Introduction and importance Amyand's hernia (AH) is a form of inguinal hernia which is consider as very rare and this type of hernia occurred up to 1% of all inguinal hernia cases. In this type of inguinal hernia, the content of hernia sac is appendix. Most patient with AH often remains asymptomatic and diagnosed intraoperatively. The diagnosis is challenging, since needs a high index of suspicion and imaging is key. Surgery is the mainstay management. We report a case of Amyand's hernia that was managed operatively in our medium complex public institution. Case presentation A 28 year's old man with normal body mass index (BMI) who had a history of right-side reducible linguino-scrotal swelling for 8 years, was admitted for elective right inguinal hernia repair. Two weeks back before admission, he noticed that swelling was slightly painful. Ultrasound of the abdomen reported normal findings. There was no history of abdominal pain and vomiting. Laboratory parameters were within normal limit. So, with a diagnosis of right sided partially reducible, incomplete, and indirect inguinal hernia, patient was operated for open hernia repair surgery, intra operatively we found dense adhesions within the sac, adhesions were released which revealed herniation of appendix into the inguinal canal. Appendix was mildly congested without gross evidence of inflammation. Hence, in view of noninflamed appendix, preperitoneal mesh (polypropylene) hernioplasty from Lichtenstein tension-free mesh repair was performed with appendicectomy. Postoperative period was uneventful, patient discharged at second day. Clinical discussion Amyand's hernia is very uncommon and characterized by the presence of the appendix in the hernia sac and it is 0.4–1% of all inguinal hernia cases, literature review also showed that incidence of Amyand's hernia is very rare, whereas only 0.1% of cases complicate into acute appendicitis due to late presentation and missed diagnosis. Conclusion Amyand's hernia (AH) makes up only a small proportion of most inguinal hernia cases, and its diagnosis is usually based on incidental finding intra-operatively. This condition may remain asymptomatic and behave like a normal inguinal hernia. Management of this type of hernia should be individualized according to appendix's inflammation stage, presence of abdominal sepsis and co-morbidity. With this approach it enables surgeons to manage more variations of Amyand's hernia. Laparoscopy for dealing Amyand's hernia is frequently diagnostic as well as therapeutic.

Background: One of the most commonly performed surgeries globally is Laparoscopic Cholecystectomy (LC) which is the gold standard surgical procedure for removal of gallbladder. It provides numerous benefits over open cholecystectomy but has also shown higher complication rates. Therefore, a system devised for pre operative assessment of intra operative difficulty level of Laparoscopic Cholecystectomy should be adopted to help with preparedness for complications and ensure an efficient course of surgery. Objective: The aim of this study was to validate a scoring system made by Randhawa Et al to assess intra operative difficulty level of Laparoscopic Cholecystectomy preoperatively. Study Design: This is a non randomized prospective observational study Methodology: This study was conducted in the department of general surgery unit 2 at Dow University Hospital, Karachi, Pakistan on 202 patients. Age, gender, BMI, history of previous hospitalization, examination finding of palpable gallbladder, previous abdominal surgery scars and sonographic findings including wall thickness of gallbladder, pericholecystic collection and impacted stone were considered to score a patient preoperatively. Results: Male gender and presence of pericholecystic fluid collection were found to be statistically significant in predicting intraoperative difficulty in patients undergoing laparoscopic cholecystectomy. Practical implications: Around 7 to 35% of laparoscopic cholecystectomy ends up getting converted into open cholecystectomy. This could be due to various reasons one of which is due to lack of preparedness for intraoperative difficulty in performing the surgery. For this reason, a scoring system that accurately predicts difficulty of surgery could help reducing this rate. Keeping this benefit in mind, a preformed scoring system was tested for its validity in assessing the intraoperative difficulty level of LC preoperatively. Keywords: Laparoscopic cholecystectomy, Scoring system, complications

Persistent Mullerian Duct Syndrome (PMDS) is a rare disorder of defective sexual development in males. It is characterized by aberrant synthesis or inadequate action of Mullerian inhibiting factor resulting in derivatives of Mullerian duct, i.e. uterus, fallopian tube and upper vagina, to persist in a phenotypic male with 46XY karyotype. Here, we report a 19-year-old male with bilateral undescended testes. Further evaluation revealed that the patient had both his testes placed intra-abdominally along with a rudimentary uterus.

Introduction: Splenic pseudo cysts are extremely uncommon. Most of these cysts are asymptomatic and may result from previous blunt abdominal trauma. We report an interesting uncommon case of a large splenic pseudo cyst without a history of previous abdominal trauma. Case Presentation: 44 years old female with normal BMI, married, non-smoker, non-alcoholic, and housewife. She had no past medical or surgical history and was not on any oral medications. She presented with upper abdominal pain and discomfort for 6 months. Irregular pain with mild intensity associated with shortness of breath, her physical examination was unremarkable. The abdominal ultrasound and contras-enchased CT showed a large splenic cyst occupying the lower pole of the spleen, Echinococcus multilocularis antibody test was negative (Titer<1:16), Thus the Echinococcosis was excluded from the differential diagnosis. The differential diagnosis, in this case, was a non-parasitic splenic cyst. The patient underwent elective diagnostic laparoscopic with laparoscopic splenectomy. Discussion: The patient had an uneventful postoperative recovery course. He was discharged from the hospital on the third postoperative day (within the expected time frame), and instructed to avoid heavy lifting for a few months and to complete the post-splenectomy vaccination protocol. Conclusion: Pseudocyst of the spleen is quite uncommon in routine clinical practice and should be differentiated from more common lesions such as hydatid cysts, abscess of the spleen, etc. The Pseudocyst of the spleen is usually asymptomatic and is detected incidentally during the abdominal scan for other reasons. Splenectomy is the gold standard treatment for splenic pseudocysts. Partial splenectomy is the recommended procedure if at least 25% of splenic parenchyma is achievable.