Incarceration of a part of the gastric wall into the abdominal cavity in a patient with hiatal hernia and complete dislocation of the stomach (upside-down stomach).

An upside-down stomach is a rare type of hiatal hernia. An 83-year-old woman presented to the emergency room with abdominal pain and vomiting. Computed tomography revealed an upside-down stomach and the incarceration of a part of the gastric body into the abdominal cavity. Upper gastrointestinal endoscopy revealed a circular ulcer caused by gastric ischemia. Although she was discharged after 1 week of conservative therapy, she was readmitted to the hospital 1 day after discharge because of a recurrence of hiatal hernia incarceration. She underwent laparoscopic surgery 4 days after readmission and recovered successfully.

Leg Pain-An Unexpected Twist.

BACKGROUND: Obturator hernia is a rare condition, often presenting with non-specific symptoms, such as thigh pain, groin pain, nausea, or vomiting. Obturator hernias are most common in thin, elderly women. Oftentimes, they are diagnosed late in the disease course resulting in complications and high morbidity and mortality. CASE REPORT: We present the case of a 75-year-old female who presented with right thigh pain with no other symptoms. After computed tomography (CT) of the abdomen/pelvis, the patient was found to have an incarcerated obturator hernia complicated by a small bowel obstruction, ultimately requiring urgent surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the very general symptoms associated with the condition, the diagnosis of obturator hernia can easily be missed, leading to a delayed diagnosis, more complications, and a higher morbidity and mortality rate. Due to the risk associated with a delayed diagnosis, it is important for emergency physicians to maintain a high clinical suspicion for the diagnosis.

Reduction en masse of incarcerated inguinal hernia: A case report.

INTRODUCTION: Reduction en masse is a rare diagnosis in which an inguinal hernia is reduced; however, the bowel remains entrapped inside the hernia sac within the preperitoneal space. Although this occurs infrequently, missed diagnosis can significantly affect patient outcomes. PRESENTATION OF CASE: A 73-year-old male presented with obstructive symptoms in the setting of no prior abdominal operations and recently self-reduced inguinal hernia. Diagnosis of reduction en masse of an inguinal hernia was made with history and cross-sectional imaging. The patient remained obstructed following reduction and underwent urgent laparoscopic exploration. The small bowel was reduced from a preperitoneal hernia sac and appeared viable, negating the need for resection. The patient subsequently underwent inguinal hernia repair and was discharged home. DISCUSSION: Although rare, clinicians should be aware of the possibility of reduction en masse of herniae as the cause of intestinal obstruction. This case presentation emphasizes the need for thorough history-taking and imaging to assist in diagnosis. When reduction en masse is diagnosed, proceeding urgently to the operating room is critical. When feasible, it is acceptable to start with laparoscopic exploration to free the bowel and assess for viability. Laparoscopic repair is even an option. Timely diagnosis and operative intervention can preserve the bowel. CONCLUSION: Reduction en masse of an inguinal hernia is a rare but potentially morbid cause of intestinal obstruction as the incarcerated inguinal hernia is essentially converted to an internal hernia with ongoing risk of bowel strangulation. Knowledge of this rare diagnosis and its associated imaging findings is essential for appropriate and timely intervention.

Laparoscopic transabdominal preperitoneal repair for a patient with Laugier's and inguinal hernia.

