Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report.

BACKGROUND: Residual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy. CASE PRESENTATION: A 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days. CONCLUSION: Residual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

Panniculectomy as a surgical option for the management of a deep surgical site infection after C-section in a morbidly obese woman: a case report.

BACKGROUND: Obesity is an independent risk factor for the occurrence of surgical site infections (SSIs) following all types of surgeries, especially after Caesarean section (C-section). SSIs increase postoperative morbidity, health economic cost and their management is quiet complex with no universal therapeutic consensus. Herein, we report a challenging case of a deep SSI after C-section in a central morbidly obese woman managed successfully by panniculectomy. CASE PRESENTATION: A 30-year-old black African pregnant woman with marked abdominal panniculus extending to the pubic area, a waist circumference = 162 cm and BMI = 47.7 kg/m2 underwent an emergency CS indicated for acute fetal distress. By day five post-operation, she developed a deep parietal incisional infection unremitting to antibiotic therapy, wound dressings and beside wound debridement till the 26th postoperative day. A large abdomen panniculus and maceration of the wound enhanced by central obesity increased the risk of failure of spontaneous closure; thus, an abdominoplasty by panniculectomy was indicated. The patient underwent panniculectomy on the 26th day after the initial surgery and her post-operative course was uneventful. Wound esthetics was satisfactory three months later. Adjuvant dietary and psychological management were associated. CONCLUSION: Post-Caesarean deep SSI is a frequent complication in obese patients. A panniculectomy may be a safe and promising therapeutic surgical option with good cosmetic results and little postoperative complications when used in a multidisciplinary anti-obesogenic approach.

Transvaginal strangulated bowel evisceration through uterine perforation due to unsafe abortion: a case report and literature review.

BACKGROUND: Induced abortion, whether therapeutic or elective, is a surgical procedure frequently practiced worldwide. It is a significant cause of maternal morbidity and mortality. When the procedure is performed in precarious conditions, by unqualified personnel, it leads to serious consequences, including uterine perforation and its associated lesions. Its management remains a medico-surgical emergency. CASE PRESENTATION: We present two cases of unsafe abortions performed by cervical dilatation and intrauterine curettage which resulted in uterine perforation and intestinal evisceration through the vagina leading to acute intestinal obstruction. Both patients underwent intensive resuscitation followed by an emergency laparotomy. The first case was a 26-year-old woman living in rural Cameroon. Following a procedure of termination of her pregnancy, the patient noted the presence of bowel at the vaginal introitus associated with signs of intestinal obstruction. She was transferred to a specialized center was after 4 days later of the onset of the evisceration. Considering the gangrened eviscerated terminal ileum, a right hemicolectomy with anastomosis was performed, as well as a suture of the uterine perforation. The second patient was an 18-year-old African living as a refugee in Cameroon. She was referred for abdominal pain in the context of intestinal obstruction with a viable jejunal loop extruding through the vagina. A simple jejunal resection was performed with end-to-end anastomosis and suture of the uterine perforation. In both cases, the postoperative course was uneventful. CONCLUSIONS: Uterine perforation is a serious complication of intrauterine gynecological procedures and instrumental abortion in particular. It can lead to evisceration of the intra-abdominal viscera through the uterine perforation. It is therefore a real surgical emergency with multiple and fatal consequences.