Tubo-Ovarian Inguinal Hernia with Ruptured Bleeding Follicle: A Case Report

Introduction: Hernias are abnormal protrusions of any abdominal-pelvic or fat organ, which are produced by a defect in the abdominal wall, the most frequent are inguinal hernias and their content is generally of the omentum or intestinal loops, the presence of pelvic organs is very infrequent and the majority of cases described are in children under five years of age. Objective: To analyze the entity in connection with a case of a patient with a tubo-ovarian inguinal hernia. Clinical case: The case of a 34-year-old female patient is presented, who was under follow-up by the gynecology service due to the presence of a left ovarian cyst, with symptoms of pain in the left iliac fossa for more than 6 months of evolution. which is performed an ultrasound, which reports left inguinal hernia for what is electively scheduled by the general surgery service, when performing the herniorrhaphy incarcerated hernia with left ovary with bleeding follicle and fallopian tube is evidenced. Conclusions: These types of findings are infrequent, documented in the literature with a global incidence of Tubo-ovarian inguinal hernias ranging from 0-8-4.4%, however it is worth clarifying that these studies are in infant patients, so its presentation in adults associated with a hemorrhagic follicle is anecdotal as in this case.

EP.FRI.398 Diverticular Disease Patient Presenting with Acute Abdominal Pain, Guidelines and Management

Aim Diverticular disease of the sigmoid colon is a common condition in Western society, 10-25% will develop an acute episode of diverticulitis, Since Hinchey’s traditional classification for perforated diverticulitis in 1978, several modifications and new grading systems have been presented to display a more contemporary overview of the disease Methods 100 patients diagnosed with acute diverticulitis admitted to the surgical unit in NMUH starting from 1/1/2019 (the first 100 patients were chosen - they attended over a period of 6 months) Data were checked for all patients from the patients' notes and electronic hospital systems for as compared to the: “Acute Diverticulitis Management Algorithm”, provided on the NMUH intranet since April 2015. Results 10% of patients Had pain and tenderness in an abdominal quadrant other than left iliac fossa. Standard investigations including WCC, CRP & erect chest radiograph were done to all patients. 84% of patients were diagnosed with CT scan while the rest were diagnosed clinically. 96% of patients had colonoscopy appointments while 4% had CT colonography appointments. There was no mention of Hinchey grade, despite cases were managed according to this classification. Conclusions There was a good degree of commitment to the management algorithm in some parts, like blood tests and antibiotic prescription, however other parts were not adhered to like the Hinchey's classification documentation for each case. There is a need for more clinical and management related classification system of acute diverticulitis, some classifications were proposed.

EP.FRI.792 Laparoscopic port positioning in paediatric appendicectomy - a closed loop audit

Aims Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children, typically with a suprapubic (SP) left-hand port position. This has been associated with bladder injury. Pre-operative bladder emptying can reduce the risk of this complication. The aim of this study was to evaluate compliance with local policy mandating left iliac fossa port placement (LIFPP) rather than SP. We assessed the rate of LIFPP before and after an educational intervention, and also audited if voiding status was included as part of the paediatric WHO checklist. Methods Retrospective data was collected before and after implementation of education, for 50 consecutive patients aged <16 years undergoing laparoscopic appendicectomy. The education programme targeted operating department practitioners, paediatric nurses and surgeons, and included seminars and regular dissemination of the local protocol. Data analysis was performed using GraphPad Prism. Results Patients were evenly distributed by gender with 94% above the age of 10. Mean age was 13.8 years. There was a statistically significant improvement in compliance with LIFPP, from 72% to 100% (p < 0.0001) after introduction of improved education, as well as significantly improved documentation of pre-operative voiding status from 12% to 40% (p = 0.0026). The rate of catheterisation intra-operatively was reduced from 20% to 8% (p = 0.1478). Conclusions Improved education has led to a significantly increased compliance with local port placement policy. Documentation of pre-operative voiding status has been included in the paediatric WHO checklist ‘SIGN IN’ section locally.

