Case Reports in Surgery The latest articles from Hindawi © 2018 , Hindawi Limited . All rights reserved. Extra-Anatomic Jump Graft from the Right Colic Vein: A Novel Technique to Manage Portal Vein Thrombosis in Liver Transplantation Sun, 14 Jan 2018 00:00:00 +0000 Background. In the context of cirrhosis, portal vein thrombosis (PVT) is present in 2.1% to 26% of patients. PVT is no longer considered an absolute contraindication for liver transplantation, and nowadays, surgical strategies depend on the extent of PVT. Complete PVT is associated with higher morbidity rates and poor prognosis, while comparable long-term outcomes can be achieved as long as physiological portal inflow is restored. Materials and Methods. We report our experience with a 45-year-old patient undergoing liver transplant with a PVT (stage III-b). To restore portal vein inflow to the liver, an extra-anatomic jump graft from the right colic vein with donor iliac vein interposition was constructed. Results. The patient recovered well, with a progressive improvement of the general conditions, and was finally discharged on p.o.d. 14. No anastomotic defects were found at the postoperative CT scan 10 months after the surgery. Conclusion. Our technical innovation represents a valid and safe alternative to the cavoportal hemitransposition, providing a proper flow restoration and reproducing a physiological setting, while avoiding the complications related to the cavoportal shunt. We believe that the reconstitution of liver portal inflow should be obtained with the most physiological approach possible and considering long-term liver function. Paolo Magistri, Giuseppe Tarantino, Tiziana Olivieri, Annarita Pecchi, Roberto Ballarin, and Fabrizio Di Benedetto Copyright © 2018 Paolo Magistri et al. All rights reserved. Mucinous Carcinomatosis: A Rare Association between an Ovarian Tumor and an E-GIST Thu, 11 Jan 2018 00:00:00 +0000 Pseudomyxoma peritonei (PMP) and extragastrointestinal stromal tumors (E-GISTs) are both rare entities. Most of the time, PMP is associated with an appendiceal tumor. An ovarian mucinous tumor can mimic appendiceal metastases. E-GIST is a mesenchymal tumor that can arise from the omentum, retroperitoneum, mesentery, or pleura. We present a case of an 87-year-old woman with mucinous carcinomatosis and acute intestinal occlusion submitted to an emergency laparotomy. She has found to have a borderline mucinous tumor of the ovary from the intestinal type with several lesions of pseudomyxoma peritonei and an E-GIST from the epiploons retrocavity (intermediated risk). In the literature, no relation was found between these two rare tumors. E-GIST was an incidental finding in the context of a mucinous carcinomatosis. Hugo Palma Rios, André Goulart, and Pedro Leão Copyright © 2018 Hugo Palma Rios et al. All rights reserved. Intrahepatic Sarcomatous Cholangiocarcinoma: Case Report and Review of the Literature Tue, 09 Jan 2018 00:00:00 +0000 The authors report a case of a patient with intrahepatic sarcomatous cholangiocarcinoma. A 45-year-old Thai man presented with a 3-month history of right upper abdominal pain. CT scan revealed hepatomegaly with a 6.5 cm hypovascular soft tissue density mass in the right lobe and showed mild delayed enhancement. On exploratory laparotomy, the tumor adherent to right diaphragm was found. We performed right hepatectomy, partial resection of right diaphragm, and cholecystectomy. The immunohistological results suggested “sarcomatous intrahepatic cholangiocarcinoma.” The tumor was recurrent in 5 months after operation and unresectable. Therefore, the treatment in this patient was supportive care. He died 11 months after his initial presentation. The literature reviews showed that intrahepatic sarcomatous cholangiocarcinoma is aggressive malignant with poor prognosis. Early detection, radical resection, and careful follow-up would be the treatment for the favorable prognosis. Thana Boonsinsukh, Vichit Viriyaroj, Thammanij Rookkachart, and Therdkiat Trongwongsa Copyright © 2018 Thana Boonsinsukh et al. All rights reserved. Free Intraperitoneal Gallstone: An Unusual Case of Small Bowel Obstruction from Extrinsic Compression Mon, 08 Jan 2018 00:00:00 +0000 Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it. Kor Woi Tiang, Hang Fai So, Yang Hwang, and Manjunath Siddaiah-Subramanya Copyright © 2018 Kor Woi Tiang et al. All rights reserved. Virtual Surgical