Treatment of a half century year old giant inguinoscrotal hernia. A case report

IntroductionInguinal hernias, although a common medical entity, can on rare occasions present as giant inguinoscrotal hernias, mostly because of the patient’s rejection of timely surgical management.Presentation of caseA 77 year old patient, with a giant inguinoscrotal hernia history for more than 50 years, was advised to undergo surgical treatment due to recurrent urinary tract infections and vague abdominal pain. Physical examination showed a right sided giant inguinoscrotal hernia extending below the midpoint of the inner thigh. Preoperative CT examination confirmed a giant inguinoscrotal hernia containing the whole of the small bowel along with its mesentery.DiscussionGiant inguinoscrotal hernias are classified into three types based on size, with each one posing a challenge to treat. There are a number of surgical options and recommendations available, depending on the type of hernia. They require close postoperative observation, because the sudden increase in the intra-abdominal pressure can account for a number of complications. Our case was classified as a type II hernia, having longevity of more than 50 years. Despite this, it was treated with forced reduction and no debulking through an extended inguinal and lower midline incision, forming a ‘V shaped’ incision. Patient recovery was uneventful and he was discharged on the 10th postoperative day.ConclusionPreoperative management and the correct surgical plan depending on the case are key elements in the successful treatment of this rare surgical entity.     

Laparoscopic resection of a retroperitoneal myolipoma presenting in a right inguinal hernia

INTRODUCTIONMyolipoma of soft tissue is an extremely rare benign lipomatous lesion. The lesions are most commonly located in the abdominal cavity, retroperitoneum, and inguinal areas. Despite their large size, myolipomas are cured by surgical resection.PRESENTATION OF CASEWe present the case of a 79 year-old man who presented with bilateral reducible inguinal hernias (right larger than left). After reducing the right inguinal hernia (RIH), the sensation of a palpable mass was noted in the right iliac fossa. CT scan suggested the content of the right inguinal hernia (RIH) to be small bowel mesentery and no other mass was noted in the right iliac fossa (possibly missed on CT scan).DISCUSSIONA very large 1.8 kg retroperitoneal lipomatous lesion, measuring 22 cm × 16 cm × 8 cm, attached to the right spermatic cord was found and excised laparoscopically during a trans-abdominal pre-peritoneal (TAPP) approach to repair the hernias. The lesion was pathologically defined as a myolipoma.CONCLUSIONThe laparoscopic TAPP approach to repair inguinal hernias allows the surgeon to inspect the peritoneal cavity, and in this case it was possible to safely dissect and remove a large, lipomatous, retroperitoneal lesion laparoscopically. To the best of our knowledge, there are no reports of local recurrence, metastatic disease, or malignant transformation of myolipomas, and the laparoscopic approach to resect such a lesion has not been reported.     

The simultaneous repair of an Irreducible Diaphragmatic Hernia while carrying out a Cesarean Section

INTRODUCTIONDiaphragmatic hernia complicating pregnancy rarely occurs while it is frequently misdiagnosed.PRESENTATION OF CASEA pregnant woman who had suffered from recurrent right upper-quadrant abdominal pain for 4 months was hospitalized near full term because the unrelieved abdominal pain was so severe that she couldn’t lie down. Following the emergency caesarean, we found a part of the transverse colon and a part of omentum were trapped in the thorax through a 3 cm by 3 cm laceration in the patient's diaphragm. We removed all trapped intestine which was about 40 cm long and repaired diaphragmatic hernia at the same time.DISCUSSIONRadiography is useful to diagonisis diaphragmatic hernia, but it had little use for pregnant women. An irreducible diaphragmatic hernia represent a surgical emergency irrespective of fetal maturity. In our case, she had her hernia repaired just during caesarean section by laparotomy.CONCLUSIONCareful examination and a timely operation are needed to treat diaphragmatic hernia complicating pregnancy.     

