Umbilical Littre hernia: A rare case report of an acute abdomen.

INTRODUCTION: Littre's hernia (LH) is due to the presence of a Meckel's diverticulum (MD) in a hernial sac. It is an extremely rare condition in less than 1 % of all MD cases. It is often asymptomatic and is diagnosed incidentally during routine surgery for hernia repair. Surgery is the main treatment. Although the management of uncomplicated MD remains controversial, MD's management in the setting of either bowel obstruction or of Littre's hernia is done according to the clinical principles combined with the availability of local expertise. PRESENTATION OF CASE: We report a case of an 11-year-old boy presented to the emergency room with a diagnosis of acute obstructive syndrome. Radiological exams were inconclusive. Intra-operatively findings showed a strangulated MD trapped in a small umbilical hernia. A simple wedge resection, followed by a primary closure of the remaining defect was performed. During 12 months of observation the patient remains in good condition. DISCUSSION: LH is an uncommon type of abdominal wall hernia. Preoperative diagnosis is difficult. Even abdominal ultrasound and computed tomography (CT) cannot reveal the right diagnosis and it is generally performed intraoperatively. The main treatment is surgery. Repair of a Littre hernia requires both management of Meckel's diverticulum and repair of the hernia with sutures or mesh. CONCLUSION: LH is a very rare type of hernia. Diagnosis is very difficult. All surgeons should be aware of this type of hernia to avoid life-threatening complications. The application of hernia repair recommendations for children may anticipate the happening of complicated LH.

Clear cell carcinoma of the abdominal wall: A case report with a review of the literature.

Introduction and importance: Clear cell carcinoma of abdominal wall is a very rare and aggressive disease. It is mostly related to malignant transformation of abdominal wall endometriosis. This paper provides a new case report and a literature review of primitive abdominal wall clear cell carcinoma. Case presentation: A 45-year-old woman with a history of a two previous caesarian section presented to the outpatient department with a tumor mass evolving since 10 years in the lower right quadrant of her abdomen. Imaging studies revealed a voluminous subcutaneous mass developing at the expense of the anterior abdominal wall. Surgical resection of the mass was performed. Histopathological examination along with immunohistochemical analysis were consistent with clear cell carcinoma. Biopsies of the endometrium and ovaries were performed and were negative for malignancy. The patient underwent therefore a hysterectomy with bilateral salpingo-oophorectomy which did not reveal any disease. The diagnosis of primitive clear cell carcinoma of the abdominal wall was then confirmed. Clinical discussion: Primitive clear cell carcinoma of the abdominal wall is an extremely rare form of cancer with usually poor prognosis. Clinicians must be aware of the possibility of malignancy of any swelling mass occurring near or within a caesarean section scar. Conclusion: Reporting more such cases is still needed to further progress in the understanding of this malignancy in addition to the development of treatment strategies.

Retrorectal epidermoid mistaken for perirectal swelling: A case report.

INTRODUCTION AND IMPORTANCE: Epidermoid cysts are developmental cysts of the retrorectal space. They are benign lesions resulting from ectodermal inclusion during neural tube closure. Generally, they are misdiagnosed given that symptoms are often vague and nonspecific. They have a high infection rate (up to 30%) and can be easily mistaken for perirectal abscesses. CASE PRESENTATION: We present a case of an epidermoid cyst in a 58-year-old woman with a retrorectal cyst mistaken for a perianal abscess, which was initially incised and drained and then, after MRI investigation, an anterior resection was performed. CLINICAL DISCUSSION: Epidermoid cysts have a high infection rate (up to 30%). Infected cysts can be easily mistaken for perirectal abscesses, pilonidal disease, or fistulae in ano. CT (computed tomography) used in conjunction with MRI (Magnetic Resonance Imaging) is the gold standard for establishing the diagnosis. A biopsy is never indicated. Surgery is the best treatment, even for asymptomatic lesions. CONCLUSION: Epidermoid cysts are rare and generally misdiagnosed. In fact, symptoms are often vague and nonspecific. Radiologic imaging (especially MRI) is essential for surgical planning and biopsy should be avoided. Once a presacral lesion is diagnosed, even if the patient is asymptomatic, complete resection remains the treatment of choice because of the risk of infection.

Obturator hernia: A case report of intestinal obstruction with challenging diagnosis and non-standardized treatment.

