Ipsilateral Spigelian hernia: just an infrequent variant?

Spigelian hernias are generally considered to occur through solitary defects in the fascial layers of the anterior abdominal wall in the 'Spigelian hernia belt' but can be found anywhere along the line of the linea semilunaris. They are uncommon in children and in adults thought to be acquired and associated with obesity. We describe an unusual case of Spigelian herniation previously unreported and possibly previously unrecognised.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty.

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

Perineal Richter's herniation following proctectomy.

In a Richter's hernia, only part of the anti-mesenteric border of the bowel is incarcerated within the underlying defect. We report three cases presenting between 18 days and 11 years following proctectomy. As all patients had functioning stomas a high index of suspicion is necessary to avoid a delay in diagnosis.

Gallstone ileus in an 'asymptomatic' parastomal hernia.

Parastomal hernias are common and often asymptomatic. We report the first known case in which later, acute symptoms developed owing to gallstone ileus in a sac containing both omentum and small bowel. Urgent computed tomography established the diagnosis.

Peritoneal mesothelioma masquerading as an inguinal hernia.

We report a case of an 80-year-old man who presented with a right inguinal hernia that appeared incarcerated. On exploration a sausage shaped mass was found in the sac, which was debulked and histologically shown to be a well differentiated malignant peritoneal mesothelioma. Rare tumours may present as inguinal hernias and palliative debulking may be effective when they present in inguinal hernia sacs.

Peritoneal mesothelioma masquerading as an inguinal hernia.

We report a case of an 80-year-old man who presented with a right inguinal hernia that appeared incarcerated. On exploration a sausage shaped mass was found in the sac, which was debulked and histologically shown to be a well differentiated malignant peritoneal mesothelioma. Rare tumours may present as inguinal hernias and palliative debulking may be effective when they present in inguinal hernia sacs.

Groin symptoms 5-7 years after a 'modified' plug and patch inguinal hernioplasty.

BACKGROUND: Chronic groin symptoms after inguinal hernia repair are recognised as a frustrating problem for patients and surgeons alike. The aim of our study was to determine the frequency and severity of groin symptoms 5-7 years after a 'modified' mesh-plug inguinal hernia repair. METHODS: Male patients undergoing a 'modified' mesh plug inguinal hernioplasty in 2002 and 2004 were investigated by means of a 'patient friendly' questionnaire evaluating the frequency and severity of groin 'discomfort' and 'pain'. RESULTS: Two hundred consecutive unselected men who had a hernia repair in 2002 (n = 89) and 2004 (n = 111) were sent a questionnaire of which 57% and 78%, respectively, replied. Significant groin discomfort, irrespective of frequency was described by three (6%) and four (5%) patients, respectively. Significant groin pain of varying severity and frequency was documented by five (6%) patients 5 years after operation and in two or 4% of patients 7 years after surgery. Overall, only four patients (3%) said their symptoms restricted their daily activity. Excluding 13 patients who had already had inguinal surgery on the other side, over 99% (105/106) of our respondents would undergo a similar future procedure on the opposite groin. This included all but one of those who had described discomfort or pain after their hernioplasty. CONCLUSION: Significant restricting groin symptoms were uncommon. None of our patients would decline similar surgery on a contralateral hernia, suggesting a negligible impact of symptoms on their daily lives. A well dissected 'modified' mesh plug inguinal hernioplasty is associated with minimal chronic groin symptoms 5-7 years later.