Search

Objective: Adenomyoma, a reactive and hamartomatous lesion of the gallbladder, is included in the differential diagnosis of several benign and malignant lesions. Macroscopic sampling is very important in the determination of these lesions. The agreed macroscopy protocol in recent years has been prepared by the Hepatopancreatobiliary Pathology Working Group. We aimed to evaluate the clinicopathologic properties of adenomyoma cases in the gallbladder and the contribution of new macroscopy techniques to the diagnosis of adenomyoma in the pre-protocol and post-protocol parts of a one-year period. Material and Method: Two institutes were included in the study. Adenomyoma cases diagnosed in the pre-protocol and post-protocol periods of one year duration were included in the study. Slides and demographic properties of the cases were reexamined. Results: While adenomyoma was present in 22 of 1879 gallbladder before the protocol, it was observed in 32 of 1781 gallbladders in the post-protocol period. 17 of the cases were male and 37 were female. The mean age of the cases was 51.8. 52% of the lesions were located in the fundus. A gallstone was observed in 37 cases, and cholesterolosis in 14 cases. In the comparison of the two periods, the number of cases was lower in the post-protocol period but a 0.6% increase in the diagnosis of adenomyoma was found. Conclusion: Adenomyoma is one of the lesions of the gallbladder that should be recognized but can be easily overlooked macroscopically. When we conducted the sampling according to the last protocol, the increase in the diagnosis of adenomyoma showed that adequate and accurate sampling was very useful for the detection of adenomyoma in the gallbladder.

Aim: To evaluate the prevalance of fundus changes in pregnancy induced hypertension and to assess the correlation between fundus changes and severity of pregnancy induced hypertension, age and parity of the patients. Materials and Methods: 100 patients admitted with pregnancy induced hypertension were included. Pre-existing diabetes mellitus, hypertension, renal disease, anaemia, connective tissue disorders, and high myopia, len and corneal opacities were excluded. Age and gravida were noted. Vision was recorded and anterior segment examined. Dilated fundus was examined. Blood pressure, proteinuria, serum uric acid and blood urea levels were noted. Hypertensive retinopathy were graded by using the Keith Wagner Barker classification. Observation: Most of PIH cases (66%) were found in the age group of 21–25 years with mean age=24.32 2.835 years. 70% of the cases were seen in primigravidas and 30% were multigravida. 75% patients of mild preeclampsia, 20% patients of severe preeclampsia and 5% of eclampsia. 38% patients had normal fundus findings and the rest 62% patients had hypertensive retinopathy, 32% had grade 1 hypertensive retinopathy, 21% had grade 2, 5% had grade 3 and 4% of the cases had grade 4 hypertensive retinopathy. Fisher’s exact test was done. Study showed positive correlation between fundus findings and severity of PIH (P value 0.000). There was no correlation of fundus findings with age or parity of the patient. Conclusion: Fundus examination plays an important role in all patients with PIH. Keywords: Fundus changes, Pregnancy induced hypertension, Preeclampsia, Eclampsia, Grades of hypertensive retinopathy.

Purpose To report a case of pattern dystrophy in a patient with McArdle disease, a rare autosomal recessive disorder of glycogen metabolism. Methods Case report. Results A 29-year-old woman with a history of muscle biopsy-confirmed McArdle disease presented with fundus findings consistent with pattern dystrophy. Multimodal imaging, including optical coherence tomography and fundus autofluorescence, was performed. Conclusion To our knowledge, this is the third reported case of pattern dystrophy in a patient with McArdle disease.

Endometrial stromal sarcomas are rare malignant tumours of the uterus. Most details about this tumour is obtained from previous case reports. In most of the cases, diagnosis is made only postoperatively. A 29 year old female, came with complaints of heavy menstrual bleeding, lower abdominal pain, mass in lower abdomen for 2 months. Clinical examination and investigations showed bulky irregularly enlarged uterus probably Fibroid Uterus. Patient was planned for Myomectomy. Intraoperatively, uterus was irregularly enlarged with cauliflower like growth of size 7 x 5 cm over fundus suggestive of Carcinoma. Total abdominal hysterectomy with bilateral salphingo oophorectomy with bilateral pelvic lymphnode dissection with infracolic omentectomy was done. Histopatholgy examination revealed as Low Grade Endometrial Stromal Sarcoma with Negative Lymph Node Spread. Postoperatively, Patient was evaluated for ER sensitivity and started on Tab. Anastrazole. Keywords: Uterine sarcoma, Endometrial stromal sarcoma, Malignant uterine tumour.

During the last decades, in vitro fertilization (IVF) became one of the most demanded reproductive technologies used for infertility treatment. Despite the significant efforts, the percentage of successful procedures remains moderate (

Background: High myopia (defined as myopia of -6D or more) is one of the main causes of visual impairment worldwide. High myopia is always accompanied by pathological structural changes such as axial elongation, posterior staphyloma, lacquer crack formation, thinning of the retina and choroid, and choroidal neovascularization. Aims and Objectives: The purpose of this study was to examine the fundus changes in eyes with high myopia. Materials and Methods: All study participants underwent dilated fundus examination and fundus photography. Myopia-related macular (posterior staphyloma, lacquer cracks, Fuchs spot, myopic chorioretinal atrophy, and myopic choroidal neovascularization)and optic disc (optic nerve head tilt,optic disc dimensions, and peripapillary atrophy) changes were evaluated. Results: Statistical analysis was performed to evaluate fundus changes in eyes with high myopia. Data analysis included 107 eyes of 57 patients.Mean ± SE was 12.07 ± 3.184D in eyes with high myopia. Mean ± AL was 26.68± 1.577mm in eyes with high myopia. The mean age was 28.54 ± 9.44 years(14-50 years). Fundus changes were: Temporal crescent in 56 (52.33%) eyes, tessellated fundus appearance in 52(48.59%) eyes, lacquer cracks in 40 (37.38%) eyes, tilted disc in 30 (28%) eyes, lattice degeneration in 20(18.69%) eyes, posterior staphyloma in 20(18.69%) eyes, focal chorioretinal atrophy in 3 (2.8%) eyes. CNV in 2 (1.86%)eyes and retinal hole in 1(1%) eye. Conclusions: Tessellated fundus and temporal crescent were the most common fundus findings among Kashmiri population with high myopia. In this population, lacquer cracks and tilted disc were also common, while CNV and retinal holes were rare.

