The methods commonly used to guide surgical excision of impalpable breast lesions include preoperative placement of hookwires, carbon injections, and, more recently, radioisotope injections. However, all of these techniques have disadvantages, not the least of which is subjecting the patient to an additional stressful and often traumatic procedure preoperatively. The use of intraoperative ultrasound to guide the excision of sonographically visible impalpable lesions is a new technique that avoids the need for a preoperative localization procedure. This report describes one of the author's (I.B.) personal series of ultrasound-guided breast excisions, collating data collected prospectively, and reviews the efficacy of this technique. Data in relation to 115 ultrasound guided breast excisions performed in 103 patients were reviewed. The technique of using a high-frequency real-time ultrasound probe intraoperatively to localize and guide excision of breast abnormalities is described. There were no failed excisions, as confirmed by specimen sonography, pathology findings, and/or follow-up ultrasound. Breast malignancies comprised 42% of all excised lesions, and of these, adequate margins of excision were achieved at the first operation in 93% of cases. Direct ultrasound localization of the lesion at the time of surgery allowed optimal placement of the incision and eliminated delays in operating time because specimens did not have to be sent to the Radiology Department for confirmation of excision. Intraoperative ultrasound-guided excision is a safe and efficient technique in the management of impalpable, sonographically visible breast lesions, and early reports in the world literature support the findings of this series, which show it to have significant advantages over other current methods, particularly with respect to a reduction in patient anxiety and improved surgical resection margins.

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A 30-year-old woman was referred for a surgical review with abdominal pain and distension 2 days post-caesearean section. Abdominal X-ray showed dilated bowel loops. CT of her abdomen however showed fat stranding around a thickened appendix, suggesting a differential diagnosis of acute appendicitis on top of a postoperative ileus. Failure to respond to intravenous antibiotics led to an emergent surgical exploratory laparotomy, by which time the progressive caecal dilatation had led to patchy necrosis and perforation of the right hemicolon intra-operatively. The patient required a right hemicolectomy and histological examination of the excised bowel supported the diagnosis of Ogilvie’s syndrome. This case highlights the red herrings that one can encounter when faced with a woman with post-caesarean section abdominal pain and aims to raise awareness among clinicians of this condition—where timely diagnosis and management is key.

Traumatic diaphragmatic injuries (TDI) are often challenging to diagnose. Research suggests that no single diagnostic study is sensitive or specific enough to identify such an injury, unless there is established herniation of intrabdominal contents. It is a rare cause of small bowel obstruction, which carries a substantial mortality rate. This report describes a case of a 41-year-old pregnant female who presented with irretractable vomiting and abdominal pain secondary to a delayed presentation of right-sided TDI. The most accepted mechanism regarding TDI is due to sudden elevation in the pleuroperitoneal pressure gradient. This case is unusual given its mechanism of injury during pregnancy and its right-sided location. She underwent laparoscopy which facilitated successful reduction of the hernial and closure of the defect. Postoperatively, she made an excellent recovery and was discharged within a few days. This report aims to increase the awareness amongst surgeons.

Incarcerated diaphragmatic hernias are often challenging to diagnose. 1 Patients often present with non-specific abdominal symptoms, and barring an imaging modality that confirms herniation of intra-abdominal contents, there is no investigation sensitive or specific enough to identify it. It is a rare cause of mechanical bowel obstruction that clinicians should be aware of. This report describes a case of an 81-year-old man who presented to the emergency department with ongoing dyspnoea and constipation secondary to a partial large bowel obstruction due to an incarcerated Morgagni hernia. This case highlights the non-specific symptoms of this condition that often leads to a delayed diagnosis and aims to increase the awareness among clinicians.