Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Motor Vehicle Collision Patient with Simultaneous Duodenal Transection and Thoracic Aorta Injury: A Case Report and Review of the Literature Mon, 26 Jan 2015 08:17:17 +0000 Blunt polytrauma can present complex management decisions. Here we report the case of a 31-year-old male involved in a high speed motor vehicle collision resulting in both duodenal and thoracic aorta injury that was managed collaboratively between the trauma, vascular, and cardiothoracic surgical teams. The patient went on to a full recovery. We also review the management of such injuries which has evolved over the past two decades resulting in less morbidity and mortality. Charlie Chen, Kevin Schuster, and Bishwajit Bhattacharya Copyright © 2015 Charlie Chen et al. All rights reserved. Voluminous Omental Inflammatory Myofibroblastic Tumor in an Elderly Man: A Case Report and Literature Review Thu, 22 Jan 2015 09:06:20 +0000 Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm of intermediate biologic potential, with uncertain etiology. This tumor occurs primarily in the lung, but the tumor may affect any organ system. A 75-year-old male was evaluated for voluminous palpable high abdominal mass with continuous and moderately abdominal pain, associated with abdominal distension for the last two months. Abdominal computed tomography showed a large ( cm) heterogeneously enhanced mass with well-defined margins. At surgery, the mass originated from the greater omentum was completely excised. Histologically the tumor was a mesenchymal neoplasm in smooth muscle differentiation and was characterized by spindle-cell proliferation with lymphocytes, plasma cells, and rare eosinophils. Immunohistochemically, the tumor cells were positive for vimentin and smooth muscle actin and negative for anaplastic lymphoma kinase. Complete surgical resection of IMTs remains the mainstay of treatment associated with a low rate of recurrence. Final diagnosis should be based on histopathological and immunohistochemical findings. Appropriate awareness should be exercised by surgeons to abdominal IMTs in combination with constitutional symptoms, abnormal hematologic findings, and radiological definition, to avoid misdiagnosed. Pasquale Cianci, Antonio Ambrosi, Alberto Fersini, Nicola Tartaglia, Vincenzo Lizzi, Francesca Sanguedolce, Antonina Parafioriti, and Vincenzo Neri Copyright © 2015 Pasquale Cianci et al. All rights reserved. Aneurysmal Rupture of a Mesodiverticular Band to a Meckel’s Diverticulum Wed, 21 Jan 2015 07:37:10 +0000 Aneurysmal rupture of a mesodiverticular band has not previously been reported in the clinical literature. We are reporting a case of hemoperitoneum in a 51-year-old male after an aneurysmal rupture of a mesodiverticular band. This case demonstrates that in rare instances, a rupture of the mesodiverticular band leading to Meckel’s diverticulum can lead to significant hemoperitoneum. This is usually caused by a traumatic injury but in our case was apparently caused by an aneurysm of the mesodiverticular artery. Patients with known Meckel’s diverticula should be aware of the possibility of rupture, as should clinicians treating those with a history of this usually benign congenital abnormality. Rapid surgical intervention is necessary to repair the source of bleeding, as massive blood loss was encountered in this case. Christian Sommerhalder, Kenneth R. Fretwell, Gregory G. Salzler, John M. Creasy, R. Jonathan Robitsek, and Sebastian D. Schubl Copyright © 2015 Christian Sommerhalder et al. All rights reserved. Endometriosis of the Vermiform Appendix within a Hernia Sac Infiltrating the Pubic Bone Mon, 19 Jan 2015 09:47:58 +0000 Purpose. Appendicular endometriosis mimicking appendicitis is a rare finding. Inguinal tumor in the course of appendicular endometriosis located within an inguinal hernia sac and infiltrating the periosteum of the pubic bone has not yet been described. Case Report. This paper describes a case of a rapidly enlarging, solid, unmovable, very painful upon palpation inguinal tumor, in a 36-year-old nulliparous woman. During surgery, a hard (approximately 4 cm in diameter) tumor infiltrating the periosteum of the right pubic bone and continuous with the inguinal hernia sac was dissected. The distal segment of the vermiform appendix was an element of the