Incidental finding and successful management of Larrey's hernia during laparoscopic cholecystectomy: Case report.

INTRODUCTION: Larrey hernias (LH) are birth defects causing abdominal viscera to protrude into the thoracic cavity. With an incidence of 2-4 %, they are exceptional in adults. CASE PRESENTATION: A 65-year-old female patient was admitted for an elective laparoscopic cholecystectomy. During history intake, besides biliary colic, no additional symptoms were reported. Physical examination yielded normal results. Chest-X ray did not reveal any anomalies. Intraoperatively, an inspection of the diaphragm revealed a 3 cm defect in the left-sided sternocostal triangle, with the omentum protruding through the thorax. After performing cholecystectomy, the content of the LH was cautiously reduced. The hernia sac was not resected, to prevent potential injury to the neighboring anatomical structures. The defect was closed using non-resorbable interrupted sutures. The postoperative course was uneventful. No recurrence was detected during follow-up. CLINICAL DISCUSSION: LH diagnosis is challenging due to its unspecific symptoms. Only 10 % of patients are asymptomatic. CT imaging establishes a positive diagnosis and identifies acute complications requiring emergency management. CONCLUSION: Asymptomatic LH cases mandate surgery. Laparoscopic management is safe and efficient. The trans-abdominal approach offers easier access to hernia content. Hernia sac resection is still debatable. The selection of defect closure technique hinges on the quality and elasticity of the tissue, as well as the size of the defect, all under the unwavering banner of the tension-free principle. Literature remains conflicting on mesh use.

Surgical management of a locally advanced jejunal stromal tumor: A case report of a challenging condition.

INTRODUCTION AND IMPORTANCE: Locally advanced jejunal stromal tumors stand as a captivating and relatively rare entity, garnering attention for several reasons. Their inaccessible location by conventional endoscopy poses a diagnostic challenge. Further, treatment decisions necessitate a multidisciplinary approach, compounded by the absence of high-level evidence studies. CASE PRESENTATION: A 54-year-old patient was admitted to our surgical department with abdominal pain and chronic anemia. Abdominal CT imaging confirmed the presence of a non-metastatic sizable jejunal tumor. The patient underwent laparotomy, revealing a locally advanced jejunal tumor contracting the ileum and the ascending colon. A monobloc oncological resection was performed, followed by the restoration of digestive continuity. Anatomopathological analysis delineated a locally advanced Stromal Tumor with a high risk of recurrence. The patient underwent a course of tyrosine kinase inhibitors for 3 years, with no reported recurrence during the subsequent 3-year follow-up. DISCUSSION: Locally advanced jejunal stromal tumors are rare. Most patients present with unspecific symptoms. Diagnosis remains challenging due to their intricate anatomical location. Decisions regarding management must be deliberated within a multidisciplinary framework, tailored to each patient's unique characteristics. While combined therapeutic modalities have demonstrated efficacy in recent studies, prudence is advised given the heightened incidence of both short and long-term complications. CONCLUSION: In the absence of randomized controlled trials, the management of locally advanced jejunal stromal tumors underscores the imperative of multidisciplinary collaboration in treatment deliberations. A wide, sometimes mutilating excision is only permissible if it is complete.

A giant gastrointestinal stromal tumor revealed by a life-threatening hematemesis: A case report of a rare entity and a challenging management.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal malignancies in the digestive tract. Despite the stomach being their site of predilection, only a few giant GISTs have been discovered in hypovolemic shock and require urgent surgery. CASE PRESENTATION: A 62-year-old patient was admitted for hematemesis. Initial examination revealed a compensated hemodynamic shock with a mass in the left hemi abdomen of 20 cm without signs of portal hypertension or peritonitis. After resuscitation, an abdominal CT scan was performed, showing an exophytic mass of the gastric antrum without local or distant lymph node involvement. Later, the patient went into hemodynamic shock, requiring vasoactive drugs. An urgent midline laparotomy was performed, revealing a 20-cm gastric GIST in the anterior wall of the antrum. Wedge resection was performed. The anatomopathological report confirmed the diagnosis of gastric GIST with a moderate risk of recurrence. The patient received adjuvant therapy for 3 years. No recurrence was detected. CLINICAL DISCUSSION: Bleeding gastric GISTs revealed by a hypovolemic shock is a rare yet critical scenario. Considering GISTs as an etiology of digestive bleeding in life-threatening cases requires a high index of clinical suspicion. Prompt intervention is vital to control hemostasis and ensure patient stability. CONCLUSION: Open surgery is mandatory for large bleeding GISTs. The surgical approach must be tailored to the tumor's specific location. Diligent execution of the surgical procedure is vital to prevent tumor rupture. Despite their size, these tumors have a favorable prognosis, enhanced by adjuvant therapy for moderate to high recurrence risk.

