Strangulated richter's hernia with caecum necrosis. Case report.

AIM: Describe a rare case of Richter's hernia with caecum incarceration into a right femoral hernia and provide a narrative literature review about its surgical management. MATERIAL AND METHODS: A 46-year-old woman presented to the Emergency Department and to our surgical unit with a two-days history of worsening abdominal pain in the right lower quadrant without nausea or vomiting, associated with an irreducible lump. Computed tomography of the abdomen described a right inguinal hernia containing small bowel with perivisceral fluid in it without signs of small bowel occlusion nor perforation. RESULTS: A Richter 's femoral hernia with necrotic caecum wall was found but the appendix was not involved. Through a mini-laparotomy, tangential caecal resection and appendectomy were performed. The femoral defect was repaired with a polypropylene mesh-plug placed in the pre-peritoneal space. Postoperative period was uneventful and the patient was discharged on the fifth post-operative day. DISCUSSION: Femoral hernias account for only 2-4% of all groin hernias and occur through a small fascial defect in the femoral canal. Due to its narrowness, it leads to a high risk of incarceration and strangulation thus explaining the increased mortality in the emergency setting (up to 10 fold compared with the elective repair). In some cases, symptoms are no specific and uncommon findings have been reported. Surgical exploration is mandatory in the presence of signs of bowel strangulation or perforation and different approaches (either open or laparoscopically) have been described in literature. CONCLUSIONS: Caecum wall necrosis secondary to an incarcerated Richter's femoral hernia is a rare but dangerous event. Surgical approach is selected on surgeon's expertise. The use of prosthetic mesh is always recommended. KEY WORDS: Bowel necrosis, Emergency surgery, Hernia repair, Richter's hernia.

A Case Report on Gallbladder Agenesis: Not a Novelty but Still a Laparoscopic Surprise.

Gallbladder agenesis (GA) is a rare embryological anomaly that presents acute cholecystitis like-symptoms. It is often an incidental finding diagnosed during surgery. We reported a case of GA in a patient who presented with dyspepsia and acute right upper abdomen pain with ultrasonographic signs of acute lithiasic cholecystitis. The preoperative assessment, according to first-level exams, is oriented to the diagnosis of acute lithiasic cholecystitis with atrophy and sclerosis. During laparoscopy, the proximal transverse colon was found strictly adherent to gallbladder fossa. The gallbladder was found to be absent. The surgical procedure consisted of lysis of multiple colo-hepatic adhesions. The diagnosis of congenital GA was made laparoscopically. The postoperative radiological images, based on CT and MR examinations, documented the diagnosis of GA with a biliary duct anatomical variant. The recovery was uneventful and the patient remained symptom-free for more than four years. GA is a clinical challenge that still poses diagnostic and therapeutic dilemmas. Although no diagnostic and therapeutic algorithm is accepted worldwide, due to heterogeneity of clinical scenarios and the variability in hospital facilities, surgeons have to be familiar with this rare entity, and conversion in laparotomy or unnecessary operative procedures should be avoided in the same operative setting.

[Primary inguinal hernia: Shouldice, Lichtenstein, Trabucco. Experience with 1,000 cases]. / Ernia inguinale primitiva: shouldice, lichtenstein, trabucco. Esperienza di 1.000 casi.

Inguinal hernia repair today offers several techniques, all of which are safe and capable of preventing recurrence. The authors review their experience with 1000 cases treated by the Lichtenstein, Trabucco and Shouldice techniques, analysing the technical features of each and the results achieved after a 2-year follow-up.

[Acute vascular abdomen: personal experience and review of the literature]. / Addome acuto vascolare: esperienza personale e revisione della letteratura.

Acute vascular abdomen presents an incidence of 1% of all cases of acute abdomen, but the mortality rate is high, ranging from 50 to 80%. Acute mesenteric ischaemia and rupture of abdominal aorta aneurysms are the most frequent causes. Prevention of causal agents and early diagnosis are the only elements capable of improving patient survival. The authors report their personal experience over the period from 1996 to June 2002, analysing different clinical cases of acute vascular abdomen and their diagnostic and therapeutic management and comparing their experience with the relevant literature data.

[Diverticulosis of the colon: complications of surgical interest]. / La diverticolosi del colon: complicanze di interesse chirurgico.

Diverticular disease is prevalently only of medical interest. Repeated episodes of diverticulitis, particularly in younger patients, and serious complications such as perforation, stenosis, fistula and haemorrhage demand surgical treatment. The timing and type of surgical operation are conditioned by the pathological picture and by the patient's general condition and age. The authors present a series of 586 patients admitted for diverticular disease, 84 of whom presented complicated diverticulosis. Nineteen cases (22.6%) underwent elective surgery in the form of an anterior rectal resection, while 65 of them underwent urgent surgery for complicated diverticulosis variously consisting in total colectomy, a Hartman's resection, a simple rectal resection or a left or right hemicolectomy.