Diagnosis and operative management of a perforated de Garengeot hernia

IntroductionA de Garengeot hernia, a femoral hernia containing the appendix, is a difficult diagnosis often made intra-operatively when the hernia sac is opened. It is a rare finding, and complications are more frequent with a de Garengeot hernia.Presentation of caseA 92 year-old female presented to the emergency department (ED) complaining of abdominal pain. A computed tomographic (CT) scan of the abdomen and pelvis demonstrated a hernia anterior to the inguinal ligament without strangulation. Two weeks later the patient returned to the ED with worsening abdominal pain in the right lower quadrant. Repeat CT scan demonstrated a 7 × 4 cm complex fluid collection in the right inguinal region, and the patient was taken to the operating room for exploration. The hernia sac was entered and found to contain the appendix with evidence of distal perforation. The appendix was taken out, and the hernia defect was repaired. The patient tolerated the procedure well.DiscussionFemoral hernias have a high risk of incarceration due to the tightness of the femoral canal (Talini et al. 2015 [4]). Due to anatomic location of the appendix, de Garengeot hernias are most often seen on the right. Incarceration of the appendix is a clear etiology for appendicitis secondary to ischemia.ConclusionFull preoperative workup for a femoral hernia often fails to diagnose the presence of the appendix within the hernia. It is important to have a high clinical suspicion for a de Garengeot’s hernia in patients with incarcerated or strangulated right femoral hernias.     

Duodenal rupture due to giant inguinal hernia: A case report

IntroductionGiant inguinal hernia is unusual, and duodenal rupture accompanying it is particularly very rare and significantly hard to manage surgically.Presentation of caseAn 81-year-old man was admitted to our institution with upper abdominal pain. He had tenderness of the upper mid abdomen and a bilateral large inguinal hernia but he did not have pain in the inguinal–scrotal area. Computed tomography (CT) showed slight dilatation of the small bowel and stomach. There were no remarkable signs of incarceration of the inguinal hernia. Therefore, he was admitted to the internal ward. On the second day in hospital, he suddenly went into shock. CT revealed that there was free air and ascites in the inguinal hernia and therefore an emergency operation was performed.The tranverse colon, ascending colon, and ileum were incarcerated, and perfolation of the cecum was found. We also detected duodenal rupture at the inferior duodenal angle. We resected the terminal ileal (almost 90 cm) and ileocecal area, followed by side-to-side anastomosis of duodenum and jejunum. We only repaired the peritoneum at the internal hernia ring. After the operation, despite intensive-care therapy, this patient passed away on the 18th postoperative day.DiscussionThe mesocolon and third portion of the duodenum were strongly pulled down into giant inguinal hernia, probably causing the rupture of the inferior duodenal angle.ConclusionGiant inguinal hernia possibly provokes duodenal rupture and therefore should definitively be repaired if feasible.     

Inguinoscrotal herniation of the ureter: Description of five cases

INTRODUCTIONDescent of the ureter into the inguinal canal or scrotum is rare but undoubtedly underreported. Most known cases were recognized at the time of surgery for hernia repair. We encountered five cases recently.PRESENTATION OF CASEWe reviewed the records and CT images of five patients with inguinal hernias containing a segment of the ureter. All of our cases, like most reported cases, featured obese adult males. Our cases had different outcomes, ranging from inadvertent injury of the displaced ureter to correction of the anomaly at the time of hernia repair.DISCUSSIONIn all of our cases, the affected ureter was displaced anteriorly from the psoas muscle by greater than 1 cm at the level of the L4 vertebra on abdominal CT. This association has not been previously described.CONCLUSIONPre-operative diagnosis by CT can prevent injury to the ureter. We hypothesize that anterior displacement of the ureter at the level of L4 as seen on CT may be predictive of inguinoscrotal herniation of the ureter.     

Autologous reconstruction of the inguinal ligament using pedicled fascia lata flap: A new technique

