENTATION

A 45 year old man presented with one day of migratory abdominal pain, predominantly focused at a tender, irreducible lump in his right lower quadrant, underlying the scar from previous reversal of loop ileostomy. CT on admission revealed an incisional hernia, containing an inflamed appendiceal tip. He underwent an uncomplicated laparoscopic appendicectomy and primary suture closure of the hernia defect, and was discharged the following day. Acute appendicitis was confirmed on histopathology.

DISCUSSION

Placement of a defunctioning ileostomy is common in the management of colonic cancers, and incisional hernias are a common complication. It is however rare for an appendix to be contained within a hernia sac, and even rarer for appendicitis to develop in this setting. As a result, the presentation of this condition may mimic that of an incarcerated or strangulated incisional hernia, with pre-operative diagnosis typically relying on diagnostic imaging.

CONCLUSION

Incisional hernia appendicitis is rare and presents a diagnostic challenge. Early recognition of this dual pathology is necessary to allow for prompt surgical management of both the appendicitis and hernia, as well as guiding the approach for hernia repair.

Our first Pfannenstiel incisional hernia. A case report

The incidence of the Pfannenstiel incisional hernia (IH) is the lowest of all IHs, it can occur due to patient-related factors or faulty technique in closure of the deeper layer. The use of prosthetic mesh repair is heralding a new era of tension-free herniorrhaphy, while the optimal location for its implantation remains controversial. As a result, no strategy or technique has become the gold standard for its repair. We report our first experience with an IH through Pfannenstiel in a 49-year-old obese female patient. Inlay polypropylene open mesh repair was performed. As the only complication, the patient presented with a seroma in the wound, which was aspirated, and she is currently asymptomatic with outpatient consultation follow-up. Pfannenstiel IHs have received minimal attention on the optimal surgical approach and postoperative results, making this case a good starting point for future studies.