BACKGROUND: Laugier's hernia is a very rare atypical femoral hernia and is challenging to diagnose preoperatively. Herein, we report a rare case of inguinal and Laugier's hernias treated with laparoscopic transabdominal preperitoneal repair. CASE PRESENTATION: A 63-year-old man was admitted to our hospital with right groin swelling for 4 years. Computed tomography revealed an indirect inguinal hernia with protrusion of the small intestine. The preoperative diagnosis was right indirect inguinal hernia; Laugier's hernia was unknown. The patient underwent laparoscopic transabdominal preperitoneal repair. During the surgery, part of the perivesical adipose tissue penetrated the lacunar ligament. It was located medial to the typical site of a femoral hernia. Thus, Laugier's hernia was diagnosed. Finally, laparoscopic transabdominal preperitoneal repair was performed for Laugier's hernia and inguinal hernia. The postoperative course was good, without recurrence. CONCLUSIONS: To our knowledge, this is the first reported case of inguinal and Laugier's hernia treated with laparoscopic transabdominal preperitoneal repair. Surgeons should be mindful that inguinal hernias can occur concurrently with other types of hernias, such as femoral hernias, including atypical variants like Laugier's hernia. Additionally, they should actively consider laparoscopic approaches such as transabdominal preperitoneal for femoral hernias. These approaches are beneficial for precise diagnosis, confirming the presence of other hernias, and simultaneously treating all coexisting inguinal hernias.

Spontaneous Chest Wall Hernias: Intercostal Lung Hernia and Inverted Intercostal Hernia.

Intercostal lung hernia and inverted intercostal hernia are rare chest wall hernias usually asymptomatic and detected incidentally on chest radiograph. In this case report, we discussed here on the chest radiograph and computed tomography imaging findings of two cases of these rare hernias with an emphasis being in differential diagnosis of chest tumors.

Case Report: A "senior" with serpentine-like syndrome-treatment of combined brachyoesophagus, intrathoracic stomach and cervical rachischisis.

Serpentine-like syndrome, characterized by the combination of intrathoracic stomach, a notably short esophagus anomaly, splenic abnormalities, and cervical spine malformations, has been associated with a high mortality rate since its identification in 2008. This report presents the case of a remarkable patient who recently celebrated her fifth birthday, marking her as the oldest documented individual with this syndrome to date. Highlighting the significance of comprehensive evaluations for concurrent malformations, the report discusses potential treatment modalities and challenges inherent in managing patients with this intricate syndrome. A comprehensive review of previously published cases is provided, comparing surgical interventions, causes of death, and age at the time of demise. This report underscores the importance of ongoing research and collaborative efforts to optimize outcomes for individuals afflicted with serpentine-like syndrome.

Recommendations for the diagnosis of occult inguinal hernias using a modified Delphi technique.

BACKGROUND: Occult inguinal hernias are inguinal hernias that are not felt on physical exam but can often be seen on imaging. Their diagnosis can be challenging, leading to unnecessary surgeon referrals, undue patient stress, and even unneeded surgery. The aim of this project was to develop recommendations for the diagnosis of occult inguinal hernias using a modified Delphi technique. METHODS: Iterative rounds of surveys were administered to an expert panel of surgeons and radiologists. Panelists were asked to rate potential hernia-related topics by levels of importance. Items with 80% agreement were included for further discussion. Panelists were asked to provide their opinion on each included subject. A virtual meeting was conducted to discuss areas without agreement and determine final recommendations. RESULTS: Three surgeons and five radiologists participated. There was strong agreement that dynamic ultrasound is a good first/confirmatory imaging choice. There was agreement that the radiology reports for studies assessing inguinal hernias should include hernia contents (80%) and hernia size (100%). Information that should be provided to the radiologist when ordering an imaging study include indication for study, patient symptoms, prior hernia surgery. Items that should be included in a radiology report include whether the presence of an inguinal hernia was assessed, hernia contents, size of defect, +/- hernia type. CONCLUSIONS: This collaboration between surgeons and radiologists creates a diagnostic imaging pathway and standardizing imaging reporting which will be used to improve the diagnosis of occult inguinal hernias. Future studies testing these recommendations in a prospective study are warranted.

Prospective randomized study comparing mesh displacement in enhanced-view totally extraperitoneal versus totally extraperitoneal laparoscopic inguinal hernia repair without mesh fixation.