Sigmoid-rectal intussusception in an elderly patient: A case report of an unusual presentation of intestinal obstruction.

INTRODUCTION: Sigmoid-rectal intussusception or invagination is an infrequently documented condition in the adult population, with only a handful of cases reported in the medical literature. The underlying pathological mechanism involves impaired peristalsis, often attributed to a malignant tumor. CASE PRESENTATION: A 78-year-old patient, with a history of abdominal pain and lower gastrointestinal bleeding, sought care at our emergency department with evident symptoms indicative of large bowel obstruction. Abdominal examination revealed distension and rectal examination found a mass mimicking an internal rectal prolapse. Subsequently, imaging studies confirmed the diagnosis of sigmoid-rectal intussusception. The patient underwent an emergency open sigmoid resection with Hartman's procedure. The postoperative course was uneventful. Anatomopathological analysis revealed the presence of stage I adenocarcinoma. A restoration of digestive continuity was scheduled six months later. One-year follow-up assessments showed no indications of local recurrence or distant metastasis. DISCUSSION: Sigmoid rectal intussusception stands as a unique and infrequently reported medical entity. The absence of distinct clinical symptoms often renders diagnosis a challenging task, with confirmation typically relying on radiological findings. In contrast to the non-surgical approaches employed in pediatric cases, intussusception in adults necessitates surgical intervention due to its predominantly malignant underpinnings. CONCLUSION: While sigmoid-rectal intussusception is an exceedingly rare occurrence, its manifestation with a multitude of non-specific symptoms can complicate clinical recognition. Nevertheless, it should be duly considered as a potential etiological factor in cases of large bowel obstruction, particularly when suggestive signs are found on rectal examination.

An unusual form of incisional hernia: A case report of Littre's hernia.

INTRODUCTION: Littre's hernia (LH) is a rare condition involving Meckel's diverticulum within a hernia sac, with an incidence of <0.1 % of all complicated hernias. To this day, only a few case reports have been published concerning this entity. CASE PRESENTATION: A 48-year-old patient with a history of four midline C sections and an incarcerated incisional midline hernia was admitted to the emergency department for small bowel obstruction evolving for 12 h. Examination revealed an incarcerated midline incisional hernia. An abdominal CT scan was performed, showing a multi-orifice incisional hernia with a small bowel loop and a 3 cm abscess. The patient underwent an urgent midline laparotomy. During surgery, we found a small bowel loop with a perforated Meckel's diverticulum, located 50 cm from the ileocaecal valve, associated with a 3 cm abscess. Surgical drainage of the abscess, resection of 20 cm of small bowel, including the diverticulum, and an appendicectomy were performed. The incisional midline hernia was managed by herniorrhaphy. The post-operative course was uneventful. CLINICAL DISCUSSION: Surgeons need to keep in mind the possibility of discovering Meckel's diverticulum in a hernia sac in every incarcerated hernia. Complete history intake and careful physical examination are important to uncover signs prompting clinical suspicion. Littre's hernia is rare and difficult to diagnose, with no distinguishing clinical features or physical signs. CONCLUSION: Managing LH involves treating the symptomatic Meckel's diverticulum with various resection methods and the hernia itself, with mesh application being a controversial topic. Prophylactic resection remains debatable among experts.

Management of a pancreatic tail hydatid cyst: a case report.

The case report describes a 73-year-old woman, with a history of diabetes, who presented with left hypochondrium pain. Interrogation revealed a long-term history of living with Echinococcus granulosus endemic area, associated to close contact with sheep and dogs. Upon physical examination, a painless mass of the left hypochondrium, fixed to the deep plane. Abdominal ultrasonography (USG) showed a 9 cm encapsulated mass in contact with the tail of the pancreas. Further investigation was carried out by performing an abdominal computed tomography (CT) scan showing: large cystic mass with a partially calcified thickened wall, containing multiple vesicles, measuring 11.5 cm, located at the tail of the pancreas. The patient was put under Albendazole for a week and then operated on. During laparotomy, a hydatid cyst was located in the tail of the pancreas. Conservative treatment was done sparing the healthy pancreatic parenchyma and avoiding major surgery for a diabetic patient.