Introduction The fundus of the uterus is a rare location for abnormally invasive placenta compared with the common site of abnormally invasive placenta in the lower segment of the uterus. Presentation of case We report a case of a 38-year-old multipara woman who had a fundal partial placenta percreta with no prior cesarean sections, which presented as a retained placenta after preterm labor, and complicated with hemorrhagic shock due to postpartum hemoperitoneum, thus it was diagnosed after surgery and managed by subtotal hysterectomy. Discussion We discuss the most common risk factors for abnormally invasive placenta and its diagnosis and management. We compare the possibility of leading to invasive placenta resulting from curettage trauma and cesarean delivery scars. Conclusion History of uterine surgical procedures without prior cesarean delivery must raise suspicion of abnormally invasive placenta regardless of its localization, especially when associates with preterm labor or retained placenta., Highlights • Placenta percreta may complicated with hemorrhagic shock due to postpartum hemoperitoneum. • Manual removal of the retained placenta percreta may cause the rupture of its vessels leading to hemoperitoneum. • Abnormally invasive placenta should be considered as a cause of preterm labor or retained placenta despite its localization. • The best management of abnormally invasive placenta remains unclear.

Introduction: The most feared complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Staple height and fundus-wall thickness might influence such leakage, and this study examined their possible impact on leak incidence. Factors including gender, age, comorbidities, and reinforcement of the staple line were also investigated.Methods: A total of 500 patients between 17 and 71 years of age who were scheduled for LSG were selected to participate in the study. For technical reasons, 53 were excluded. The fundus-wall thickness of 447 patients after LSG was investigated. The impact of staple height, fundus-wall thickness, demographic and medical factors on leak incidence were investigated. Most of our patients (309) were female (69%), while 138 were male (31%).Results: The mean thickness of the proximal fundus wall was 2,904 μm, 3,172 μm in men and 2,784 μm in women. The leak rate was 4.9%. Age, fundus-wall thickness, and BMI showed a strong influence on leak risk, but this effect was significant only for age (p = 0.01). Patient gender and staple size showed no significant influence on the correlation between fundus-wall thickness and leak risk. Gender displayed a small effect of influence on this correlation, with η2 = 0.05.Discussion: Because older age had a significant effect on increasing the risk of staple-line leakage, there is a need for a more specific focus on these patients. Thinner fundus wall and female gender might predispose patients to staple-line leaks, but a significant value could not be reached. Therefore, staple size should remain the surgeon's choice based on clinical experience.

Gynecological pathology like ovarian cysts or serosal myomas are known to undergo torsion. Images of a case with hysteroscopic evidence of torsion of pedicle of a type 0 submucous myoma inside the uterine cavity is presented. We have discussed three possible reasons for this phenomenon to happen inside a confined space of uterine cavity. First presence of a long, soft pliable pedicle arising from fundus, second the ratio of the length (L) of pedicle to its width (W) greater than one and third a larger uterine cavity in parous women allowing the space for torsion.

Background The accessory spleen has no anatomical or vascular relationship with the normal spleen, The tissue structure and physiological function of the accessory spleen are the same as those of the normal spleen, which usually locate in the splenic hilum and the tail of the pancreas. The aims of this manuscript are to present a rare case of the gastric accessory spleen and a review of the literature. Case presentation A 19-year-old male patient was sent to the emergency department with stomach bleeding after drinking alcohol. The computed tomographic scan showed a 1.2 cm × 1.7 cm mass at the lesser curvature of the gastric fundus. Gastrointestinal endoscopy displayed a submucosal elevated lesion on the gastric fundus, and gastrectomy was performed. Postoperative pathological examination proved an accessory spleen in the stomach. The postoperative course was uneventful, and the patient was discharged on the 6th day after the surgery. Conclusions The accessory spleen at the fundus of stomach is extremely rare, especially in this case, which is accompanied by acute gastric bleeding, and it is difficult to diagnosis before operation. Many literatures reported that it was misdiagnosis as tumor, so it is necessary to diagnose accessory spleen correctly.

INTRODUCTION: Uterine inversion is the collapse of uterine fundus into the endometrial cavity resulting in turning the uterus partially or completely inside out. Uterine inversion during cesarean section is an extremely rare obstetric complication and the exact incidence is not known. CASE DESCRIPTION: We report complete inversion of uterus in 38-year-old female, Gravida 2 Para 1+0, 38+0 weeks gestational age, admitted for elective lower segment cesarean section due to previous 1 scar. Delivery of the baby was uneventful. Complete inversion of uterus through uterine incision was noticed immediately after detachment of placenta. Oxytocin infusion was discontinued immediately, and uterine inversion was reversed manually by exteriorizing uterus and then making a fist and applying force on the fundus. Uterus was closed back in two layers, but it remained relaxed despite, massaging, oxytocin and sublingual misoprostol; therefore, modified B-lynch sutures were applied. This helped the patient to be prevented from any further complications. She was discharged as planned and was stable on follow up visits. CONCLUSION: Uterine inversion was promptly identified and corrected without any major complications.

The aim of this paper is to describe the distinctive ultrasound findings of a case of vaginal bleeding caused by the presence of a foreign body. We present the case of an infant who consulted for vaginal bleeding and foul-smelling discharge. The ultrasound revealed signs of vaginal distension due to heterogeneous-hematic contents and parietal thickening. At Doppler examination, a striking finding of increased vascularization limited to the upper two-thirds of the vaginal wall was found, which was initially interpreted as a sign of local inflammation suggesting the presence of an underlying foreign body. At direct vaginoscopic examination remains of toilet paper in the vaginal fundus were found. The presence of a foreign body in the vagina is an uncommon cause of discharge and vaginal bleeding in pediatrics, therefore, this etiology should be kept in mind when the adequate clinical context arises. Doppler ultrasound represents a first-line complementary method when this entity is suspected.

Acute puerperal uterine inversion is a rare, potentially life-threatening complication of pregnancy. A dilated cervix with a relaxed uterus and simultaneous downward traction on the fundus are the possible factors leading to inversion of the uterus. The best way to manage the neurogenic component would be to reposition the uterus. The first-line procedure which is commonly used for manual replacement of uterus is referred to as Johnson's manoeuvre. Use of tocolytics in a situation where postpartum haemorrhage is a common accompaniment is fraught with danger. There are a few techniques which have been used during surgery to reduce the inverted uterus: Huntingdon's operation, Haultain's operation and hysterectomy. It is recommended to use an uterotonic drug in the initial phase of management after repositioning. Oxytocin infusion, misoprostol per rectum or prostaglandins can be used for this purpose.