INTRODUCTIONA technique of reconstructing the inguinal ligament using a pedicled fascia lata flap is described.PRESENTATION OF CASEA 62-year-old man was referred with massive bilateral abdominal wall hernias, following numerous attempts at repair and subsequent recurrences. There was complete absence of the right inguinal ligament.The inguinal ligament was reconstructed using a strip of fascia lata, pedicled on the anterior superior iliac spine. This was transposed to cover the external iliac vessels, and sutured to the pubic tubercle. The musculoaponeurotic abdominal wall was reconstructed with two 20 cm × 20 cm sheets of porcine acellular dermal matrix and an overlying sheet of polypropylene mesh, sutured to the remaining abdominal wall muscles laterally, and to both inguinal ligaments. The cutaneous abdominal wall was closed with an abdominoplasty technique.The reconstruction has remained intact nine months following surgery.DISCUSSIONComplete destruction of the inguinal ligament is rare but can occur following multiple operative procedures or trauma. To date, the only published reports of inguinal ligament reconstruction have been performed using synthetic mesh. The use of autologous tissue should reduce the risk of erosion into the neurovascular bundle, seroma formation, and enhance integration into surrounding tissues.CONCLUSIONThis new technique for autologous reconstruction of the inguinal ligament provides a safe alternative to the use of synthetic mesh in the operative armamentarium of plastic and hernia surgeons.     

Dual mesh repair for a large diaphragmatic hernia defect: An unusual case report

IntroductionDiaphragmatic hernia secondary to traumatic rupture is a rare entity which can occur after stab wound injuries or blunt abdominal traumas. We aimed to report successfully management of dual mesh repair for a large diaphragmatic defect.Case reportA 66-year-old male was admitted with a right sided diaphragmatic hernia which occurred ten years ago due to a traffic accident. He had abdominal pain with worsened breath. Chest X-ray showed an elevated right diaphragm. Further, thoraco-abdominal computerized tomography detected herniation a part of the liver, gallbladder, stomach, and omentum to the right hemi-thorax. It was decided to diaphragmatic hernia repair. After an extended right subcostal laparotomy, a giant right sided diaphragmatic defect measuring 25 × 15 cm was found in which the liver, gallbladder, stomach and omentum were herniated. The abdominal organs were reducted to their normal anatomic position and a dual mesh graft was laid to close the diaphragmatic defect. Patients’ postoperative course was uneventful.DiscussionDiaphragmatic hernia secondary to trauma is more common on the left side of the diaphragm (left/right = 3/1). A right sided diaphragmatic hernia including liver, stomach, gallbladder and omentum is extremely rare. The main treatment of diaphragmatic hernias is primary repair after reduction of the herniated organs to their anatomical position. However, in the existence of a large hernia defect where primary repair is not possible, a dual mesh should be considered.ConclusionA dual mesh repair can be used successfully in extensive large diaphragmatic hernia defects when primary closure could not be achieved.     

Laparoscopic extraction of a giant peritoneal loose body: Case report and review of literature

IntroductionA peritoneal loose body is a rare finding and is sometimes founded incidentally during laparotomy or autopsy. A giant peritoneal loose body, measuring more than 50 mm, is very rare, and only a few cases of laparoscopic extraction of these giant bodies have been reported in the literature.Presentation of caseA 70-year-old man presented for evaluation of urinary frequency. He had no history of previous abdominal surgery or trauma. Computed tomography of the abdomen and pelvis showed a giant oval-shaped mass with calcification of the luminal core, measuring 58 mm in diameter. Magnetic resonance imaging revealed a lesion with low intensity in T1-/T2-weighted images. Exploratory laparoscopy was performed. During the procedure, a yellow-white, oval-shaped mass with a “Boiled egg” appearance was discovered in front of the rectum. The mass was freely floating in the peritoneal cavity, without attachment to any intraperitoneal organs. The giant peritoneal loose body was extracted through a small incision, using an enlarged trocar site.DiscussionMost peritoneal loose bodies are small, not exceeding 2 cm in diameter, and are asymptomatic. Only a few cases of giant peritoneal loose bodies exceeding 5 cm have been reported.ConclusionA giant peritoneal loose body is very rare and laparoscopic extraction was a useful technique. We report a case of a giant peritoneal loose body and review previously published series.     

