Right Recurrent Femoral Hernia with Left Inguinal Hernia - A Case Report

Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, they occur approximately 10 times as frequently in women than in men because of the wider bone structure of the female pelvis³. Femoral hernias develop in the upper part of the thigh near the groin just below the inguinal ligament, where abdominal contents pass through a naturally occurring weakness called the femoral canal. Femoral hernia have the highest rate of incarceration amongst groin hernia, 5%–20%⁵

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.

Systematic use of transvaginal hydrolaparoscopy as a minimally invasive procedure in the exploration of the infertile patient: results and reflections

Background: The aim of this study was to evaluate the added value of transvaginal hydrolaparoscopy (THL) in the investigation of the infertile patient. Methods: A retrospective cohort study, based on records from 01/09/2006 to 30/12/2019 was undertaken in a tertiary care infertility centre. THL was performed in 2288 patients. These were patients who were referred for endoscopic exploration of the female pelvis as part of their infertility investigation. In 374 patients with clomiphene-resistant polycystic ovary syndrome (PCOS), ovarian capsule drilling was also performed. The outcome objectives of this study included the evaluation of the added diagnostic value of THL as well as the feasibility and safety of the visual inspection of the female pelvis using this technique. Results: Of the 2288 procedures failed access to the pouch of Douglas occurred in in 23 patients (1%). The complication rate was 0.74%, due to bowel perforations (n= 13) and bleeding (n= 4) requiring laparoscopy. All bowel perforations were treated conservatively, with 6 days of antibiotics, and no further complications occurred. Findings were normal in 49.8% of patients. Endometriosis was diagnosed in 366 patients (15.9%); adhesions were present in 144 patients. Conclusions: THL is a minimally invasive procedure, with a low complication and failure rate, providing an accurate visual exploration of the female pelvis in a one-day hospital setting. When indicated, minimally invasive surgery is possible in the early stages of endometriosis and for ovarian capsule drilling in patients with clomiphene-resistant PCOS.

Optimization of follow-up MRI protocol for malignant neoplasms of the female pelvis

Introduction. MRI is widely used to follow-up malignant neoplasms of the female pelvis. Aim. To optimize the use of MRI sequences for follow-up of female patients with malignant pelvic neoplasms. Materials and methods. Retrospective analysis of female pelvic MRI has been performed on 1.5 T MR scanner. This study includes 530 protocols. Results. The authors describe different protocols for assessment and differential diagnosis of recurrence, postradiation and postoperative changes. It includes applicable sequences, axis and the structure which require evaluation. In all cases, dynamic follow-up has to include analysis of patient's previous studies, anamnesis, previous treatment, as well as the end of chemotherapy and radiotherapy. All of the above, combined with the oncologist's treatment of choice determines the objective of this study. Nowadays, MRI is the method which most accurately characterizes postoperative and postradiation structural changes. MRI is useful in detection of pelvic lymph nodes. The role of MRI has high potential in assessing the effectiveness of chemotherapy and radiation therapy. Conclusion. In order to make the optimal scan protocol, follow-up of malignant neoplasms of the pelvic organs in women require the use of clinical and anamnestic data along with the results of patient's previous studies. The combined use of various sequences and techniques can improve the diagnostic significance of pelvic MRI at follow-up. Contrast enhancement has additional role in diagnostics of recurrent of pelvic organs in women. The use of different contrast enhancement techniques has proven effective in case of postradiation and postoperative complications.

Comparison between turbo spin-echo and echo planar diffusion-weighted imaging of the female pelvis with 3T MRI

Background Echo-planar imaging (EPI)-diffusion-weighted imaging (DWI) may take unclear image affected by susceptibility, geometric distortions and chemical shift artifacts. Purpose To compare the image quality and usefulness of EPI-DWI and turbo spin echo (TSE)-DWI in female patients who required imaging of the pelvis. Material and Methods All 57 patients were examined with a 3.0-T MR scanner. Both TSE- and EPI-DWI were performed with b values of 0 and 1000 s/mm2. We compared geometric distortion, the contrast ratio (CR) of the myometrium to the muscle and the apparent diffusion coefficient (ADC) values for the myometrium and lesion. Two radiologists scored the TSE- and EPI-DWI of each patient for qualitative evaluation. Results The mean percent distortion was significantly smaller with TSE- than EPI-DWI ( p = 0.00). The CR was significantly higher with TSE- than EPI-DWI ( p = 0.003). There was a significant difference in the ADC value for the uterus and lesions between the EPI- and TSE-DWI ( p < 0.05). Finally, the ADC values of cancer were significantly different from those for the uterus and benign with both the two sequences ( p < 0.05). The scores for ghosting artifacts were higher with TSE- than EPI-DWI ( p = 0.019). But there were no significant differences between TSE- and EPI-DWI with regard to image contrast and overall image quality. Conclusion TSE-DWI on the female pelvis by 3T MRI produces less distortion and higher CR than EPI-DWI, but there is no difference in contrast and image quality.

Multimodality imaging review of complex pelvic lesions in female pelvis

Complex pelvic lesions can originate from various anatomical structures in the pelvis and pose a diagnostic dilemma due to a wide range of possible diagnoses. Accurate characterisation of these lesions would often require an algorithmic approach, which incorporates clinical findings, sequential use of multiple imaging modalities and a multiparametric approach. This approach usually aims at identifying key imaging features, which aid in anatomical localisation, morphology and tissue characterisation. There have been various attempts to standardise the lexicon used for describing adnexal masses in female patients; stratify their risk of cancer and suggest appropriate next steps in the management pathway. Through this review, we extend this approach to complex pelvic masses in female pelvis in general and will focus on optimal use of different imaging modalities to arrive at definitive diagnosis or meaningful differential diagnosis. We will also discuss potential pitfalls of imaging diagnosis and common mimics.