Purpose: This report describes the diagnosis of ocular toxocariasis presenting as endophthalmitis in an adult intravenous drug user. Methods: A case is reported. Results: Fundus imaging showed numerous white opacities obscuring the macula. Toxocara canis serology was reactive with an enzyme immunoassay titer of 1:2 (positive ≥ 1:32). Findings from bacterial and fungal cultures were negative, and vitrectomy cytology revealed no organisms. Postoperatively, serial optical coherence tomography imaging demonstrated a slight decrease in size of an intraretinal hyperreflective lesion in the macula. Conclusions: Owing to a variety of presentations, ocular toxocariasis can be challenging to diagnose. In a patient with a history of intravenous drug use where fungal and bacterial organisms are more common causes of endophthalmitis, it is important to have a wide differential of causative organisms, particularly in the context of negative culture results and a worsening clinical examination.

Posterior gastric vessel is commonly encountered (4-99%) during surgery of the stomach, spleen, and pancreas. Due to high variations in its origin, and course, it has not been unanimously described in literature. Its significance in bariatric surgery is largely neglected. We reviewed videos of 100 bariatric surgery cases done in our institute. This vessel was noted in 88 cases. We could identify the vessel in 54/63 LSG cases and all cases required division to free the fundus. It was identified in 34/37 RYGB cases. Thirty-one cases required lateralization while 3 cases required division due to more medial origin of the vessel. Its division or lateralization facilitates adequate mobilization of fundus to achieve the ideal configuration of sleeve in LSG and pouch in LRYGB.

Febre de origem indeterminada é definida como temperatura corporal maior ou igual a 38,3 °C com duração mínima de três semanas sem um diagnóstico estabelecido, apesar de investigação apropriada. A febre de origem indeterminada permanece um dos mais desafiadores diagnósticos em medicina. A epidemiologia é ampla e dependente da etiologia, idade, geografia, exposição ambiental e status imune. As doenças infecciosas são as causas mais prevalentes em países em desenvolvimento, enquanto que em países desenvolvidos, as causas mais prováveis são devido às doenças inflamatórias não infecciosas. Descreve-se o caso clínico de uma paciente de 31 anos de idade, com quadro febril inexplicado instalado após uma semana da realização de cesárea de emergência. Nos exames laboratoriais apresentava leucocitose com desvio à esquerda, com hemocultura e urocultura negativas. Ao ultrassom pélvico transvaginal: Útero aumentado de volume com fundo ao nível da cicatriz umbilical. Cavidade endometrial com pequena quantidade de líquido e coágulos, sem conteúdo expansivo no interior, endométrio fino e ausência de coleções. A paciente foi submetida à extensa avaliação clínica e cirúrgica em busca do esclarecimento da origem do quadro febril, porém este permaneceu inexplicado.

A 3-month-old girl presented with developmental delay and clustered asymmetric epileptic spasms (video). She was first-born to nonconsanguineous healthy parents with a smooth perinatal transition. Examination revealed normal head size, central hypotonia, and characteristic fundus findings (figure 1, A and B). EEG revealed hypsarrhythmia (figure 1C). Peculiar fundus and neuroimaging findings (figure 2) confirmed the diagnosis of Aicardi syndrome (AS). Epileptic spasms failed to respond to adrenocorticotropin and vigabatrin. This report emphasizes the utility of skillful neuroophthalmologic assessment in children with epileptic spasms.

Laparoendoscopic hiatal hernia repair (LEHHR) involves laparoscopic repair of hiatal hernia with concomitant transoral incisionless fundoplication (TIF). The objective of this case presentation is to highlight the benefits of LEHHR in a patient with long term follow up. This patient is a 56-year-old woman with symptoms of gastroesophageal reflux disease for 40 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm hiatal hernia. DeMeester score was 21.3. She underwent LEHHR 33 months ago. The patient underwent laparoscopic cholecystectomy for symptomatic biliary dyskinesia. This provided the opportunity to examine the operative anatomy. There were minimal adhesions to the liver. The partial fundoplication was intact. The angle of His was preserved. The fundus was spared from any adhesions as TIF utilizes the cardia rather than the fundus to create the wrap. The plane behind the stomach was undisturbed. LEHHR has 10 main benefits. Anatomical benefits result from the preservation of the angle of His. Functional benefits relate to a partial fundoplication which normalizes pH values. LEHHR avoids bleeding from short gastric vessels and the creation of a wrap when anatomical obstacles present. Strategic benefits are directed toward any subsequent revisional reflux surgery. The lack of adhesions, easy access to the base of left crus, and sparing the fundus render revisional surgery straightforward.

Purpose: To study the ocular morbidities associated with retinal vein occlusion. Materials and Methods: Ours was a cross-sectional observational study, carried out on 100 patients of Retinal Vein Occlusion in a tertiary care centre of Western Maharashtra. After written and informed consent, detailed history was taken, vision assessed, detailed slit lamp evaluation and dilated fundus examination was done. Fundus camera was used to obtain fundus photographs. Macular edema was confirmed using OCT. Diagnosed cases of RVOs were then looked for complications like Macular Edema, Vitreous Haemorrhage, Disc Neovascularisation, Iris/Neovascularisation. Result: Vitreous haemorrhage was the most common complication noted (18%), followed by macular edema (10%), iris neovascularisation (3%) and disc neovascularisation (3%). Macular edema was the most common complication in BRVO, vitreous haemorrhage in CRVO. The incidence of ocular complications was higher in patients with CRVO compared to patients with BRVO and HRVO. Conclusion: Various complications associated with RVO can lead to permanent blindness. Hence early detection of these can help reduce the burden of blindness in society. Keywords: Macular edema, Neovascularisation, Retinal vein occlusion, Vitreous haemorrhage.

Background: Idiopathic Intracranial Hypertension (IIH) is seen typically in obese women in their child-bearing age, management of patients with IIH can be problematic. Aim of Study: The purpose of this study is to assess single spinal tapping using wide pore Tuohy needle as a modality for treatment of IIH. Objective: The purpose of this study is to assess single Tuohy needle spinal tapping as a modality for treatment of IIH. Patients and Methods: This was a prospective case series of twenty women with IIH who underwent full neurological and ophthalmological evaluation including fluoruscopic fundus examination and neuroimaging studies. They were followed-up and treated using only single Tuohy needle spinal tapping. Results: Single spinal tapping can control IIH safely with a success rate of 100%. Conclusion: Single spinal tapping using Tuohy needle is recommended as a treatment modality in women with IIH.

