Key Clinical Message: Desmoplastic round cell tumor, though rare, must be taken into consideration as a differential diagnosis, thus aiding in early evaluation and changing the trajectory of the natural history of the disease condition, and improving the prognosis of patients. Abstract: Desmoplastic small round cell tumor is a rare, aggressive tumor of mesenchymal origin with an incidence of 0.74 cases per million. We present a young adult with a periumbilical mass who was diagnosed as a desmoplastic round cell tumor and later was treated with exploratory laparotomy and resection of the tumor with no recurrence during a 6-month follow-up period.
Introduction and importance: Porcelain gall bladder is an uncommon end-stage modification of chronic cholecystitis, with an incidence ranging from 0.06 to 0.8% along with a plausibility of malignant transformation. Case presentation: We present a 55-year-old female presenting with complaints of epigastric and right hypochondriac region pain who underwent prophylactic laparoscopic cholecystectomy after making a provisional diagnosis of calcified gall bladder on a computed tomography workup. On histopathological examination, she was later diagnosed with a porcelain gallbladder devoid of features suggestive of malignant transformation. Clinical discussion: Porcelain gallbladder is a cholecystopathological condition in which the gallbladder wall gets calcified, either completely or partially. Though the exact pathomechanism of gallbladder calcification is unknown, it is believed to be due to chronic inflammation. Recent studies have shown that gallbladder calcification is associated with a lower risk of the development of gallbladder cancer. Imaging studies, followed by post-operative histopathological examinations, are used to diagnose the porcelain gallbladder. Though the management of asymptomatic patients is debatable, prophylactic cholecystectomy is the preferred treatment for symptomatic porcelain gallbladder patients. Conclusion: Individual porcelain GB patients should be addressed based on the presenting condition, whether surgically or via clinical monitoring and follow-up, taking into consideration the advantages and limitations of both treatment modalities.
Background: Intra-peritoneal onlay mesh (IPOM) repair, a type of Laparoscopic Ventral Hernia Repair (LVHR), comprises bridging the defect from the peritoneal side with a composite mesh. Recently, IPOM-Plus has become the recommended type of LVHR in which the defect in the fascia is sutured before placing the mesh. Materials and methods: This study is a retrospective cohort study conducted at Shree Birendra Hospital (SBH), Nepal. Patients who had undergone IPOM-Plus or IPOM during the past five years (Aug 2016 to Aug 2021) were selected. Data regarding demographics, intraoperative and post-operative outcomes were collected from individual case sheets. Recurrence of hernia was checked at six-month follow-up. Data analysis was performed using SPSS version 25 taking a p-value of <0.05 as statistically significant. Results: A total of 130 patients were included in this study, out of which 73 patients had undergone IPOM (Group I) and 57 patients underwent IPOM-Plus (Group II). In both the groups, there were no statistical difference in age, sex and Body Mass Index (BMI) of the patients. Hernia defect size among Group I and II varied significantly (p-value < 0.001). The mean operative time for Group II (111.05 ± 28.14 min) was significantly higher than Group I (80.00 ± 27.96 min) (p-value < 0.001). Hernia recurrence within six months was higher in Group I (15.1%) than Group II (3.5%) (p-value = 0.029). The adjusted odds ratio (AOR) for six-month recurrence after IPOM repair was 14.86 (95% CI: 2.51-87.85, p-value = 0.003) times higher than that after IPOM-Plus repair. Conclusions: Although the operative time and length of hospital stay is longer, IPOM-Plus repair has shown better outcomes regarding six-month recurrence compared to IPOM repair.
Introduction and Importance: Amyand hernia is an accidental finding that occurs in 0.19-1.7% of patients with inguinal hernia, with children being more commonly affected than adults. However, the management depends on the guidelines given by Losanoff and Basson. Case Presentation: A 62-year-old male presented with complaints of progressive swelling in the right inguinal region without any clinical spectrum of bowel obstruction or strangulation. Examination revealed a right-sided indirect inguinal hernia with positive Ziemann technique. Open hernioplasty revealed an appendix within a hernia sac and was found to be adhered to the surrounding structure with a fibrotic band. According to the Losanoff and Basson protocol, the patient had an appendectomy and an open mesh repair with polypropylene mesh without any post-operative complications. Clinical Discussion: Amyand hernia are often predominantly present in children, with a rare presence in the elderly. Pre-operative clinical diagnosis remains a challenge, and the management depends upon the Losanoff and Basson protocol. Appendectomy of the normal appendix within the hernia sac is often recommended to prevent the sequelae (appendicitis, rupture) following manipulation during hernioplasty. Conclusion: Amyand's hernia is a rare clinical entity and difficult to diagnose due to its uncomplicated presentation. Nevertheless, the progress of appendix inflammation, the possibility of abdominal sepsis, and co-morbidities should all be taken into consideration when deciding how to manage individual patients.
Introduction and importance: Left-sided gall bladder, a rare biliary abnormality with an incidence of 0.04-0.3%, is characterized by the presence of the gall bladder to the left of the ligamentum teres. However, they are often missed during pre-operative imaging and often encountered intraoperatively, thus challenging the surgical intervention for the surgeons. Case presentation: We herein present a 40-year-old male presented with colicky right hypochondriac pain and epigastric discomfort, diagnosed incidentally during laparoscopic cholecystectomy as a left-sided sided gall bladder without situs inversus, which was missed during pre-operative ultrasonography and was treated without any complications with conventional four-port technique without changes in the trocar placement. Clinical discussion: Gall bladder is normally found in the gall bladder fossa to the right of the ligamentum teres in the plane of the von Rex-Cantlie line; however, left-sided gall bladder is found to the left of the ligamentum teres and is frequently associated with inversus of the abdominal structures and associated vessels. They are frequently overlooked during preoperative diagnostic imaging, ultrasound for colicky discomfort, and encountered during intraoperative operations, confounding the treating surgeon's anatomic expertise. Intra-operative cholangiography is sometimes used as an adjunct, and operations can be accomplished with or without modifications in trocar position. Conclusion: Despite preoperative imaging, biliary abnormalities can be discovered accidently during laparoscopic cholecystectomy. Thus, diligent recognition of structures and related anomalies by the treating surgeon has a high value in the best possible outcome for the patient, and left-sided gall bladder can be done with minimum difficulty even without interposition of trocar placement.
INTRODUCTION: Coronavirus disease (COVID-19) is a global a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients commonly present with respiratory tract symptoms and fever. However two third are asymptomatic and unusual presentation is evolving. This has cause management dilemma among physicians. PRESENTATION OF CASE: A 35 year young otherwise healthy male presented to emergency department of this institute with fever of 103 °F, abdominal pain, and pancytopenia with progressive fall in hemoglobin level was tested positive for COVID-19. Contrast enhance computed tomography of the patient revealed hemoperitoneum with splenic infarct. He was admitted in intensive care unit and managed with supportive treatment. DISCUSSION: Respiratory and gastrointestinal symptoms with hematological abnormalities like lymphopenia, thrombocytopenia are common presentation of COVID-19. Although coagulopathy and vasculitis has been a well-documented entity in patients with COIVD-19, visceral infarction leading to spontaneous hemoperitoeum was unusual and rare clinical presentation. CONCLUSION: A high degree of clinical suspicion and thorough evaluation helps in the diagnosis of COVID-19 and related complications. The management of cases with unusual presentation requires judicious and careful approach.
