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Purpose: To report an adult case of cervical lung herniation involving the azygous lobe and to review the literature., Methods: A trauma patient was incidentally found to have a cervical lung herniation involving the azygous lobe. We reviewed the literature on cervical lung herniation, described techniques used to diagnose and evaluate cervical lung herniations and summarized management options., Results: Cervical lung herniation results in a defect in Sibson's fascia allowing the apical lung to protrude above the thoracic inlet. In the adult population, these are commonly seen after trauma or surgical intervention, but congenital forms have also been described in the pediatric population. Apical herniation of the lung can cause symptoms due to mass effect on the esophagus or trachea. We report an adult case of cervical lung herniation involving the azygous lobe., Conclusion: Cervical lung herniation is a relatively rare entity compared to lung herniation through the rib cage. Knowledge of this entity is essential to properly evaluate trauma patients and to diagnose patients who have symptoms of cough, dysphagia or a bulging neck mass., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Competing Interests: The authors report no conflicts of interest.

Purpose: The primary goal of this study was to determine the incidence of occult paraumbilical hernias during open primary umbilical hernia repair. The secondary objective was to further characterize the clinical features of these patients and hernias.Methods: This was a retrospective chart review of patients undergoing primary umbilical hernia repair at Shouldice Hospital, from 2007 to 2017. Inclusion criteria were utilized to elucidate patients, where a concomitant occult paraumbilical hernia was found. Descriptive statistics were used throughout.Results: 5850 patients underwent primary umbilical hernia repair, 459 (7.85%) patients had concomitant primary umbilical and paraumbilical hernias. There was a preoperative suspicion/diagnosis of a paraumbilical hernia in 166 (2.8%) of these patients. In 293 (5.01%) patients who had open primary umbilical hernia repair, at least one associated occult paraumbilical defect was found during surgery. Most of umbilical and concomitant occult paraumbilical hernias were small and medium size defects. The great majority of the reported occult paraumbilical hernias were found in the supraumbilical position at a distance of 3 cm or less from the top of the umbilical defect.Conclusion: The incidence of concomitant occult paraumbilical hernias in patients mildly overweight undergoing primary umbilical hernia repair is 5.01%, relevant to surgical decision-making. Since the great majority of these paraumbilical defects are superior to the umbilical defect, an adequate incision and dissection for at least 3 cm above the umbilical hernia may reduce the number of missed concomitant hernias and result in less presumed recurrences. [ABSTRACT FROM AUTHOR]

Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely.

A 9 yr old female spayed domestic shorthair was presented with a 12-day history of stranguria. Six years previously, the cat had a bilateral perineal herniorrhaphy with cystopexy and pubic osteotomy. At presentation, survey radiographs and a positive-contrast vaginourethrocystogram were performed, which revealed cystolithiasis and recurrent bilateral perineal hernias with bladder retroflexion. A cystopexy was repeated, followed by bilateral perineal repairs using the internal obturator muscle flap transposition. To the authors' knowledge, this is the first reported case of a perineal hernia with recurrent bladder retroflexion after cystopexy diagnosed with positive-contrast vaginourethrocystogram in a female cat., (© 2023 by American Animal Hospital Association.)