OVARIAN ECTOPIC PREGNANCY- A RARE CASE REPORT

Background:Ovarian pregnancy is classified as a rare cause of non tubal pregnancy wherein maximum ends in rupture in early months of pregnancy. Sign and symptoms often mimic tubal rupture. To distinguish between the two based on presenting complaints and ultrasonography findings is difficult. Generally confirmation of ovarian preganancy is done only after histopathological examination due to its similarity in presenting complaints to tubal pregnancy. Medical management has also been tried for unruptured ectopic pregnancy. Case:Presenting a rare case report of ruptured left ovarian pregnancy. pt was 26yrs old multiparous with previous two cesarean 7yrs and 4 yrs back with one MTP kit taken 6 months back with pain in left iliac fossa. USG findings were suggestive of tubal rupture, however during laparotomy ruptured left ovarian pregnancy was diagnosed followed by left oopherectomy later on confirmed by histopathological examination.

Bilateral tubal incarceration into the broad ligaments caused by pelvic endometriosis: A case report

Introduction: Endometriosis is characterised by the presence of functional endometrial tissue outside the uterus. Salpinges are a common location of endometriotic implants. Endometriosis located into the broad ligament is a rare event. Case description: A 38-year-old infertile woman presented to our attention with moderate left iliac fossa pain after menses and intermenstrual bleeding. Transvaginal ultrasounds and pelvic magnetic resonance evidenced the presence of bilateral haematosalpinges. At the laparoscopic pelvic exploration, fallopian tubes were absent. Opening and dissecting the apical portion of the broad ligaments, we identified bilateral haematosalpinges incarcerated in the homolateral broad ligaments. We performed bilateral salpingectomy. Histological examination confirmed the presence of endometriosis. Conclusion: Care must be taken to the diagnostic assessment, counselling about the surgical programme before the intervention especially in patients during the reproductive period when the possibility of ablative surgery and subsequent need for an assisted reproductive technique exists.

Experience with placing peritoneal dialysis catheters in the iliac fossa in cases of frozen pelvis

Peritoneal dialysis (PD) is a modality frequently preferred by patients for the management of their end-stage kidney disease; however, a major factor in its success is PD catheter placement and subsequent function. Optimal placement of PD catheters is generally accepted to be in the true pelvis, for this reason, many patients who are found to have a pelvic cavity obliterated by adhesions are often denied the opportunity to do PD. We report on four cases of an alternative advanced laparoscopic technique used in patients with inaccessible pelvic cavities, with three catheter placements in the intraperitoneal left iliac fossa/paracolic gutter and one case in the right paracolic gutter with subsequent good outcomes. This report suggests that a ‘frozen pelvis’ is not a contraindication to successful PD, with alternative catheter tip placement in the iliac fossa.

Pancreas-kidney transplantation: what every radiologist should know

Pancreas transplantation is a well-established treatment for patients with complicated diabetes mellitus and advanced renal failure. The most common procedure is simultaneous pancreas-kidney transplantation, in which the pancreas graft is positioned in the right pelvic region and the kidney graft is positioned in the left iliac fossa. Various imaging methods are used for the post-transplantation evaluation of the graft parenchyma and vascular anatomy, as well as for the identification of possible complications. As the number of cases increases, it is fundamental that radiologists understand the surgical procedure and the postoperative anatomy, as well as to recognize the possible postoperative complications and their imaging aspects, with the aim of providing the best guidance in the postoperative management of transplant recipients.

APENDICITIS AGUDA IZQUIERDA; UNA PRESENTACIÓN POCO HABITUAL DE UNA PATOLOGÍA MUY COMÚN EN LA POBLACIÓN ECUATORIANA. REVISIÓN BIBLIOGRÁFICA Y REPORTE DE UN CASO.

