Anterior abdominal wall swelling as incarcerated Spigelian hernia in an elderly female: A diagnostic dilemma.

Spigelian hernias are difficult to detect and palpate during physical examination due to their deeper location. They can be asymptomatic or present with acute complications such as incarceration, strangulation, or bowel obstruction. Here we present a case of a 58-year-old female with history of palpable swelling over the left iliac fossa region with abdominal distension. A computed tomography with oral contrast revealed features suggestive of incarcerated Spigelian hernia with small bowel obstruction, which was later managed with laparoscopic ventral hernia repair and repair of seromuscular tear of the small bowel. Computed tomography is the gold standard for diagnosing the condition and assessing bowel status. Conservative treatment is not effective due to the high likelihood of complications, and surgery is the mainstay of management. The approach to surgery depends on the patient's characteristics, the type of hernia, and the surgeon's experience. Mesh repair is advocated regardless of approach.

Acute intestinal obstruction secondary to ingested foreign body in an adult with autism spectrum disorder: A rare case report and review of literature.

Key Clinical Message: Foreign body ingestion is common in pediatric age group however can be found in any age group with intellectual disability and neurodevelopmental delay. There is usually a delay in presentation and interventions following foreign body ingestion in patients with neurodevelopmental delay, leading to increased morbidity, mortality, and complications owing to inability of such patients giving relevant history. Most ingested foreign bodies naturally pass through the digestive tract without untoward effects. Only a few patients may require surgical interventions. Principle of management should be to reduce anxiety among patients and their visitors. Speedy recovery is enhanced so that they can return to their familiar environment soon. Abstract: Foreign body ingestion is common in pediatric populations and may be found in any age group with intellectual disability and neurodevelopmental delay. As the patient cannot give a clear and relevant history, there is usually a delay in presentation and interventions following foreign body ingestion in patients with neurodevelopmental delay, leading to increased morbidity, mortality, and complications. Most foreign bodies pass through the digestive system without any complications, and very few require surgical intervention. The goal should be to reduce anxiety among patients and their visitors and to enhance speedy recovery so that they can return to their familiar environment soon. Here we report a case of Acute intestinal obstruction secondary to ingestion of the head portion of a doll which was managed with emergency laparotomy with enterotomy and removal of foreign body in a 16 years female with Autism Spectrum Disorder.

Traumatic Abdominal wall hernia with ileal perforation following blunt trauma abdomen: A rare case report and review of literature.

Blunt trauma abdomen with abdominal wall herniation with bowel perforation is an acute emergency condition. Road traffic accidents causing blunt trauma are common in a youngster like in our case. Once the patient is resuscitated, ultrasonography and Computed tomography must be done. Early surgical exploration with mesh or primary repair of the defect is the mainstay of management. We have a case of a 25-year-old male with blunt trauma abdomen and anterior wall hernia following a road traffic accident who was managed with emergency exploratory laparotomy as computed tomography suggested anterior abdominal wall herniation of bowel content.

Malignant rectal GIST managed with chemotherapy (Imatinib Mesylate): A case report and a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors involving the gastrointestinal tract, arising from the interstitial cells of Cajal. GIST comprises about 1% of all GI tumors. Rectal GISTs are rare and comprise of approximately 5% of all GISTs and only 0.1% of rectal tumors are found to be GISTs. Rectal GISTs may be diagnosed incidentally or present with symptoms, including defecation problems, bleeding, and/or pain. We report a case of a 46-year-old male with rectal GIST metastasized to the liver and bilateral lung parenchyma managed by Imatinib Mesylate (IM) regimen. Rectal GIST although being rare, must be considered as a differential diagnosis in a patient presenting with defecatory problems with bleeding.

Cough syrup bottle at rectum in elderly male: a rare case report.