Ureterosciaic hernia is a rarely described pathology that represents a diagnostic and therapeutic challenge for the treating physician. In this case report, we present a patient with symptomatic bilateral ureteroschial hernias and a pelvic kidney on the left. The definitive surgical treatment of the hernias was performed in the robotic-assisted laparoscopic technique.This is the second case describing bilateral intestinal sciatic hernia, in combination with its diagnosis and robotic surgical repair.In this paper we present the fourth known case of a robotic approach to the surgical treatment of ureterosciaic hernia with detailed presentation of diagnostic and therapeutic measures, as well as postoperative results and literature research on this rare pathology., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Study Design: Retrospective multicenter study., Objectives: Although surgery is frequently selected for the treatment of idiopathic spinal cord herniation (ISCH), its impact on functional outcomes has yet to be fully understood given the limited number of patients in previous studies. This study aims to evaluate the symptomatic history and surgical outcomes of ISCH., Setting: Three institutions in Japan., Methods: A total of 34 subjects with ISCH were retrospectively enrolled and followed up for at least 2 years. Demographic information, imaging findings, and clinical outcomes were collected. Functional status was assessed using the JOA score., Results: The types of neurologic deficit were monoparesis, Brown-Sequard, and paraparesis in 5, 17, and 12 cases, with their mean disease duration being 1.2, 4.2, and 5.8 years, respectively. Significant differences in disease duration were observed between the monoparesis and Brown-Sequard groups (p < 0.01) and between the monoparesis and paraparesis groups (p = 0.04). Surgery promoted significantly better recovery rates from baseline. Correlations were observed between age at surgery and recovery rate (p < 0.01) and between disease duration and recovery rate (p = 0.04). The mean recovery rates were 82.6%, 51.6%, and 29.1% in the monoparesis, Brown-Sequard, and paraparesis groups, respectively. The monoparesis group had a significantly higher recovery rate than did the Brown-Sequard (p = 0.045) and paraparesis groups (p < 0.01)., Conclusions: Longer disease duration was correlated with the progression of neurologic deficit. Older age, and worse preoperative neurologic status hindered postoperative functional recovery. These results highlight the need to consider surgical timing before neurologic symptoms deteriorate., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objectives: Although rare in etiology, anterior bony wall defects of the external auditory canal (EAC) accompanied by temporomandibular joint herniation may cause various otologic symptoms. Surgical treatment can be considered based on symptom severity because many previous case reports have highlighted its efficacy. This study aimed to review the long-term results of surgical treatment of EAC anterior wall defect and to suggest a stepwise approach when creating a treatment plan., Methods: We performed a retrospective review of 10 patients who underwent surgical management to address the EAC anterior wall defect and its associated symptoms. Medical records, temporal bone computed tomography scans, audiometry, and endoscopic examination findings were analyzed., Results: The primary repair of the EAC defect was the first to be surgically addressed in most cases, excluding one case with a severe combined infection. Of the 10 cases, 3 patients exhibited either postoperative complications or symptom recurrence. Six patients had resolved symptoms consequent to primary surgical repair, and four patients underwent revision surgery undergoing a more invasive procedure, such as canalplasty or mastoidectomy., Conclusion: Primary repair of the anterior wall defect of the EAC seems to be overpromoted for lasting results but is not as promising as previously noted. We therefore propose to create a novel treatment flowchart regarding the surgical treatment of anterior wall defects of the EAC based on clinical experience., Level of Evidence: IV., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc.)

A paraduodenal hernia is a rare type of hernia, however it is the most common type of internal hernias. It can develop after surgery, trauma, or be congenital. Paraduodenal hernias are rare in children. Clinical presentation is nonspecific. Patients range from being asymptomatic to presenting with clinical symptoms associated with small bowel obstructions. Diagnostic tools such as X-ray, plain abdominal radiography, and computed tomography may be used to diagnose paraduodenal hernias. Described is the case of a 5-year-old female who died suddenly of a bowel obstruction due to a paraduodenal hernia found at postmortem examination. In the hours prior to death, she reported stomach pain, vomiting, and later developed a fever. Postmortem CT study showed free fluid in the abdomen and bowel distention. Internal examination showed an obstructed bowel with ischemic sections extending from the distal portions of the small bowel up to the proximal portions of the transverse colon. The ischemic portions were entrapped within a clear membranous sac within the abdominal cavity. The sac was concluded to be a paraduodenal hernia. Paraduodenal hernias are rare and difficult to diagnose but they must be considered in the diagnostic process, as without surgical intervention the mortality rate can be high.

