Groin Hernia Repair during the COVID-19 Pandemic-A Romanian Nationwide Analysis.

Background and Objectives: Groin hernia repair surgery (GHRS) is among the most common elective interventions. The aim of this three-year nationwide study on GHRS is to provide a thorough analysis of the impact that the COVID-19 pandemic had on the Romanian Health System in regard to elective procedures. Materials and Methods: 46,795 groin hernia cases obtained between 2019 and 2021 from the DRG database using ICD-10 diagnostic codes. The data were collected from all 261 GHRS performing hospitals nationwide, including 227 public hospitals (PbH) and 34 private hospitals (PvH). The 42 variables taken into account were processed using Microsoft Excel 2021, applying Chi square, F-Test Two-Sample for variances, and Two Sample t-Test. The significance threshold considered was p < 0.001. Results: Of the grand total of cases, 96.2% were inguinal hernias, 86.8% were performed on men, 15.2% were laparoscopic procedures, and 6.88% were in PvH. Overall, due to the pandemic, the total number of GHRS decreased with 44.45% in 2020 and with 29.72% in 2021 compared to pre-pandemic year 2019. April 2020 shows the steepest decrease in GHRS (91 procedures nationwide). In the private sector, there was an opposite trend with increases in the number of cases by 12.21% and a 70.22% in both pandemic years. The mean admission period (MAP) for all procedures was 5.5 days. There was a significant difference between PbH and PvH (5.75 vs. 2.8 days, p < 0.0001). During the pandemic, the MAP in PbH decreased (6.02 in 2019, 5.82 in 2020 and 5.3 in 2021), remaining stable for PvH (2.9 days in 2019, 2.85 days in 2020 and 2.74 days in 2021). Conclusions: The COVID-19 pandemic significantly reduced the overall number of GHRS performed in Romania in 2020 and 2021, compared to 2019. However, the private sector thrived with an actual increase in the number of cases. There was a significant lower MAP in the PvH compared to PbH throughout the three-year period.

Outpatient treatment of abdominal wall hernia. A strategy to reduce the impact of the COVID-19 pandemic.

AIM: The aim of this study is to demonstrate the feasibility and efficacy of the treatment of abdominal wall hernias in ambulatory setting in selected patients to break down long waiting lists due to the COVID 19 pandemic. METHODS: From February to June 2021, we performed 120 hernia repair operations with local anesthesia in ambulatory settings without anesthetists. (105 inguinal hernia, 6 femoral hernia and 9 umbilical hernia). All patients were selected from our waiting lists first through a telephone interview through an adequate collection of the anamnesis and then clinically (LEE index and ASA score) and based on the characteristics of the hernia. RESULTS: For all patients, the operation was performed under local anesthesia with lidocaine and naropine. Lichtenstein tension-free mesh repair were performed for all patients with inguinal hernia; polypropylene mesh-plug was the technique used to repair the crural hernias while a direct plastic was performed for the treatment of umbilical hernias.. The mean age was 58 years. We did not observe any intraoperative complications and patients were discharged after 4 hours of operation. There was no case of readmission. Only 3 (2.5%) patients developed scrotal bruising. We did not observe any other complications or recurrence at 30 days and 6 months. Most patients (97.5%) expressed satisfaction for local anesthesia and for the path created. CONCLUSION: Hernia pathologies could be treated in ambulatory setting with good results in selected patients and could represent an alternative to face the limitations imposed by the COVID pandemic on daily surgical activities. KEY WORDS: Ambulatory surgery Cocid-19 Epidemic,Wall hernia.

The impact of the COVID-19 pandemic on unilateral inguinal hernioplasty surgery in Brazil.