dissected tumor. Histological examination revealed endometriosis of the distal vermiform appendix. After 6 months of hormone treatment, she was referred for reoperation due to tumor recurrence. Once again histological examination of the resected tissue revealed endometriosis. There was no further recurrence of the disease with goserelin therapy. In addition to the case report, we present a review of the literature about endometriosis involving the vermiform appendix and the inguinal canal (Amyand’s hernia). Conclusion. This case expands the list of differential diagnoses of nodules found in the inguinal region of women. Damian Ziaja, Tomasz Bolkowski, Krzysztof Januszewski, Wioletta Skrzypulec-Plinta, Jerzy Chudek, and Krzysztof Ziaja Copyright © 2015 Damian Ziaja et al. All rights reserved. Primary Adrenal Leiomyosarcoma in an Arab Male: A Rare Case Report with Immunohistochemistry Study Mon, 19 Jan 2015 08:20:02 +0000 Primary adrenal leiomyosarcoma is a rare form of adrenal mesenchymal tumors. Immunohistochemistry (IHC) together with histology takes a major role in determining the tumor type and predicting their biological behavior and differentiating them from adrenal cortical carcinoma. Appropriate radiological investigation is necessary to rule out metastatic disease from primary tumors elsewhere in the body. In this case, we report a primary leiomyosarcoma of the adrenal gland in a 61-year-old Bahraini male clinically presumed to be a renal neoplasm. Veena Nagaraj, Mohammed Mustafa, Essa Amin, Waleed Ali, Shamil Naji Sarsam, and Abdulla Darwish Copyright © 2015 Veena Nagaraj et al. All rights reserved. A Rare Combination of Ovarian and Uterine Leiomyomas with Goblet Cell Carcinoid of the Appendix Mon, 19 Jan 2015 05:55:25 +0000 We present a case of the rare combination of unilateral ovarian leiomyoma, uterine leiomyoma, and goblet cell carcinoid tumor of the appendix in a premenopausal woman who presented with right iliac pain. Immunohistochemistry study for desmin (muscle marker) and chromogranin and synaptophysin (neuroendocrine markers) confirmed immunophenotyping origin. Interestingly, both tumors showed positive reaction for estrogen receptor. To our knowledge, such a combination has not been reported previously in the literature. In this paper, the pathogenesis and differential diagnosis of both types of tumors are discussed. Abdulrahman F. Al-Shaikh, Abdulla Darwish, Veena Nagaraj, and Abeer Alsada Copyright © 2015 Abdulrahman F. Al-Shaikh et al. All rights reserved. Immediate Postoperative Pain: An Atypical Presentation of Dropped Gallstones after Laparoscopic Cholecystectomy Wed, 14 Jan 2015 11:23:01 +0000 Cholecystectomy is one of the most commonly performed surgical procedures in the United States. A common complication is dropped gallstones, and the diversity of their presentation poses a substantial diagnostic challenge. We report the case of a 58-year-old man presenting with chronic right upper quadrant hours status post cholecystectomy. Imaging demonstrated retained gallstones in the perihepatic space and symptoms remitted following their removal via laparoscopic operation. Gallstones are lost in roughly 1 in 40 cholecystectomies and are usually asymptomatic. The most common presentations are months or years status post cholecystectomy due to fistula, abscess, or sinus tract formation. We report this case hoping to bring light to a rare presentation for dropped gallstones and provide advice on the management of this common complication of cholecystectomy. Samba Binagi, Jason Keune, and Michael Awad Copyright © 2015 Samba Binagi et al. All rights reserved. A Challenging Case of a Large Gastroduodenal Artery Pseudoaneurysm after Surgery of a Peptic Ulcer Mon, 12 Jan 2015 09:22:44 +0000 We report a 48-year-old man in whom a chronic postbulbar duodenal ulcer destroyed much of the back wall of the duodenum and gastroduodenal artery causing pseudoaneurysm. The lesion was found and evaluated by contrast-enhanced computed tomography (that revealed a large pseudoaneurysm of 83 mm 75 mm in diameter) and by angiography and then treated with transcatheter embolization leading to a complete resolution of the lesion. The case is rare and important for several reasons. First, we demonstrate that pseudoaneurysm of the gastroduodenal artery caused by a duodenal ulcer can occur and present a