Background: Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature., Purpose: To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury., Study Design: Narrative and literature review; Level of evidence, 4., Methods: A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms., Results: The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks., Conclusion: Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.

Background: Acute epiploic appendagitis is a rare differential diagnosis of unclear or acute abdomen., Aim: To describe - by means of a scientific case report - the extraordinary diagnosis of acute epiploic appendagitis along with contained diverticulitis and incarcerated herniation of the greater omentum into the hernial sac of a former trocar site (medical history, significant for laparoscopic ovarian cyst removal) in a 29-year-old female based on experiences obtained in the successful clinical case management, and on selective references from medical scientific literature., Case Summary: Medical history: A 29-year-old female was admitted with abdominal pain in the lower left quadrant. She reported a laparoscopic ovarian cyst removal 3 years prior. Physical examination of the abdomen revealed tenderness in the lower left quadrant without a palpable mass.Leading diagnoses were found using transabdominal ultrasound and confirmed by an abdominal CT scan; namely, incarcerated trocar hernia, diverticulitis of sigmoid colon, and acute epiploic appendagitis. Therapeutic approach was comprised of an explorative laparoscopy (because of the incarcerated hernia), adhesiolysis, removal of a tip of the greater omentum out of the hernial sac, closure of the hernial orifice, and removal of an unclear, inflamed, and bloody fatty tissue from the wall of the descending colon ( histopathological investigation confirmed acute epiploic appendagitis). This was flanked by conservative treatment of diverticulitis of the sigmoid colon.Further clinical course was uneventful, with discharge on the 3 rd postoperative day with favorable long-term outcome, characterized by no further complaints for 15 months., Discussion: Acute epiploic appendagitis is an inflammatory, usually self-limiting condition of the epiploic appendages of the colon. It typically manifests with abdominal pain in the lower left quadrant. Imaging is an important diagnostic tool to determine whether the patient has, in fact, acute epiploic appendagitis, so recognizing the characteristic oval lesions with the surrounding inflammation and central fat attenuation on CT, as well as the hyperechoic oval lesions with a hypoechoic peripheral band on ultrasound images is crucial. Nevertheless, it is often overlooked in patients and confused with other differential diagnoses, such as appendicitis or diverticulitis. Although the condition appears infrequently, it is essential to be proficient in the diagnostic evaluation, as a misdiagnosis may lead to unnecessary treatment and even surgical intervention., In Conclusion: , the patient was initially diagnosed with an incarcerated abdominal hernia, and therefore subsequently underwent surgery. The inflamed epiploic appendage was discovered in laparoscopic exploration, removed, and confirmed through the histopathology report. This is an approach to be performed with great caution so as not to 1. : misinterpret an inflamed diverticula or covered perforation of it as well as not 2. : overlooking a peritoneal tumor lesion., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Spinal anaesthesia (SA) is one of the most prevalent types of anaesthetic procedures. There are very few reports of cord herniation through the site of spinal canal stenosis due to tumour. A 33-year-old female presented with acute paraparesis after spinal anaesthesia for caesarean section. Magnetic resonance imaging (MRI) revealed an intradural mass from posterior of T6 to T8-T9 interface. We operated the patient and after laminectomy of T6 to T9, dermoid tumour containing hairs was totally resected and cord was completely decompressed. After 6 months, the patient is without any neurological deficit. Puncturing the dura with cerebrospinal fluid (CSF) in the presence of an extramedullary mass could cause cord herniation through the blockade. In these cases, awareness about related signs even in absence of symptoms or complaints could help us to prevent post-SA neurological deficit.