Planning and Piezoelectric Surgery in Tumor Extirpative Surgery Aimed at Inferior Alveolar Nerve Preservation Sun, 31 Dec 2017 00:00:00 +0000 A myriad of extirpative surgical protocols for the management of benign tumors of the jaws have been presented in the literature. Through significant advancements in computer-aided design and computer-aided manufacturing (CAD/CAM) technology and surgical instrumentation, today surgeons have at their disposal robust technology-driven techniques that are aimed at improving surgical outcomes. Our goal is to investigate the benefits of implementing virtual surgical planning (VSP) in conjunction with piezoelectric surgery (PES) to ensure success while minimizing the risk of complications during extirpation of tumors of the mandible. This case report describes the successful extirpation of an ossifying fibroma of the mandible in an adult patient using both VSP and PES. Eric L. Chung, Faizan Alawi, Anh D. Le, and Rabie M. Shanti Copyright © 2017 Eric L. Chung et al. All rights reserved. Erratum to “Torsion of Hydrosalpinx with Concurrent Acute Cholecystitis: Case Report and Review of Literature” Thu, 28 Dec 2017 00:00:00 +0000 Preeti R. John and Amelia M. Pasley Copyright © 2017 Preeti R. John and Amelia M. Pasley. All rights reserved. Bowel Resection and Ileotransverse Anastomosis as Preferred Therapy for 15 Typhoid Ileal Perforations and Severe Peritoneal Contamination in a Very Elderly Patient Thu, 21 Dec 2017 00:00:00 +0000 Typhoid ileal perforation (TIP) is the most lethal complication of typhoid fever. Although TIP is a surgical emergency by consensus, there is still much controversy regarding the most appropriate surgical approach to be used. Bowel exteriorization and secondary closure are usually recommended for patients presenting late with multiple TIPs and heavy peritoneal soiling. We, however, discuss a unique case of an 86-year-old patient with 15 typhoid ileal perforations successfully treated with one-step surgery comprising bowel resection and ileotransverse anastomosis in a resource-constrained setting of Cameroon. Benjamin Momo Kadia, Desmond Aroke, Martin Hongieh Abanda, Tsi Njim, and Christian Akem Dimala Copyright © 2017 Benjamin Momo Kadia et al. All rights reserved. A First Report of Synchronous Intracapsular and Extracapsular Hepatic Adenoma Tue, 19 Dec 2017 10:18:31 +0000 Although the gallbladder is the most common site of ectopic liver, it has been reported in many other organs, such as kidney, adrenal glands, pancreas, omentum, stomach, esophagus, mediastinum, lungs, and heart. Hepatocytes in an ectopic liver behave like normal hepatocytes; furthermore, they can be associated with the same pathological findings as those in the main liver. Ectopic liver in the gallbladder can undergo fatty change, hemosiderosis, cholestasis, cirrhosis, hemangioma, focal nodular hyperplasia, adenoma, and even carcinogenesis. The incidence of extracapsular hepatic adenoma is not known, but only two cases have been reported. Here, we provide the first case report of synchronous multiple intracapsular and extracapsular hepatic adenomas. A 60-year-old woman with multiple hepatic adenomas and one 7 × 5 × 5 cm ectopic hepatic adenoma attached to the gallbladder fundus complicated with abdominal pain is presented. Murat Derebey, Ilhan Karabicak, Savas Yuruker, Gokhan Lap, Bilge Can Meydan, Murat Danaci, Kagan Karabulut, and Necati Ozen Copyright © 2017 Murat Derebey et al. All rights reserved. A Case of Midgut Volvulus Associated with a Jejunal Diverticulum Tue, 19 Dec 2017 10:14:33 +0000 Midgut volvulus in adults is a rare entity that may present with intermittent colicky abdominal pain mixed with completely asymptomatic episodes. This small bowel twist may result in complications of obstruction, ischemia, hemorrhage, or perforation. With a midgut volvulus, complications may be life-threatening, and emergent surgical intervention is the mainstay of treatment. This current case involves an 80-year-old woman with intermittent abdominal pain with increasing severity and decreasing interval of time to presentation. A CAT scan revealed mesenteric swirling with possible internal hernia. A diagnostic laparoscopy followed by laparotomy revealed a midgut volvulus, extensive adhesions involving the root of the mesentery, and a large jejunal diverticulum. The adhesions were lysed enabling untwisting of the bowel, allowing placement