diagnostic challenge (as far as we know, only three cases have been reported previously in the literature). Second, this case report focuses on the importance of ligation of the gastroduodenal artery when bleeding of peptic ulcers occurs. Additionally, we present an overview of the relevant literature. Rocio Santos-Rancaño, Esteban Martín Antona, and José Vicente Méndez Montero Copyright © 2015 Rocio Santos-Rancaño et al. All rights reserved. Combined Therapy for Distant Metastasis of Sacral Chordoma Sun, 11 Jan 2015 14:01:18 +0000 Chordomas are known as rare primary malign tumours that have formed from primitive notochord remains. Sacral chordomas grow slowly but locally and aggressively. Chordomas are locally invasive and have low tendency to metastasis and have a poor prognosis in long-term follow-up. Metastasis may be seen in a rate of 5–40% of the chordomas. Metastasis of chordomas is common in liver, lung, lymph nodes, peritoneum, and brain. The treatment approaches, including surgery, have been discussed in the literature before. Susceptibility to radiotherapy and chemotherapy is controversial in these tumours. The success of surgical treatment affects survival directly. In this report, we will report a sacral chordoma case in which an intraperitoneal distant metastasis occurred and discuss the surgical approach. Birol Özkal, Can Yaldız, Peyker Temiz, and Cüneyt Temiz Copyright © 2015 Birol Özkal et al. All rights reserved. Recurrent Breast Cancer in a Patient with a Ventriculoperitoneal Shunt Thu, 08 Jan 2015 12:56:36 +0000 We report a case of a patient with recurrent infiltrating ductal carcinoma of the breast encasing a ventriculoperitoneal shunt. We also review the current literature regarding reports of breast malignancy around a ventriculoperitoneal shunt, as well as the potential relevance of such shunts to the preoperative evaluation and management of patients with breast cancer. Libby R. Copeland-Halperin and Robert A. Cohen Copyright © 2015 Libby R. Copeland-Halperin and Robert A. Cohen. All rights reserved. Spontaneous Perforation of Pyometra Presenting as Acute Abdomen and Pneumoperitoneum Mimicking Those of Gastrointestinal Origin Mon, 05 Jan 2015 12:42:36 +0000 Gastrointestinal (GI) perforation accounts for over 90% of acute abdomen and pneumoperitoneum. The presence of pneumoperitoneum secondary to spontaneously perforated pyometra is an interesting yet confusing finding given the absence of gastrointestinal (GI) perforation, because pyometra is more common in postmenopausal women. We report an instructive case of diffuse peritonitis caused by spontaneous perforation of pyometra. A 70-year-old postmenopausal female was admitted to surgical emergency with signs of diffuse peritonitis. After resuscitation, an emergency laparotomy was performed because of suspicion of GI perforation. At laparotomy, about 2,000 mL of purulent fluid was found to be present in peritoneal cavity, while GI tract was intact. A rent with a diameter of 5 mm was found on anterior fundus of uterus. A total abdominal hysterectomy with a bilateral salpingo-oophorectomy was performed. Despite intensive care and a course of antibiotics, the patient died of multiple organ failure resulting from sepsis on postoperative day 16. Our case illustrates the importance of clinical knowledge of acute gynecological diseases, which are not uncommonly encountered by the general surgeon. Moreover, good appreciation of pelvic anatomy and close collaboration with gynecology and GI surgery colleagues is essential as operative intervention is often required. Takahiro Yamada, Nanako Ando, Naoshi Shibata, Motomu Suitou, Hiroshi Takagi, Kazutoshi Matsunami, Satoshi Ichigo, and Atsushi Imai Copyright © 2015 Takahiro Yamada et al. All rights reserved. A Differential Diagnosis of Haematuria following a Motor Vehicle Collision: Nutcracker Syndrome Thu, 01 Jan 2015 11:56:04 +0000 A young female presented to the emergency department following a motor vehicle collision. She complained of left flank pain and was found to have haematuria. After investigation no trauma related injuries were identified. However, an incidental finding of nutcracker phenomenon/syndrome was made. Nutcracker phenomenon is a rare cause of haematuria resulting from nontraumatic compression of the left renal vein between the superior mesenteric artery and the