Abstract: Herniation of the temporomandibular joint (TMJ) into the external auditory canal (EAC) is rare. The TMJ and EAC are separated by the anterior bony wall of the EAC. Such a defect can be caused by trauma, infection, neoplasm, inflammation, and in rare cases, congenital bony defects. If asymptomatic or mildly symptomatic, supplemental treatment is primarily given, but if the symptoms are severe enough that the patient regularly feels discomfort, surgical procedure is considered. To our knowledge there are no reports about surgery-related complications and recurrence during the postoperative follow-up period for TMJ herniation in English literature. Here, the authors report the first case of implant protrusion after TMJ herniation surgery along with a literature review., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

This report describes two cases of spontaneous small intestinal evisceration via normally inserted umbilical stumps, without abdominal wall trauma. Both cases occurred immediately following uneventful parturition. The authors believe that these represent cases of umbilical cord herniation. This is a well-recognised condition in humans, but has not been previously described in equines. One foal died before veterinary intervention. The second foal underwent a jejunal resection with end-to-end anastomosis and survived to successfully race. This report describes a previously unrecognised condition and highlights the importance of rapid and appropriate intervention on farm., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin., Case Report: The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum., Conclusion: These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices., (Copyright © 2022 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely. [ABSTRACT FROM AUTHOR]

Background: Internal herniation through the foramen of Winslow is a rare cause of bowel obstruction. The presented case illustrates this condition and considerations made regarding treatment., Case Presentation: An elderly woman was admitted to the hospital with sudden onset of epigastric pain and vomiting. Blood tests were normal except for a lactate value of 2.5 mmol/L (normal value < 1.8). Computer tomography showed internal herniation of the caecum through the foramen of Winslow. Initial treatment with intravenous fluids, a nasogastric tube and fasting did not resolve the bowel obstruction. The herniated caecum was laparoscopically reduced, and there were no signs of intestinal ischaemia., Interpretation: Internal herniation through the foramen of Winslow is rare. There are no evidence-based guidelines on treatment, or on prophylactic measures to prevent recurrence. Both laparoscopic and open surgical approaches have been reported, with or without closure of the foramen. There is little documentation on recurrence rates.

Case Description: An 8-year-old 6.8-kg neutered male Dachshund was presented for evaluation of vomiting, diarrhea, anorexia, and swelling over the right perineal region. The dog had a history of a bilateral perineal herniorrhaphy and castration 14 months prior to presentation., Clinical Findings: Bilateral perineal hernias were confirmed by digital rectal examination. Abdominal ultrasonography confirmed the presence of intestine within the right hernia. Three days after admission to the hospital, the region of the right perineal hernia became painful, erythematous, and edematous. Computed tomography revealed jejunal incarceration within the right hernia with dilation of 1 jejunal segment that indicated intestinal obstruction., Treatment and Outcome: Abdominal exploratory surgery was performed, during which irreducible small intestinal incarceration was confirmed. Intra-abdominal jejunal resection and anastomosis was performed, and an approximately 13-cm-long section of the jejunum was resected. Bilateral perineal herniorrhaphies with internal obturator and superficial gluteal muscle transposition were performed. Six months after surgery, digital rectal examination of the dog revealed that the repair was intact. The dog had no perineal hernia-related clinical signs at the time of the recheck examination., Clinical Relevance: For the dog of the present report, surgical management of small intestinal strangulation associated with a perineal hernia was successful. Although a portion of the small intestines can frequently be found within perineal hernias in dogs, perineal hernia-related small intestinal strangulation has not been previously described, to the authors' knowledge. Veterinarians and clients should be aware of this potential complication secondary to perineal hernia and be prepared to perform an abdominal surgical procedure to address small intestinal incarceration in affected dogs.

Several complications may occur following iliac bone grafting, one of the common sites for autologous bone harvesting. Of these, it is difficult to localize the damage in neurological complications due to the presence of several nerves in a similar distribution area with variations among individuals. To minimize these complications, conventional clinical anatomical studies using normal human cadavers have estimated the theoretical neurological damage area corresponding to the surgical intervention area. We report a case of neuromuscular damage in a 93-year-old woman who had an iliac crest defect after a bone graft, based on the virtual and physical dissections with histological confirmations.In this study, the patient was confirmed to have severe neuromuscular complications with major complications including a hernia protruding through the iliac defect. One of the two ilioinguinal nerves was extracted with the hernia sac through the iliac defect, and its distal part was completely damaged. The iliohypogastric nerve, which was far from the defect foramen, also showed remarkable fibrosis and demyelination, affected by the degeneration of the transversus abdominis muscles.The present anatomical findings show that the area of eventual neuromuscular damage should be estimated to larger than the conventionally predicted area of direct nerve damage, which is usually concomitant with the surgical intervention area.