Introduction Acute appendicitis is one of the most common urgent surgical pathologies in the Ecuadorian population, and the atypical presentation of the appendix on the left side is presented as a diagnostic challenge, since it is observed more frequently in congenital anomalies such as malrotation of the midgut, a rare disorder with an incidence of one in 10,000 individuals. Case description We present the clinical case of an 8-year-old girl with no significant pathological history, admitted to the Pediatrics service with a 48-hour history of abdominal pain located in the left hemiabdomen, accompanied by nausea, vomiting, abdominal distention and thermal rise; tender abdomen on palpation in the flank and left iliac fossa, positive Mussy's sign. The patient presented with leukocytosis and neutrophilia; imaging examinations revealed thickening of the mesenteric fat at the level of the left iliac fossa and air-fluid levels at an elevation of the colonic framework. She underwent surgery and the findings were an appendicular plastron made up of a perforated appendix in the distal third and undamaged appendicular base, omentum and distal third of the descending colon; her postsurgical evolution was favorable. Conclusion Acute appendicitis can present with atypical symptoms due to unusual locations of the appendix, one of the unusual presentations can present in malrotation. Most cases are asymptomatic until the development of acute complications and require imaging for diagnosis, becoming a challenge when defining the appropriate and timely treatment.

Differential diagnosis of a calcified cyst found in an 18th century female burial site at St. Nicholas Church cemetery (Libkovice, Czechia)

During archaeological excavations in burial sites, sometimes stoned organic objects are found, in addition to human remains. Those objects might be of a different origin, depending on various factors influencing members of a community (i.e. diseases, trauma), which provides information about their living conditions. The St. Nicholas Church archaeological site (Libkovice, Czechia) in the 18th century horizon of the cemetery, yielded a maturus-senilis female skeleton with a stone object in the left iliac fossa. This object was an oviform cyst-like rough structure, measuring 54 mm in length, 35 mm in maximum diameter and 0.2–0.7 mm shell thickness. Within the object there were small fetal bones (long bones, i.e. femur and two tibias, two scapulas, three ribs, vertebrae and other tiny bone fragments). Methods utilized to analyze the outer and inner surface morphology of the cyst and its inside, included: X-ray, CT imaging, SEM, histological staining and EDS. The EDS analysis revealed the presence of primarily oxygen, calcium and phosphorus in bone samples, and oxygen and silicon, in stone shell. Based on the length of the femur (20.2 mm) and tibia (16 mm) shafts, the fetal age was determined as being in the 15–18 week of pregnancy. The differential diagnosis was conducted, including for the three most probable cases: fetiform teratoma (FT), fetus-in-fetu (FIF) and lithopedion. The possibility of fetiform teratoma was discounted due to the presence of an anatomically correct spine, long bones and the proportions of the find. Although the low calcium content in the shell (2.3% atom mass), the lack of skull bones and the better developed lower limbs indicate fetus-in-fetu rather than lithopedion, the analyses results are unable to conclusively identify the object under one of these two categories since there are insufficient such cases in excavation material with which to draw comparison.

Large retroperitoneal hematoma following vaginal delivery: a case report

Background Retroperitoneal hematoma after vaginal delivery is rare but can lead to maternal morbidity and mortality. Diagnosis of this condition is challenging due to its complexity and its nonspecific signs and symptoms. To date, studies and case reports regarding retroperitoneal hematoma are few, particularly in low-income countries where risk factors for this condition may be more prevalent and the prognosis poorer. Case presentation We report the case of a 37-year-old multiparous african (Congolese) woman who presented to the emergency department of a large referral hospital in Bukavu, Democratic Republic of the Congo (DRC), 2 weeks after a spontaneous nontraumatic vaginal delivery. She had abdominal pain that began immediately after delivery and progressed throughout the postpartum period. The patient had anemia, hypotension, tachycardia, and a left costo-lumbar arch distorting the body shape on a soft and depressed abdomen. She had visited a private clinic on days 3 and 7 postpartum; however, signs and symptoms of retroperitoneal hematoma went unrecognized. Using abdominal ultrasound, we diagnosed an extensive hematoma in the retroperitoneal space from the left iliac fossa to the left flank. Laparotomy was performed to evacuate the hematoma, and the patient recovered. Conclusion Retroperitoneal hematoma following a nontraumatic vaginal delivery is an unusual situation in general obstetrical practice. The knowledge of this potentially life-threatening condition in resource-limited settings enables effective diagnosis and management by ultrasound and laparotomy.