Small,spontaneously ruptured gastrointestinal stromal tumor in the small intestine causing hemoperitoneum: A case report

IntroductionGastrointestinal stromal tumors (GISTs) are clinically asymptomatic until they reach a significant size; therefore, GISTs that are 2 cm or less are typically asymptomatic. Patients with symptomatic GISTs typically present with abdominal pain, gastrointestinal bleeding, or a palpable mass but rarely present with hemoperitoneum.Presentation of caseA 72-year-old Japanese man presented to us with acute onset abdominal pain. Physical examination showed peritoneal irritation in the lower abdomen. Findings of abdominal computed tomography were suggestive of hemoperitoneum; therefore, urgent surgery was performed. Approximately 1500 ml of blood in the abdominal cavity was removed. A small, ruptured mass was found in the middle of the small intestine, and partial resection of the small intestine, including the mass, was performed. The resected tumor was 2 cm in size and exhibited an exophytic growth pattern. Immunohistochemical staining revealed that the tumor was positive for KIT and CD34; therefore, a final diagnosis of GIST was made. Treatment with imatinib at 400 mg per day was started from postoperative month 1. The patient is doing well without recurrence 5 months after surgery.DiscussionEven small GISTs in the small intestine can spontaneously rupture and cause hemoperitoneum. Moreover, when a patient presents with sudden abdominal pain and hemoperitoneum without an evident mass on imaging, clinicians should be aware of the possibility of bleeding from a small GIST in the small intestine.ConclusionWe present an extremely rare case of a patient with a small, spontaneously ruptured GIST in the small intestine, resulting in hemoperitoneum.     

Localized constrictive pericarditis compressing and obstructing the right ventricular inflow tract due to a giant anterior calcified cardiac mass. A case report

IntroductionLocalized pericardial constriction is a rare form of constrictive pericarditis CP. Depending on the CP location, clinical presentation may be variable, including compression and obstruction of right ventricular inflow tract(RVIT), coronary obstruction, or pulmonary stenosis.Case presentationA 72-year-old man presented a 2-year history of dyspnea and atrial fibrillation. A contrast enhanced angio computerized tomography clearly demonstrated a large spherical mass about 11 × 9 × 4 cm in the anterior pericardium, presenting as a mediastinal tumor causing compression and obstruction of the RVIT. The patient underwent surgical procedure. The outer calcified layer of the pericardial mass was a thick layer of calcification surrounding an inner amorphous low density material. The inferior calcified layer of the pericardial mass which was extremely adherent with the epicardium, was carefully excised, without employment of cardiopulmonary bypass, from the aorta and pulmonary artery origin to the diaphragm and all areas between the right and left phrenic nerves. The final diagnosis was idiopathic CP.DiscussionThe clinical presentation was due to right ventricular free wall compression and obstruction of the RVIT by a giant calcified anterior cardiac mass. The differential diagnosis with other calcified masses in the anterior mediastinum such as teratoma, hemopericardium after blunt trauma and idiopathic or tuberculous CP should be considered.ConclusionHerein we report a very rare case with localized CP causing compression and obstruction of RVIT due to a giant anterior calcified cardiac mass, treated successfully with pericardectomy. Careful dissection is mandatory for a successful procedure.     

A sign on CT that predicts a hazardous ureteral anomaly

IntroductionAn aberrant course of the distal ureter can pose a risk of ureteral injury during surgery for inguinal hernia repair and other groin operations. In a recent case series of inguinoscrotal hernation of the ureter, we found that each affected ureter was markedly anterior to the psoas muscle at its mid-point on abdominal CT. We hypothesized that this abnormality in the abdominal course of the ureter would predict the potentially hazardous aberrant course of the distal ureter.Presentation of casesWe reviewed all evaluable CT urograms performed at St. Louis University Hospital from June 2012 to July 2013 and measured the ureteral course at several anatomically fixed points.Discussion93% (50/54) of ureters deviated by less than 1 cm from the psoas muscle in their mid-course (at the level of the L4 vertebra). Reasons for anterior deviation of the ureter in this study included morbid obesity with prominent retroperitoneal fat, congenital renal abnormality, and post-traumatic renal/retroperitoneal hematoma. We determined that the optimal level on abdominal CT to detect the displaced ureter was the mid-body of the L4 vertebra.ConclusionAnterior deviation of the ureter in its mid-course appears to predict inguinoscrotal herniation of the ureter. This finding is a sensitive predictor and should raise concern for this anomaly in the appropriate clinical setting. It is not entirely specific as morbid obesity and congenital anomalies may result in a similar imaging appearance. We believe that this association has not been reported previously. Awareness of this anomaly can have significant operative implications.     