of the small bowel in the correct anatomic position and resection of the jejunal diverticulum. This is a rare case of midgut volvulus with intermittent abdominal pain, associated with jejunal diverticulum managed successfully. A midgut volvulus should be considered in the differential diagnosis of a patient who present with a small bowel obstruction secondary to an internal hernia, especially when a swirl sign is present on the CAT scan. Joseph Gutowski, Rachel NeMoyer, and Glenn S. Parker Copyright © 2017 Joseph Gutowski et al. All rights reserved. Large Enterolith Complicating a Meckel Diverticulum Causing Obstructive Ileus in an Adolescent Male Patient Sun, 17 Dec 2017 00:00:00 +0000 We present a unique case of a 16-year-old male patient who was eventually diagnosed with a large enterolith arising from a Meckel’s diverticulum. The enterolith had caused intermittent intestinal symptoms for three years before resulting in small bowel obstruction requiring surgical intervention. Meckel’s enterolith ileus is very rare with only few cases described in the literature. To our knowledge, this is only the second case of Meckel’s enterolith which had caused intermittent symptoms over a period of time, before resulting in ileus, and the first case where the intermittent symptoms lasted several years before bowel obstruction. The patient had been evaluated with colonoscopy, computerized tomography (CT), and magnetic resonance imaging enterography (MRIE); a calcified pelvic mass had been found, but no further diagnosis other than calcification was established. The patient presented at our emergency department, with symptoms of obstructive ileus and underwent exploratory laparotomy, where a large enterolith arising from a Meckel’s diverticulum (MD) was identified, causing the obstruction. A successful partial enterectomy, enterolith removal, and primary end-to-end anastomosis took place; the patient was permanently relieved from his long-standing symptoms. Consequently, complications of Meckel’s diverticulum and enterolithiasis have to be included in the differential diagnosis of abdominal complaints. Constantinos Nastos, Dimitrios Giannoulopoulos, Ioannis Georgopoulos, Christos Salakos, Dionysios Dellaportas, Ioannis Papaconstantinou, Theodosios Theodosopoulos, and Georgios Polymeneas Copyright © 2017 Constantinos Nastos et al. All rights reserved. Spleen-Preserving Surgery in Splenic Artery Aneurysm Sun, 17 Dec 2017 00:00:00 +0000 Endovascular interventions are increasingly used in the treatment of a splenic artery aneurysm (SAA), which is a rare and life-threatening clinical disorder. However, in cases of SAA rupture, minimally invasive interventions are unsuitable, and open surgery remains the gold standard method. In open surgery, care should be taken to preserve the spleen and its immune function in cases where an arterial segment of sufficient length allows for reconstruction. An SAA was detected in a 51-year-old woman who presented to our polyclinic with left upper quadrant pain. An endovascular intervention was unsuccessful, and open surgery was performed. Approximately 5 cm of aneurysm in the middle segment of the splenic artery was treated by arterial anastomosis, and the spleen was preserved. The patient experienced no postoperative complications and remained asymptomatic at the seventh month of follow-up. The aim of this case report is to emphasize the importance of splenic sparing surgery in cases of SAAs. Ulaş Aday, Emre Bozdağ, Ebubekir Gündeş, Selçuk Gülmez, and Kamuran Cumhur Değer Copyright © 2017 Ulaş Aday et al. All rights reserved. Left Paraduodenal Hernia: A Rare Complication following Laparoscopic Appendectomy Wed, 06 Dec 2017 10:39:59 +0000 Paraduodenal hernias are rare congenital internal hernias accounting for <2% of intestinal obstruction. Left paraduodenal hernias (LPDHs) into the fossa of Landzert are the more common type and result from abnormal rotation of the midgut and failure of peritoneal fusion. Sequelae of these hernias usually occur spontaneously in the 4th or 5th decade of life and are more common in males and have a significant risk of incarceration and subsequent strangulation. We describe a case of a 15-year-old female who develops a LPDH following laparoscopic appendectomy, resulting in jejunal incarceration and subsequent small intestinal obstruction. The patient discussed is from an atypical demographic, being young and