Summary Objective Giant Malignant gastrointestinal stromal tumor (MGIST) is a very rare disease in China, the morbidity no more than 3%, around 1/100000/year cases have been reported in the world. It has the characteristic of transfer, easy to recur and high rate of resistance. We present a case of MGIST with Two step treatment. Methods A 54 years old male self-discovery has a mass which was located in the upper abdominal. He has abdominal distension after the meal, without vomit, nausea, eructation, acid regurgitation. A computed tomography (CT) and a gastroscope have been performed two days after admission. CT showed a abdominal mass was located in the left side of the abdominal, the size was 23 × 14cm, the boundary between the fundus of stomach was unclear. Gastroscope showed a huge bulge in the fundus of stomach, occupy the fundus of stomach and the upper body of stomach which revealed a diagnosis of MGIST. In this case, we performed interventional therapy, chemotherapy, surgical treatment and prevent recurrence treatment. Results During each months of the following, the size of the malignant gastrointestinal stromal tumor has been reduced. After 6 months of the targeted therapy, we performed the surgical treatment, and the patient has been discharged after 10 days of the surgery. After 3 months and half years of the surgery, there do not have any uncomfortable and having chemotherapy after surgery. Conclusion Two step treatment can been the maximum benefit for the patient which have the MGIST.

We report a case of vitreopapillary traction mimicking optic disc swelling in a 73-year-old female with pseudophakia in the left eye and satisfactory postoperative vision of 6/6 and N5 two years prior. She presented with insidious onset of blurred vision in her left eye for two months. She was referred to Universiti Kebangsaan Malaysia Medical Centre (UKMMC) for further investigations of apparent optic disc swelling in the left eye by a general ophthalmologist. Her left eye vision was 6/18, pinhole 6/12, with near vision at N6. There was no relative afferent pupillary defect and anterior segment examination was normal. Examination of the posterior segment revealed a pink optic disc with blurred and elevated margins without hyperaemia. Vessels of the optic nerve head appeared normal and a lamellar macular hole was present with dull foveal reflex clinically. Right eye examination was normal. Optical coherence tomography (OCT) of the left eye using the raster line scan showed vitreopapillary traction surrounding the optic disc and vitreomacular traction (VMT) with lamellar macular hole. The patient was counselled for surgical release of VMT, however, she opted for conservative management. Peripapillary vitreoretinal traction is a rare cause of pseudo-optic disc swelling. Thorough fundus examination with the help of OCT is crucial in making a prompt diagnosis, preventing unnecessary investigations, and evaluating other retinal pathologies which may benefit from treatment.

PURPOSE To describe optical coherence tomography angiography findings at baseline and during the follow-up of choroidal neovascularization secondary to choroidal rupture (CR) in a patient with kidney transplant treated by a single intravitreal injection of ranibizumab. METHODS The clinical course, conventional multimodal imaging findings including ultra-widefield fundus color photography and fundus autofluorescence (Optos California, Marlborough, MA), spectral-domain optical coherence tomography (SD-OCT Spectralis; Heidelberg Engineering, Heidelberg, Germany), fluorescein angiography (FA; Heidelberg Engineering, Heidelberg, Germany), indocyanine green angiography ,and optical coherence tomography angiography (Plex-Elite, Carl Zeiss Meditec, Inc, Dublin, CA) findings at baseline and during the follow-up of a patient with choroidal neovascularization secondary to CR. RESULTS A 19-year-old young man with a history of blunt trauma presented with acute visual decline of the right eye. He had a systemic history of kidney transplant. His best-corrected visual acuity was 20/200 in the right eye and 20/20 in the left eye at baseline. Funduscopic examination and ultra-widefield fundus autofluorescence imaging revealed a double vertical macular lesion corresponding to a CR in the right eye. Spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography revealed active Type 2 choroidal neovascularization secondary to the CR. Optical coherence tomography angiography showed a high-flow neovascular network consistent with conventional multimodal imaging. One month after intravitreal injection of ranibizumab, bestcorrected visual acuity was 20/100, optical coherence tomography angiography showed a contraction and remodeling of the neovascular flow, and exudative signs disappeared on multimodal imaging. No side effect was detected. CONCLUSION Optical coherence tomography angiography is able to detect choroidal neovascularization secondary to CR at baseline and during the follow-up after a single intravitreal injection of ranibizumab. Ranibizumab was effective in the treatment of this sight-threatening lesion in a patient with a history of kidney transplant.

It is estimated that 50% of puerperal mortality occur within the first 24 hours. At thistime the involution process occured. Involutionary disorders cause complications whichis the leading cause of maternal mortality. Most of postpartum women do not obtainexercise guidance after giving birth. They are only advised to do simple mobilizationwithout planned guidance. The purpose of this study was to determine the effectivenessof early exercise against uterine involution (fundus and lochea). The research methodused Quasi Experimental (pre-post test non equivalent control group design). It wasconducted from May to August 2017. The samples were 40 respondents spontaneousprimiparous postpartum mother. The study was started by 1) divided the samples intocontrol group and treatment group, 2) measured the fundus and lochea, 3) providedearly exercise on treatment group, 4) re-measured fundus and lochea in both groups, 5)analyzed the effectiveness of early exercise to fundus and lochea expenditure decrease.The data analysis used Mann Whitney with α = 0.05. The results showed p value is 0.000(fundus) and p value are 0.001 (lochea). It means that early exercise is effective againstuterine involution (fundus and lochea). The results can provide positive contribution inpreventing maternal mortality caused by puerperal complications.