OBJECTIVE: to analyze data from patients hospitalized for unilateral inguinal hernioplasty in Brazil in the year before the COVID-19 pandemic, and during the period of the pandemic. METHODS: this is a descriptive study, using data referring to hospitalizations for the surgical procedure of unilateral inguinal hernioplasty in Brazil from March 2019 to February 2020, comparing with data from March 2020 to February 2021. Data were collected from the Hospital Information System (SIH/SUS) and the selected variables were: number of hospitalizations, average hospital stay rate and mortality rate. RESULTS: in all, 119,312 hospitalizations were performed for unilateral inguinal hernioplasty in Brazil from March 2019 to February 2020. During the pandemic period, 53,445 hospitalizations were recorded for this procedure. The average hospital stay increased compared to the previous year. The mortality rate recorded in the year before the pandemic was 0.11, while in the period of the pandemic, it was 0.20. CONCLUSION: It was observed that during the period of the COVID-19 pandemic in Brazil, the number of hospitalizations for unilateral inguinal hernioplasty was reduced by 55,21%. However, there was a significant increase in the mortality rate of this procedure. These results can be explained by the increase in mortality in patients infected with the SARS-CoV-2 virus, and also by the restriction of performing elective surgeries, prioritizing emergency situations, which are more complicated, and consequently, with higher mortality.

Telemedicine versus face-to-face follow up in general surgery: a randomized controlled trial.

BACKGROUND: Telemedicine provides healthcare to patients at a distance from their treating clinician. There is a lack of high-quality evidence to support the safety and acceptability of telemedicine for postoperative outpatient follow-up. This randomized controlled trial-conducted before the COVID-19 pandemic-aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) by telephone compared to face-to-face follow-up after uncomplicated general surgical procedures. METHODS: Patients following laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face-to-face outpatient clinic. Patient demographics, perioperative details and postoperative outcomes were compared. Patient satisfaction was assessed via a standardized Likert-style scale. RESULTS: One hundred and twenty-three patients were randomized over 12 months. Mean consultation times were significantly shorter for telemedicine than face-to-face clinics (telemedicine 10.52 ± 7.2 min, face-to-face 15.95 ± 9.96 min, P = 0.0021). There was no difference between groups in the attendance rates, nor the incidence or detection of postoperative complications. Of the 58 patients randomized to the telemedicine arm, 40% reported high, and 60% reported very high satisfaction with the method of clinic follow-up. CONCLUSION: Telemedicine postoperative follow-up is safe and acceptable to patients and could be considered in patients undergoing uncomplicated benign general surgery.

Impact of the COVID-19 pandemic on hernia surgery in a Swedish healthcare region: a population-based cohort study.

BACKGROUND: Swedish healthcare has been reorganised during the COVID-19 pandemic, affecting the availability of surgery for benign conditions. The aim of this study was to determine the effects of COVID-19 on emergency and elective hernia surgery in a Swedish healthcare region. METHODS: Using procedure codes, data from inguinal and ventral hernia procedures performed at the three hospitals in Jönköping Region, Sweden, from March 1st 2019 to January 31st 2021, were retrieved from a medical database. The cohort was divided into two groups: the COVID-19 group (March 1st 2020-January 31st 2021) and the control group (March 1st 2019-January 31st 2020). Demographic and preoperative data, hernia type, perioperative findings, and type of surgery were analysed. RESULTS: A total 1329 patients underwent hernia surgery during the study period; 579 were operated during the COVID-19 period and 750 during the control period. The number of emergency ventral hernia repairs increased during the COVID-19 period, but no difference in inguinal hernia repair rate was seen. The characteristics of patients that underwent hernia repair were similar in the two groups. Moreover, the decrease in elective ventral hernia repair rate during the COVID-19 period did not result in a higher risk for strangulation. CONCLUSION: There is no evidence to suggest that the decrease in the number of elective ventral hernia repairs during the COVID-19 period had any impact on the risk for strangulation. Indications for surgery in patients with a symptomatic ventral or inguinal hernia should be carefully evaluated. Studies with greater power and longer follow-up are needed to gain a full understanding of the effects of the COVID-19 pandemic on hernia surgery.

The neglected surgery - Hernioscopy - Maybe the best choice for strangulated groin hernias in the COVID-19 pandemic.