Foreign body in the anal canal may be inserted for sexual gratification or sexual assault or accidental or drug trafficking. We report a case of a male who accidentally inserted a cough syrup bottle in his rectum. Presentation is usually late due to fear and embarrassment. The manual attempt of removal may be tried under adequate anesthesia. Post-procedure sigmoidoscopy or colonoscopy may be helpful to diagnose laceration or mucosal injury.

Morphometric analysis of foramen ovale, foramen spinosum, and foramen rotundum of human skull using computed tomography scan: a cross-sectional study.

There is limited literature of objective assessments of foramina of skull base using computed tomography (CT) scan. This study was carried out to analyze the dimensions of foramen ovale (FO), foramen spinosum (FS), and foramen rotundum (FR) using CT scan imaging of the human skull and their associations with sex, age, and laterality of the body. Materials and methods: A cross-sectional study was carried out in the Department of Radiodiagnosis and Imaging at BP Koirala Institute of Health Sciences (BPKIHS), Nepal using a purposive sampling method. We included 96 adult patients (≥18 years) who underwent CT scan of the head for any clinical indications. All those participants below 18 years, inadequate visualization or erosions of skull base foramina, and/or not consenting were excluded. Appropriate statistical calculations were done using the statistical package for social sciences (SPSS), version 21. The P-value of less than 0.05 was considered statistically significant. Results: The mean length, width, and area of FO was 7.79±1.10 mm, 3.68±0.64 mm, and 22.80±6.18 mm2, respectively. The mean length, width, and area of FS was 2.38±0.36 mm, 1.94±0.30 mm, and 3.69±0.95 mm2, respectively. Similarly, the mean height, width, and area of FR was 2.41±0.49 mm, 2.40±0.55 mm, and 4.58±1.49 mm2, respectively. The male participants had statistically significant higher mean dimensions of FO and FS (P<0.05) than the female participants. There were statistically insignificant correlations of dimensions of these foramina with age and between the left and right side of each foraminal dimensions (P>0.05). Conclusions: The sex-based difference in dimensions of FO and FS should be clinically considered in evaluating the pathology of these foramina. However, further studies using objective assessment of foraminal dimensions are required to draw obvious inferences.

Nontraumatic spontaneous bilateral intracerebral haemorrhage in a young patient: a rare case report.

Spontaneous bilateral intracerebral haemorrhage is a rare surgical occurrence, especially in young populations with poor prognosis. Hypertension is the leading cause but vascular malformations, infections and rare genetic conditions are also responsible. Case presentation: Twenty-three-year-old male with no prior comorbidities presented to emergency with sudden onset loss of consciousness and 1 episode of seizure. No history of intoxication or trauma was given. Glasgow Coma Scale at presentation was E1V2M2. CT scan head revealed bilateral basal ganglia haematoma along intraventricular haemorrhage. Clinical discussion: The patient was managed conservatively in the Neurosurgical Intensive care unit. Supportive management was provided. The patient's motor response was improving and a repeat CT scan showed a resolving haematoma. However, due to poor economic conditions, the patient party left against medical advice. Conclusion: Spontaneous bilateral basal ganglia haemorrhage is a rare surgical emergency with no clear consensus on a management approach. This case highlights the importance of undiagnosed hypertension in causing intracerebral haemorrhage in poor economic groups.

Superior mesenteric artery syndrome mimicking gastric outlet obstruction: a case report and a literature review.

Superior mesenteric artery (SMA) syndrome, an uncommon cause of intestinal obstruction, may present with clinical features mimicking gastric outlet obstruction. Case presentation: The authors present a case of a 65-year-old gentleman who presented to our institute with complaints of sudden onset abdominal distension and multiple episodes of bilious vomiting for 4 days. On examination, he was cachexic and dehydrated and was diagnosed later with SMA syndrome based on contrast-enhanced computed tomography abdomen findings. Discussion: After the diagnosis of SMA syndrome was made, the patient was planned for the operation. On exploration, a hugely distended stomach dilated first and the second part of the duodenum with SMA compressing the third part of the duodenum was found for which duodenojejunostomy was done. Conclusion: The high degree of suspicion is necessary for cachectic patients presenting with features of gastric outlet obstruction to diagnose SMA syndrome. Physical examination supported by radiological investigations can diagnose SMA syndrome to some extent. Treatment should be focused on relieving obstruction along with fluid and electrolyte resuscitation and nutritional supplementation. Some cases may require surgical correction.