female. In addition, the precipitating event prompting incarceration of the hernia appears to be the application of pneumoperitoneum, placement in the Trendelenburg position, and manipulation of small intestine for the purpose of facilitating laparoscopic appendectomy. To our knowledge, this is the first reported case of LPDH exacerbated by laparoscopic procedure. Mathew A. Kozman and Oliver M. Fisher Copyright © 2017 Mathew A. Kozman and Oliver M. Fisher. All rights reserved. Retroperitoneal Necrotizing Fasciitis from Fournier’s Gangrene in an Immunocompromised Patient Sun, 03 Dec 2017 00:00:00 +0000 Introduction. Necrotizing fasciitis (NF) is a devastating soft tissue disease causing fulminant clinical deterioration, and extension into the retroperitoneum has a high mortality rate. This disease process demands a strong clinical suspicion for early identification which must be coupled with frequent wide surgical debridements and intravenous antibiotics for improved outcomes. Various clinical risk factors may render a weakness in the patient’s immune status including diabetes mellitus, chronic renal failure, obesity, and autoimmune disorders, such as a human immunodeficiency virus (HIV) infection. Case Report. A 55-year-old male presented with hypotension requiring a large intravenous fluid resuscitation and vasopressors. He was diagnosed with the human immunodeficiency virus upon presentation. A computerized tomographic scan revealed air and fluid in the perineum and pelvis, ascending into the retroperitoneum. Multiple surgical debridements to his perineum, deep pelvic structures, and retroperitoneum were completed. After colostomy placement, antibiotic administration, and wound care, he was closed using split-thickness skin grafting. Conclusion. NF is a sinister and fulminant disease requiring prompt diagnosis and surgical intervention. The best chance for survival occurs with emergent surgical debridement and appropriate intravenous antibiotics. While retroperitoneal NF is consistent with uniformly poor outcomes, patients are best treated in an American Burn Association-verified burn center. Samuel B. Weimer, Marc R. Matthews, Daniel M. Caruso, and Kevin N. Foster Copyright © 2017 Samuel B. Weimer et al. All rights reserved. Successful Outcome and Biliary Drainage in an Infant with Concurrent Alpha-1-Antitrypsin Deficiency and Biliary Atresia Wed, 29 Nov 2017 00:00:00 +0000 We describe the rare instance of concomitant biliary atresia and alpha-1-antitrypsin deficiency and the first documented successful portoenterostomy in this scenario. The potential for dual pathology must be recognized and underscores that prompt diagnosis of biliary atresia, despite concomitant alpha-1-antitrypsin deficiency, is essential to afford potential longstanding native liver function. Andrew W. Wang, Kimberly Newton, and Karen Kling Copyright © 2017 Andrew W. Wang et al. All rights reserved. Abdominal Pregnancy in the Small Intestine Presenting as Acute Massive Lower Gastrointestinal Hemorrhage Wed, 29 Nov 2017 00:00:00 +0000 An abdominal pregnancy is an ectopic pregnancy in which the implantation site occurs in the abdominal cavity outside the female reproductive organs. There have been four reported cases that ruptured into the gastrointestinal tract and into the large intestine. We present the first case of an abdominal pregnancy rupturing into the small intestine with a good outcome. Apiradee Pichaichanlert, Vor Luvira, and Nakhon Tipsunthonsak Copyright © 2017 Apiradee Pichaichanlert et al. All rights reserved. Gallbladder Mucus Plug Mimicking Ascaris Worm: An Ambiguous Cause of Biliary Colic Sun, 26 Nov 2017 00:00:00 +0000 Biliary colic is a visceral pain caused by attempts of the gallbladder or bile duct to overcome the obstruction in the cystic duct or ampulla of Vater. Obstruction can be due to different etiologies such as stone, mass, worm, and rarely by mucus plug. We report the case of a 31-year-old gentleman who presented with recurrent biliary colic and weight loss. Work-up showed linear calcifications in the gallbladder extending to the common bile duct suggesting hepatobiliary ascariasis. Further investigations including stool analysis, upper endoscopy, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) did not support our provisional diagnosis. Laparoscopic cholecystectomy was performed. Histopathological finding was grossly ambiguous; a rope-like mucus plug