aorta. It affects females more than males and its presentation can range from asymptomatic to debilitating haematuria, pelvic congestion in females, varicosities in males, and pain. No validated diagnostic criteria exist and treatment is usually surgical in those with debilitating symptoms or refractory anaemia. Gary Sharp and Derek Glenn Copyright © 2015 Gary Sharp and Derek Glenn. All rights reserved. Perforated Jejunal Diverticula Secondary to a Large Faecolith: A Rare Cause of the Acute Abdomen Tue, 30 Dec 2014 12:22:22 +0000 Jejunal diverticula are uncommon and usually asymptomatic. Very rarely, they can lead to acute complications such as bleeding, obstruction, and perforation. This report describes our experience of a case of jejunal diverticula perforation secondary to a large faecolith, with particular focus on the aetiology and management of this rare condition. Peter John Webster, Abigail Hyland, Amarvir Bilkhu, Satheesh Hanavadi, and Narinder Sharma Copyright © 2014 Peter John Webster et al. All rights reserved. Resection of a Catecholamine-Elaborating Retroperitoneal Paraganglioma Invading the Inferior Vena Cava Sun, 28 Dec 2014 06:09:48 +0000 Paragangliomas are rare tumors originating outside of the adrenal medulla which can be associated with catecholamine secretion or mass effect, one of which typically leads to their discovery. The differences between these tumors and traditional intra-adrenal pheochromocytomas are a subject of recent investigations. Standard of care therapy is medical management and surgical resection of the tumor. When tumors are biochemically active, medical optimization of the autonomic nervous system is a critical component to a safe, definitive resection. Tumors arising in the retroperitoneum present technical challenges for the surgeon as they are often large and difficult to access, making an oncologic resection much more difficult. Lastly, these tumors are mostly benign and rarely invade adjacent structures—an operative finding not always predicted by preoperative imaging—which, if present, adds significant complexity and risk to the resection. A case illustrating these challenges in the management of a biochemically active retroperitoneal paraganglioma invading the inferior vena cava follows. E. M. Mannina, Z. Xiong, R. Self, and E. Kandil Copyright © 2014 E. M. Mannina et al. All rights reserved. Sterile Acellular Dermal Collagen as a Treatment for Rippling Deformity of Breast Thu, 25 Dec 2014 00:10:19 +0000 Prosthetic implants are frequently used for breast augmentation and breast reconstruction following mastectomy. Unfortunately, long-term aesthetic results of prosthetic breast restoration may be hindered by complications such as rippling, capsular contracture, and implant malposition. The advent of use of acellular dermal matrices has greatly improved the outcomes of prosthetic breast reconstruction. We describe a case of rippling deformity of breast that was treated using an acellular dermal matrix product, AlloMax. The patient presented with visible rippling of bilateral prosthetic breast implants as well as significant asymmetry of the breasts after multiple excisional biopsies for right breast ductal carcinoma in situ. A  cm piece of AlloMax was placed on the medial aspect of each breast between the implant and the skin flap. Follow-up was performed at 1 week, 3 months, and 1 year following the procedure. The patient recovered well from the surgery and there were no complications. At her first postoperative follow-up the patient was extremely satisfied with the result. At her 3-month and 1-year follow-up she had no recurrence of her previous deformity and no new deformity. Brittany Busse, Hakan Orbay, and David E. Sahar Copyright © 2014 Brittany Busse et al. All rights reserved. Dealing with a Porcelain Aorta during Coronary Artery Bypass Grafting Wed, 24 Dec 2014 08:23:47 +0000 We report a complex case of multivessel CAD in a patient with a porcelain aorta and high-grade left subclavian artery stenosis. Utilizing a staged left subclavian artery stent placement with a next-day plan for a four-vessel, on-pump CABG and ascending aortic replacement, this case highlights an organized approach to diagnosing and dealing with a heavily calcified aorta while describing a stepwise algorithm to deal with aortic calcifications prior to initiating cardiac surgery. T. M. Ayodele Adesanya and Ahmet Kilic Copyright © 2014 T. M. Ayodele Adesanya and Ahmet Kilic. All rights reserved. Radical Resection of a Late-Relapsed Testicular Germ Cell Tumour: Hepatectomy, Cavotomy, and Thrombectomy Sun, 21 Dec 2014 00:10:22 +0000 Up to 3.2% of patients with testicular germ cell tumours represent with late-relapsing disease. Aggressive surgical resection confers the greatest chance of cure in this patient group. We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein. Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus. This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation. C. Ní Leidhin, C. E. Redmond, A. M. Cahalane, H. M. Heneghan, R. Motyer, E. R. Ryan, and E. Hoti Copyright © 2014 C. Ní Leidhin et al. All rights reserved. Gossypiboma Posing as a Diagnostic Dilemma: A Case Report and Review of the Literature Mon, 15 Dec 2014 00:10:38 +0000 The term gossypiboma is used to describe a retained surgical sponge after operation. It is a rare but serious complication which is seldom reported because of the medicolegal implications. Gossypiboma usually has varied and vague presentation and is also difficult to detect on radiological investigations. It can even remain silent and present years after the operation. We report a case of a 38-year-old lady who presented with vague pain and chronic lump in the right iliac fossa region. She had a history of cesarean section 4 years ago. Radiological investigations were inconclusive in detecting the retained sponge. A working diagnosis of mesenteric cyst was made and an exploratory laparotomy was done where she was found to have a large gossypiboma densely adhered to the small bowel and surrounding structures. Though rare, gossypiboma should be kept in mind as a differential diagnosis in postoperative cases presenting as vague pain or chronic lump even years after the operation. K. N. Srivastava and Amit Agarwal Copyright © 2014 K. N. Srivastava and Amit Agarwal. All rights reserved. Bisphosphonate-Induced Periprosthetic Fracture: A Cause of Painful Total Hip Arthroplasty Wed, 10 Dec 2014 00:10:52 +0000 Background. Cases have been reported in the literature of periprosthetic fractures associated with the use of bisphosphonates occurring in the long term following a Total Hip Replacement (THR). We report an interesting case of periprosthetic fracture secondary to bisphosphonate use only a few months after a THR. Case Report. A 72-year-old lady (on bisphosphonates for 10 years) underwent a THR for osteoarthritis. She was pain-free in the first four months postoperatively. Thereafter, she developed spontaneous onset of pain in the lateral aspect of her thigh and groin and found it difficult to weight-bear. X-rays and blood tests were unremarkable. An ultrasound and MRI scan showed no evidence of effusion/collection or periprosthetic fracture. A radionuclide bone scan showed an abnormal appearance of the right femoral shaft. A subsequent CT scan showed an oblique vertical split on the anterior surface of the upper right femoral shaft. This stress fracture was managed nonoperatively with protected weight bearing. She has progressed well with good clinical and radiological signs of fracture healing. Conclusion. This case is an important addition to our knowledge that bisphosphonate-induced periprosthetic stress fractures can be a cause of hip pain only a few months following a THR. Rahul Bhattacharyya, Stephanie Spence, Gavin O’Neill, and Kumar Periasamy Copyright © 2014 Rahul Bhattacharyya et al. All rights reserved. Prune Belly Syndrome with Overlapping Presentation of Partial Urorectal Septum Malformation Sequence in a Female Newborn with Absent Perineal Openings Tue, 09 Dec 2014 00:10:19 +0000 Prune belly syndrome (PBS) is a rare congenital anomaly characterized in males by a triad of anomalous genitourinary tract, deficient development of abdominal wall muscles, and bilateral cryptorchidism. Although similar anomalies have been reported in females, by definition they do not full fill the classical triad. Urorectal septum malformation sequence (URSM) is a lethal condition characterized by presence of ambiguous genitalia, absent perineal openings (urogenital and anal), and lumbosacral abnormalities. In this original case report, the authors discuss the presentation and management of what would be analogous to a