BACKGROUND To evaluate fundus examinations in terms of traumatic retinal tears or dialysis that may be related to canalicular lacerations (CLs). MATERIALS AND METHODS This retrospective study was conducted on patients with CL repair from June 1, 2009 to May 30, 2018. The authors collected the data from the patients' medical records, including their demographic details, mechanism and setting of injury, associated ocular injuries, type of stent used, setting of repairs, duration of follow-up, complications, pre- or intraoperative findings of biomicroscopic and fundus examinations, refractive errors, postoperative follow-up of fundus examination, and management. RESULTS Sixty patients (43 males and 17 females) were included in the study. The mean age of all the patients was 27.50 ± 21.72 (min: 1-max: 94) years. Isolated CL was found in 38 patients. Nonisolated CL, which means with some additional pathologies, were found in 22 patients (37%, approximately 1/3). Retinal follow-up records were available in 49 patients with a mean follow-up period of 7.48 ± 9.82 months. Retinal tears were seen in 3 patients (0.05%) with no predisposing risk factors. Two of these tears were found in the follow-up period after the traumas. CONCLUSION Consequent retinal tears after canalicular lacerations were not strongly addressed in previous works. In this study, the authors aimed to view CL from a different perspective. Canalicular laceration is also an ocular trauma that may threaten vision. The authors emphasized that performing detailed fundus examinations and follow-up in all canalicular traumas is necessary.

The surgical treatment of intracranial aneurysms is a routine operation in the neurosurgeon practice. Complex aneurysms are those with morphological irregularities, usually large or giant; thrombosed, partially thrombosed or calcified; with aberrant fundus/neck ratio and near eloquent neurological structures. These cases demand special skills by the surgical team. The present article is a report of two cases of complex aneurysms successfully treated, with a discussion on the role of neurophysiological monitoring. In these two cases of supra- and infratentorial complex giant aneurysms, intraoperative monitoring was extremely relevant. Thus, we believe that treating complex and giant aneurysms carries several pitfalls, and the use of multimodal intraoperative monitoring is mandatory to mitigate risks and deliver the best result to the patient.

BACKGROUND AND OBJECTIVE: To analyze the examination practices and referral of patients with diabetic retinopathy (DR) by optometrists in routine clinical care. PATIENTS AND METHODS: Diabetic patient records from 2012 to 2018 were retrospectively reviewed for documentation of dilated fundus exam (DFE), imaging, follow-up appointments, and referrals. Concordance between clinical exam and coding was also analyzed. RESULTS: For 97.8% of encounters, DFE was performed, the patient was referred for DFE, or DFE was scheduled for follow-up. When DFE was performed at the initial visit, this resulted in referral of 19.8% of patients to an ophthalmologist. Imaging was obtained occasionally, with fundus photos in 2.6% and optical coherence tomography in 14.5% of encounters. Concordance of DR grading between exam and coding was 78.8%. Recommended follow-up times were incorrect based on DR severity level in 13.8% of encounters. CONCLUSION: Although DFE was performed reliably by optometrists, utilization of imaging, DR grading and coding, and appropriate follow-up periods could be improved. [ Ophthalmic Surg Lasers Imaging Retina. 2019;50:608–612.]

Low-positioned placentas which are located in the lower uterine segment (LUS), either a low-lying placenta or a placenta previa, are associated with increased obstetric risks. However, most second trimester low-positioned placentas resolve during pregnancy and have a higher position in the third trimester, without posing any risks. We performed a systematic review and meta-analysis to evaluate the proportion of second trimester low-positioned placentas that have a position towards the fundus in the third trimester. Our aim was to find a cut-off value that included all women in whom the placenta will remain low in the third trimester, thus who are at increased risk of obstetric complications. Subsequently, we assessed whether an anterior or posterior placental location influenced this proportion. We searched MEDLINE and EMBASE and clinicaltrials.gov up to April 2019 for studies on the sonographic follow-up of second trimester low-positioned placentas, with a distance between the placenta and the internal os of the cervix of 20 mm or less at a gestational age of above 15 week and a follow up after 28 weeks. Studies were scored on methodological quality using the Newcastle-Ottowa Scale (NOS). A meta-analysis was conducted to summarize the proportion of second trimester low-positioned placentas with a position towards the fundus in the third trimester. We calculated the proportion at different cut-off values of the distance from the placental edge to the internal os of the cervix (0 mm, 10 mm and 20 mm). Also, anteriorly and posteriorly located placentas and women with and without a prior cesarean delivery were compared. We included 11 eligible studies which reported on 3586 women with a low-positioned placenta in the second trimester. Proportions of placentas with a position towards the fundus in the third trimester ranged between 0.63 and 1.0. Pooled proportions were 0.90 (95% CI 0.87-0.93) for IOD

The case concerns a 20 year-old woman with a sudden visual loss in her left eye. In the fundus examination, a focal pre-retinal haemorrhage was observed in the superior temporal vascular branch with accompanying vitreous haemorrhage. There was a favorable spontaneous outcome. Eighteen months later, she presented with a new visual loss in the same eye, showing a sub-hyaloid pre-macular haemorrhage that was satisfactorily drained by hyaloidotomy using a Nd-YAG laser. The patient had also presented with an upper digestive tract haemorrhage and menorrhagia. A haemostasis study was performed that showed a coagulation factor VII deficiency. This is a very uncommon disorder that has not been previously described in association with the appearance of pre-retinal haemorrhages.

PURPOSE: To describe the foveal characteristics of children with a history of retinopathy of prematurity (ROP) using optical coherence tomography angiography (OCTA). METHODS: All eyes were examined by OCTA (RTVue AVANTI, Optovue Inc, Fremont, CA) with a scan of 3 × 3 mm cantered on the fovea. The size of the foveal avascular zone (FAZ), central retinal thickness (CRT), and foveal bulge were measured. RESULTS: Forty-eight eyes of 26 children with a history of ROP and a mean age of 8.8 years with a range of 4–16 years (ROP group) were studied. Sixty-six eyes of 36 children without any fundus abnormalities and with an average age of 10.5 years and a range of 3–17 years (control group) were studied as controls. The mean FAZ area in the ROP group was 0.18 mm(2) which was significantly smaller than the 0.32 mm(2) in the control group (p