resembling ascaris worm was noted. The patient’s condition improved instantly after the procedure. To our knowledge, we are reporting the first case in the English literature describing this unique entity of symptomatic gallbladder disease to increase awareness and improve its management. Salah Termos, Mohammad Alali, Majd Alkabbani, Abdullah AlDuwaisan, Ahmad Alsaleh, Khalifa Alyatama, and Hussein Hayati Copyright © 2017 Salah Termos et al. All rights reserved. A Case of Small Bowel Obstruction and Enterocutaneous Fistulation Resulting from a Mesenteric Haematoma following Blunt Abdominal Trauma Sun, 26 Nov 2017 00:00:00 +0000 A 23-year-old male with a history of previous abdominal surgery was involved in a road traffic accident. He was discharged after initial assessment but represented several days with small bowel obstruction secondary to a mesenteric haematoma. He underwent resection and recovered well but represented later on the day of discharge with a leaking surgical wound consistent with an enterocutaneous fistula. This was managed conservatively and closed spontaneously after ten days. This case serves to highlight that adhesions from previous surgery can tether the small bowel causing mesenteric injury following blunt-force trauma. It also demonstrates that postoperative ileus can result in an enterocutaneous fistula that has the appearance of an anastomotic breakdown but which resolves more rapidly. Matthew North, Nicholas Aveyard, Oyeniyi Diya, Jeremy Berger, and Maitham Al-Whouhayb Copyright © 2017 Matthew North et al. All rights reserved. Mesh Migration into the J-Pouch in a Patient with Post-Ulcerative Colitis Colectomy: A Case Report and Literature Review Thu, 23 Nov 2017 09:29:11 +0000 Mesh repair offers advantages like lower postsurgical pain and earlier return to work. Thus, it has become a widely used treatment option. Here, we present the first case report of a mesh migration into a J-pouch in a patient with history of ulcerative colitis who underwent total abdominal colectomy with J-pouch and ileoanal anastomosis and a subsequent laparoscopic ventral hernia repair with mesh. Asem Ghanim, Benjamin Smood, Joseph Martinez, Melanie S. Morris, and John R. Porterfield Copyright © 2017 Asem Ghanim et al. All rights reserved. Inflammatory Fibroid Polyp: An Unusual Cause of Ileoileal Intussusception Thu, 16 Nov 2017 07:33:39 +0000 Inflammatory fibroid polyp (IFP), or Vanek’s tumor, is a rare benign lesion of the gastrointestinal tract. Clinical manifestations of IFP vary based on size and location within the GI tract. This case describes a patient who presented with hematochezia and abdominal pain. Computed tomography revealed ileoileal intussusception without a clear lead point. The patient underwent resection of the intussuscepted small bowel with primary anastomosis. A large polypoid mass was identified as the pathological lead point. Histopathological and immunohistochemical analysis revealed an IFP. Review of the literature indicates that early surgical intervention is the treatment of choice for intussusception caused by IFP. Lesions are typically reported as solitary, and resection is curative. Haley S. Adams, Brian Bergstrom, Bret Haines, and Nathan Roberts Copyright © 2017 Haley S. Adams et al. All rights reserved. Mesenchymal Hamartoma of the Liver: Complete Excision Always Necessary Thu, 16 Nov 2017 00:00:00 +0000 Mesenchymal hamartoma (MH) is not an uncommon tumor of the liver in the age group of 2–10 years. It is the second most common benign liver tumor in children. Previously considered a developmental anomaly, newer insights into other theories of origin including toxic-metabolic, ischemic, and a true neoplastic process are in progress. Previous understanding of a purely benign nature of the tumor is being overridden by a real malignant transformation. Complete excision of the tumor with clear margins is recommended to achieve a long term cure. A thorough understanding of the natural history of these tumors and skillful surgical treatment are indispensable elements of care. Suman B. Koganti, Venu Madhav Thumma, and Bheerappa Nagari Copyright © 2017 Suman B. Koganti et al. All rights reserved. Case Report of Foreign Body Stuck in Esophagus with Failure of Endoscopic Management in a Man with a History of Pica Wed, 01 Nov 2017 00:00:00 +0000 This is a case report of foreign body ingestion in a 55-year-old intellectually disabled