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches., Competing Interests: Declaration of competing Interest The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Author WBL holds several patents related to rib fixation and receives royalties from DePuy Synthes Inc. The remaining authors report no conflict of interest., (Published by Elsevier Inc.)

A 71-year-old woman was brought in by ambulance to the emergency department with sudden-onset difficulty in breathing whilst shopping at a large UK retail shopping centre. She had no respiratory history and portable chest X-ray revealed a huge gastrothorax, secondary pneumothorax and mediastinal shift. Clinical deterioration with haemodynamic instability required urgent decompression. Successful needle decompression followed by tube thoracostomy improved patient condition with no further complications. Surgical repair was performed but was delayed by COVID-19. This case provides a rare presentation of an acute life-threatening tension gastrothorax with difficult management considerations. A review of the management options is undertaken., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We sought to assess hernia characteristics and classification through comprehensive review of the literature involving broad ligament herniation., Methods: A literature search via MEDLINE and Embase databases was conducted to identify and select broad ligament herniation studies published between January 1, 2000 and September 30, 2020. Extracted data included previous surgical history, previous obstetric history, diagnostic imaging, herniated organ, hernia classification, and repair performed. The reported data has been compared to a unique case of broad ligament herniation that presented to our institution., Results: A total of 44 articles with 49 cases were identified for the study. Eighteen (36.7%) patients had a history of previous abdominal surgery while 29 (59.2%) had a history of previous childbirth. Type I (51.0%) and Type II (18.4%) defects were most commonly reported with most patients reporting only one defect (85.7%) using the Cilley classification. Twenty-nine patients underwent primary laparoscopic repair of the defect while 19 patients underwent exploratory laparotomy., Conclusions: The analysis of previously reported cases adds to the limited literature on broad ligament hernias and highlights the surgical management of this uncommon pathology. It also highlights the need for a broad differential diagnosis when female patients present with pelvic pain or symptoms of small bowel obstruction. The broad ligament should be fully inspected when mesenteric defects are suspected as multiple defects can be present as evidenced by the attached case study., Competing Interests: Conflict of interests: none., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Objective: To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication and discuss opportunities for prevention. Women with muscle invasive bladder cancer undergo RC with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for POP., Methods: We present 4 cases of high-grade POP in women who underwent RC for bladder cancer. We reviewed the literature by conducting a Boolean search in PubMed with the terms "("radical cystectomy") AND ("enterocele" OR "pelvic organ prolapse" OR "rectocele" OR "vaginal vault prolapse").", Results: All 4 women reported a bulge sensation in the vagina and physical exam confirmed POP. Three had radiographic findings consistent with high-grade enterocele at rest. Three experienced prolonged intra-abdominal pressure rise post-RC that may have further weakened pelvic floor support, while the fourth had a history of surgery for high-grade POP. Nine articles on POP following RC were identified. Four focused on treatment and 3 focused on prevention., Conclusion: Administration of a single validated question would have identified all 4 cases of postoperative enterocele and is sensitive to detect most women who are experiencing POP. Attention to the pelvic floor on cross-sectional imaging with identification of features that indicate POP, such as herniation of intestinal contents below the pubo-coccygeal line, will identify and/or confirm high-grade enterocele. Familiarity with risk factors for POP and identification of weakened vaginal wall support opens up the opportunity for prevention., (Copyright © 2020. Published by Elsevier Inc.)