<b>Introduction:</b> While elective surgeries have been postponed worldwide due to the COVID-19 pandemic, emergency operations cannot be delayed and are continuously being performed just like before the pandemic outbreak [1]. </br></br> <b>Aim:</b> Although elective surgeries have been postponed worldwide due to the COVID-19 pandemic, emergency operations cannot be delayed and are continuously being performed. In general surgery practice, incarcerated / strangulated inguinal hernias take a prominent place among emergency surgeries. In 1% of these patients, the hernia contents retreat spontaneously into the abdomen until the hernia sac is opened. It is strongly recommended that these bowel segments be evaluated for possible intestinal necrosis.</br></br> <b>Results:</b> Patients who underwent emergency surgery and hernioscopy in the Sakarya Training and Research Hospital General Surgery Service due to incarcerated or strangulated inguinal hernia between March 2020 and October 2020 were included in the study. Hernioscopy procedure was performed using the single-port and glove-port methods. For each patient, the following variables were recorded: age, duration of complaints, comorbidities, hernia repair method, operation time, incarcerated organ, postoperative complications and whether ischemia improved after reduction or resection was required. </br></br> <b> Conclusion:</b> Hernioscopy is a procedure performed under spinal anesthesia which prevents unnecessary laparotomies and should be considered as first-line treatment during the COVID-19 pandemic in patients who undergo emergency surgery for strangulated inguinal hernia.

Using an E-Health Application for Post-operative Monitoring After Inguinal Hernia Repair: A Feasibility Study.

BACKGROUND: E-Health care is already well established in some (non-) surgical specialties and is considered as a means of improving patient-centred care. Considering the demand of remote health care changes, especially in the COVID-19 pandemic, it is essential to investigate the feasibility of e-Health care within one of the most performed surgery procedures: inguinal hernia repair. METHODS: A total of 60 patients used the e-Health application in this study compliant. Primary objectives were to investigate the accuracy of the "deviating post-operative course" alerting by the e-Health application. Secondary objectives included patient perspective and e-Health costs analysis. RESULTS: Forty-four patients reported no deviation in the post-operative course using the e-Health application of which 93.2% (n = 41) was in concordance with the findings during standard follow-up. Within 16 patients reporting a deviating post-operative course, a true complication was found in 25% (n = 4). Based on in-hospital costs, a hypothetical e-Health follow-up scenario was more expensive (€59.5 per patient) than current standard follow-up care (€28.2 per patient). Usage of the e-Health application showed a high perceived overall patient satisfaction: 4.2 (on a Likert-scale of 1-5). CONCLUSION: An e-Health application is a promising tool for identifying patients who require in-person or phone follow-up assessment. Patients' perspectives surveys revealed high potential and willingness of using this application. A hypothetical e-Health follow-up scenario showed to be more expensive compared to current standard follow-up. If the identified (dis)advantages can be improved, e-Health follow-up care appears to be promising in terms of safety and feasibility. Future studies can leverage on this study and further investigate the use of e-Health within the field of general surgery.

Association between COVID-19 related elective surgery cancellations and pediatric inguinal hernia complications: A nationwide multicenter cohort study.

BACKGROUND: Optimal inguinal hernia repair timing remains controversial. It remains unclear how COVID-19 related elective surgery cancellations impacted timing of inguinal hernia repair and whether any delays led to complications. This study aims to determine whether elective surgery cancellations are safe in pediatric inguinal hernia. METHODS: This multicenter retrospective cohort study at 14 children's hospitals included patients ≤18 years who underwent inguinal hernia repair between September 13, 2019, through September 13, 2020. Patients were categorized by whether their inguinal hernia repair occurred before or after their hospital's COVID-19 elective surgery cancellation date. Incarceration and emergency department encounters were compared between pre and postcancellation. RESULTS: Of 1,404 patients, 604 (43.0%) underwent inguinal hernia repair during the postcancellation period, 92 (6.6%) experienced incarceration, and 213 (15.2%) had an emergency department encounter. The postcancellation period was not associated with incarceration (odds ratio 1.54; 95% confidence interval 0.88-2.71; P = .13) or emergency department encounters (odds ratio 1.53; 95% confidence interval 0.94-2.48; P = .09) despite longer median times to inguinal hernia repair (precancellation 29 days [interquartile range 13-55 days] versus postcancellation 31 days [interquartile range 14-73 days], P = .01). Infants were more likely to have the emergency department be their index presentation in the postcancellation period (odds ratio 1.69; 95% confidence interval 1.24-2.31; P < .01). CONCLUSION: Overall, COVID-19 elective surgery cancellations do not appear to increase the likelihood of incarceration or emergency department encounters despite delays in inguinal hernia repair, suggesting that cancellations are safe in children with inguinal hernia. Assessment of elective surgery cancellation safety has important implications for health policy.