man with a history of pica and previous removal of ten plastic gloves from his rectum four months prior to this presentation. The patient presented after ingesting plastic gloves which formed large, rigid esophageal and gastric bezoars that were not amenable to endoscopic removal. An exploratory laparotomy and gastrostomy was performed, and a 10 × 4.5 × 2 cm gastric bezoar consisting of rigid plastic gloves was removed without complication. Special considerations must be taken when considering the ingestion of nonfood items in the intellectually disabled population as these cases may not present classically with symptoms of a gastric bezoar. Holly Mulinder, Allison Ammann, Yana Puckett, and Sharmila Dissanaike Copyright © 2017 Holly Mulinder et al. All rights reserved. Cholecystectomy of an Intrahepatic Gallbladder in an Ectopic Pelvic Liver: A Case Report and Review of the Literature Tue, 31 Oct 2017 00:00:00 +0000 Introduction. Ectopic pelvic liver is an exceedingly rare condition usually resulting after repair of congenital abdominal wall defects. Intrahepatic gallbladder is another rare condition predisposing patients to cholelithiasis and its sequelae. We describe a cholecystectomy in a patient with an intrahepatic gallbladder in a pelvic ectopic liver. Presentation of Case. A 33-year-old woman with a history of omphalocele repair as an infant presented with signs and symptoms of symptomatic cholelithiasis and chronic cholecystitis, however, in an unusual location. After extensive workup and symptomatic treatment, cholecystectomy was recommended and performed via laparotomy and hepatotomy using microwave technology for parenchymal hepatic transection. Discussion. Given the rare combination of an intrahepatic gallbladder and an ectopic pelvic liver, advanced surgical techniques must be employed for cholecystectomies, in addition to involvement of hepatobiliary experienced surgeons due to the distortion of the biliary and hepatic vascular anatomy. Conclusion. Cholecystectomy by experienced hepatobiliary surgeons is a safe and effective treatment for cholecystitis in patients with intrahepatic gallbladders in ectopic pelvic livers. Rachel Mathis, Joshua Stodghill, Timothy Shaver, and George Younan Copyright © 2017 Rachel Mathis et al. All rights reserved. A Rare Case of Inguinal Hernia with Complete Bladder Herniation Tue, 31 Oct 2017 00:00:00 +0000 Involvement of the bladder in inguinal hernias is rare and occurs in less than 5% of the cases. The diagnosis and management of this condition may present a challenge to the surgeon. We present a case of an elderly gentleman who presented with a large left-sided inguinoscrotal hernia causing an obstructive uropathy which was surgically repaired. The patient made a quick postoperative recovery with complete resolution of renal function. Ayaaz Habib Copyright © 2017 Ayaaz Habib. All rights reserved. Rare Case of Large Bowel Injury due to Direct Blunt Trauma to a Preexisting Femoral Hernia Wed, 25 Oct 2017 00:00:00 +0000 We report a case of an 85-year-old man with a known asymptomatic left femoral hernia who was admitted to the emergency ward a few hours after falling from a bicycle and suffering from blunt trauma of the handlebar to the left inguinal region. The clinical findings and a computed tomography (CT) scan detecting free air in the femoral hernia sac suggested bowel perforation. Emergency laparotomy 6 hours after the incident confirmed a tear of the sigmoid colon accompanied by free blood and faeces in the left inguinal region of the abdomen. A segmental sigmoid resection and a primary end-to-end colorectal anastomosis were performed. The postoperative course was complicated by delayed oral feeding, a local infection, and a partial left testicle necrosis that led to secondary resection. The patient was discharged after 32 days of in-hospital care. Three months post trauma, we recorded a restitutio ad integrum. The case exemplifies that blunt trauma to preexisting femoral hernias may cause potentially lethal bowel perforation and that the time interval between time of injury and surgical treatment may be a prognostic factor. CT scans seem most suitable for ruling out bowel perforation. The scarce literature for blunt trauma to hernias is reviewed. C. Tinner, M. Odermatt, and P. Villiger Copyright © 2017 C. Tinner et al. All rights reserved. Synchronous Occurrence of Primary Breast Carcinoma and Primary