Outcomes of laparoscopic repair in complicated groin hernia: A single institutional based cohort study in Nepal.

Introduction: Laparoscopic hernia repairs have comparable recurrence rate with less persisting pain and numbness and quicker return to usual activities as compared to open mesh repair. The excellent outcomes of minimally invasive surgery encourage us to extend the laparoscopic technique to complicated groin hernia. Method: A total of 22 patients with complicated groin hernia who presented to our institute from September 2017 to September 2018 were included in this prospective cohort study. Inclusion criteria were patients with age greater than 18 years and clinically diagnosed as complicated groin hernia. Patients with peritonitis, those with previous abdominal surgery and unfit for general anesthesia were excluded from our study. Results: The most common age group was 51-60 (31.8%) years.17 cases were repaired with totally laparoscopic approach (12 TEP, 5 TAPP). Laparoscopic repair with additional procedure was needed in 3 cases and 2 cases were converted to open for completion of the procedure. The mean operating time was 154.8 ± 51.6 (range: 90 to 230) minutes. The average length of hospital stay was 3.8 ± 3 (range: 1 to 12) days. Bleeding from the inferior epigastric and testicular vessels were the major intra-operative complication (11.8%). Seroma and surgical site infection were seen in 2 (11.8%) patients. Conclusion: Laparoscopic approach in cases of complicated groin hernia can achieve desirable patient outcomes without major complications, provided good patient selection and expertise. The evidence for laparoscopic repair as the choice of procedure in complicated groin hernia can be established from further comparative studies.

Clinico-pathological characteristics of obstructing colorectal cancer and its management outcomes at a tertiary referral center of Eastern Nepal.

BACKGROUND: The aim of this study is to explore the treatment strategies being followed for patients with obstructing colorectal cancer (OCRC) at our institute and to know the management outcomes. METHODS: This study included 28 patients who were diagnosed with obstructing colorectal cancer (OCRC) either preoperatively or intraoperatively over a period of 5 years. RESULTS: Most were in the younger age group with mean age of 49.78 ± 15.96 years with 1/4th of the patients being younger than 40. There was no difference in incidence of OCRC among genders. It was found to be common in rural areas of the eastern Nepal, 16(57%) patients from such areas. 21.4% patients had complete bowel obstruction at presentation. The investigating modalities used were abdominal X-ray, ultrasonoghraphy of abdomen/pelvis, abdominal CT-scan, colonoscopy, serum CEA, punch biopsy and Faecal occult blood test. The anatomical shift to the right was observed with 54% lesions in the proximal colon. Majority were in advanced stage (stage 3:53.6%, stage 4:32.1%) with histologically adenocarcinoma (100%) and a higher incidence of synchronous lesion (28.6%). Patients averaged 13.82 days in the hospital with post-operative mortality rate of 3.6%. The 1-year and 2-years disease free survivals were 89.3% and 82.1% while overall survivals were 92.8% and 82.1% respectively. CONCLUSION: In developing countries like ours, relatively younger patients present to health center with obstructive colorectal cancer with anatomical shift to the right sided lesions. The treatments provided at our center and their outcomes are not inferior to that of the developed world.