Intestinal ischemia in patients with incarcerated groin hernia: proposal and validation of a score.

PURPOSE: Intestinal ischemia (II) is the most critical factor to determine in patients with incarcerated groin hernia (IGH) because II could be reversible, and it is considered as a "time sensitive condition." Although predictive factors of II were identified in several previous studies, preoperative diagnosis of II cannot be reliably made or excluded by any known parameter. The aims of this study were: to devise and to validate a clinic-biologic score, with a strong discriminatory power, for predicting the risk of II in patients with IGH. METHODS: We conducted a retrospective bicentric study including 335 patients with IGH. Logistic regression analysis was used to identify independent predictive factors of II. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second independent population of 45 patients admitted for IGH in the same departments (internal validation). RESULTS: Four independent predictive factors of II were identified: heart rate, duration of symptoms before admission, prothrombin, and neutrophil-to-lymphocyte ratio (NLR). A predictive score of II was established based on these independent predictive factors. Sensitivity was 94.50%; specificity was 92.70%. The AUC of this score was 0.97. The AUC was 0.96 when the score was applied on the second population of patients. CONCLUSIONS: We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score was 0.97). This score is reliable and reproducible, so it can help a surgeon to prioritize patients with II for surgery (especially at this time of COVID-19 pandemic), because ischemia could be reversible, avoiding thus intestinal necrosis.

A Canadian national survey: Perspectives on routine pathological examination of hernia sacs after inguinal hernia and hydrocele repair among pediatric urologists, surgeons, and pathologists.

BACKGROUND/OBJECTIVE: This study aims to understand perspectives on routine pathological examination of hernia sacs following pediatric inguinal hernia and hydrocele repair among Canadian pediatric urologists, surgeons, and pathologists. STUDY DESIGN: All active members of Pediatric Urologists of Canada (PUC), Canadian Association of Pediatric Surgeons (CAPS), and the divisional heads of anatomical pathology at the Canadian children's hospitals (AP) were invited to participate between June 2019 and January 2021 in an anonymous multiple-choice-based questionnaire. RESULTS: The response rates were 71% from PUC (24/34), 20% from CAPS (25/130), and 64% from AP (7/11). The majority of the surgeons (PUC:54%, CAPS:68%) did not routinely send hernia sacs for pathological examination after inguinal hernia repair. Most felt there was a little value in such examination (PUC:96%, CAPS:72%). Among those who submit hernia sacs, the majority did not receive reports that were clinically significant impacting patient management (PUC:82%, CAPS:50%). On the other hand, the pathologists had mixed opinion on the value of examining hernia sacs. Most of them only did gross examination (86%), unless requested by surgeons or concerning features were noted on gross examination. The majority have found clinically meaningful abnormal findings (71%), including vas deferens and portions of the spermatic cord. DISCUSSION: Currently, there are no evidence-based clinical guidelines on pathological assessment of hernia sacs after pediatric inguinal hernia and hydrocele repair. Instead of making it mandatory, future guidelines should highlight specimens that should be submitted for further investigations (e.g., challenging cases where inadvertent surgical injuries might have occurred). Future studies should also address whether patients who may be at higher risk of having clinically significant pathology can be identified pre- or perioperatively to more efficiently triage specimens that would benefit from pathological examination. Limitation of the study includes low response rate from the CAPS members during the COVID-19 pandemic. CONCLUSIONS: While most of the pediatric urologists and surgeons felt there is a little value of pathological examination of hernia sacs following inguinal hernia and hydrocele repair, half of the anatomical pathologists felt there is value. Future studies should aim to establish evidence-based clinical guidelines taking stakeholders perspectives into consideration.