Introduction: Cardiac herniation is a rare complication after pulmonary surgery, and there are only a few reports about it. We now report a case of cardiac herniation presenting as superior vena cava obstruction after pneumonectomy., Case Presentation: A-52-years old woman diagnosed right pulmonary squamous cell carcinoma was carried out right pneumonectomy, the pulmonary artery and right superior pulmonary vein were dissected and ligated intrapericardial. The patient developed tachycardia arrhythmias, hypotension, followed by loss of consciousness at about 18 h after operation. After resuscitation, the patient was conscious but developed cyanosis of the superior vena cava drainage area, uropenia, and hypotension (80/30 mmHg). Bedside-echocardiography showed that the SVC was obstructed due to thrombus formation. Chest radiography a shift of the heart into right hemithorax. Rethoracotomy was performed and the herniated heart was replaced into the pericardium, and the pericardium was repaired with Gore Tex patch. The patient recovered smoothly after the second surgery., Conclusion: Cardiac herniation is a rare and fatally complication after thoracic surgery, and the prompt recognition with timely intervention is life-saving. Cardiac herniation is a rare but fatal complication of pneumonectomy. The increasing frequency of surgical resection for locally advanced thoracic carcinoma has led to a renewed emphasis regarding early diagnosis and treatment for cardiac herniation. Here we discuss a case of cardiac herniation presented with acute superior vena cava obstruction syndrome and hemodynamic instability after intrapericradial right pneumonectomy.

Background: Catamenial pneumothorax is generally uncommon, with an incidence of less than 3-6% in women with spontaneous pneumothorax. As few cases of catamenial pneumothorax with diaphragmatic defect and liver herniation have been reported, this case report may be useful for understanding the cause and treatment. This case highlights the importance of the approach for liver hernia in patients with catamenial pneumothorax and endometriosis., Case Presentation: We report a case of catamenial pneumothorax in a 43-year-old woman with diaphragmatic partial liver hernia who was treated with thoracoscopic surgery. She was diagnosed with a right pneumothorax at menstruation onset. Chest computed tomography showed a nodule protruding above the right diaphragm. We performed thoracoscopic surgery to treat the persistent air leak and biopsied the nodule on the right diaphragm. There were blueberry spots on the diaphragm; the nodule was found to be the herniated liver. The diaphragmatic defect was sutured. Histological examination of the tissue near the partial prolapsed liver revealed endometrial tissue., Conclusions: It is speculated that ectopic endometrial tissue in the diaphragm will periodically necrose to become a diaphragmatic tear, which is a pathway for air to enter the thoracic cavity and eventually a herniated liver. Thoracoscopic surgery should be considered in patients with catamenial pneumothorax when a diaphragmatic lesion is suspected.

Background: Spontaneous rib fractures, especially in association with chest wall herniation, represent an uncommon pathology. As such, there are little data analyzing approaches to treatment or regarding the success of intervention. The goal of this study was to analyze our cumulative experience with this unusual condition., Methods: A case series of 12 patients was gathered from a single institution based on outpatient visits between February 2015 and October 2018. Each chart was retrospectively reviewed with particular attention to age, gender, BMI, area of injury, and smoking history. Patients presented with complaints of dyspnea or pain related to rib fractures with or without intercostal neuralgia. Each of these patients was noted to have rib fractures with lung herniation either on imaging, outside hospital records, or physical exam. A thorough medical history was obtained with attempts to find common predisposing factors as well as data regarding any previous surgical intervention for their herniation., Results: Nine of the 12 patients reviewed had recent or prior surgical intervention. Every patient seen in the clinic with a spontaneous fracture and herniation incidentally had a BMI >30 and was therefore classified as obese. Additionally, every patient who had a recurrence after their first surgical attempt at repair had a BMI greater than or equal to 35. All 12 patients seen at our institution were males. The failure rate of operative intervention was 66%., Conclusions: Obesity was a prevalent comorbidity in the patient population we reviewed. Given the role obesity plays in abdominal and hiatal hernia repair success rates, it should be considered that obesity is a significant contributor to chest wall herniation if rib fractures occur. With 66% chest wall repair failure, patient selection is critical in the success of surgical intervention. Perhaps additional patient optimization, especially weight loss, should be considered prior to surgery.