Colon Adenocarcinoma Wed, 25 Oct 2017 00:00:00 +0000 A 65-year-old female patient presented to the emergency clinic with abdominal pain, meteorism, and intermittent rectal bleeding. Colonoscopy was performed, and a hepatic flexure tumor was detected. Histopathological examination of biopsy revealed adenocarcinoma. Thoracoabdominal CT was performed for staging, and a spiculated contour mass was found incidentally on the left breast. Mammography and ultrasonography were performed for the cause of these findings, and suspicious lesions of malignancy were seen in the left breast. Invasive ductal carcinoma was detected in core needle biopsy samples from lesions. In the multidisciplinary council consisting of oncologist, pathologist, radiologist, and general surgery specialist, it was decided to perform breast operation first and then colon operation, followed by adjuvant chemotherapy. In the first operation, left total mastectomy and sentinel lymph node biopsy were performed. One week after her initial operation, the patient underwent right hemicolectomy. After operations, the patient did not develop postoperative complications and was sent to medical oncology department for adjuvant chemotherapy. Gurkan Yetkin, Fevzi Celayir, Ismail Ethem Akgun, and Ramazan Ucak Copyright © 2017 Gurkan Yetkin et al. All rights reserved. Intracranial Myeloid Sarcoma Metastasis Mimicking Acute Subdural Hematoma Sun, 22 Oct 2017 07:59:32 +0000 Myeloid sarcoma, a rare consequence of myeloproliferative disorders, is rarely seen in the central nervous system, most commonly in the pediatric population. Although there are a handful of case reports detailing initial presentation of CNS myeloid sarcoma in the adult population, we have been unable to find any reports of CNS myeloid sarcoma presenting as a large mass lesion in a herniating patient. Here, we present the case of a patient transferred to our facility for a very large subdural hematoma. Based on imaging characteristics, it was felt to be a spontaneous hematoma secondary to coagulopathy. No coagulopathy was found. Interestingly, he did have a history of acute myeloid leukemia (AML) diagnosed 2 months previously, and intraoperatively he was found to have a confluent white mass invading both the subdural and subarachnoid spaces. There was minimal associated hemorrhage and final pathology showed myeloid sarcoma. This is the first report we are aware of in which CNS myeloid sarcoma presented as a subdural metastasis and also the first report in which we are aware of this etiology causing a herniation syndrome secondary to mass effect. Amandip S. Gill, Rabina Gill, Paul Kaloostian, Dina Elias, John S. Roufail, Aurora S. Cruz, Panayiotis E. Pelargos, Frank P. K. Hsu, Ronald C. Kim, Robert E. Ayer, and Samer Ghostine Copyright © 2017 Amandip S. Gill et al. All rights reserved. Retroperitoneal Ectopic Pregnancy: Diagnosis and Therapeutic Challenges Sun, 22 Oct 2017 00:00:00 +0000 Background. Retroperitoneal ectopic pregnancy is extremely rare. This unusual location represents a great challenge for clinicians due to the difficulties of diagnosis and high risk of life-threatening complications. Case Report. We report the case of a spontaneous early pregnancy of undetermined location in a patient with a history of previous laparoscopic surgery. Diagnosis steps using clinical examination, ultrasound, and magnetic resonance imaging led to the localization of the pregnancy, in the left side of the para-aortic region, in the retroperitoneal space. Conclusion. Retroperitoneal ectopic pregnancy is an uncommon entity with rather complex pathogenesis. Clinicians should carefully interpret clinical signs, biological findings, and imaging features and be aware of unusual locations such as the retroperitoneum for ectopic pregnancies. Early diagnosis and appropriate management strategy are conditio sine qua non for successful treatment outcomes. Salma Ouassour, Abdelhai Adib Filali, Mohamed Raiss, Rachid Bezad, Zakia Tazi, Mohamed Hassan Alami, Jihane Bennani, and Rachida Dafiri Copyright © 2017 Salma Ouassour et al. All rights reserved. Open Approach to Primary Lumbar Hernia Repair: A Lucid Option Tue, 17 Oct 2017 00:00:00 +0000 Background. Lumbar hernia is a rare type of hernia. Awareness of the anatomical basis of this hernia is important for proper diagnosis and treatment. Introduction. Lumbar hernia is a protrusion of either extraperitoneal fat or