A Rare Case of Extended Retroperitoneal Biloma Due to Spontaneous Perforation of Common Bile Duct, Mimicking a Strangulated Right Inguinal Hernia: A Case Report and Literature Review.

BACKGROUND Biloma is the collection of bile outside the biliary tree as a result of visceral perforation. The most common site of disruption is the gallbladder, whereas common bile duct lesions usually occur following medical procedures or trauma. Spontaneous perforation of the common bile duct has been previously reported in the literature. Retroperitoneal biloma secondary to spontaneous perforation of the common bile duct is an extremely rare pathological entity. The purpose of this report is to inform clinical doctors of this rare entity, which can have fatal consequences for the patient. CASE REPORT We present the case of an 89-year-old man who was hospitalized with symptoms of vomiting, nausea, fatigue, and diffuse abdominal pain. The clinical examination and blood tests revealed peritonitis, a finding which was confirmed by the computed tomography of the abdomen as a retroperitoneal fluid collection, extending from the region posterior to the duodenum and head of the pancreas to the right inguinal fossa. As the patient's clinical status deteriorated, an urgent laparotomy was performed, revealing the presence of retroperitoneal biloma secondary to spontaneous perforation of the common bile duct. The operation was never completed as the patient died during the operation. CONCLUSIONS The diagnosis of this entity is difficult and is made during surgery. A large spectrum of treatment approaches has been used, but, regardless of the method, the goal is to halt the spreading abdominal contamination with bile and to treat the associated biliary pathology.

Right-sided strangulating diaphragmatic hernia in an adult without history of trauma: a case report.

BACKGROUND: Diaphragmatic hernia involves protrusion of abdominal contents into the thorax through a defect in the diaphragm. This defect can be caused either by developmental failure of the posterolateral foramina to fuse properly, or by traumatic injury of the diaphragm. Left-sided diaphragmatic hernias are more common (80-90%) because the right pleuroperitoneal canal closes earlier and the liver protects the right diaphragm. Diaphragmatic hernias in adults are relatively asymptomatic, but in some cases may lead to incarcerated bowel, intraabdominal organ dysfunction, or severe pulmonary disease. The aim of this report is to enlighten clinical doctors about this rare entity that can have fatal consequences for the patient. CASE PRESENTATION: We present a rare case of a right-sided strangulating diaphragmatic hernia in an adult Caucasian patient without history of trauma. Clinical examination revealed bowel sounds in the right hemithorax, which were confirmed by the presence of loops of small intestine into the right part of the thorax through the right diaphragm, as was shown on chest X-ray and computerized tomography. Deterioration of the clinical status of the patient led to an operation, which revealed strangulated necrotic small bowel. Approximately 1 m of bowel was removed, and laterolateral anastomosis was performed. The patient had an uneventful postoperative recovery and was discharged 8 days later. CONCLUSIONS: Surgery is required to replace emerged organs into the abdomen and to repair diaphragmatic lesion. A delayed approach can have catastrophic complications for a patient.

Multidimensional analysis of the learning curve for laparoscopic colorectal surgery in a regional hospital: the implementation of a standardized surgical procedure counterbalances the lack of experience.

BACKGROUND: Although a larger proportion of colorectal surgeries have been performed laparoscopically in the last few years, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single centre study was to determine, using various parameters and following a well-structured and standardized surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience in laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique. METHODS: From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (group A:50 - group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analysed and compared between groups. RESULTS: There was no significant difference between groups in the distribution of conversions (p = 0.635) and complications (p = 0.637). Patients in both groups underwent surgery for the same median number of lymph nodes (p = 0.145) and stayed the same number of days in the hospital (p = 0.109). A statistically important difference was found in operation duration both for the total (p = 0.006) and for each different type of colectomy (sigmoidectomy: p = 0.026, right colectomy: p = 0.013, extralevator abdominoperineal resection: p = 0.050, low anterior resection: p = 0.083). CONCLUSIONS: Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardized surgical procedure.