The proportion of femoral herniae presenting as emergencies remained unchanged. This accounts for the morbidity and mortality in femoral surgery, which remains high and similar to a decade ago. Early diagnosis by clinicians and general practitioners and elective surgery are required to reduce mortality. Further investigation into the effect of the opposition technique on femoral vein compression and deep venous thrombosis is warranted.

INTRODUCTION The aim of this study was to assess the value of the Hardman Index and the Glasgow Aneurysm Score in predicting postoperative mortality in patients with ruptured abdominal aortic aneurysm (rAAA), and to assess the correlation between the two. PATIENTS AND METHODS Patients admitted with rAAA were identified from a hospital database. Hospital records were reviewed and a retrospective Hardman Index and Glasgow Aneurysm Score was calculated. Poor postoperative prognosis was considered at a Glasgow Aneurysm Score > 95 or a Hardman Index ≥ 3. RESULTS A total of 96 patients with a median age of 77.5 years (interquartile range, 71-83 years) and a male:female ratio of 2:1 were identified. Of these, 37 patients were not offered surgery and this was associated with 100% mortality. Of the 59 operated patients, 36 (61%) patients died postoperatively. Operated patients had a median Glasgow Aneurysm Score of 91 (interquartile range, 77-101) and a Hardman Index of 2 (interquartile range, 1-2). In this group, a Glasgow Aneurysm Score > 95 or a Hardman Index ≥ 3 was not associated with mortality (P = 0.10 and P = 0.79, respectively). Correlation between the scoring systems was poor (+0.42 τ b ). CONCLUSIONS The scoring systems assessed did not help predict the outcome of rAAA surgery, and correlated poorly with each other. They do not aid clinical judgement. GATT GOLDSMITH MARTINEZ et al.

A 53-year-old man with known situs inversus totalis (SIT) presented to out-patients with pains in his left upper quadrant. He was a diet-controlled diabetic. An upper abdominal ultrasound scan confirmed a left-sided liver and gallbladder containing numerous calculi. Liver function tests were normal and a laparoscopic cholecystectomy was performed. Operative techniqueThe patient was placed in the supine position with slight head-up and right tilt to improve visualisation. Two surgeons, both right-handed, were positioned to the right of the patient. The monitor was at the head of the patient on his left side. Four ports were used in total. A 10-mm camera port was inserted infra-umbilically and an additional 10-mm port in the subxiphoid area in the midline. A 30-degree camera was used. Two 5-mm ports were inserted in the left subcostal region at the mid-clavicular and the anterior axillary lines (Fig. 1).Initial laparoscopy confirmed SIT. The caecum was positioned on the left, the spleen on the right and liver on the left together with the gallbladder (Fig. 2). The left anterior axillary line port was used to grasp the gallbladder fundus and provide cephalic traction. Hartmann's pouch was dissected using a grasper from the subxiphoid port and hook diathermy via the left midclavicular line port (Figs 3 and 4).Dissection of Calot's triangle proved straightforward. The dissection was carried out through the left midclavicular line port with the dominant hand and clips were applied to the cystic artery and cystic duct through the subxiphoid port. There was no associated aberrant biliary anatomy encountered. The gallbladder was delivered through the subxiphoid port using an Endocatch ® retrieval bag. Laparoscopic cholecystectomy in situs inversus

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A 78-year-old lady presented with signs and symptoms of a strangulated femoral hernia. Peri-operatively she was found to have appendicitis within the hernia sac. Appendicectomy and non-mesh hernia repair were performed. Histology revealed acute inflammation and a villous adenoma of the appendix. Villous adenomas of the vermiform appendix are extremely rare tumours of the gastrointestinal tract. This is the first case combining two very rare pathologies--acute appendicitis presenting as strangulated femoral hernia and villous adenoma of the appendix. Early diagnosis and surgery are required to avoid high morbidity of perforated appendicitis within a femoral hernia. First, we discuss the diagnosis and surgical treatment of acute appendicitis within a femoral hernia. Second, the presence of an adenoma changes the aetiology of appendicitis. More importantly, changes in surgical management of acute appendicitis presenting as a strangulated femoral hernia owing to a co-existing adenoma are discussed.