Актуальність. В експериментальній медицині білі щури є найбільш переважними лабораторними тваринами при моделюванні різних патологічних станів, правомірність екстраполювання результатів на людину повинна бути попередньо обґрунтована ступенем міжвидової морфофункціональної тотожності досліджуваних органів. Мета дослідження. Вивчення і систематизація особливостей гістологічної будови шлунку білих щурів. Методи дослідження. Дослідження здійснено на 30 білих щурах-самцях репродуктивного віку, масою 200,0 ± 20,0 грам. Матеріалом слугували, фіксовані в 10% розчині нейтрального формаліну, препарати шлунка білих щурів. Дослідження здійснено за допомогою традиційних гістологічних методів отримання серійних парафінових зрізів, товщиною 4 мкм, які фарбували гематоксиліном та еозином. Вивчення отриманих препаратів здійснено за допомогою світлового мікроскопа «Коnus», оснащеного цифровою мікрофотонасадкою Sigeta DCM-900 9.0MP з адаптованою для даних досліджень програмою Вiorex 3 (серійний номер 5604). Результати. Виняткова особливість слизової оболонки фундального відділу шлунка білих щурів полягає в тому, що вона покрита товстим багатошаровим плоским, частково зроговілим епітелієм, який властивий поверхням, що зазнають механічного впливу. За гістологічною структурою слизової оболонки шлунка білих щурів передшлунок (фундальний або беззалозистий відділ) відноситься до видової особливості даних лабораторних тварин. Слизова оболонка гастрального (залозистого) відділу, будучи здебільшого гомологічною до людини, відрізняється від неї надзвичайно щільною концентрацією трубчастих залоз, в стінках яких знаходяться всі необхідні екзокриноцити, що забезпечують процеси ферментативного травлення в умовах кислого середовища. Висновки. Фундальний відділ шлунку білих щурів призначений виконувати роль своєрідного змішувача харчової маси і просування її в залозистий відділ шлунку. За гістологічною структурою слизової оболонки шлунку білих щурів тільки пілоричний і гастральний (залозистий) відділи є цілком гомологічними шлунку людини, що необхідно враховувати при плануванні експериментальних досліджень., Background. In experimental medicine, albino rats are the most preferable laboratory animals in simulating various pathological conditions, the validity of which extrapolation of the results to humans should be previously justified by the degree of interspecific morphofunctional identity of the organs studied. Objective. Study and systematization of the features of the histological structure of the albino rats stomach. Methods. 30 mature albino male rats weighted 200,0±20,0 g were involved into the study. The specimens of albino rats stomach, fixed in 10% neutral buffered formalin solution, have been studied. The study was carried out using conventional histological methods for obtaining serial paraffin sections of 4 µm thick, stained with hematoxylin-eosin. The obtained specimens were studied on the “Konus” light microscope equipped with Sigeta DCM-900 9.0MP digital microphoto attachment with the Biorex 3 (serial number 5604) software adapted for these studies. Results. An exceptional feature of the mucous membrane of the fundus of the albino rats’ stomach is that it is coated with a relatively thick, stratified squamous partlially keratinized epithelium, which is characteristic to surfaces exposed to mechanical action. Histological structure of the mucous membrane of the albino rats’ stomach assigns the fundus (fundal or nonglandular part) to the specific feature of the above laboratory animals. The mucous membrane of the gastric (glandular) part, being basically homologous to a human one, differs from it by the extremely dense concentration of tubular glands, in the walls of which all necessary exocrinocytes are located, providing enzymatic digestion processes in acidic medium. Conclusion. The fundus of the stomach of albino rats is intended to act as a peculiar mixer of the bolus and to move it into the glandular part of the stomach. Histological structure of the mucous membrane of the albino rats’ stomach shows that only the pyloric and gastric (glandular) parts are totally homologous to the human stomach, which should be taken into account when planning experimental studies., Актуальность. В экспериментальной медицине белые крысы являются самыми предпочтительными лабораторными животными при моделировании различных патологических состояний, правомерность экстраполирования результатов которых на человека должна быть предварительно обоснована степенью межвидовой морфофункциональной тождественности изучаемых органов. Цель. Изучение и систематизация особенностей гистологического строения желудка белых крыс. Методы. Исследование осуществлено на 30 белых крысах-самцах репродуктивного возраста, массой 200,0±20,0 грамм. Материалом служили, фиксированные в 10% растворе нейтрального формалина, препараты желудка белых крыс. Исследование осуществлено с помощью традиционных гистологических методов получения серийных парафиновых срезов, толщиной 4 мкм, которые окрашивали гематоксилином и эозином. Изучение полученных препаратов осуществлено с помощью светового микроскопа «Коnus», оснащенного цифровой микрофотонасадкой Sigeta DCM-900 9.0MP с адаптированной для данных исследований программой Вiorex 3 (серийный номер 5604). Результаты. Исключительная особенность слизистой оболочки фундального отдела желудка белых крыс заключается в том, что она покрыта относительно толстым многослойным плоским, частично ороговевающим эпителием, который присущ поверхностям испытывающим механическое воздействие. По гистологическому строению слизистой оболочки желудка белых крыс преджелудок (фундальный или безжелезистый отдел) относится к видовой особенности данных лабораторных животных. Слизистая оболочка гастрального (железистого) отдела, являясь в основном гомологичной таковой человека, отличается от нее чрезвычайно плотной концентрацией трубчатых желез, в стенках которых находятся все необходимые экзокриноциты, обеспечивающие процессы ферментативного пищеварения в условиях кислой среды. Выводы. Фундальный отдел желудка белых крыс предназначен выполнять роль своеобразного смесителя пищевой массы и продвижения ее в железистый отдел желудка. По гистологическому строению слизистой оболочки желудка белых крыс только пилорический и гастральный (железистый) отделы являются вполне гомологичными желудку человека, что необходимо учитывать при планировании экспериментальных исследований.

Objective of the Study: This study designed to identify the rate of prevalence of fundus changes in pregnancy induced hypertension population and also to analyze the correlation with blood pressure and proteinuria parameters. Materials and Methods: Patients those are attending to ophthalmology department with the diagnosed pregnancy induced hypertension were admitted in current study. Demographics, blood pressure, gravida, gestational period, and proteinuria other details were recorded. Previous history related any eye symptoms were recorded. Patients after admission in to the ward, fundus examination carried out by dilating the pupil with direct ophthalmoscope. Results: A total of 70 patients were examined. Mean age of the patient was 24.12 years (15-40). Changes in the retina were noted in 37 patients (53.29%). Grade I in 33 patients (47.14%) and Grade II in 4 patients (6.15%). There was no haemorrhages, no hard exudates, and no retinal detachments recorded in any of admitted subjects. Conclusion: According to grade I & II hypertensive related retinopathy, the retinal changes were measured in total of 53.29% in total pregnancy induced hypertension population. Hence, fundus examination in these cases assisted to assess the severity of pregnancy induced hypertension. Keywords: Proteinuria, Pregnancy induced hypertension, Retinal changes.

