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The falciform ligament is a remnant of the embryonic ventral mesentery containing the obliterated umbilical vein and round ligament. It extends from the umbilicus to the superior aspect of the diaphragm. We report about a 53-year-old fit and well patient who presented with acute upper abdominal pain with tenderness to palpation. Ultrasound scan was unremarkable, but blood tests revealed raised inflammatory markers. Thus, computed tomography was performed. This demonstrated acute torsion and fat necrosis of the falciform ligament, which was the aetiology of the upper abdominal pain. Such pathology is rare with 23 previously reported cases. Conservative management is usually proposed, but on occasion, surgical intervention may be warranted in cases that do not respond to initial supportive measures. We describe this case to demonstrate a rare cause of a common presentation to the surgical service.

De Garengeot hernia is a rare subtype of femoral hernia whereby the vermiform appendix is located within the hernial sac. Even rarer is the presence of appendicitis within the hernia sac. De Garengeot’s hernia is difficult to diagnose pre-operatively and can prove technically difficult at operation particularly with regards to mobilization of the caecum and appendix in order to perform appendicectomy. Laparoscopic, open, with and without mesh repair of de Garengeot hernia have all been described in the literature with varying degrees of success. We present a case of an 82 year old lady presenting with an acutely painful right sided groin lump. CT scan revealed the presence of de Garengeot hernia with acute appendicitis. We describe in text and photo format our approach to the hernia repair, appendicectomy and provide a short review of the literature with regards to the different operative approaches to such a patient.

BACKGROUND In an effort to further reduce the morbidity and mortality profile of laparoscopic cholecystectomy, the outcomes of such procedure under regional anesthesia (RA) have been evaluated. In the context of cholecystectomy, combining a minimally invasive surgical procedure with a minimally invasive anesthetic technique can potentially be associated with less postoperative pain and earlier ambulation. AIM To evaluate comparative outcomes of RA and general anesthesia (GA) in patients undergoing laparoscopic cholecystectomy. METHODS A comprehensive systematic review of randomized controlled trials with subsequent meta-analysis and trial sequential analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. RESULTS Thirteen randomized controlled trials enrolling 1111 patients were included. The study populations in the RA and GA groups were of comparable age ( P = 0.41), gender ( P = 0.98) and body mass index ( P = 0.24). The conversion rate from RA to GA was 2.3%. RA was associated with significantly less postoperative pain at 4 h [mean difference (MD): - 2.22, P < 0.00001], 8 h (MD: -1.53, P = 0.0006), 12 h (MD: -2.08, P < 0.00001), and 24 h (MD: -0.90, P < 0.00001) compared to GA. Moreover, it was associated with significantly lower rate of nausea and vomiting [risk ratio (RR): 0.40, P < 0.0001]. However, RA significantly increased postoperative headaches (RR: 4.69, P = 0.03), and urinary retention (RR: 2.73, P = 0.03). The trial sequential analysis demonstrated that the meta-analysis was conclusive for most outcomes, with the exception of a risk of type 1 error for headache and urinary retention and a risk of type 2 error for total procedure time. CONCLUSION Our findings indicate that RA may be an attractive anesthetic modality for day-case laparoscopic cholecystectomy considering its associated lower postoperative pain and nausea and vomiting compared to GA. However, its associated risk of urinary retention and headache and lack of knowledge on its impact on procedure-related outcomes do not justify using RA as the first line anesthetic choice for laparoscopic cholecystectomy.

We report a case of a 55-year-old man taxi driver admitted electively for high tibial osteotomy for relief of bilateral medial compartment osteoarthritis. He was obese and an ex-smoker but medical history was otherwise unremarkable. Day 1 postoperatively the patient started to suffer vomiting episodes and the abdomen was distended. C Reactive protein and white cell count were both elevated but other bloods were normal. CT abdomen and pelvis was performed which showed acute interstitial pancreatitis. Glasgow score was calculated as 2. He was treated aggressively with analgesia, intravenous fluid and intravenous antibiotics. He has made a good recovery following these conservative measures. To our knowledge, this is the first case in the literature reporting pancreatitis as a complication of high tibial osteotomy. This case highlights the importance of close monitoring for abdominal complications even in the setting of elective orthopaedic surgery where it is a rare phenomenon.

We report a 23 year-old male patient who presented to the emergency department with 2 days of central abdominal pain, with associated pyrexia, lethargy and nausea. Of note he had had COVID-19 in November 2020 which self-resolved. Examination revealed right sided abdominal and epigastric tenderness. His C-reactive protein was 302U/L but the remaining bloods unremarkable. The working diagnosis was unclear and a computed tomograph of the abdomen and pelvis arranged which revealed uncomplicated appendicitis with mesenteric lymphadenopathy. He underwent laparoscopic appendicectomy, revealing a macroscopically inflamed appendix without perforation or peritoneal contamination. Day 1 post-operatively, he deteriorated with acute hypoxia, tachypnoea and rigors. Additionally his inflammatory markers had increased. Respiratory physician advice was sought and an urgent computed tomograph pulmonary artertiogram performed, showing no pulmonary embolus but did show bilateral lower lobe consolidation and groundglass opacities in both lungs suspicious of COVID-19. Furthermore given his persistently low blood pressure, he underwent echocardiogram which revealed the presence of COVID-19 myocarditis and impaired left ventricular systolic dysfunction with an ejection fraction of 35%. He was admitted to the intensive care unit for blood pressure support and monitoring from a respiratory perspective. With such measures both his chest and cardiovascular function improved markedly and he was discharged on long-term cardioprotective medication. This highly rare long COVID-19 related complication following laparoscopic appendicectomy is highlighted for surgeons to be aware of and consider in cases of post-operative deterioration in patients with prior COVID-19 infection.

Septic arthritis of the manubriosternal joint is a rare pathology, often mistaken for other disease processes given its location and chest pain symptoms. We present a case of a 58-year-old man presenting with a dull ache in his chest after returning from a holiday. Initially under the care of the physicians locally, he was investigated for respiratory and cardiac causes of chest pain with no findings. Eventually, a lump was noted on examination of the chest prompting further imaging, which confirmed a diagnosis of manubriosternal septic arthritis. He was discussed and referred to tertiary cardiothoracics, who recommended conservative treatment with 6 weeks of antibiotics. To date, there has been a good recovery. We present this case alongside a discussion of the limited literature, in particular highlighting how difficult a diagnosis it is to make but one that surgeons and medics alike should be aware of.

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