intraperitoneal contents through either of the lumbar triangles. Primary lumbar hernias are extremely rare thereby rendering such a case reportable, to create an awareness about this condition to upcoming surgeons. Case Report. A case of primary lumbar hernia treated successfully by open mesh repair is presented. Discussion. The anatomical aspects underlying this condition along with diagnostic tests, their pitfalls, and surgical approaches are discussed. Conclusion. Awareness of this condition is essential for arriving at a clinical diagnosis. CT scan provides a road map for deciding the approach. Both the traditional open and the newer laparoscopic approaches are described. However open meshplasty is still a very safe and effective method of treatment. Ketan Vagholkar and Suvarna Vagholkar Copyright © 2017 Ketan Vagholkar and Suvarna Vagholkar. All rights reserved. Symptomatic Bochdalek Hernia in Pregnancy: A Rare Case Report Mon, 16 Oct 2017 00:00:00 +0000 Introduction. Symptomatic Bochdalek hernia in pregnancy is quite rare. To the best of our knowledge, there are a total of 44 cases reported in the literature between 1959 and 2016 (Hernández-Aragon et al., 2015; Koca et al., 2016). Difficulty and delay in diagnosis may lead to life-threatening complications. Case Report. We report a case of Bochdalek hernia during the 30 gestational weeks’ pregnancy in whom pregnancy continued after surgical repair which resulted in term birth. Discussion. Bochdalek hernia is diagnosed with an incidence of 1 in 2200–12500 live births, while symptomatic diaphragm hernia is much less in adults. The actual incidence of diaphragmatic hernias during pregnancy is still unknown. Symptoms may include abdominal distension, recurrent abdominal pain, nausea, vomiting, inability to defecate, dyspnea, and chest pain. The patient with diaphragmatic hernia may be asymptomatic until the late weeks of gestation, as in our case, or herniation may occur during advanced gestational weeks with increased intraabdominal pressure. Conclusion. In conclusion, diagnosis of the diaphragm hernia during pregnancy is very rare. Diagnosis is rarer in symptomatic patients due to its rarity and the duration of diagnosis may, therefore, be delayed. Diaphragm hernia should be kept in mind in symptomatic patients due to its high maternal and fetal mortality rates. Selçuk Yetkinel, Çağhan Pekşen, and Remzi Kızıltan Copyright © 2017 Selçuk Yetkinel et al. All rights reserved. Mediastinal Tracheostoma for Treatment of Tracheostenosis after Tracheostomy in a Patient with Mucopolysaccharidosis-Induced Tracheomalacia Thu, 12 Oct 2017 00:00:00 +0000 Background. Treatment of tracheostenosis after tracheostomy in pediatric patients is often difficult. Mucopolysaccharidosis is a lysosomal storage disease that may induce obstruction of the airways. Case Presentation. A 16-year-old male patient underwent long-term follow-up after postnatal diagnosis of type II mucopolysaccharidosis. At 11 years of age, tracheostomy was performed for mucopolysaccharidosis-induced laryngeal stenosis. One week prior to presentation, he was admitted to another hospital on an emergency basis for major dyspnea. He was diagnosed with tracheostenosis caused by granulation. The patient was then referred to our institution. The peripheral view of his airway was difficult because of mucopolysaccharidosis-induced tracheomalacia. For airway management, a mediastinal tracheostoma was created with extracorporeal membrane oxygenation. To maintain the blood flow, the skin incision for the mediastinal tracheal hole was sharply cut without an electrotome. The postoperative course was uneventful, and the patient was weaned from the ventilator on postoperative day 19. He was discharged 1.5 months postoperatively. Although he was referred to another institution because of respiratory failure caused by his primary disease 6 months postoperatively, his airway management remained successful for 1.5 years postoperatively. Conclusion. Mediastinal tracheostomy was useful for treatment of tracheostenosis caused by granulation tissue formation after a tracheostomy. Yasuhiro Chikaishi, Kenichi Kobayashi, Shuichi Shinohara, Akihiro Taira, Yusuke Nabe, Shinji Shinohara, Taiji Kuwata, Masaru Takenaka, Soichi Oka, Ayako Hirai, Kazue Yoneda, Koji Kuroda, Naoko Imanishi, Yoshinobu Ichiki, and Fumihiro Tanaka Copyright © 2017 Yasuhiro Chikaishi et al. All rights reserved.