Significance Pregnancy-induced hypertension is a unique yet common complication in pregnant women and may cause retinopathy. Optical coherence tomography (OCT) may help find the features of retinopathy that are difficult to observe through fundus examination. Not all patients can fully recover from retinopathy. Purpose This report describes a case of pregnancy-induced hypertension with retinopathy and represents the features of retinopathy in OCT and fundus fluorescein angiography. Case report A 29-year-old pregnant woman presented with bilateral blurred vision and xanthopsia 2 days before her induced labor; she was also diagnosed as pre-eclamptic in the obstetrics department. The vision in her right eye was 20/33, and that in her left eye was 20/20. Fundus fluorescein angiography showed scattered-dot hypofluorescence around the disc at an early stage, and needle-like hyperfluorescence gradually appeared near the disc with late-stage fluorescein leakage in both eyes. Optical coherence tomography revealed multiple shallow retinal detachments with hyperreflective bright spots in the outer retina and clumped hyperreflective materials on the retinal pigment epithelium (RPE). Conclusions Typical findings and some tiny changes in the outer retina and RPE can be observed through spectral-domain OCT. The clumped hyperreflective deposits in the outer retina may be by-products of RPE swelling and necrosis that lead to barrier dysfunctions and fluid leakage. These described features may help diagnose retinopathy from pregnancy-induced hypertension. Although it is a self-limited disease, the disruptions in the ellipsoid and interdigitation zones may not fully recover and result in reduced visual dysfunction. Therefore, control of hypertension is indicated.

Postpartum haemorrhage (PPH) is a potentially life-threatening condition. Women undergoing caesarean section (CS) are at particular risk, and improvements in the management of PPH during CS are required. We investigated the use of a tissue hardness metre to quantify uterine contractions during CS with a view to its application for obstetric bleeding management. Fifty pregnant women at term who underwent elective CS were recruited. Using a tissue hardness metre, we measured uterine hardness twice during CS: after placental removal and before peritoneum closure. Each measurement was conducted at two standardised points: fundus and corpus uteri. Concurrently, obstetricians subjectively graded uterine contractions as weak, medium, or strong. The hardness metre accurately quantified the degree of uterine contraction assessed by the obstetricians, and could be an effective clinical tool for early recognition of intra-operative massive bleeding. IMPACT STATEMENT What is already known on this subject? Maintaining adequate uterine contraction leads to prevention of excessive blood loss, which decreases the incidence and severity of PPH. However, the assessment of uterine contraction is currently judged by obstetricians, who manually and subjectively evaluate uterine contraction according to uterine hardness. Therefore, uterine atony remains a clinical diagnosis without a universal definition. What do the results of this study add? The present study investigated the use of a tissue hardness metre to quantify uterine contractions during CS with a view to its application for obstetric bleeding management. The hardness metre was able to quantify the degree of uterine contraction perceived by obstetricians. Quantifying uterine hardness during CS correlates with the amount of intra-operative bleeding and is useful for early recognition of massive haemorrhage. What are the implications of these findings for clinical practice and/or further research? To improve the management of atonic PPH and avoid serious complications, the tissue hardness metre should be considered as a potential clinical tool during CS.

This study included 125 patients with acute cholecystitis of them 29 were males. All were subjected to fundus-first (FF) laparoscopic cholecystectomy. The mean operative time was 63±8 minutes (range 37-95 minutes). There were 4 cases of prolonged post-operative bile leakage, 3 of them stopped spontaneously within one week, and last one needed an endoscopic biliary stent. Gall bladder perforation with peritoneal contamination occurred in 6 patients. Laparoscopic trans-choledochal CBD exploration was indicated in 3 patients due to residual stone in intra-operative cholangiography. Conversion to open cholecystectomy was acquired in 4 patients the mean hospital stay was 1.6 days (range 6 hours to5 days) except those with post-operative bile leakage that stayed from 8-14 days. Key words: acute cholecystitis, laparoscopic cholecystectomy

In order to help veterinarians in application of surgical procedures in cat and detection of gall bladder disease so that, we gathered twenty-one domestic cats and concluded that three main forms were collected; single gall bladder, duplex fundus and bilobed gall bladder. Both the gall bladder forms and the hepatic ducts distribution were not related. The bile duct was constructed from the left and right hepatic ducts in addition to the cystic one. In some cases, we explored that a short common hepatic duct. Sonographically, the gall bladder ap- peared differ in conformance, encir- cled by echogenic wall and adjacent to the right medial lobe laterally and the quadrate lobe medially.

The goal of this study was to report the first case of antral stenosis in a cat. We have described a clinical case of a 9 months old domestic shorthaired cat referred for persistent and refractory vomiting, anorexia and loss of weight. Ultrasound (US) examination detected a mild gastric distension, mild wall thickening (5mm), severe serosal irregularities and a constriction between the fundus and body. Computed tomography (CT) was then performed: a severe gastric stenosis between the body and antrum with minimum contrast transit was detected and confirmed by flexible endoscopic examination. The antral localization of the stenosis was revealed after a cranial celiotomy and Y-U plastic was necessary to correct the defect. The patient completely recovered after surgery with significant body weight gain and remained in remission throughout a 2-years follow-up. While in human medicine there is evidence of acquired antral stenosis, no information is available about the same lesion in the feline species. To the best of our knowledge, this is the first case of antral stenosis in cats.

A cotyledonoid dissecting leiomyoma (CDL) is a rare variant of a uterine smooth muscle cell tumor and is characterized by intramural and extrauterine growth patterns with dissection of the uterine myometrium.We encountered a case of a CDL with multiple lung nodules. Computed tomographic and magnetic resonance imaging results revealed the presence of a multilobulated abdominal mass with cystic components contiguous to the uterine corpus and well-demarcated nodules measuring ≤2 cm in diameter in the bilateral lungs. Simple hysterectomy and bilateral salpingo-oophorectomy were performed.Macroscopically, a placenta-like tumor protruded from the medial fundus of the uterine corpus toward the intraluminal and peritoneal cavities. Histologically, the tumor was composed of neoplastic spindle cells with hyalinized degeneration and vascular proliferation. Endometrial glands with stroma and vascular invasion were also noted.This is the first report of a CDL with possible metastasis. Histological features, including intravascular growth, may predict the aggressive behavior of this tumor. Keywords: Adenomyosis, Leiomyoma, Smooth muscle tumor