PURPOSE: In laparoscopic inguinal hernia repair, it is thought that the mesh can be displaced more in the enhanced-view totally extraperitoneal (eTEP) technique. The aim of this study was to compare eTEP and totally extraperitoneal (TEP) techniques without mesh fixation in terms of mesh displacement and hernia recurrence. METHODS: Between December 2022 and April 2023, 60 consecutive patients with unilateral inguinal hernia were randomized into two groups; eTEP group (n = 30) and TEP group (n = 30). There was without mesh fixation in both groups. Study was registered at http://Clinicaltrials.gov (NCT06070142). The mesh was marked with three radiopaque clips. Pelvic radiographs were performed to evaluate the displacement of the mesh. The primary outcome of this study was mesh displacement. In addition, this is the first study in the literature to compare eTEP and TEP techniques in terms of mesh displacement without fixation in laparoscopic inguinal hernia. RESULTS: There was no significant difference between the groups in terms of mesh displacement, recurrence, postoperative VAS scores, length of hospital stay, hematoma, and seroma formation. The operation time was higher in the eTEP group and was statistically significant. CONCLUSION: Without mesh fixation, the eTEP technique does not increase the risk of mesh displacement and recurrence. The eTEP technique can be safely applied without mesh fixation in laparoscopic inguinal hernia repairs. TRIAL REGISTRATION: ClinicalTrials number: NCT06070142.

The rate of ileostomy site incisional hernias: more common than we think?

PURPOSE: Incisional hernias (IH) rates after diverting loop ileostomy reversal (DLI-R) have been reported up to 24%. We aimed to characterize the incidence rate and risk factors associated with DLI-R site IH formation within 1-year in a large patient cohort. METHODS: A retrospective review at a single quaternary referral center hospital of adult patients who underwent DLI-R over a 5-year period and abdominal computerized tomography (CT) imaging performed within 1-year for any indication postoperatively was conducted. All CTs scans were independently reviewed by staff surgeons to determine the presence of a fascial defect at the DLI-R site. RESULTS: 2,196 patients underwent DLI-R; of these, 569 (25.9%) underwent CT imaging for any indication. Mean patient age, 54.8 (± 14.9), BMI 27.6 kg/m2. 87 (15%) patients had a parastomal hernia at time of DLI-R. After median follow-up of 10 months, 203 patients (35.7%) had IH at the DLI-R site. Age (p = 0.14), sex (p = 0.39), race (p = 0.75), and smoking status (p = 0.82) weren't associated with IH after DLI-R. Comorbidities weren't significantly associated with IH following DLI-R. In univariate analysis, increased BMI (p < 0.001), presence of a parastomal hernia (p = 0.008), and suture type (p = 0.01) were associated with IH development. On multivariate analysis, BMI remained significant, and polyglyconate compared to polydioxanone suture were associated with higher rates of IH (p < 0.001). CONCLUSION: We observed that the rate of incisional hernias within 1-year of diverting ileostomy reversal was indeed common at 36%. Granted, a high percentage of the population was excluded due to heterogeneity in radiographic evaluation that could be mitigated in future prospective studies. Our study suggests that IH preventative strategies include weight loss for overweight and obese patients prior to DLI-R and that the optimal suture for DLI-R is polydioxanone.

Risk factors for incisional hernia after open abdominal aortic aneurysm repair: a systematic review and meta-analysis.