A 28-year-old man presented with a progressive inward deviation of the left eye in the last 4 years. Examination revealed -3 abduction and elevation deficit in the left eye with 50 prism diopters (PD) esotropia and 12 PD of hypotropia. The patient had multiple fibromas on the forearms with pulsatile globe and was diagnosed as neurofibromatosis type 1. Myopic strabismus fixus was suspected. MRI revealed left temporal lobe herniation through a dysplastic sphenoid wing, compressing the posterior half of the superior rectus and lateral rectus muscles, resulting in an esotropia-hypotropia complex. Surgical treatment involved suture myopexy (Yokoyama's technique) of the left superior rectus and lateral rectus muscles with a 6.5 mm left medial rectus recession. Two months postoperatively, the patient had minimal residual esotropia and hypotropia. MRI orbits should always be performed in high myopes with strabismus to assess extraocular muscle pathways., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Hernia sacs with pathological evaluation over a 19-year period were analysed with regards to pathological diagnoses, full costing and the impact on patient management., Materials and Methods: The database of the Department of Pathology were searched over the study period (2001 to 2019 inclusive) for hernia sacs. The total cost of complete pathology examination was calculated on average numbers and rates of pay that existed over the study period., Results: A total of 3619 hernia sacs from the abdominal, hiatus/diaphragmatic, inguinal and femoral hernias were retrieved. Of these 3592 cases (99.25%) had sections taken for histological evaluation. A total of 3437 cases representing 95.7% of all hernia sacs did not show any pathological abnormality. If non-neoplastic clinically insignificant lesions seen in hernia sacs is included, then 3552 of 3592 (98.9%) hernia sacs underwent full pathological evaluation for no patient benefit.On average two blocks or tissue sections per case were processed incurring a technical cost of $53 175.00. The total pathologist cost in reporting the 3592 cases was approximately $39 870.00 and rose to $40 410.00 when interpretation of ancillary tests was factored in. $95 328.90 (average $26.90 per specimen with a yearly average total cost of $5 017.31) was spent over the 19-year period in full pathological examination of 3592 hernia sacs., Conclusion: Given the low return on investment and the difficult to quantify time savings and reallocation, we do not advocate the routine sampling of hernia sacs. Gross examination will suffice in 99% of the cases. Selective cases may be sampled if clinically indicated., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Orbital fat herniation is primarily in a subconjunctival location. However, herniation through the inferior orbital fissure (IOF) has been scantly reported. Here, we report a cadaveric case of herniation of orbital fat through the inferior orbital fissure and into the infratemporal fossa. The cadaver's orbital anatomy and orbital fat herniation were found during routine dissection. The details of this case are reported. We also discuss anatomical variations of the inferior orbital fissure as well as the related vascular and nervous system structures related to orbital fat herniation. This is a rare case of a cadaver with this anatomical abnormality.

