Vaginal Evisceration of Small Bowel With Extraperitoneal Ileal Resection of the Herniated Loops: A Case Report.

Introduction: Vaginal evisceration is an extremely rare surgical emergency that can be described as the extrusion of abdominal viscera through a defect or a rupture of the vaginal wall. We reported the case of an acute abdomen due to small bowel evisceration secondary to vaginal vault dehiscence that required combined vaginal-abdominal approach. Case: We discuss the case of a 72-year-old female who presented to the emergency department for a large prolapse with visible extrusion of the small bowel per vagina. The eviscerated bowel was resected by external vaginal approach due to excessive swelling of the loops which made it impossible to reduce them through the vagina defect. A midline laparotomy was undertaken for further assessment, and the vault defect was closed by transabdominal repair. Conclusion: From its first description in 1864, just a few cases of vaginal evisceration had been described in the medical literature; the most common organ to eviscerate is the distal ileum, although cases of omentum, colon, fallopian tube, and appendix evisceration have also been reported. We described a rare case of transvaginal evisceration of the small bowel in our emergency department; it is a rare surgical emergency that must be managed to prevent serious consequences, such as bowel ischemia and necrosis, sepsis, and death. We suggest that a multidisciplinary approach to prompt examination and management by gynecologists and general surgeons is recommended to reduce the risk of morbidity and mortality. With this paper the authors would like to share the surgical manage of this rare emergency with other surgeons all around the world.

[Eyebrow reconstruction with a scalp island flap based on the superficial temporal artery]. / Ricostruzione del sopracciglio con lembo a isola di cuoio capelluto basato sull'arteria temporale superficiale.

The Authors describe the reconstruction of an eyebrow, in a case of complete traumatic avulsion, using a scalp island flap based on the superficial temporal artery, in a young person aged 32 years. The lesion represented a serious aesthetic disablement capable of causing disturbed psychic equilibrium and individual relationships, in view of the fact that the eyebrows play a decisive role in the characterisation of the face and expressive gestures. The strategy of using a scalp island flap with a limited amplitude only slightly larger than that of the site in which it was inserted enabled optimal projection of the newly constructed eyebrow to be achieved during suturing.

A rare case of acute abdomen in the adult: The intestinal duplication cyst. case report and review of the literature.

INTRODUCTION: Duplications of the gastrointestinal tract are rare congenital anomalies that can occur anywhere throughout the gastrointestinal tract. The reported incidence is 1/4500, and more than 80% occurs before the age of two as an acute abdomen or bowel obstruction. The most common site is Ileum (60%), while the colonic localisation is reported between 4 and 18%. PRESENTATION OF THE CASE: Herein we report the case of a 35-year-old man, presented at the Emergency Department with fever and localised abdominal pain in the right iliac fossa. Preoperative abdominal ultrasound and CT scan showed a cystic mass of 44 × 43 × 70 mm adjoining the posterior wall of the right colon. He underwent explorative laparoscopy, laparotomy conversion, right hemicolectomy with an intra-operative diagnosis of colonic duplication cyst, confirmed by histology. DISCUSSION: The review of the literature showed as the intestinal duplication cysts are rare congenital anomalies. The clinical presentation is variable and depends on the site and the related complications. A surgical approach based on the resection of the involved bowel tract is the treatment associated with the best long-term outcomes. CONCLUSION: It is important to include intestinal duplication in the differential diagnosis of acute abdomen, to ensure the best therapeutic strategy.

[Anastomotic occlusive mucosal web. An unusual complication of the Knight-Griffen procedure associated with protective ileostomy]. / Il diaframma mucoso. Una singolare complicanza della tecnica di Knight-Griffen associata a stomia protettiva.

In stapled anastomosis following anterior rectal resection, the anastomotic occlusive web rate is unknown and the management of this complication is not well defined. A 74-year-old man underwent a curative resection of a rectal cancer and, at the same time, a jejunal resection of an incidental stromal tumor. The colorectal anastomosis, performed according to the Knight-Griffen technique, and the hand-sewn end-to-end jejunal anastomosis were covered by a protective loop ileostomy. A number of features makes the case very unusual. The anastomotic occlusive web was made up of mucosal layer in the absence of a granulation reaction. Several factors contributed to the onset and misidentification of this complication. After the endoscopic approach had failed, the condition was successfully treated during an emergency operation for intestinal perforation.

[Retroperitoneal bronchogenic cyst: a case report and review of the literature]. / Cisti broncogena retroperitoneale. Caso clinico e revisione della letteratura.