Woodhouse category 1 PBS in a female newborn associated with an overlapping presentation of URSM. Azhar Farooqui, Alaa AlAqeel, and Zakaria Habib Copyright © 2014 Azhar Farooqui et al. All rights reserved. Sentinel Bleeding as a Sign of Gastroaortic Fistula Formation after Oesophageal Surgery Tue, 02 Dec 2014 07:33:39 +0000 Gastroaortic fistula formation is a very rare complication following oesophageal resection and, in most cases, leads to sudden death. We report the case of a 65-year-old male with an adenocarcinoma of the oesophagus who underwent neoadjuvant chemoradiation followed by a minimally invasive transthoracic oesophagectomy with gastric tube reconstruction and intrathoracic anastomosis. After an uneventful postoperative course and hospital discharge, the patient reported blood regurgitation on postoperative day 23. Endoscopy revealed an adherent blood clot on the oesophageal wall, which after dislocation caused exsanguination. Autopsy determined the cause of death being massive haemorrhage due to a gastroaortic fistula. The sudden onset of haemorrhage makes this condition particularly difficult to treat. Recognition of warning signs such as thoracic or epigastric pain, regurgitation of blood, or the passing of bloody stools or melena is crucial in the early detection of fistula and may improve patient outcome. M. Uittenbogaart, M. N. Sosef, and J. van Bastelaar Copyright © 2014 M. Uittenbogaart et al. All rights reserved. Kimura Disease Manifesting as Synchronous Bilateral Parotid Swelling in a Young Middle-Eastern Patient Mon, 24 Nov 2014 10:16:09 +0000 Kimura disease is a rare, benign, chronic inflammatory swelling of the subcutaneous tissue, lymph nodes, and glandular tissue. Characteristic features of the disease include, but not limited to, painless subcutaneous head and neck swelling, blood and tissue eosinophilia, and markedly elevated immunoglobulin E (IgE) levels. Herein, we report a rare case of Kimura disease manifesting as synchronous bilateral parotid swelling of 12 years duration in a 33-year-old Middle-Eastern man. To our knowledge only few cases have been reported in the literature involving bilateral parotid glands, and this is the first case to be reported in the Middle East. Fatemah Faras, Fawaz Abo-Alhassan, Khalid Al-Sebeih, and Jassem Bastaki Copyright © 2014 Fatemah Faras et al. All rights reserved. Rescue ALPPS: Intraoperative Conversion to ALPPS during Synchronous Resection of Rectal Cancer and Liver Metastasis Mon, 24 Nov 2014 00:00:00 +0000 Future liver remnant (FLR) is the most important deciding factor in planning for liver resection. Portal vein embolization (PVE) was first introduced in the 1980s to induce liver hypertrophy, enabling removal of multiple/bilobar tumors. PVE was later combined with sequential hepatectomies with the aim of allowing the liver remnant to hypertrophy (15–20%) between procedures. However, the interval between the two procedures (3–8 weeks) put patients at risk for disease progression. With portal vein ligation alone or when combined with sequential hepatectomy, there is also a risk for inadequate liver hypertrophy because of intrahepatic portal collaterals leading to a high (19–30%) dropout rate. The ALPPS procedure (associating liver partition and portal vein ligation for staged hepatectomy) was recently developed as a feasible means to perform extensive/bilobar liver resections. It produces rapid, enormous hypertrophy of the remnant, making previously unresectable lesions resectable. Indications for ALPPS include any extensive liver resection with inadequate FLR. Here we present a novel indication for ALPPS as a rescue when inadequate FLR was faced intraoperatively, during a simultaneous resection of rectal primary and liver metastasis. Terence Jackson, Kelly A. Siegel, and Christopher T. Siegel Copyright © 2014 Terence Jackson et al. All rights reserved. Successful Outcome of Triangle Tilt as Revision Surgery in a Pediatric Obstetric Brachial Plexus Patient with Multiple Previous Operations Sun, 23 Nov 2014 00:00:00 +0000 Introduction. Obstetric brachial plexus injury (OBPI) occurs during the process of labor and childbirth. OBPI has been reported to be associated with shoulder dystocia, macrosomia, and breech delivery. Its occurrence in uncomplicated delivery is possible as well. Case Presentation. The patient in the present