From inguinal to giant femoral hernia: An unusual postoperative twist - A rare case report

INTRODUCTION AND IMPORTANCE

Femoral hernias following inguinal hernia repairs are an unusual occurrence that presents diagnostic challenges for healthcare providers. Surgical repair of inguinal hernias is generally successful, but complications and recurrence can arise. The coexistence of femoral hernias following inguinal hernia repairs is rare, requiring careful evaluation and management.

CASE PRESENTATION

A middle-aged patient sought medical attention with complaints of recurrent groin pain and a palpable bulge in the inguinal region. Initial imaging studies, including ultrasonography and contrast-enhanced computed tomography (CT), pointed towards an inguinal hernia, leading to the scheduling of surgical repair. However, during the operation, the surgeon discovered a femoral hernia, highlighting the limitations of imaging techniques in accurately diagnosing these hernia types.

CLINICAL DISCUSSION

Due to anatomical variations and overlapping signs and symptoms, distinguishing between femoral and inguinal hernias can be challenging. Scar tissue from previous inguinal hernia repairs can further complicate imaging interpretations. Intraoperative exploration becomes crucial to confirm the diagnosis and facilitate proper surgical repair.

CONCLUSION

The reported case emphasizes the importance of maintaining vigilance in evaluating patients with suspected hernias, particularly those with prior inguinal hernia repairs. Relying solely on imaging studies can lead to misdiagnosis, as illustrated by the discovery of a femoral hernia during surgery. Healthcare providers should be aware of the possibility of femoral hernias and conduct comprehensive evaluations to ensure timely intervention and improve patient outcomes. Further research and awareness are essential to optimize the care of such uncommon clinical scenarios.

Rectal Foreign Body: A Case Report

The rectal foreign body is a rare presentation, often related to sexual gratification, sexual assault, or the result of ingestion and rarely accidental, and with rising incidence. We present a case of a 47-year-old heterosexual male with an alleged history of accidental insertion of a foreign body through the anus three days prior without peritonitis or obstipation. After investigations, the patient underwent a failed sigmoidoscopic removal followed by exploratory laparotomy, foreign body removal, and an uneventful post-operative period. It should be noted that early diagnosis and timely intervention are important to prevent complications in rectal foreign bodies. Assessment of the shape, size, nature, and location of the object through appropriate imaging is necessary. Exploratory laparotomy is inevitable in cases of failed manual extraction techniques and complicated cases.

Keywords

case reports; foreign bodies; laparotomy; rectum; sigmoidoscopy.

Spontaneous enterocutaneous fistula in a patient with femoral hernia: a case report

BACKGROUND

Enterocutaneous fistula commonly occurs in the post-operative setting. However, a handful of cases have been reported to occur secondary to strangulation of hernia, mostly femoral due to the narrow femoral ring through which this type of hernia passes through.

CASE PRESENTATION

We encountered a case of spontaneous fecal fistula, which occurred in the setting of an incarcerated femoral hernia. The patient did not develop peritonism, or obstruction, throughout the course of the disease. The hernia ruptured on day 7 of incarceration. Exploratory laparotomy under epidural anesthesia revealed a femoral hernia with ileum as content, arising approximately 20 cm from the ileocecal junction. Reduction of the contents was done, and a resection performed along with repair of the hernia.

CONCLUSION

As very few literature describe the formation of spontaneous fecal fistula, we discuss the presentation in this report.

Synchronous Fibromatosis Indistinguishable from Suspected Synchronous Gastrointestinal Stromal Tumor: A Case Report

Desmoid tumors most commonly occur in the anterior abdominal wall in approximately 50% of cases and are locally aggressive. We describe a case of a 38-year-old lady who was investigated as a case of gastrointestinal tumor. Post-operative immunohistochemistry staining showed the presence of a synchronous desmoid in the abdominal wall and proximal ileum. Wide local excision remains the gold-standard of treatment with pharmacotherapeutics and radiotherapy serving as adjuvant or palliative treatment options.

Appendicitis as a presentation of COVID-19: A case report

Background

Coronavirus disease-19 (COVID-19) is an infectious respiratory disease caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). Respiratory symptoms and flu-like presentation are the most defined clinical manifestations. However, gastrointestinal symptoms with acute abdomen have been reported in a small percentage, occasionally mimicking acute appendicitis. Hence, the diagnosis of COVID-19 should be suspected and investigated in every case of acute abdomen in the present situation.