Background: Anterior spinal cord herniation (aSCH) is a rare cause of myelopathy which may present as pure motor syndrome and mimic other degenerative diseases of the spinal cord. In slowly progressive cases, diagnosis may be impeded by equivocal imaging results and mistaken for evolving upper motor neuron disease. As early imaging studies are lacking, we aimed to provide a detailed description of imaging and neurophysiology findings in a patient with aSCH, focusing on the early symptomatic stages., Case Presentation: We here present the case of a 51-year old male patient with an episode of pain in the right trunk and a normal spinal MRI. After a symptom-free interval of 8 years, spasticity and paresis evolved in the right leg. There was subtle ventral displacement and posterior indentation of the thoracic spinal cord on MRI which, in retrospect, was missed as an early sign of aSCH. After another 3 years, symptoms spread to the left leg and a sensory deficit of the trunk became evident. Follow-up MRI now clearly showed an aSCH. Neurosurgical intervention consisted of remobilization of the herniated spinal cord and patch closure of the dura defect. Over the following years, motor and sensory symptoms partially improved., Conclusions: The history of this patient with aSCH illustrates the importance of careful longitudinal clinical follow-up with repeated imaging studies in progressive upper motor neuron syndromes. Specific attention should be paid to a history of truncal pain and to MRI findings of a ventrally displaced spinal cord. Neurosurgical intervention may halt the progression of herniation.

An internal hernia is defined as a protrusion of an abdominal viscera through the defects of the gastrointestinal mesentery or peritoneum-lined fossa. Sigmoid mesocolic hernias are an uncommon type of internal hernias, accounting for only 6% of all internal hernias. Furthermore, intramesosigmoid hernia is one of the three subtypes of the sigmoid mesocolic hernias. Internal hernias are potentially fatal conditions with diagnostic challenges. Patients presenting with acute obstruction, no surgical history and no external hernia should receive an urgent CT scan to facilitate early surgery and to minimise the risk of strangulation and bowel resection. Here, we report a case of strangulated small bowel obstruction secondary to an intramesosigmoid hernia with a successful laparoscopic repair. We also present a literature review of all reported cases so far and give an up-to-date perspective on intramesosigmoid hernia., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lacrimal gland (LG) involvement in patients with Graves ophthalmopathy (GO) has been considered as a potential cause of the associated GO symptoms and different studies demonstrated the LG involvement in patients with GO than healthy controls. The aim of this study was to evaluate LG involvement, through measurement of its herniation, using a magnetic resonance imaging (MRI) index, in patients with different GO activities., Methods: Thirty-two consecutive Caucasian patients affected by GO were enrolled and grouped in group A (16 with inactive GO, CAS < 3) and B (16 with active GO, CAS ≥ 3) according to their GO activity. All patients underwent clinical-endocrinological assessment, a complete ocular evaluation, and orbital MRI examination., Results: No difference was found between the hormonal parameters, thyroid ultrasound-derived parameters, and thyroid-stimulating hormone (TSH) receptor (TSH-R) antibodies (TRAb) levels in group B and those in group A. The LG herniation (LGH) measurement evaluated by MRI was significantly higher in group B for both right (10.1 (7.3-17) vs. 7 (0-3.4) mm; p = 0.004) and left (8.5 (6.6-13) vs. 5.8 (0-12) mm; p = 0.026) eye than group A. A positive correlation was found between TRAb and LGH herniation (Rho 0.462, p = 0.009)., Conclusions: Measurement of LGH seems to be a good marker of the disease and GO activity., Key Points: • Lacrimal gland herniation is a simple index related to disease activity • Lacrimal gland herniation is correlated to TRAb levels • Lacrimal gland evaluation could be useful to differentiate active from inactive Graves ophthalmopathy in an early stage of disease.

As a result of the complexity and diversity of diseases in the region of the groin, differentiation of the various soft-tissue and bone pathologies remains a challenge for differential diagnosis in routine clinical practice. In the case of athletes with pain localized in the area of the groin, femoroacetabular impingement (FAI) and athlete's groin must be considered as important causes of the groin pain, whereby the common occurrence of double pathologies further complicates diagnosis. Despite the importance of groin pain and its differential diagnoses in everyday clinical practice, there has been a lack of recognized recommendations for diagnostic procedure to date. To this end, a consensus meeting was held in February 2017, in which a group composed equally of groin and hip surgeons took part. With the formulation of recommendations and the establishment of a practicable diagnostic path, colleagues that are involved in treating such patients should be sensitized to this issue and the quality of the diagnosis of groin pain improved in routine clinical practice.