Incarcerated and eventrated abdominal wall hernia reconstruction with autologous double-layer dermal graft in the field of purulent peritonitis—A case report

IntroductionDouble-layer dermal grafts are used for the management of complicated abdominal wall hernias in obese, high risk patients. The method has not yet been used in case of emergency in septic/dirty environment.Case reportA 76-year old female patient (BMI 36.7 kg/m²) was admitted with mechanical bowel obstruction and sepsis caused by a third time recurred, incarcerated and eventrated abdominal wall hernia. During the emergency surgery perforation of the terminal ileum and the ascending colon was detected, along with a feculent peritonitis and extended abdominal wall necrosis. Extended right hemicolectomy and necrectomy of the abdominal wall were performed. The surgery resulted in an abdominal wall defect measuring 223 cm², for the management of which direct closure was not possible. Using a specific method, an autologous dermal graft was prepared from the redundant skin. The first dermal graft was placed under the abdominal wall with 5 cm overlap, and the second layer was placed onto the first layer with 3 cm overlap in a perforated fashion. The operating time was 250 min. No significant intra-abdominal pressure elevation was measured. No reoperation was performed. On the fifth postoperative day, the patient was mobilised. She was discharged in satisfactory general condition on the 18th postoperative day. There is no recurrent hernia 8 months after the surgery.DiscussionAbdominal wall reconstruction was possible in a necrotic, purulent environment by using a de-epithelised autologous double layer dermal graft, without synthetic or biological graft implantation. The advantage of the procedure was cost-effectivity, and the disadvantage was that only in an obese patient is the sufficient quantity of dermal graft available.ConclusionA homogeneous internal and perforated outer dermal graft was suitable for bridging the abdominal gap in the case of an obese, high risk patient. Autologous dermal grafts can be a safe and feasible alternative to biological meshes in emergency abdominal wall surgeries. Evaluation of a case series can be the next cornerstone of the method described above.     

Laparoscopically assisted simple suturing obliteration (LASSO) of the internal ring using an epidural needle: A handy single-port laparoscopic herniorrhaphy in children

BackgroundMany different laparoscopic techniques for pediatric inguinal hernia (PIH) have been developed, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports. Single-port laparoscopic percutaneous extraperitoneal closure is one of the most simple and reliable methods. We describe our modifications of laparoscopically assisted simple suturing obliteration (LASSO) using an epidural needle with preperitoneal hydrodissection.Materials and methodsTwo hundred and seven patients with PIH were treated with single-port LASSO from February 2010 to July 2013. Under laparoscopic visualization, an 18-gauge epidural needle was inserted at the corresponding point of the internal ring. The hernia defect was obliterated extraperitoneally by a nonabsorbable suture that was introduced into the abdomen on one side and withdrawn on the opposite side in an identical subcutaneous path around the internal ring using the hydrodissection-lasso technique.ResultsA total of 251 PIHs were successfully performed by LASSO, 163 patients had unilateral inguinal hernia repair, and 44 patients underwent repair of bilateral inguinal hernias. Mean operating time for unilateral and bilateral inguinal hernia repairs was 18.1 ± 5.4 min and 26.6 ± 4.8 min, respectively. There were no perioperative complications. Only one recurrence was observed to date.ConclusionsLASSO using an epidural needle with preperitoneal hydrodissection as a handy technique has proved to be a safe and effective procedure. It is easy to perform with high parent satisfaction, invisible scarring, and good cosmetic results, and therefore is a worthy choice for PIH.     