BACKGROUND: The incidence of incisional hernia (IH) after an open abdominal aortic aneurysm (AAA) repair can reach up to 35%, contributing to long-term morbidity. Individual studies have been limited in identifying modifiable risk factors for IH after an open AAA repair. This meta-analysis aims to review all the risk factors for IH after an open AAA repair. METHODS: We searched Cochrane Central, Embase, PubMed, MEDLINE, and Web of Science databases for original studies. Risk factors assessed were age, sex, comorbidities, surgical incision, blood loss, and surgical site infection (SSI). Data analysis was done using RStudio 4.1.2. We computed Relative Risk (RR) for dichotomous outcomes and Mean differences (MD) with 95% Confidence Interval (CI) for continuous outcomes. P-values less than 0.05 were considered statistically significant. RESULTS: Ten studies met the inclusion criteria among 1,795 screened articles. Among those ten studies, there were a total of 1,806 patients of which 341 patients developed IH. Older age (Mean 69.6-70.7 years, MD 1.39 years, CI [1.12-1.66], P < 0.01), midline vertical incision (RR 1.55, CI [1.06-2.25], P = 0.02) and increased intraoperative blood loss (MD 429.8 ml, CI [234.8- 624.8], P < 0.01) were associated with an increased incidence of IH. Surgical site infection (SSI) was noted as a risk factor for IH after open AAA repair (RR 2.36, CI [1.31-4.24], P = 0.004). No statistically significant association was found between the incidence of IH and sex (RR 1.0, CI [0.8-1.14], P = 0.98), smoking (RR 1.01, CI [0.93-1.09], P = 0.88), diabetes (RR 1.38, CI [0.85-2.25], P = 0.19), and chronic kidney disease (RR 1.55, CI [0.47-5.09], P = 0.46). CONCLUSION: This meta-analysis shows that age, midline vertical incision, intraoperative blood loss, and SSI are risk factors for IH after open AAA repair.

Continuous Splenogonadal Fusion Diagnosed by Laparoscopy in a Child With a Communicating Hydrocele.

Splenogonadal fusion is a rare congenital anomaly primarily affecting males, characterized by an abnormal fusion of the spleen and the gonad. There are two primary forms: continuous, in which the normal spleen is directly connected to the gonad via a cord of fibrous or splenic tissue, or a combination of both, and discontinuous, in which ectopic splenic tissue fuses to the gonad without connection to the normal spleen. Continuous splenogonadal fusion is often associated with other congenital defects, such as cryptorchidism, limb anomalies, and micrognathia. Due to its rarity and nonspecific symptoms, splenogonadal fusion is typically diagnosed incidentally during surgery for undescended testis or inguinal hernia. We present a case of a five-year-old boy with a communicating hydrocele who underwent surgical repair. Intraoperative findings during inguinal exploration revealed a fibrous connection to the upper pole of the left testicle, extending into the internal inguinal ring. Diagnostic laparoscopy confirmed continuous splenogonadal fusion, demonstrating splenic tissue and a fibrous cord with islands of splenic tissue extending from the spleen to the internal inguinal ring. A portion of the fibrous cord with splenic nodules was excised and examined pathologically, confirming the diagnosis of splenogonadal fusion. The diagnosis of continuous splenogonadal fusion primarily relies on intraoperative findings during surgery for other conditions. Laparoscopy can be instrumental in diagnosing this rare condition.

Evaluation of Open Rives-Stoppa and Lichtenstein Repair Methods for Bilateral Inguinal Hernias: A Single-Centre Comparative Analysis.

Aim The purpose of the study is to compare the two common open surgical methods for bilateral inguinal hernias: bilateral Lichtenstein repair and Rives-Stoppa repair. It evaluates their benefits, drawbacks, and outcomes to improve the management of bilateral inguinal hernias and enhance patient care and results. Background Abdominal wall hernias are prevalent in the surgical field, and they occur when intra-abdominal organs protrude through weakened or torn regions in the abdominal wall. The Lichtenstein repair, also known as the tension-free mesh repair, is one of the most widely used techniques that involves placing a synthetic mesh over the hernia defect to reinforce the abdominal wall. The Rives-Stoppa technique takes the posterior approach, which involves placing a large mesh in the preperitoneal space, which provides broad coverage of the potential hernia sites. Method This retrospective study included 86 male patients from the Department of General Surgery at Indus Health Network, Karachi, Pakistan. Data were collected up to three months post-operation for all open bilateral inguinal hernia repairs performed between January 2017 and April 2021. The patients were divided into two groups: group A underwent Lichtenstein repair, while group B underwent Rives-Stoppa repair. The procedures were performed by different surgeons and surgical trainees under direct supervision. Results Regarding post-operative complications (scrotal swelling, epididymo-orchitis, seroma formation, ipsilateral testicular swelling, surgical site infection, erectile dysfunction, wound dehiscence, fever, hydrocele, sensory abnormality, hernia recurrence in 3 months, post-operative pain in 14 days), there was no significant difference observed between the two groups. There were two recurrences within three months after Lichtenstein repair and one recurrence after Stoppa repair, but no statistical difference was demonstrated. Conclusion Statistically, both the Lichtenstein repair and the Rives-Stoppa repair demonstrated similar outcomes. However, the Rives-Stoppa repair offers distinct advantages for bilateral inguinal hernia repair, making it a preferable option in many cases as this approach utilises a single midline incision, simultaneously facilitating access to both hernial sites. This method ensures complete coverage of the myopectineal orifices bilaterally, addressing all potential hernia sites in the lower abdomen. These features collectively contribute to the technique's efficacy in managing bilateral hernias.