This unusual clinical case adds itself to the limited list of existing reports of retroperitoneal bronchogenic cysts in the international literature. It emphasizes the difficulties encountered in making a preoperative diagnosis, since these lesions can be described as both solid and cystic masses. A 69-year-old man underwent surgery to remove an expanding mass diagnosed as originating in the adrenal gland and discovered during clinical investigation for other indications. The lesion was excised only after adrenalectomy whereupon its cystic nature was revealed. Retroperitoneal bronchogenic cysts, though rare, should be considered in the differential diagnosis of retroperitoneal expanding lesions, especially in the presence of cystic tumours of the left adrenal region. This is the first case of a retroperitoneal bronchogenic cyst reported in an adult in Italy.

[Aggressive angiomyxoma of the pelvis and perineum: a case report and review of the literature]. / Angiomixoma aggressivo della pelvi e del perineo. Presentazione di un caso clinico e revisione della letteratura.

Aggressive angiomyxoma is a rare mesenchymal tumour arising from soft tissue of the pelvis and perineum. Other features of this tumour are non-specific clinical signs, local invasion, a high local recurrence rate, and recurrence long after initial excision. We provide a case report with a review of the literature. A 57-year-old woman with a large bulky mass in the perineum was admitted to our institution. She had previously undergone iterative surgery for excision of pelvic and perineal masses. The preoperative diagnostic procedure is described as well as the therapeutic surgical approach (a double simultaneous laparotomic and perineal approach was opted for). The surgical procedure was difficult, time-consuming and dangerous owing to an extensive area of hard retroperitoneal sclerosis involving the low urinary viscera, the vaginal stump and the mesorectum. Radical excision of the mass favoured the re-establishment of the normal pelvic anatomy, resolution of the preoperative symptoms and complete recovery of working capability. Surgical excision is the gold standard in the treatment of aggressive angiomyxoma. This benign neoplasm may sometimes present a malignant course owing to involvement of pelvic viscera. It is also associated with a high late recurrence rate due to local aggressiveness, and longterm follow-up is therefore necessary.

[Usefulness of lateral internal sphincterotomy combined with hemorrhoidectomy by the Milligan-Morgan's technique: results of a prospective randomized trial]. / L'utilità della sfinterotomia interna laterale associata all'emorroidectomia sec. Milligan-Morgan: risultati di uno studio prospettico randomizzato.

Pain is invariably experienced after haemorrhoidectomy. Internal anal spasm is considered to be a major factor in the genesis of such pain. This prospective randomized study was designed to compare the effectiveness of two manoeuvres (surgical sphincterotomy and chemical sphincterotomy) in reducing post-haemorrhoidectomy pain. Sixty patients (38 males, 22 females) with grade III and IV haemorrhoids were included in this study. In all cases resting anal pressure was reported in the range of 50-100 mm Hg. Group A patients underwent Milligan-Morgan haemorrhoidectomy plus chemical sphincterotomy; group B patients underwent Milligan-Morgan haemorrhoidectomy plus internal left lateral sphincterotomy (0.8-1 cm in length) and group C patients underwent Milligan-Morgan haemorrhoidectomy alone. The postoperative course was carefully evaluated and was found to be better in group B. None of the patients treated by surgical sphincterotomy developed incontinence. Two patients in group C developed anal strictures. When indicated, internal left lateral sphincterotomy (0.8-1 cm) is a safe procedure and reduces post-haemorrhoidectomy pain and stenosis.

[Rectal prolapse. Functional results after the Orr-Loygue's rectopexy technique]. / Il prolasso del retto. Risultati funzionali dopo rettopessi secondo Orr-Loygue.

The aims of surgery in rectal prolapse are various: reducing the prolapse, preventing relapse, clearing up incontinence and avoiding constipation. Among several technical options available, anterior rectopexy would appear to be the most suitable for achieving these aims. A retrospective clinical study was conducted in 32 patients operated on from January 1996 to June 1999. For patient recruitment, the preoperative examinations were clinical evaluation, barium enema, anorectal manometry, and urodynamic tests. Surgical procedures were Orr-Loygue rectopexy in 29 cases and Ripstein rectopexy in 3 cases. A sigmoidectomy was also performed in 9 cases and a Burch cystopexy in 4 cases. Early results are available for all patients; only 29 have been evaluated after a mean follow-up of 47 months (range: 30-72). Rectal tenesmus, faecal incontinence and urinary incontinence improved in all cases. Constipation cleared up in 9 cases after a complementary sigmoidectomy; in 15 of the remaining 20 patients constipation persisted or developed. Indications for surgery for rectal prolapse must be considered with caution. The good results of anterior rectopexy depend on correct surgical technique and prevention of septic and pelvic complications. Sigmoidectomy does not increase the morbility rate. A planned colic resection in patients with delayed transit would prevent postoperative constipation. The good results are stable even over long-term follow-up periods. This procedure is also effective for the treatment of genital prolapses.