Case presentation

We report a case of a 25-year-old male who presented with features of acute appendicitis. Despite the equivocal ultrasound results, he was scheduled for an emergency appendectomy for Alvarado's score 7 out of 10, who underwent a successful appendectomy. The patient had initially tested negative on an upper respiratory COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) with normal chest X-ray but few hours after the surgery patient developed a high-grade fever. An RT-PCR for COVID-19 was resent following a suspicion that came out to be positive.

Clinical discussion

Several case reports have suggested a probable association between COVID-19 and appendicitis. This case shows the limited effectiveness of clinical diagnosis for the surgical abdomen in COVID-19 patients as these two conditions share similar symptoms often needing a clinical vigilance.

Conclusion

This case reports acute appendicitis in a patient who tested positive for SARS-CoV-2 subsequently following emergency appendectomy highlighting the acute gastrointestinal presentation of COVID-19. This case exemplifies the necessity to be familiar with the gastrointestinal symptoms of COVID-19 and maintain a high level of suspicion for COVID-19 infection in cases of abdominal pain.

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Acute appendicitis can be one of the presentation of COVID-19.

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Clinicians need to be familiar with the gastrointestinal symptoms of COVID-19.

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Rapid diagnosis of COVID-19 in patients with acute abdominal pain should be done to prevent the virus from spreading.

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A negative RT-PCR for COVID-19 can't totally exclude COVID-19.

Comparision of ultrasonographic diagnosis with ‘Tzanakis’ Score in acute appendicitis

Introduction: Acute appendicitis is one of the most common acute surgical abdominal conditions requiring surgery. Ever since the inflamed appendix was demonstrated in the 1980’s by Ultrasonography, it has been used as an aid to clinically diagnose acute appendicitis. Tzanakis scoring system is a combination of clinical examination, Ultrasonography and inflammatory markers. Methods: A retrospective non-randomized observational study was conducted from April 2014 to March 2015 on all cases of acute appendicitis, which underwent preoperative ultrasound before appendectomy (open/laparoscopic) at the Department of surgery, Nepal Medical College Teaching Hospital. Ultrasound findings and Tzanaki score were compared in the cases. No studies could be found in literature comparing ultrasound diagnosis with Tzanaki score in appendicitis. Results: The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound were 73%, 50%, 95% and 12% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of Tzanaki were 87%, 50%, 96% and 23% respectively. Tzanaki score is better than ultrasound alone as a diagnostic test for acute appendicitis. Conclusion: Tzanaki score is better than ultrasound in diagnosis of acute appendicitis.  

Outcome of Supracondylar Fractures of the Humerus in Children Treated by Closed Reduction and Percutaneous Pinning

Supracondylar fractures of humerus in children are common injuries. Displaced fractures areinherently unstable. Conservative treatment results in malunion. Open reduction and internalfixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102displacedsupracondylarfractures of humerus, agedbetween one andhalf yearto 13 years, weretreated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wireswereput.Above elbow plaster ofparis back slab was appliedinall cases for atleastfour weeks.Backslab,K-wireswere removedafterfourweeks andelbowrangeofmotionexercisewas started.Resultswere analyzed using Flynn’s criteria. All patients were followed up to 14th week postoperatively. Incross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively.We recommend this procedure fordisplacedsupracondylarfractures inchildrenas itis safeandcost effectiveprocedurewithacceptablecomplication rates.Key words: closed reduction, humerus, percutaneous pinning, supracondylar fracture

Outcome of supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning

Supracondylar fractures of humerus in children are common injuries. Displaced fractures are inherently unstable. Conservative treatment results in malunion. Open reduction and internal fixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102 displaced supracondylar fractures of humerus, aged between one and half year to 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wires were put. Above elbow plaster of paris back slab was applied in all cases for at least four weeks. Back slab, K-wires were removed after four weeks and elbow range of motion exercise was started. Results were analyzed using Flynn's criteria. All patients were followed up to 14th week postoperatively. In cross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively. We recommend this procedure for displaced supracondylar fractures in children as it is safe and cost effective procedure with acceptable complication rates.

Femoral Diaphyseal Fractures in Children Treated by Intramedullary Nailing

Abstract

Osteopoikilosis- A Radiological Curosity

Abstract