A single-centre, retrospective study of incisional hernia repair outcomes post kidney transplantation.

PURPOSE: Incisional hernias (IH) after kidney transplantation (KTx) can cause significant morbidity in kidney transplant recipients (KTR). We aimed to report the outcomes of surgical repair of IH in KTR from our centre. METHODS: We retrospectively analysed all the IH repairs in KTR from May 2018 to May 2023. We documented pre-transplant baseline characteristics, peri- and post-KTx events and outcomes and post-IH repair complications. We also documented length of stay, survival, and hernia recurrence post-IH repair. RESULTS: We performed 35 incisional hernia repairs in 34 KTR from May 2018 to May 2023 with an overall incidence of 1.63% symptomatic IH. Mean patient age was 56.7 ± 10.1 years and mean body mass index (BMI) 29.7 ± 6.49 kg/m2. A history of previous hernia operation and open abdominal operations was present in 11.4% and 22.9% of the population, respectively. The types of repairs performed were primary (5.7%), onlay (62.9%), inlay (2.9%) and retromuscular sublay (28.6%). Mean hernia neck size was 8.9 ± 5.6 cm. After IH repair, there was no perioperative mortality with an average 5.5 ± 3.9 days of length of stay. There were seven episodes (20%) of IH recurrence. There was a 6% of superficial wound dehiscence rate and a 3% of surgical site infection. Pearson's correlation test revealed that post-operative hernia recurrence was not related with neck size, post-transplant complications or pre- and post-transplant characteristics, as well as post-transplant outcome. CONCLUSIONS: The recurrence rate in our cohort was 20%. Known risk factors for IH in KTR as well as post-KTx events were not correlated with hernia recurrence or other post-hernia repair complications.

Evaluation of risk factors associated with the peritoneal flap hernioplasty for complex incisional hernia repair - a retrospective review of 327 cases.

BACKGROUND: Repair of large incisional hernias is challenging, and the risks of postoperative complications have been associated with obesity, smoking, and diabetes. The present study was conducted to determine the impact of these risk factors on short and long-term outcomes following the repair with the peritoneal flap hernioplasty (PFH). METHODS: Three hundred twenty-seven patients undergoing PFH for incisional hernia repair were identified. Patient demographics and clinical data were recorded. Patients presenting signs of complications were assessed during a visit to the outpatient clinic. A multivariable regression analysis was performed to evaluate the association between BMI, smoking and diabetes, and postoperative complications. RESULTS: The study included 157 males (48.0%) and 170 females (52.0%). Median BMI was 30.9 kg/m2. Diabetes was present in 13.8% of patients. 23.2% were active smokers. The recurrence rate was 2.4%. The odds ratios for postoperative complications were increased by 9% per BMI unit (P < 0.01), due predominantly to a rise in superficial wound infections (P < 0.01) and seroma production (P = 0.07). The adjusted odds ratio increased fourfold in patients with BMI > 40 kg/m2 (P = 0.06). CONCLUSION: Incisional hernia repair with the PFH technique is associated with a low risk of short and long-term complications. The risk is associated with obesity and significantly increased in patients with a BMI exceeding 40 kg/m2, where a fourfold increase was observed predominantly due to seroma and superficial wound infections. The recurrence rate was 2.4% and was unaltered across BMI categories. No association was established between smoking, diabetes, and the risk of all-cause complications.