Pandemic's impact on inguinal hernia management in infants. / Impacto de la pandemia en el manejo de la hernia inguinal en lactantes.

INTRODUCTION: The SARS-CoV-2 pandemic brought about a reduction in surgical activity. The objective of this work was to analyze its impact on inguinal hernia morbidity. MATERIAL AND METHODS: A retrospective study of cases and controls was carried out. Patients under 18 months of age undergoing inguinal hernia surgery from January 1, 2019 to August 31, 2020 were included. They were divided into two groups: patients undergoing surgery before (group A) or after (group D) the state of alarm was declared in Spain. Primary variables: episodes of incarceration and postoperative complications. Secondary variable: urgent or scheduled surgery. Demographic variables: sex, gestational age (GA), previous pathologies, age at diagnosis (AD), and age at surgery (AS) (months). RESULTS: 64 patients were included - 43 in group A and 21 in group D. In group A, median GA was 37+3, 90.5% of patients were male, median AD was 2.33, and median AS was 3.27. In group D, median GA was 31+2, 72.1% of patients were male, median AD was 3, and median AS was 3.63. There were no statistically significant differences. However, differences in terms of previous pathologies were significant (16.3% for Group A vs. 38.1% for group D) (p = 0.05). Regarding the primary variable, 25.6% of patients in group A had incarcerations vs. 33.3% of patients in group D (p = 0.51), whereas 9.3% of patients in group A had postoperative morbidity vs. 14.3% of patients in group D (p = 0.41). Regarding the secondary variable, 88.4% of surgeries in group A were scheduled vs. 90.5% of surgeries in group D (p = 0.583). CONCLUSION: In spite of reduced surgical activity, inguinal hernia morbidity did not surge in our environment. An increase in patients with previous pathologies was noted, which means severe patients should be prioritized.

INTRODUCCION: La pandemia del SARS-CoV-2 supuso una reducción de las jornadas quirúrgicas. Analizamos el efecto en la morbilidad de la hernia inguinal. MATERIAL Y METODOS: Estudio retrospectivo de casos y controles. Incluimos menores de 18 meses intervenidos de hernia inguinal desde 01/01/2019 hasta 31/08/2020, divididos en 2 grupos: intervenidos antes (grupo A) o después (grupo D) de la declaración del estado de alarma. Variables principales: episodios de incarceraciones y complicaciones postoperatorias. Variable secundaria: intervención urgente o programada. Variables poblacionales: sexo, edad gestacional (EG), patología previa, edad al diagnóstico(ED) y a la intervención (EI) (meses). RESULTADOS: Incluimos 64 pacientes, 43 grupo A y 21 grupo D. En el grupo A la mediana de EG fue 37+3, el 90,5% fueron varones, la mediana ED fue 2,33 y EI 3,27. En el grupo B la mediana de EG fue 31+2, el 72,1% fueron varones, la mediana ED fue 3 y EI 3,63. No hubo diferencias estadísticamente significativas. Si fueron significativas las diferencias en patología previa 16,3% A y 38,1% D (p = 0,05). Sobre la variable principal: 25,6% del A sufrieron incarceraciones frente a 33,3% del D (p = 0,51) y un 9,3% tuvieron morbilidad postoperatoria en A frente a 14,3% en D (p = 0,41). Respecto a la variable secundaria un 88,4% se realizaron de forma programada en el grupo A y un 90,5% en el grupo D (p = 0,583). CONCLUSION: Pese a la reducción de jornadas quirúrgicas no ha aumentado la morbilidad de la hernia inguinal en nuestro medio. Hemos observado un aumento de pacientes con patología previa, implicando la priorización de los pacientes más graves.

Appropriate mesh size in the totally extraperitoneal repair of groin hernias based on the intraoperative measurement of the myopectineal orifice.

