Case Reports in Surgery The latest articles from Hindawi © 2017 , Hindawi Limited . 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. Jejunal Diverticular Perforation Causing Small Bowel Obstruction in a Type 4 Hiatal Hernia: A Rare Case Report of a Nonagenarian Patient and Review of Relevant Literature Tue, 10 Oct 2017 00:00:00 +0000 Type IV paraesophageal hernia (PEH) is very rare and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a case of a 90-year-old male patient who presented at our emergency department complaining of epigastric pain that he had experienced over the past few hours and getting progressively worse. On the day after admission, his pain became severe. Chest radiography revealed an intrathoracic intestinal gas bubble; emergency exploratory laparotomy identified a type IV PEH with herniation of only the jejunum with perforated diverticula on mesenteric side through a hiatal defect into mediastinum. There are a few published cases of small bowel herniation into the thoracic cavity in the literature. Our patient represents a rare case of an individual diagnosed with type IV PEH with herniation of jejunum with perforated diverticula. Saptarshi Biswas, Shekhar Gogna, and Prem Patel Copyright © 2017 Saptarshi Biswas et al. All rights reserved. Gossypiboma Resection after Eight Years in a Patient with Rheumatoid Arthritis and Diabetes Tue, 03 Oct 2017 00:00:00 +0000 Gossypiboma is the term used to refer to a mass formed by surgical material left in the body cavity after surgery. We present the case of a middle-aged woman with a history of rheumatoid arthritis controlled with corticosteroids and biologic therapies, uncontrolled type II diabetes mellitus, and cesarean section with postoperative bleeding eight years earlier, who presents with right lower quadrant abdominal pain and is found to have a gossypiboma from her previous operation. A subsequent operation is undertaken to remove the gossypiboma. After the procedure, our patient’s diabetes and chronic back pain greatly improve, raising the question of gossypiboma’s role in these diseases. A review of our patient’s records found that a correct sponge count was recorded after her cesarean section, raising questions about the operating room policies regarding surgical counts, the presence of falsely correct counts, and the need for postoperative plain films in procedures with an increased risk of a retained object. Our patient’s presentation eight years after the inciting surgery raises questions about the involvement her immunosuppressive therapy may have had in cloaking the gossypiboma. Our case also raises the question of surgical culpability, including the ethical and legal considerations for apology from the culpable surgeon. Kenley Unruh and Hsien Sing Sam Hsieh Copyright © 2017 Kenley Unruh and Hsien Sing Sam Hsieh. All rights reserved. Vaginal Cuff Dehiscence Presenting with Free Air 60 Days after Robotic-Assisted Hysterectomy Mon, 02 Oct 2017 06:36:12 +0000 Introduction. The vast majority of patients presenting with pneumoperitoneum have visceral organ perforation and require urgent diagnostic laparoscopy. Nonsurgical causes are relatively rare and may be attributed to multiple etiologies. Case Presentation. Here we describe the case of a 38-year-old Caucasian female who presented to the emergency department with three days of cramping, epigastric abdominal pain. Her physical exam was notable for tenderness to palpation in the epigastric area and abdominal and chest X-rays showed free air under the diaphragm. Free air around the porta hepatis was verified on CT scan. Approximately 90% of pneumoperitoneum cases are due to perforation of visceral organs and therefore require operative management. An urgent exploratory laparoscopy revealed no clear source of free air, but postoperatively the patient developed a large volume of watery discharge from her vagina. Subsequent workup revealed a 1 cm vaginal cuff dehiscence which was later repaired with no postoperative complications. Conclusion. Although the majority of patients with pneumoperitoneum require urgent exploratory laparoscopy, a careful diagnostic workup may reveal sources of free air that are not related to hollow viscous perforation. Vaginal cuff dehiscence represents a rare yet nonurgent source of pneumoperitoneum. This differential should be considered in light of the possible intra- and postoperative complications of surgery. D. Munger, M. Iannamorelli, C. Galvez, and C. Service Copyright © 2017 D. Munger et al. All rights reserved. Late Ps. aeruginosa Inguinal Mesh Infection 12 Years after the Initial Operation: Report of the Case and Short Review of the Literature Wed, 27 Sep 2017 06:09:52 +0000 Inguinal hernia mesh repair is one of the most frequent operations performed worldwide. The Lichtenstein technique and its various modifications are the most popular operations for groin hernia repair. The rate of surgical site infection (SSI) following inguinal hernia repair ranges between 0 and 14% in various series. Most of these infections developed early postoperatively. The incidence of late mesh infection following open inguinal hernia repair still remains unclear and highly variable. Late deep mesh infections are relatively rare specially after more than 10 years. The most common pathogens reported in the literature are E. coli and St. aureus. The infection is treated by conservative means initially but in case of failure then the mesh should be removed surgically. A unique case of a patient with very late (chronic) mesh infection is presented. The infection was due to Pseudomonas aeruginosa, which occurred 14 years after the initial operation and presented as subcutaneous fistula. Dimitrios Filippou Copyright © 2017 Dimitrios Filippou. All rights reserved. Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature Wed, 20 Sep 2017 06:44:07 +0000 Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient’s history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone. Sara Abou Azar, Mohammad Rachad Wehbe, Sarah Jamali, and Ali Hallal Copyright © 2017 Sara Abou Azar et al. All rights reserved. A Large Lumbar Adnexal Neoplasm Presenting Characteristics of Eccrine Poroma and Poroid Hidradenoma Tue, 19 Sep 2017 07:10:18 +0000 Poroma is a rare benign neoplasm that derives from eccrine sweat glands epithelium. Its histological subtypes, with respect to its position within skin layers, are eccrine poroma, hidroacanthoma simplex, poroid hidradenoma, and dermal duct tumor. Poromas commonly exhibit benign clinical behavior as they are usually small and asymptomatic and do not exhibit malignant behavior. Although their histological subtypes share similar histological characteristics, they rarely coexist in the same tumor. In this report we present the case of an unusual poroma in terms of histological and clinical behavior as it was large and presented histological characteristic of both eccrine poroma and poroid hidradenoma. Coexistence of different histologic subtypes in the same tumor indicates simultaneous tumorigenesis, differentiation from one cell type to another, or parallel differentiation from a common progenitor cell. Implications in treatment remain unknown partly due to the rarity of such cases. Adamantios Michalinos, Dimitrios Schizas, Antonios Sarakinos, Georgios Athanasiadis, Eleftherios Spartalis, Dimitrios Vlachodimitropoulos, and Theodore Troupis Copyright © 2017 Adamantios Michalinos et al. All rights reserved. Amyand’s Hernia, State of the Art and New Points of View Sun, 17 Sep 2017 08:56:00 +0000 Background. Amyand’s hernia (AH) is an inguinal hernia containing the vermiform appendix, with an incidence between 0.4% and 1% of all inguinal hernias. Acute or perforated appendicitis can complicate AH. Case Presentation. A 75-year-old Caucasian man presented with incarceration of vermiform appendix in inguinal hernia sac. Diagnosis was posed preoperatively with computed tomography (CT) scan. Patient underwent urgent surgery and simultaneous appendectomy and hernia repair by Bassini’s technique were performed. Conclusions. Preoperative diagnosis of AH is rare; however it could be useful for surgeon to choose operative approach. Treatment of AH depends on grade of appendix inflammation and/or perforation. The technique utilized to repair hernia depends largely on surgeon’s preferences; the presence of inflamed or perforated appendix is not an absolute contraindication for using a prosthetic mesh. Guido Mantovani, Michela De Angelis, Francesco Di Lecce, Annalisa Pascariello, Domenico Risio, and Luigi Boccia Copyright © 2017 Guido Mantovani et al. All rights reserved. Hem-o-lok Clips Migration: An Easily Neglected Complication after Laparoscopic Biliary Surgery Thu, 14 Sep 2017 06:26:23 +0000 Clip migration into the common bile duct (CBD) is a rare but well-established phenomenon of laparoscopic biliary surgery. The mechanism and exact incidence of clip migration are both poorly understood. Clip migration into the common bile duct can cause recurrent cholangitis and serve as a nidus for stone formation. We present a case, a 54-year-old woman, of clip-induced cholangitis resulting from surgical clip migration 12 months after laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LC+LCBDE) with primary closure. Jun-wen Qu, Gui-yang Wang, Zhi-qing Yuan, and Ke-wei Li Copyright © 2017 Jun-wen Qu et al. All rights reserved. Jejunojejunal Intussusception due to Metastatic Melanoma Seven Years after the Primer Tue, 12 Sep 2017 09:20:31 +0000 Intestinal intussusception in adults is a rare medical condition accounting for less than 5% of all intussusceptions. Herein we present a 45-year-old patient with a history of abdominal pain and loss of weight. CT scan revealed jejunojejunal intussusceptions. The patient was subjected to exploratory operation and small intestine resection due to a mass causing intestinal intussusception. Pathology confirmed suspected diagnosis of metastatic melanoma to small intestine secondary to melanoma, 7 years after the initial manifestation. Postoperative evaluation with 18FDG-PET/CT revealed increased uptake in the thyroid gland. Subsequent total thyroidectomy revealed severe Hashimoto thyroiditis and no signs of metastasis. The patient received adjuvant immunotherapy and is healthy with no signs of recurrence 3 years after the initial diagnosis and treatment. Alexander Giakoustidis, Thomas Goulopoulos, Anastasios Boutis, George Kavvadias, Aristidis Kainantidis, Thomas Zaraboukas, and Dimitrios Giakoustidis Copyright © 2017 Alexander Giakoustidis et al. All rights reserved.