Intestinal Obstruction among Patients Admitted in the Department of Surgery of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Although intestinal obstruction is a very common surgical emergency, there is a dearth of evidence regarding its prevalence at our institute. The objective of this study is to find out the prevalence of intestinal obstruction among patients admitted to the Department of Surgery of a tertiary care centre. Methods: A descriptive cross-sectional study on a total of 6735 admitted patients' in Department of Surgery a tertiary care centre was conducted from 1st January, 2014 to 31st March, 2015. Data were collected retrospectively with ethical approval from Institutional Review Committee (Reference number: 106/071/072). All patients admitted to the surgery ward of the hospital with an age of 18 and above were included in the study. Convenience sampling was used. The data were recorded and analyzed using Microsoft Excel and Statistical Package for Social Sciences version 16.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: Out of the 6735 admitted cases, the prevalence of intestinal obstruction among the admitted patients in the surgery department of the tertiary care centre was found to be 100 (1.48%) (1.19-1.77 at 95% Confidence Interval). The most common presentations were pain in the abdomen 93 (93%), vomiting 74 (74%), and abdominal distension 55 (55%). Conclusions: The prevalence of intestinal obstruction in our study was lower than the similar studies done in similar settings. Keywords: intestinal obstruction; large intestine; small intestine; surgery.

Intestinal tuberculosis masquerading as carcinoma colon: a case report of diagnostic quandary in low-resource setting.

Intestinal tuberculosis (TB) is a rare condition comprising a majority of the extra-pulmonary TB cases. Owing to a similar clinical presentation, ultrasonographic and biopsy findings of intestinal TB with that of other abdominal pathologies such as carcinoma colon, their clinical delineation is very difficult unless aided with other modalities of investigations such as colonoscopy, culture of the biopsy material, etc. and even advanced methods such as polymerase chain reaction and gene X-pert of the biopsy material. Having all these investigations may not even lead to a correct diagnosis of intestinal TB as evidenced in the reported cases in the literature, advocating the need of diagnostic laparoscopy in the diagnosis of intestinal TB to eliminate extensive and unnecessary surgeries. Here, we present a case of intestinal TB in a 51-year-gentleman who got diagnosed in the course of treatment for a suspected carcinoma colon.

Ileosigmoid knotting: A case report of unique cause of acute abdomen in a Nepalese patient.

INTRODUCTION AND IMPORTANCE: Ileosigmoid knotting is a surgical emergency. Common in Asian males, it is presented with signs and symptoms of diffuse peritonitis. Aggressive resuscitation with intravenous fluids and antibiotics followed by workup enable the patient hemodynamically stable. Explorative laparotomy followed by colo-colic anastomosis and double barrel ileostomy is curative. CASE PRESENTATION: A 32-year-old-male from Nepal with a chief complain of diffuse abdominal pain for a day and signs of peritonitis presented to Emergency room. After assessing and stabilizing the patient, explorative laparotomy was performed. Ileal and sigmoid resection followed by colo-colic anastomosis and double barrel ileostomy was done. On regular follow-up, he is in his usual state of health. DISCUSSION: The incidence of ileosigmoid knotting is reported to be about 1.6 cases per year. It is often misdiagnosed as non-specific intestinal obstruction which confers poor prognostic value to the patient. It should be identified promptly and intervened timely. CONCLUSION: Ileosigmoid knotting is a rare but dangerous differential of acute abdomen not to be missed. Early assessment and quick decision making is the key to provide excellent prognosis to the patient in need, provided adequate surgical skills are demonstrated.

Pancreaticoduodenectomy: Impact of Volume on Outcomes at a Tertiary Care Center-Our Experience in Single Institute of Nepal.

BACKGROUND: Pancreaticoduodenectomy is a complex high-risk surgical procedure usually done for malignant disease carrying significant postoperative morbidity and mortality. An audit and analysis of rate of postoperative morbidity and mortality and the impact of case volume can provide information about the lacunas in patient care and methods to improve it for safe and early discharge of patients. This study was conducted to find out demographic profile, the rate of perioperative morbidities, mortality, and impact of case volume on patients undergoing pancreaticoduodenectomy for malignant disease which may serve as a guide to uplift the patient care in our center. METHODS: Retrospective analysis of prospectively collected data of patients undergoing pancreaticoduodenectomy from 2015 to 2019 was performed. A total of 62 patients were included in the study. Patient's clinic-demographic details and intraoperative and postoperative events were recorded. The rate of various postoperative morbidities and mortality and year-wise trend of these factors were analyzed. RESULTS: Most of the patients were in the sixth decade of life (38.7%) with male preponderance (61.3%). Pancreatic cancer was most commonly seen followed by cholangiocarcinoma (46.8%). SSI (32.3%), intraabdominal collection (25.8%), anastomotic leak (14.5%), pancreatic fistula (22.6%), and postpancreatectomy hemorrhage (8.1%) were the major postoperative events. Mortality was found in 12.9% patients. CONCLUSION: There has been a decrease in rate of all these postoperative adverse events and improvement in the intraoperative blood loss and surgical duration with advancing years and increasing number of cases.

