Initiatives are required to improve awareness of younger people with regard to lifestyle risk factors for CRC, especially since this group stand to benefit most from risk reduction. Those with a lower educational level also had poor awareness but felt that the NHS should not prescribe exercise and lifestyle change; targeting this group would need to take this into account.

HighlightsCholecystectomy is a common procedure increasingly performed in the day surgery setting.A true left sided gallbladder is a rare finding. Retrospective studies suggest a prevalence of 0.1–0.7%.Exact aetiology and pathway for its anatomical variation is has yet to be determined.It can be associated with number of other structural variation affect the biliary system the knowledge of which is paramount in hepatobiliary surgery.

Obturator hernias are rare and are often diagnosed late. This case report discusses an 82-year-old female who had symptoms of subacute bowel obstruction. Following a computed tomography abdomen pelvis, she underwent a laparotomy for an incarcerated right obturator hernia. The hernia was repaired using a single suture and she made a good recovery. A review of the literature around obturator hernias is discussed.

Ann R Coll Surg Engl 2010; 92:1 Broad ligament defects are rare, and are most commonly described in association with bowel obstruction secondary to intestinal herniation. Internal hernias account for less than 1% of all hernias; of these 4-7% involve the broad ligament. 1 Defects are mostly unilateral. Only seven cases of bilateral defects have been reported since 1925, all involving small bowel herniation. We identified six previous cases of colonic herniation through unilateral defects. 2,3 Broad ligament defects are classified as congenital and acquired. 4 In our case, the concurrent diagnosis of phocomelia, in the absence of any surgical, obstetric or gynaecological insult supports a congenital aetiology.This report describes the first case of caecal herniation with concurrent appendicitis in a patient with bilateral broad ligament defects. Case historyA 36-year-old woman with phocomelia, gravida 0 para 0, presented with right iliac fossa pain and vomiting. She had no additional medical history.On examination, she was apyrexial with a mildly distended abdomen and tenderness in the right iliac fossa. The white cell count and C-reactive protein level were slightly elevated. Abdominal ultrasound revealed a small amount of free fluid in the right iliac fossa; the appendix was not visualised, and the uterus and adnexae appeared normal.At diagnostic laparoscopy, an acutely inflamed appendix and bilateral large defects of the broad ligament were identified. The Internal herniations through broad ligament defects are very rare. We present the first report of the triad of broad ligament defect, internal herniation of the caecum and appendicitis. A 36-year-old woman with phocomelia presented with right iliac fossa pain and vomiting. The patient had no previous history of trauma or surgery. Abdominal ultrasound showed a small amount of free fluid. At laparoscopy, bilateral broad ligament defects were found, with herniation of the caecum and an inflamed appendix through the right-sided defect. A laparoscopic salpingo-oophorectomy was required for reduction of the herniated bowel, and an appendicectomy was performed. Broad ligament defects may be congenital or acquired. In this case, in light of the limb abnormality and absence of previous surgery, a congenital aetiology is more likely. Ultrasound scan is not reliable and, although computed tomography may be of help, a diagnostic laparoscopy is the best investigation. Figure 1 The right-sided broad ligament defect. The caecum and base of the appendix have herniated through the defect (lying to the left of the image). The tip of the appendix has passed back through the defect but it is not possible to reduce the hernia due to a tight constricting band (between the two instruments). ON-LINE CASE REPORTAnn R Coll Surg Engl 2010; 92:

We present a rare case of Amyand’s hernia that was surgically managed using an open repair of hernia combined with laparoscopic appendicectomy. A 68-year-old man presented with an irreducible recurrent right-sided inguinal hernia and abdominal pain. This gentleman had undergone three previous inguinal hernia repairs on the right, and one on the left using the open mesh technique. Ultrasound suggested the possibility of the appendix within the hernial sac and clinical correlation was advised. An open groin approach was taken to repair the incarcerated hernia. This revealed an indirect inguinal hernia containing the appendix with signs of inflammation. The base of the appendix was not visible due to there being a long appendix with fixed cecum in the abdomen. To safely resect the appendix, a laparoscopy was performed and the appendix was successfully removed. The inguinal hernia was repaired using a sutured technique without mesh. There were no post-operative complications.

We describe a highly unusual case of solitary rectal ulcer syndrome (SRUS) that presented as a large polyp protruding from the anal canal. A 67-year-old man presented with rectal bleeding and mucus discharge. At examination under anaesthesia, a large pedunculated polypoidal lesion was found, measuring 25 × 20 mm, arising posterolaterally from the anorectal junction and protruding externally 50 mm in size. SRUS can be a misnomer as the condition can present in a number of different ways and only a minority of patients has a solitary ulcer. Other findings include multiple ulcers, hyperaemic mucosa or a broad-based polypoidal mass. In this case, a rare presentation of SRUS in the form of a large polyp was confirmed by histology. A key learning point is to remember that although less common than other causes of rectal symptoms, it should be considered as part of the differential diagnosis once sinister causes have been excluded.

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