Purpose: To report a case of bilateral contractile peripapillary staphyloma (CPS) examined by optical coherence tomography (OCT) and video recording. Observation: We report the clinical history of a male infant with bilateral CPS. Two ophthalmic examinations under general anesthesia were performed during follow-up examinations. During the first fundus examination when the infant was 4 months old, we observed staphylomatous excavation around the optic disc, an almost normal disc appearance at the bottom of the excavation, and irregular contraction bilaterally. OCT images showed deep excavation around the optic disc bilaterally and hyperreflective tissue beneath the sclera in the right eye. During the second examination when the child was 4 years and 1 month, in addition to the previous fundus findings, the fundus examination showed white fibrous tissue on the optic disc and pigmentation around the optic disc in the right eye and a retinal cyst in the left eye. Bilateral simultaneous video recordings showed that the contractions were not synchronized between the eyes. Conclusions: In a patient with bilateral CPS, we observed unsynchronized contraction between the eyes and the presence of sequential hyperreflective tissue under the sclera using bilateral ophthalmic approaches. Keywords: Contractile peripapillary staphyloma, Swept-source optical coherence tomography, Video recording

There is limited published data currently available on scleral cysts in the posterior pole. Here, we detail the case of a patient who was suspected to have a peripapillary scleral cyst imprinting the optic nerve head (ONH) profile. The 52-year-old asymptomatic and otherwise healthy woman presented with unilateral ONH blurred margins of the left eye for 1 year. Her best-corrected visual acuity in the right and left eye was 20/20 and 20/25, respectively. Fundus observation of the right eye revealed no significant abnormalities; on the left eye a tilted disc with blurred margins in the superior quadrants and gliosis-associated changes in the lower quadrants were identified. Structural optical coherence tomography (OCT) showed a posterior hyporeflective cystic space at the level of the ONH, and OCT-angiography revealed flow void. The differential diagnosis of ONH edema was considered and the case discussed with the neuro-ophthalmology unit. Given the clinical history, the absence of symptoms and the multimodal imaging findings, a peripapillary scleral cyst was considered to be the most likely explanation for the edematous appearance and the anomalous tilted configuration of the ONH. This case suggests that although rare, even more so in the absence of an ONH coloboma, a postequatorial scleral cyst should be considered in the differential diagnosis of ONH lesions.

We report an uncommon case of bilateral impending central retinal vein occlusion (CRVO) in a young girl with newly diagnosed chronic myeloid leukaemia (CML) and its successful reversal with leukapheresis. A young girl presented with vomiting and fever. Examination revealed hepatosplenomegaly and multiple enlarged lymph nodes. Investigations show severe hyperleukocytosis and anaemia. Bone marrow aspirate and trephine biopsy confirmed CML in the chronic phase. She was promptly referred to the ophthalmology team for assessment of vasculopathy. Bilateral fundus showed swollen and hyperaemic optic discs. There were dilated and tortuous retinal venules with perivascular white cell extravasation, scattered intraretinal haemorrhages, and Roth spots at mid-periphery. She received four cycles of leukapheresis and, consequently, her leukocytes reduced dramatically with associated significant improvement in fundus findings. This case highlights uncommon impending CRVO in a young girl and the dramatic improvement in fundus signs following leukapheresis that halted and reversed the progression of impending CRVO.

OBJECTIVES Prolapse procedures with uterine preservation offer an alternative to colpopexy with hysterectomy. Few studies have examined the differences in anatomic or subjective outcomes following sacral hysteropexy versus sacral colpopexy with hysterectomy. This study sought to compare the ability of sacral hysteropexy and sacral colpopexy with hysterectomy to resist downward traction as an estimate of apical support in human cadavers. METHODS Sacral hysteropexy was performed on unembalmed female cadavers. A metal bolt/washer was threaded through the uterine fundus, down the cervical canal. and out the vagina and fastened to a waxed surgical filament, which ran over a fixed pulley at the table's end. Successive weights were added to provide increasing loads on the uterine fundus, and the distances traversed by the fundus were recorded. The same process was repeated after completion of a total hysterectomy (with vaginal cuff closure) and subsequent sacral colpopexy in the same specimen. Data were analyzed using paired-sample t test and repeated-measures analysis of variance (Sigma Plot version 13.0), with P ≤ 0.05 considered statistically significant. RESULTS Eight female cadavers were utilized. With the addition of each weight, the average distance traversed by the uterine fundus or vaginal cuff gradually increased. There were no statistical differences in the distances moved by the apex between sacral hysteropexy and total hysterectomy/sacral colpopexy. CONCLUSIONS These results suggest that functional support provided by sacral hysteropexy and sacral colpopexy with hysterectomy may be similar. Further studies are needed to correlate these findings with patient satisfaction, which may vary despite similar anatomic results.

Highlights • The number of cases which can undergo thoracoscopic repair for congenital diaphragmatic hernia is limited. • Reducing the herniated viscera in thoracoscopic repair of CDH can be dangerous due to their vulnerability of neonatal organs. • This twisting technique allows for gentle reduction of diaphragmatic hernias with a hernia sac, without a risk of injury., Reducing the herniated viscera such as the spleen, the liver, and the bowel in thoracoscopic repair of congenital diaphragmatic hernia can be challenging. The small instruments involved can easily create damage, particularly to the friable capsule of the solid organs involved. We herein demonstrate a new gentle method of reducing the diaphragmatic hernia using sequential twisting of the sac. The patient was a 3 day old girl with left sided Bochdalek diaphragmatic hernia. Chest X-ray showed intestinal herniation into the thoracic cavity, and we planned to perform elective Minimal-invasive surgery. Once in the chest, the fundus of the hernia sac is grasped with a blunt endosurgical grasper. The grasper is then turned, twisting the sac around the shaft of the instrument and thereby reducing the hernia content. Once maximal reduction with one hand is achieved, the twisted tissue is grasped with the contralateral instrument and the maneuver repeated until the entire hernia content is reduced. Subsequently, the sac is removed circumferentially using the monopolar electrocautery hook. The diaphragm is then closed with interupted figure-eight sutures of 2-0 silk. The operative time was 65 min, and there were no intraoperative complications. She was discharged home on postoperative day 5. Half a year later, she was asymptomatic without any signs of recurrence. In conclusion, the twisting technique allows for gentle, gradual reduction of diaphragmatic hernias with a sac without injury to the herniated viscera.