Chronic inguinal pain after laparoscopic intraperitoneal onlay mesh (IPOM) repair for inguinal hernia treated successfully with laparoscopic selective neurectomy: A case report

IntroductionLaparoscopic intraperitoneal onlay mesh (IPOM) repair is occasionally used for inguinal hernia repair. Here, we report a case of chronic neuropathic pain after laparoscopic IPOM repair for inguinal hernia, which was treated successfully with laparoscopic selective neurectomy.Presentation of caseA 59-year-old man with bilateral inguinal hernia underwent laparoscopic repair. Transabdominal preperitoneal repair was performed on the left side, whereas IPOM repair was performed on the right side due to a peritoneal defect. At postoperative month 1, he presented with severe pain and numbness distributed from the right inguinal region to the inner thigh region. The symptoms had persisted for 1 year despite medical treatment. We diagnosed that the symptoms might be due to the entrapment of nerves in the contracted mesh, and performed a second surgery via laparoscopic approach 13 months after the first surgery. On laparoscopic exploration, the lateral side of the mesh was contracted and involved nerve branches. We ligated and cut off these nerve branches. His symptoms resolved immediately after the surgery. At postoperative month 12, he has passed without any pain, numbness, and hernia recurrence.DiscussionLaparoscopic exploration would be useful to figure out chronic neuropathic pain after laparoscopic inguinal hernia repair.ConclusionLaparoscopic IPOM repair for inguinal hernia should be avoided as much as possible because it may cause chronic neuropathic pain. Laparoscopic selective neurectomy is an option for patients with chronic neuropathic pain after laparoscopic hernia repair.     

Surgical treatment strategies for giant inguinoscrotal hernia – a case report with review of the literature

Background

An inguinoscrotal hernia is defined as “giant” if descending below the midpoint of the inner thigh of a patient in upright position. In developed countries this is a rare entity. In the literature different surgical techniques have been reported so far to achieve a successful treatment.

Case presentation

We present the case of a 63 year-old man suffering from a giant inguinoscrotal hernia, whom we treated using a combined open transabdominal and inguinal approach following an unsuccessful laparoscopic attempt. Meshes were placed in a premuscular position (Lichtenstein’s procedure) and in a preperitoneal position. In addition, a reconstruction of the abdominal wall by modified components separation technique was performed. During the early postoperative period no complications were registered. Intensive care treatment was not necessary. The patient was discharged on postoperative day 8 in an excellent condition. Six months after surgery a scrotal hematocele was diagnosed and operatively removed. After a follow-up of 1.5 years neither hernia recurrence, nor chronic groin pain were recorded. The patient reported to be sexually active. His quality of life improved notably.Additionally, a Medline and PubMed database research was performed to create an overall picture of the existing surgical treatment strategies. Included were patients with diagnosis of primary giant inguinoscrotal hernia according to the given definition. Emergency interventions and cases without details of the surgical approach were excluded.

Conclusions

Firstly, this report describes a novel, successful surgical treatment of a giant inguinoscrotal hernia without administering preoperative progressive pneumoperitoneum therapy or visceral resection. Secondly, we summarize cases previously reported as a practical guide for possible surgical therapy approaches.

     

Spontaneous entero-labial fistula complicating Richters hernia: Report of a case

BackgroundRichter's hernia is defined as a type of hernia in which only part of the circumference of the antimesenteric border of a bowel wall is incarcerated within the hernia sac leading to ischemia, gangrene and perforation of the hollow viscus. Richter's hernia is known to cause strangulation without obstruction due to involvement of only a part of the circumference of a bowel wall. Inguino-labial Richter's hernia presenting with the complication of spontaneous entero-cutaneous fistula is rare.AimThis is to report a case of spontaneous entero-labial fistula complicating Richters hernia occurring in an adult female.Case reportA 61-year-old woman presented with a history of sudden generalized abdominal pain. She had a prior history left inguino-labial swelling of six years duration, which was initially reducible but became irreducible two weeks prior to presentation. There was associated discharge from the swelling a few days later. She was pale and febrile. Her temperature was 39.2 °C, pulse rate was 110 per minute and blood pressure was 130/60 mmHg. A diagnosis of left inguinolabial hernia was made.She was resuscitated and an exploration of the groin swelling was made. A rupture of the anti-mesenteric border of the ileum with strangulated preperitoneal fat was found. She had resection and anastomosis of the ileum.ConclusionSpontaneous faecal fistula in inguinal region following rupture of strangulated Richter's hernia especially in adults is uncommon and can occur even in absence of obstructive symptoms. In presentation of any groin swelling, there is need for an early accurate diagnosis followed by prompt treatment. The delay in its diagnosis and management may result in this rare complication of spontaneous faecal fistula. This reflects the state of health care in the developing world and needs to be addressed by the concerned authorities.     