Living with a giant inguinoscrotal hernia for 35 years-a case report.

In this modern era, giant inguinoscrotal hernias are very rare to experience in a medical career. We discuss a case of a 65-year-old man with a history of an inguinoscrotal hernia with progressive growth for the past 35 years. On examination, he had a 20 cm × 15 cm non-reducible swelling with multiple ulcers over the skin surface extending to the mid-thigh with otherwise no other bladder and bowel complications. These large hernias pose a different set of surgical problems. Open surgery was performed, hernial sac opened, contents reverted and left orchidectomy were done with scrotal reconstruction. The defect was closed with Vicryl 1-0 over the muscle layer and the skin was stapled. Daily wound care was provided. Besides, this case also compels us to explore possible reasons for the occurrence of such potentially dangerous surgical problems in low-to-middle income countries (LMIC).

Pudendal flap-a good option for creating neo-scrotum after Fournier's gangrene: a case series.

Scrotal skin loss following Fournier's gangrene is very distressing to the patients. The management is complex and challenging shown by the multiplicity of flaps and techniques described in the literature. We included a total of 14 patients with the diagnosis of Fournier's gangrene over a period of 1 year in our department. We used a modified pudendal thigh flap to reconstruct neo-scrotum in patients with scrotal defects resulting from excision and debridement of Fournier's gangrene. The average age group of the patients in our study was 41.8 years. The average body mass index in our study was 22.36 kg/m2. The average defect size in our study was 7.05 × 13.07 cm2. There was a single case of flap necrosis. Modified pudendal thigh flap produces a neo-scrotum that looks natural in appearance, provides good quality skin cover and cushion to the testes as well as protective sensation.

Amyand's hernia in a 5-year-old child: a case report and literature review.

Amyand's hernia in a child is a very rare entity. It poses a diagnostic challenge to the surgeon due to its variety of presentation. We are presenting a case of a 5-year-old child who presented to our institute with right-sided irreducible inguinal hernia. On exploration, the content of the hernia was caecum with normal appendix for which herniotomy with appendectomy was done.

Appendiculo-cecal intussusception: a case report and literature review.

Intussusception of the appendix is a rare disease that constitutes a diagnostic challenge to the surgeon. Intussusception is defined as the telescoping of a segment of the gastrointestinal tract into an adjacent one. We are reporting a case of a 14-year-old boy who presented in our institution with the features of acute appendicitis. On exploration appendiculo-cecal intussusception was found for which right hemicolectomy with ileotransverse colon anastomosis was done.

Laparoscopic approach for diaphragmatic hernia repair in adult: our experience of four cases.

Diaphragmatic hernia can be congenital or acquired. Usual clinical presentation may range from asymptomatic cases to serious respiratory/gastrointestinal symptoms and occasionally atypical presentation as lumbar hernia also. The diagnosis of diaphragmatic hernia is based on clinical investigation and is confirmed by plain X-ray film and computed tomography scan. Various treatment approaches, open, laparoscopic and combination, are available for this condition. However, laparoscopic approach has recently gained in popularity. Surgical repair typically involves primary or patch closure of the diaphragm through an open or endoscopic abdominal or thoracic approach. This paper reflects our experience of repair of diaphragmatic hernias to evaluate its safety, efficacy and outcomes.