Early postoperative parastomal evisceration after explorative laparotomy: case report of a rare and potentially life-threatening surgical complication.

BACKGROUND: Parastomal evisceration represents a preventable surgical complication that should not occur with appropriate technical diligence and surgical skills. While late parastomal hernias are well described in the literature, there is a paucity of reports on the early postoperative occurrence of parastomal intestinal evisceration. CASE PRESENTATION: An urgent laparotomy was performed on a 58-year-old female patient for an acute cecal perforation with generalized peritonitis related to underlying colon cancer. Intraoperative revelations necessitated a carcinologic right colectomy and the creation of an end-loop ileocolostomy. Following six sessions of adjuvant chemotherapy, Computed tomography scans raised uncertainties about the presence of peritoneal carcinomatosis. Consequently, a collaborative decision was reached in a multidisciplinary discussion to conduct a surgical biopsy of these deposits before reinstating digestive continuity. The surgical procedure started with stoma mobilization. However, adhesions and a relatively confined aperture curtailed a comprehensive peritoneal cavity exploration. Thus, a midline incision was executed. The verdict from the frozen section examination affirmed metastatic presence, prompting the retention of the stoma. Within 48 h post-surgery, an early-stage parastomal evisceration occurred, stemming from an inadequately sealed aponeurotic sheath. The exposed bowel surface was encased in fibrin, necessitating meticulous irrigation with a warm saline solution before repositioning it within the peritoneal cavity. Accurate adjustment of the aponeurosis closure ensued, coupled with a meticulous reconstitution of the stoma. The postoperative course was uneventful. The patient was subsequently referred for hyperthermic intraperitoneal chemotherapy. CONCLUSIONS: Preventing parastomal evisceration requires adherence to established stoma-creation protocols, including creating a properly sized fascial opening and secure fixation. In instances of excessive fascial opening, ensuring a tension-free and meticulous closure is imperative.

Iatrogenic incarcerated diaphragmatic hernia following laparoscopic resection of a diaphragmatic cystic lymphangioma: A case report.

INTRODUCTION: Incarcerated iatrogenic right diaphragm hernia stands as a rare occurrence. Swift diagnosis and timely management are imperative. This article presents a particularly uncommon case of a right diaphragmatic hernia resulting from a neglected defect following the resection of a diaphragmatic lymphangioma and sheds light on the pitfalls that may lead to such a post-operative event. PRESENTATION OF CASE: Our surgical ward admitted a 36-year-old patient presenting symptoms indicative of bowel obstruction. Four months earlier, the patient had undergone laparoscopic resection of a lymphangioma located in the right dome of the diaphragm. Thoracic auscultation yielded hyperactive bowel sounds at the lower lung field and the right costophrenic angle. Abdominal distention was observed without any signs of peritoneal irritation. A thoracic and abdominal CT scan provided confirmation of a right diaphragmatic hernia. Subsequently, an immediate laparotomy was performed. The right colic hepatic flexure was released, and the diaphragmatic breach was sutured. The postoperative course was uneventful. DISCUSSION: Iatrogenic diaphragmatic hernia remains a possible complication of this surgery. It could occur even on the right side where the liver has a cushioning effect. Incarcerated diaphragmatic hernia is a surgical emergency that should be operated on as quickly as possible. A systematic check of the diaphragm's integrity at the end of the surgical procedure could prevent such complications. CONCLUSION: While surgical techniques and laparoscopic instrumentation have witnessed significant advancements in recent years, achieving proficiency and the precise execution of surgical techniques remain of utmost importance.

Invasive mucinous adenocarcinoma of the lung revealed by a subcutaneous metastasis: A case report of a rare presentation.