Unexpectedly ease surgery for a worrisome abdominal mass: Pedunculated GISTs

INTRODUCTIONDiscovery of abdominal masses often poses significant diagnostic difficulties. GISTs are mesenchymal masses, with specific histological features. Dimensions may vary from millimeters to giant tumours. We would like to present our case, which had an unexpectedly easy operative course which was easily handled with a simple surgical excision with a short operative duration.PRESENTATION OF CASEA 38 years old female patient was diagnosed to have an abdominal heterogen mass of 15 cm × 12 cm × 10 cm in dimension. Abdominal computed tomography revealed the solid mass between the stomach and pancreas corpus and tail, possibly orginating from the pancreas. With the preoperative diagnosis of locally invasive distal pancreas cancer the patient underwent laparotomy, following the dissection, the mass was observed to be originating from the posterior gastric Wall, extending exophytically with a peduncle of 5 cm in width, without any visual evidence for peritoneal invasion and metastasis. The tumour and the peduncle was resected with stapler device. Total operation time was 30 min. Postoperative course was uneventful. Pathologic diagnosis was gastrointestinal stromal tumour (GIST).DISCUSSIONPedunculated large GISTs are not frequent and they can enlarge as 15 cm in diameter and compress the neighbouring organs. When they were huge, it is difficult to differentiate the origin of the masses. GISTs should be considered in differential diagnosis of giant abdominal masses.CONCLUSIONWhen GISTs are huge and pedunculated, it can be difficult to differentiate the origin of the masses. This case report presents unexpectedly ease surgery for a worrysome abdominal mass.     

Giant gallstone performed by emergency laparoscopic cholecystectomy

INTRODUCTIONGallstone disease is very common, but the gallstone bigger than 5 cm in diameter is very rare. It is very challenging to be removed by laparoscopic cholecystectomy (LC) and poses extra difficulty in emergency.PRESENTATION OF CASEA 70-year-old man complained of abdominal pain in the right upper quadrant with fever of 38 °C for two days. Abdominal ultrasound indicated acute cholecystitis and a single, extremely large gallstone (95 mm × 60 mm × 45 mm). Emergency laparoscopic cholecystectomy was performed successfully.DISCUSSIONGallstone over 5 cm in diameter is very rare. LC will be very difficult for these cases, especially for the emergency cases. Emergency laparoscopic cholecystectomy can be successfully performed with clear exposure of the anatomy of the Calot's triangle. To the best of our knowledge, such giant gallstone has been rarely reported.CONCLUSIONWe have proven that for the rare giant gallstone about 10 cm in size, LC is a feasible option if the anatomy of the Calot's triangle can be clearly exposed; otherwise, open cholecystectomy is a safe choice.     

Fijación del material protésico en la hernioplastia inguinal abierta: sutura vs. cola sintética

IntroductionThe use of synthetic glues has become normal practice in several surgical fields. The objective of this study is to compare the short and medium term results of glue and conventional suture in the fixation of the prosthesis in open inguinal hernia repair with a plug and patch technique.Materials and methodsA comparative prospective study was conducted on 198 patients with a diagnosis of a non-recurrent inguinal hernia subjected to open surgery and randomly assigned to mesh fixation with cyanoacrylate glue (n = 101) or with suture (n = 98). The demographic characteristics, short-term complications, hospital stay, time off work, hernia recurrence, and chronic inguinal neuralgia, were analysed.ResultsThe overall morbidity was 13.9% in the glue group, and 30.9% in the suture group. No undue inflammatory reactions or mesh migration were observed in the group. The post-operative stay was 14.7 h for the glue group, and 19.1 h in the suture group (P < .0001). No differences were found regarding days off work. The short-term morbidity was higher in the suture group (19.6% vs. 10.9%). After one year, there was one recurrence in the suture group (1%), and none in the glue group. However, the incidence of moderate/severe intensity chronic neuralgia was 2.9% in the glue group, and 10.3% in the suture group (P = .03).ConclusionThe use of cyanoacrylate is safe and effective in open inguinal hernia repair, with good results in the short and medium term.