INTRODUCTION AND IMPORTANCE: Obturator Hernia (OH) is a rare clinical entity that constitue less than 1% of all abdominal hernias. It happens in elderly thin women malnourished. The diagnosis is usually delayed because symptoms are non-specific, and patients commonly have features of intestinal obstruction. There are no international guidelines for treatment and the best surgical approach still unknown. CASE PRESENTATION: We report a case of strangulated OH in a 75 year woman who consulted in our service for an acute intestinal obstruction. Intra-operatively findings showed loop of ileum entering through a defect in the right obturator canal. The obturator defect was closed by approximation flap of peritoneum and covered by right ovair and fallopian tube. CLINICAL DISCUSSION: This case is reported because of its an uncommon type of abdominal wall hernia with high probability of bowel strangulation and highest morbidity and mortality rates. There are no international guidelines for treatment and the best surgical approach still unknown. CONCLUSION: The diagnosis of OH should be suspected every time there is an intestinal obstruction of unknown origin in emaciated elderly women. Open or laparoscopic sutured repair surgery and placement of mesh remain the most common method of repair.

Postoperative morbidity risk factors after conservative surgery of hydatic cyst of the liver: a retrospective study of 151 hydatic cysts of the liver.

BACKGROUND: The purpose of the present paper is to assess the morbidity specifics risk factors of hepatic hydatid cyst after conservative surgery. METHODS: We conducted a retrospective study of 102 patients over a period of 13 years, from 2006 to 2019. We included all patients operated on hydatid cyst of the liver, complicated and uncomplicated, in the Department of General Surgery in Tahar Sfar hospital, Mahdia, Tunisia. We excluded patients who received an exclusive medical treatment and those who have other hydatic cyst localizations. RESULTS: The cohort was composed of 102 patients with a total of 151 cysts operated on using conservative surgery, among them there was 75 women (73.5%) and 27 men (26.5%). The median age was 43, with extremes ranging from 12 to 88 years. The majority of patients (94.1%) were from rural areas. The cysts were uncomplicated in about half of the cases (48%), elsewhere complications such as compression of neighboring organs (25.5%), opening in the bile ducts (16.7%), infection (9.8%), and rupture in the peritoneum (2%) were found. Conservative surgery was the mainstay of treatment with an overall mortality rate of 1.9%. The overall morbidity rate was 22%: 14% specific morbidity and 8% non-specific morbidity. External biliary fistula was the most common postoperative complication (9%). The predictive factors of morbidity in univariate analysis were: preoperative hydatid cyst infection (P = 0.01), Compressive cysts (P = 0.05), preoperative fever and jaundice, (respectively P = 0.03 and P = 0.02), no one achieved statistical significance in the multivariate model. CONCLUSIONS: Preoperative hydatid cyst infection, compressive cysts and preoperative fever and jaundice could be predictor factors of morbidity after conservative surgery for liver hydatid cyst. They must be considered in the treatment and the surgical decision for patients with hydatid cyst.

Trichobezoar: A case report of a double gastric and ilial localization revealed by an occlusion.

INTRODUCTION AND IMPORTANCE: A bezoar is an agglutination of ingested materials forming an indigestible and insoluble mass inside the gastrointestinal tract. Trichobezoars formed by ingested hair are rare. The stomach tends to be the typical location. In some cases there is an extension to the duodenum, jejunum or even to the colon and it is called Rapunzel syndrome. CASE PRESENTATION: We present a case of an occlusion due to double trichobezoars in 17 years old woman who underwent an extraction by enterotomy and gastrotomy. CLINICAL DISCUSSION: Trichobezoar is a compact conglomeration of swallowed hair and makes up less than 6% of all bezoars. It appears in young women under 20 years of age who carry psychiatric or chronic metabolic diseases that can alter the behavioral balance. Physical examination is often poor in uncomplicated forms: forms without peritonitis or occlusion or hemorrhage or appendicitis or pancreatitis but it may reveal a well-limited, smooth, firm, and mobile epigastric mass. For uncomplicated forms or forms complicated by hemorrhage, the reference examination requested in the first line remains the esophagogastroduodenoscopy (EGD) which allows a dual role both diagnostic and therapeutic. Computed Tomography (CT) remains the preferred imaging modality requested urgently in case of an occlusion or peritonitis presentation. Endoscopic extraction represents the therapeutic approach for uncomplicated forms but surgical treatment remains the main therapeutic means of trichobezoar. CONCLUSION: Trichobezoars are rare and present both diagnostic and therapeutic challenge. Laparotomy remains the most successful surgical treatment although laparoscopy currently appears to have promising results in expert hands. A post-operative pscychologic management is essential to correct psychobehavioral disorders of patients to prevent recurrence.

Acute abdomen during pregnancy: appendicular deciduosis-a case report.