INTRODUCTION: Lung cancer stands as the second most prevalent tumour and the foremost cause of cancer-related mortality. It typically manifests through respiratory symptoms. Subcutaneous metastases originating from pulmonary cancers are rare occurrences, with a remarkably low incidence. PRESENTATION OF CASE: A 53-year-old patient, with a history of smoking and unchecked chronic obstructive pulmonary disease, sought care at our outpatient clinic due to the rapid development of a subcutaneous mass. The patient underwent surgical excision of the mass under local anaesthesia. The anatomopathological examination confirmed the diagnosis of cutaneous metastasis from an infiltrative adenocarcinoma. A whole-body CT scan revealed an invasive mucinous adenocarcinoma of the lung. Consequently, palliative chemotherapy was initiated. Unfortunately, the patient succumbed to the disease three months later. DISCUSSION: Subcutaneous metastasis originating from pulmonary sources is a rare phenomenon, with scant literature available on the subject. The presence of pulmonary cutaneous metastasis serves as an ominous sign of rapidly progressing and aggressive lung cancer. The prognosis in such cases is reserved, with an overall survival rate measured in months. The approach to management in these instances predominantly revolves around palliative chemotherapy, although surgical excision of metastases may be considered in select cases. CONCLUSION: Lung cancer unmasked by subcutaneous metastasis represents a rare clinical scenario. While chemotherapy remains the cornerstone of treatment, surgical intervention to remove metastases may be contemplated in a restricted subset of cases. Further research is imperative to ascertain the impact of surgery on both quality of life and overall survival.

Abdominal cocoon: A rare case report of a small bowel obstruction.

INTRODUCTION: Sclerosing encapsulating peritonitis (SEP), or abdominal cocoon, is a remarkably rare entity. It consists of a fibrous layer or cocoon-like sac encasing, in most cases, the small bowel. The lack of specific symptoms makes preoperative diagnosis challenging. CASE PRESENTATION: A 50-year-old patient, with no history of abdominal surgery or medical diseases, was admitted for symptoms of small bowel obstruction. On examination, the patient was underweight with a BMI of 18 kg/m2. Vital signs were stable. His abdomen was mildly distended and soft. Abdominal CT scan showed signs in favor of a left paraduodenal hernia with incarcerated small bowel loops. Intraoperatively, the small bowels were encapsulated in a cocoon-like structure formed by thick fibrous tissue associated with multiple adhesions. Careful adhesiolysis with complete resection of the membrane was performed. The postoperative course was uneventful. One year later, the patient was symptom-free. DISCUSSION: SEP is thought to be a persistent inflammatory disorder due to a cause that remains unidentified. It is divided into two categories based on its etiology: primary and secondary. The most common mode of SEP revelation is bowel obstruction. Because there is no clear consensus on SEP management, the therapeutic approach typically follows the management strategy of bowel obstruction. CONCLUSION: SEP is an uncommon cause of bowel obstruction. Preoperative detection can be challenging in the absence of pathognomonic signs. Treatment is based on surgery, specifically entailing complete excision of the cocoon and adhesiolysis.

Case Report: Caecal volvulus management from diagnosis to treatment in a young patient.

Caecal volvulus (CV) is a rare cause of intestinal obstruction, defined by an axial torsion of the caecum, ascending colon, and terminal ileum around the mesenteric vascular pedicles, leading to ischemia and bowel necrosis. A 20-year-old woman, with no significant medical history, was admitted for generalized abdominal pain evolving for three days, along with constipation and abdominal distension, but with no vomiting. Physical examination showed a generalized abdominal tenderness with no rigidity or rebound tenderness, associated with abdominal distension and tympanic upon percussion. Laboratory findings were within normal limits. An abdominal computed tomography scan revealed distension of a loop of the large bowel with its long axis extending from the right lower quadrant to the epigastrium or left upper quadrant. Colonic haustral pattern was absent. An abdominal computed tomography scan showed a rounded focal collection of air-distended bowel with haustral creases in the upper left quadrant. In addition, spiraled loops of the collapsed cecum (giving a whirl sign) were noted, along with low-attenuating fatty mesentery from the twisted bowel. The patient underwent an emergency laparotomy and caecectomy using GEA 80 charges. The patient had no complaints post-operation. CV is a rare cause of bowel obstruction, mainly caused by an exceedingly mobile caecum. Despite its rareness, CV represents the second most common cause of large bowel volvulus, behind sigmoid volvulus. For acute obstruction by CV, it is hard to differentiate it clinically from obstruction of the small bowel; therefore, radiological exams are needed. Surgery is the gold standard treatment for CV. We report a rare case of CV to highlight the rarity of this pathology, specify its diagnostic and therapeutic means, and its clinical and biological evolution.