The current role of barbed sutures in fascial closure of ventral hernia repair: a multicenter study using the abdominal core health quality collaborative database.

BACKGROUND: Barbed sutures (BS) have been increasingly used in the last two decades across surgical disciplines but little is known about how widespread their adoption has been in ventral hernia repair (VHR). The aim of this study was to document the use of barbed sutures in VHR in a multicenter database with associated clinical and patient-reported outcomes. METHOD: Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent VHR with fascial closure from 2020 to 2022. A univariate analysis compared patients with BS against non-barbed sutures (NBS) across the preoperative, intraoperative, and postoperative timeframes including patient-reported outcomes concerning quality of life and pain scores. RESULTS: A total of 4054 patients that underwent ventral hernia repair with BS were compared with 6473 patients with non-barbed sutures (NBS). Overall, BS were used in 86.2% of minimally invasive ventral hernia repairs and about 92.2% of robotic surgery compared to only 9.6% of open procedures. Notable differences existed in patient selection, including a higher BMI (32 vs 30.5; p < 0.001), more incisional hernias (63.3% vs 51.1%; p < 0.001), wider hernias (4 cm vs 3 cm; p < 0.001), and higher ASA score (p < 0.001) in patients with BS. Outcomes in patients with BS included a shorter length of stay (mean days; 1.4 vs 2.4; p < 0.001), less SSI (1.5% vs 3.6%; p < 0.001), while having similar SSO (7.6% vs 7.3%; p = 0.657), readmission (3.0 vs 3.2; p = 0.691), and reoperation (1.5% vs 1.45%; p = 0.855), at a longer operative time (p < 0.001). Hernia-specific questionnaires for quality of life (HerQLes) and pain in patients with BS had a worse preoperative score that was later matched and favorable compared to NBS (p = 0.048). PRO concerning hernia recurrence suggest around 10% at two years of follow-up (p = 0.532). CONCLUSION: Use of barbed sutures in VHR is widespread and highly related to MIS. Outcomes from this multicenter database cannot be reported as superior but suggest that barbed sutures do not have a negative impact on outcomes.

Retrograde Umbilical Hernia Repair During Abdominoplasty: A Safe and Simple Technique.

BACKGROUND: Abdominoplasties are a very common procedure that is geared toward improving the abdominal contour and restoring quality of life. Main candidates for surgery are postpartum patients and patients after massive weight lost results in excess skin. The high incidence of umbilical hernias in the general population raises the question of whether combining its repair with cosmetic abdominoplasties is a safe and effective procedure. PURPOSE: Determine the safety of the "retrograde umbilical hernia" (RUH) technique, which utilizes a pre-peritoneal approach to the hernia, during abdominoplasty procedure and expand the literature on hernia repair during aesthetic abdominal surgery. METHODS: This is the retrospective cohort study of all patients that underwent abdominoplasty by the senior author. Eligible patients were divided into 2 groups: where one group included all patients who underwent abdominoplasty with RUH repair, and the second group underwent sole abdominoplasty. Baseline variables, surgical notes, and post-operative outcomes were obtained from the patients' medical records and analyzed for the purpose of this study. RESULTS: In total, 744 patients underwent abdominoplasties during the course of our study, 112 of which underwent concomitant umbilical hernia repair using the retrograde technique. The RUH technique was not found to result in a higher rate of complications compared to a similar population of traditional abdominoplasties. CONCLUSIONS: The retrograde umbilical hernia repair is a safe and efficient technique that can be easily implemented during abdominoplasty procedures in a heterogeneous population of patients. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Role of sarcopenia in complex abdominal wall surgery: does it increase postoperative complications and mortality?