BACKGROUND: Insufficient coverage of the area of a possible groin hernia is an important risk factor in hernia recurrence. To prevent recurrence, it is important to use the appropriate mesh size based on the size of the myopectineal orifice (MPO), which is the weak area of the abdominal wall where inguinal hernias occur. We aimed to estimate the appropriate mesh size for groin hernias by investigating MPO size. METHODS: Four hundred and six patients underwent groin hernia repair using a totally extraperitoneal (TEP) approach at the Zeze Hospital between July 2009 and December 2017. We investigated patients' backgrounds, MPO components dimensions, and hernia recurrence, and evaluated the appropriate mesh size. RESULTS: The 359 male and 47 female patients had an average age of 63 ± 15 years. In 171, 147, and 88 cases, hernias were localized to the right, left, and bilaterally, respectively. The number of lateral, medial, femoral, and combined hernias was 317, 124, 11, and 42, respectively. The 95th percentile for the horizontal and vertical lengths in cases of hernia orifice ≥ 3 cm were 9.6 cm and 7.0 cm, respectively, while it was 9.2 cm and 6.4 cm in cases of hernia orifice < 3 cm. We added 2 cm and 3 cm to the 95th percentile for the length and width of the MPO, resulting in 13.2 × 10.4 cm and 15.6 × 13.0 cm in cases with hernia orifice < 3 cm and ≥ 3 cm, respectively. Relapse after TEP occurred in 1 patient (0.2%). CONCLUSION: The appropriate mesh size for TEP repair, derived from intraoperative MPO measurements, was estimated as 13.2 × 10.4 cm and 15.6 × 13.0 cm when the hernia orifice was < 3 cm and ≥ 3 cm, respectively. Using appropriate mesh sizes based on MPO measurement may reduce groin hernia recurrence after TEP.

Characteristics of laparoscopic and open hernia repair simulation models: a systematic review.

PURPOSE: Barriers to education in open and laparoscopic hernia repair technique include a steep learning curve and reduced theatre time for junior surgical trainees. This is particularly evident during the current COVID-19 pandemic. Simulation models may provide further opportunities for training in hernia repair outside of the traditional surgical apprenticeship model. METHODS: A systematic review was carried out following PRISMA guidelines to identify and evaluate simulation models in hernia repair. Of the 866 records screened, 27 were included in the analysis. These were assessed for face, content and construct validity, as well as their attempt to measure educational impact. RESULTS: Simulation models were identified comprising of animal tissues, synthetic materials and virtual reality (VR) technology. Models were designed for instruction in repair of inguinal, umbilical, incisional and diaphragmatic hernias. Twenty-one laparoscopic hernia repair models were described. Many models demonstrated validity across several domains, and three showed transferability of skills from simulation to the operating room. Of the six open hernia repair simulation models, none were found to have demonstrated an educational impact in addition to assessing validity. CONCLUSION: Few models individually were able to demonstrate validity and educational impact. Several novel assessment tools have been developed for assessment of progress when performing simulated and real laparoscopic inguinal hernia repair. More study is required, particularly for open hernia repair, including randomized controlled trials with large sample sizes to assess the transferability of skills.

Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter.

BACKGROUND: During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS: A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS: A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION: Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE: Epidemiological, level IV.

Rare encounter: hydrocoele of canal of Nuck in a Scottish rural hospital during the COVID-19 pandemic.

We report the case of a 32-year-old woman who presented with reducible indirect inguinal hernia and a challenging constellation of symptoms, signs and radiographic findings. Surgical approach superseded conservative management when the patient's abdomen became acute, with a rising lactate and haemodynamic instability. Specifically, the presence of a fluid collection was concerning for sinister acute pathology. Our patient was rediagnosed intraoperatively with hydrocoele of canal of Nuck. This so-called 'female hydrocoele' is an eponymous anatomical rarity in general surgery, presenting as an inguinolabial swelling with variable clinical profile. Hydrocoele of canal of Nuck takes origin from failure of transitory reproductive anlagen to regress and is thus analogous to patent processus vaginalis. Its true incidence is speculative, with just several hundred cases globally. We aim to provide insights into surgical patient management for a rare entity during the COVID-19 outbreak, from the unique perspective of a small rural hospital in Scotland.