report is a 6.5-year-old girl, who suffered a severe brachial plexus injury at birth and had many reconstructive surgical procedures at an outside brachial plexus center before presenting to us. Discussion. The traditional surgical treatments by other surgical groups were unsuccessful and therefore the patient came to our clinic for further treatment. She had triangle tilt surgery with us, as a salvage procedure. Conclusion. The OBPI patient in this study clearly showed noticeable clinical and functional improvements after triangle tilt surgical management. The posture of the arm at rest was greatly improved to a more normal position, and hand to mouth movement was improved as well. Triangle tilt surgery should be conducted as a first choice treatment for medial rotation contracture of the shoulder in OBPI patients. Rahul K. Nath, Vishnu Halthore, and Chandra Somasundaram Copyright © 2014 Rahul K. Nath et al. All rights reserved. Solitary Cecal Diverticulitis: An Unusual Cause of Acute Right Iliac Fossa Pain—A Case Report and Review of the Literature Sun, 23 Nov 2014 00:00:00 +0000 Solitary cecal diverticulitis is a rare cause of acute abdominal pain in the Western world. Its clinical presentation, in most cases, mimics acute appendicitis. A 38-year-old Caucasian man presented with acute abdomen and clinical signs of acute appendicitis. Laparotomy was performed and revealed an inflammatory, solitary diverticulum of the cecum. A typical appendectomy was performed and a catheter was inserted for draining percutaneously the inflamed diverticulum of the cecum. The patient had an uneventful recovery and was discharged on the 4th postoperative day. This frequently misdiagnosed condition, in most cases, is being suspected and identified intraoperatively as acute appendicitis. The aim of this study is to review the available different surgical management options and to present an alternative therapeutic approach that may be valuable under specific circumstances. Nikolaos Mudatsakis, Marinos Nikolaou, Konstantinos Krithinakis, Michail Matalliotakis, Nikolaos Politis, and Emmanouil Andreadakis Copyright © 2014 Nikolaos Mudatsakis et al. All rights reserved. Transvaginal Appendectomy in Morbidly Obese Patient Thu, 20 Nov 2014 11:07:11 +0000 Introduction. Laparoscopic appendectomy has significant benefits in obese patients. However, morbid obesity can be accepted as an exclusion criterion for natural orifice transluminal endoscopic surgery (NOTES). Here, we present a transvaginal appendectomy in a 66-year-old morbidly obese (BMI 36 kg/m2, ASA III) patient. Case and Technique. Acute appendicitis was suspected based on history, physical examination, laboratory tests, and ultrasound findings. During laparoscopic surgery, a 5 mm trocar was inserted through the umbilicus and a 5 mm telescope was placed. A 12 mm trocar and a 5 mm grasper were inserted separately through the posterior fornix of the vagina under laparoscopic guidance. The appendix was divided with an endoscopic stapler through the transvaginal 12 mm trocar and removed from the same trocar. The operating time was 75 minutes with minimal blood loss (<10 mL). The patient was discharged 16 hours after surgery uneventfully and she did not require any analgesic administration. Conclusion. To the best of our knowledge, this is the first clinical case that focuses on the transvaginal appendectomy at morbid obesity. We can say that morbid obesity does not constitute an obstacle for treatment of acute appendicitis by transvaginal endoscopic surgery. Mehmet Ali Yagci, Cuneyt Kayaalp, and Mustafa Ates Copyright © 2014 Mehmet Ali Yagci et al. All rights reserved. Necrotising Myositis, the Deadly Impersonator Wed, 19 Nov 2014 14:04:00 +0000 We report two cases of patients with necrotising myositis who presented initially with limb pain and swelling on a background of respiratory complaints. Patient 1, a previously well 38-year-old female, underwent various investigations in the emergency department for excessive lower limb pain and a skin rash. Patient 2, a 61-year-old female with a background of rheumatoid arthritis and hypertension, presented to accident and emergency feeling generally unwell and was treated for presumed respiratory sepsis. Both deteriorated rapidly and were referred to the plastic surgery team with soft tissue necrosis, impending multiorgan failure and toxaemia. Large areas of necrotic muscle and skin were debrided, which grew group A streptococci, Streptococcus pyogenes. Patient 1 had a high above knee amputation of the left leg with extensive debridement of the right. Despite aggressive surgical intervention and microbiological input with intensive care support, patient 2 died. These two cases highlight the importance of early diagnosis and prompt surgical and pharmacological intervention in managing this life-threatening disease. Pain is the primary symptom with skin changes being a late and subtle sign in a septic patient. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) may be of use if there is concern to aid diagnosis of this life-threatening disease. A. Rahman, A. K. Abou-Foul, A. Yusaf, J. Holton, and L. Cogswell Copyright © 2014 A. Rahman et al. All rights reserved. Giant Mature Primary Retroperitoneal Teratoma in a Young Adult: Report of a Rare Case and Literature Review Wed, 19 Nov 2014 12:39:22 +0000 Teratomas are neoplasms of the embryonic tissues that typically arise in the gonadal and sacrococcygeal regions of adults and children. Primary adult retroperitoneal teratomas are rare and demand challenging management options. We report a case of a unilateral primary retroperitoneal mature cystic teratoma mimicking an adrenal mass in a 28-year-old female patient. Complete resection of the mass was performed by a laparotomy approach. Because of the risk of malignancy, follow-up radiographic studies were performed to ensure the oncologic efficacy of resection. The patient remains free of recurrence to date. Walid Sasi, Giuseppe A. Ricchetti, Laila Parvanta, and Robert Carpenter Copyright © 2014 Walid Sasi et al. All rights reserved. Single-Incision Laparoscopic Surgery for Intersigmoid Hernia Wed, 19 Nov 2014 12:38:42 +0000 Intersigmoid hernia is a rare form of internal hernia. Here, we report a case of intersigmoid hernia and provide a brief review of the 62 cases involving the mesosigmoid reported in Japan from 2000 to 2013. In the current case, a 26-year-old man with no previous history of abdominal surgery presented with abdominal pain and vomiting. Abdominal computed tomography revealed an extensively dilated small bowel and a closed loop of small bowel in the mesosigmoid. The patient was diagnosed with an intestinal obstruction due to an incarcerated internal hernia involving the mesosigmoid. There was no blood flow obstruction at the incarcerated bowel. An elective single-incision laparoscopic surgery was performed after decompression of the bowel using ileus tube. As the ileum herniated into the intersigmoid fossa, the patient was diagnosed with an intersigmoid hernia. The incarcerated small bowel was reduced in order to make it viable, and the hernial defect was closed with interrupted sutures. The patient had an uneventful recovery and was discharged on postoperative day five. Takahiro Watanabe, Hidetoshi Wada, Masanori Sato, Yuichirou Miyaki, and Norihiko Shiiya Copyright © 2014 Takahiro Watanabe et al. All rights reserved. Fournier’s Gangrene as a Postoperative Complication of Inguinal Hernia Repair Wed, 19 Nov 2014 07:00:11 +0000 Fournier’s gangrene is the necrotizing fasciitis of perianal, genitourinary, and perineal regions. Herein, we present a case of scrotal Fournier’s gangrene as a postoperative complication of inguinal hernia repair. A 51-year-old male with giant indirect hernia is presented. Patient underwent inguinal hernia repair, and after an unproblematic recovery period, he was discharged. He applied to our outpatient clinic on the fifth day with swollen and painful scrotum and it turned out to be Fournier’s gangrene. Polypropylene mesh was not infected. Patient recovered and was discharged after repeated debridements. Basic principles in treatment of Fournier’s gangrene are comprised of initial resuscitation, broad-spectrum antibiotics therapy, and early aggressive debridement. In the management of presented case, aggressive debridement was made right after diagnosis and broad-spectrum antibiotics were given to the hemodynamically stable patient. In these circumstances, the important question is whether we could prevent occurrence of Fournier’s gangrene. Tolga Dinc, Selami Ilgaz Kayilioglu, Isa Sozen, Baris Dogu Yildiz, and Faruk Coskun Copyright © 2014 Tolga Dinc et al. All rights reserved.