BACKGROUND: Sarcopenia is defined as the loss of skeletal muscle mass and is associated with an increased risk or morbidity and mortality in complex surgical patient populations. Its role in complex abdominal wall surgery (AWS) is yet to be determined. The aim of this study is to establish if sarcopenia has an impact on postoperative complications, mortality and hernia recurrence. METHODS: Retrospective study of patients undergoing elective surgery for complex incisional hernias > 10 cm (W3 of European Hernia Society classification) between 2014-2023. Sarcopenia was stablished as the skeletal muscle index (SMI), measured at L3 transversal section of a preoperative CT-scan. Previously defined literature-based SMI cutoff values were used: men ≤ 52.4 cm2/m2, women ≤ 38.5 cm2/m2. RESULTS: 135 patients undergoing complex AWS were included. Of them, 38 were sarcopenic (28.1%). The median follow-up time was 13 months (IQR 12-25). In total, 11 patients died (8.1%). We found that sarcopenia was associated with a higher risk of mortality [HR 7.494 (95% CI 1.985-28.289); p 0.003]. There were no statistically significant differences in postoperative complications or hernia recurrence between both groups. CONCLUSION: Although sarcopenia does not seem to have an influence on hernia recurrence or the development of postoperative complications, whether local or systemic, in our study sarcopenia is associated with a higher risk of mortality after complex abdominal wall surgery. Nonetheless, with the results obtained in our study, we think that prehabilitation programs before complex AWS is advisable.

Left Para-Duodenal Hernia Presenting With Recurrent Abdominal Pain: A Diagnostic Challenge.

Paraduodenal hernias (PDH) are a type of internal hernia that results from errors in midgut rotation and failure of mesenteric fusion. Internal hernias themselves are a rare presentation that accounts for less than 1% of total hernias, and paraduodenal hernias contribute more than half of internal hernias. Left paraduodenal hernias (LPDH) occur more frequently as compared to right paraduodenal hernias. Left paraduodenal hernias happen when the small intestine bulges out in the left paraduodenal space, which is also called the space of Landzert. This can cause vague abdominal pain and signs of intestinal blockage, which makes diagnosis difficult. We present a case of a 28-year-old male with recurrent abdominal pain for 7 years, diagnosed with LPDH via laparotomy after inconclusive imaging studies, such as the whirlpool sign on USG. Intraoperatively, jejunal loops were found in Landzert's fossa, hindering hernia repair and adhesiolysis. Clinicians must maintain a high index of suspicion for PDH when assessing nonspecific abdominal symptoms to ensure timely diagnosis and management, optimising patient outcomes.

Incidental discovery of asymptomatic low-grade mucinous appendiceal tumor during paraumbilical hernia repair: A case report emphasizing intraoperative vigilance.

INTRODUCTION: Mucinous appendiceal tumor is an exceptionally rare and indolent epithelial neoplasm characterized by the production of mucin within the appendix. Here we present a rare case of a large, asymptomatic mucinous appendiceal tumor discovered incidentally during repair of a paraumbilical hernia. CASE PRESENTATION: A 73-year-old man with a complex medical history presented with epigastric pain, nausea, vomiting, and constipation. Diagnosed with a strangulated paraumbilical hernia. During hernia repair surgery, a low-grade mucinous appendiceal tumor was accidentally discovered. Post-operative monitoring over 18 months, including colonoscopy and CT scans, showed no recurrence. DISCUSSION: Appendiceal primary tumors, though rare, can originate from neuroendocrine or epithelial cells. Epithelial tumors, including mucinous adenocarcinoma, produce mucin, potentially leading to pseudomyxoma peritonei, characterized by mucinous ascites and abdominal swelling. These tumors are often incidentally discovered during surgery, as symptoms are nonspecific, resembling acute appendicitis or causing abdominal distension. Diagnosis requires histopathology, revealing mucin accumulation and irregular glandular structures. Treatment typically involves cytoreductive surgery with hyperthermic intraperitoneal chemotherapy to manage the condition effectively. CONCLUSION: This case emphasizes the critical need for intraoperative vigilance and histopathological analysis in detecting appendiceal mucinous tumors during abdominal surgery, ensuring accurate diagnosis and favorable outcomes.