Despite the fact that it is rarely found in the appendix during pregnancy, ectopic decidua can, in some cases, cause the occlusion of the appendicular lumen by extrinsic compression due to the expansion of endometrial tissue or due to decidua polyp formation. This condition consequently leads to appendicular inflammation. We report the case of a 27-year-old primigravida woman, 32 weeks of gestation, who presented to our facility with a 2-day history of isolated right iliac fossa pain. The diagnosis of an acute appendicitis was suspected and a planned appendectomy was performed. Microscopical examination showed appendicular deciduosis.

Trocar site post incisional hernia: about 19 cases.

It is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. Therefore, having port-site incisional hernia caused by trocars of laparoscopy must be avoided. The aim of this work is to specify predictive factors, therapeutic modalities and to insist on prevention of this avoidable complication. It is a retrospective and descriptive study over a period of 10 years, between January 2006 and December 2015. This series includes 19 consecutive patients who present port-site incisional hernia. Age, initial intervention, site and size of the trocars incisional hernia, diagnostic method, delay and type of the second procedure with the final results were examined and recorded. Our study contains 19 female. The average age was 55 years (29-78). Risk factors were resent in 12 patients. All our patients were operated initially by laparoscopic approach. The average onset time was 6.6 months (3-12). Fourteen patients presented swelling at the trocar site and 5 patients had an emergent surgery due to the strangulation of the port-site incisional hernia. For these five patients a primary suture was made. Hernia content was the great omentum in 11 cases and small bowel in 8 cases. It was umbilical in 16 patients and in the left flank in 3 patients. They occur all where it was placed a 10 mm trocar. The evolution was suitable in all cases. There were two recurrences, one after primary suture and the other after a mesh repair. Port-site incisional hernia is rare. The most incriminated risk factors are essentially trocar size, obesity and open coelioscopy. Vital prognosis can be engaged if port-site incisional hernia is incarcerated or strangulated then prevention is necessary.

Choledochoduodenal fistula due to peptic duodenal ulcer diagnosed by X-barium meal study: interest of medical treatment.

Peptic ulcer complication has decreased over le last years. Spontaneous bilio-digestive fistulas, in the absence of primary biliary disease, remain a very unusual complication of the upper digestive tract. The choledochoduodenal fistula is an extremely rare entity which can be caused by a duodenal peptic ulcer. It appears with the symptoms of peptic ulcer disease. They are diagnosed incidentally on radiological exams. It was suspected after finding pneumobilia on abdominal ultrasound and confirmed by X-barium meals study. The purpose of this observation is to report the case of a patient presenting a choledochoduodenal fistula diagnosed by X-barium meal to underline the importance of this radiological exam to diagnose this disease and to insist on the conservative treatment for choledochoduodenal fistula caused by a duodenal peptic ulcer. The prognosis of patients treated medically is good, although the fistula can remain asymptomatic. Angiocholitis and biliary sequelae remain rare and do not warrant prophylactic surgical treatment.

[Lichtenstein versus Lichtenstein plus plug in prosthetic inguinal hernia repair: preliminary results of a prospective randomized controlled trial]. / Lichtenstein versus Lichtenstein plus pluf dans les cures prothétique des hernies inguinales: résultats préliminaires d'une étude contrôlée prospective randomisée.

BACKGROUND: Mesh- based hernioplasties became the reference in inguinal hernia repair. AIM: To evaluate the results of combining a conic Plug to the Lichtenstein Mesh for inguinal hernia repair. METHODS: Between January 2007 and January 2009 we included 50 patients with primary or recurrent inguinal hernia in a prospective comparative randomized controlled trial. The randomization concerned the association of the conic Plug to the Lichtenstein Mesh. The primary objectives were to establish if any differences in operation time, postoperative pain response and/or postoperative recovery time, chronic pain and recurrence could be detected between the 2 groups. All patients were seen and data were collected after 2 weeks, 6 months and 2 years. RESULTS: Twenty two patients were treated by Lichtenstein Mesh (group A) and we associated the conic Plug to 28 patients (group B). The mean age was 56 years. Forty three patients were discharged after 24 hours. The postoperative pain was low with visual analogue scores ≤ 5 for 48 patients. One patient had residual pain treated efficiency with medical treatment. No recurrence in the 2 groups in 2 years outcome. There were no significant differences between the 2 groups. CONCLUSION: Results of the Lichtenstein plus Plug technique are similar to the Lichtenstein results. There were no significant differences between the 2 groups concerning early or late complications. The recurrence will be revaluated after 5 and 10 years outcome.