Abdominal apoplexy: rupture of short gastric artery after retching

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare but often fatal condition resulting from a variety of disease processes affecting abdominal vasculature. A 30-year-old woman presented with acute abdominal pain and breathlessness and was in class II hypovolemic shock. She had a history of multiple episodes of retching with non-bilious vomiting prior to that. Computed tomography (CT) reported a non-rotation of the gut, gross intraperitoneal free fluid with debris, and possible perforated appendicitis. Laparoscopy revealed a gross hemoperitoneum of 2.5 L, with bowel findings consistent with non-rotation of the gut, but technical difficulty in identifying the source of bleeding led to conversion to laparotomy. A ruptured short gastric artery was ascertained to be the source of bleeding and was successfully ligated. A retrospective review of the preoperative CT showed intraperitoneal free fluid with Hounsfield unit measurements of 48 and 52, suggestive of acute hemoperitoneum. ISIH is often a delayed diagnosis or missed diagnosis due to its low incidence. The presence of vomiting and abdominal pain with hypovolemic shock, especially in a young individual, should raise the suspicion of ISIH, which can be confirmed via early CT imaging to facilitate achieving hemostasis during surgery

Giant submandibular sialolipoma masquerading as huge goitre: a case report

Background: Sialolipoma is a rare tumour which may arise from both major and minor salivary glands and has recently been described as a variant of salivary gland lipomatous lesions. Case presentation: We report a 54-year-old male who presented with a 7-year history of large right anterior neck swelling. He was clinically euthyroid and had no compressive or infiltrative symptoms. He sought medical attention due to the discomfort exerted by the weight of the mass and was keen for excision. The swelling appeared like a goitre but physical examination proved otherwise. Imaging was suggestive of a benign tumour arising from the right parapharyngeal fossa. The mass was surgically excised and was noted to be adherent to part of the submandibular gland. Histopathological examination revealed a new variant of benign adipocytic tumour of salivary gland or sialolipoma arising from the submandibular gland. Besides being the largest sialolipoma to be reported, there are also no reports of giant submandibular sialolipomas masquerading as a huge goitre in appearance. Conclusion: Submandibular sialolipomas can present in really large sizes and appear as a giant goitre. It is important to differentiate between benign lipomas from liposarcomas and tailor the management accordingly. Surgical enucleation is the preferred choice of treatment for these benign tumours with low recurrence rates

Surgery for deep infiltrating rectal endometriosis-Selecting the right approach

Endometriosis involving the bowel is a form of deep infiltrating endometriosis (DIE). The endometriotic lesions can infiltrate the bowel layers mimicking a malignancy. The majority of bowel involvement happens in the colon and rectum. We report our experience in surgically managing rectal endometriosis in two patients, one via a conservative approach and the other with a more radical approach and their associated short-term and long-term outcomes are observed. In principle, surgery remains the mainstay of treatment in managing rectal DIE with adjuvant hormonal therapy. The selection of surgical approach should be based on disease factors such as the size of the lesions and extent of the disease, patient factors including fitness for surgery and expectations as well as logistics and resource limitations

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Abdominal apoplexy: rupture of short gastric artery after retching

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare but often fatal condition resulting from a variety of disease processes affecting abdominal vasculature. A 30-year-old woman presented with acute abdominal pain and breathlessness and was in class II hypovolemic shock. She had a history of multiple episodes of retching with non-bilious vomiting prior to that. Computed tomography (CT) reported a non-rotation of the gut, gross intraperitoneal free fluid with debris, and possible perforated appendicitis. Laparoscopy revealed a gross hemoperitoneum of 2.5 L, with bowel findings consistent with non-rotation of the gut, but technical difficulty in identifying the source of bleeding led to conversion to laparotomy. A ruptured short gastric artery was ascertained to be the source of bleeding and was successfully ligated. A retrospective review of the preoperative CT showed intraperitoneal free fluid with Hounsfield unit measurements of 48 and 52, suggestive of acute hemoperitoneum. ISIH is often a delayed diagnosis or missed diagnosis due to its low incidence. The presence of vomiting and abdominal pain with hypovolemic shock, especially in a young individual, should raise the suspicion of ISIH, which can be confirmed via early CT imaging to facilitate achieving hemostasis during surgery.</jats:p

Traumatic abdominal wall hernia after impact from handlebar: A case report

Traumatic abdominal wall hernia (TAWH) is a rare type of hernia resulting from blunt abdominal trauma. It develops following the inertia of sudden, high-energy blunt trauma or focused low energy impact. A 22-year-old motorcyclist presented to the emergency department following a collision with an automobile. Clinical examination demonstrated a bulging mass at the lower abdomen, resulting from impact with the motorcycle handlebar. A contrast-enhanced CT scan of the abdomen revealed a disruption of both rectus abdominis muscle and linea alba at the lower abdomen with loops of small bowels and mesentery herniating through the defect, associated with multiple air pockets and pneumoperitoneum. Exploratory laparotomy showed TAWH containing loops of small bowel and mesentery in addition to mesenteric tears. Small bowel resection with primary anastomosis and repair of the anterior abdominal wall defect using interrupted polypropylene sutures was performed. The patient recovered well postoperatively and was discharged home three days later. A follow-up at 1 year showed no evidence of recurrence

Managing traumatic testicular dislocations: what we know after two centuries

Traumatic testicular dislocation (TTD) is a rare consequence of blunt scrotal trauma. A 21-year old gentleman presented with inguinal pain following a motorcycle accident and physical examination revealed absence of both testes within a well-formed scrotal sac with bilateral inguinal swellings. Ultrasonography confirmed viability and location of the testes at the superficial inguinal pouch. He underwent emergent surgical reduction with orchidopexy and was discharged the next day. No evidence of testicular dysfunction or atrophy was noted at follow-up. We reviewed reports of TTDs reported in English over the last two centuries and discuss its occurrence, evolution and management.</jats:p

Managing traumatic testicular dislocations: what we know after two centuries

Traumatic testicular dislocation (TTD) is a rare consequence of blunt scrotal trauma. A 21-year old gentleman presented with inguinal pain following a motorcycle accident and physical examination revealed absence of both testes within a well-formed scrotal sac with bilateral inguinal swellings. Ultrasonography confirmed viability and location of the testes at the superficial inguinal pouch. He underwent emergent surgical reduction with orchidopexy and was discharged the next day. No evidence of testicular dysfunction or atrophy was noted at follow-up. We reviewed reports of TTDs reported in English over the last two centuries and discuss its occurrence, evolution and managemen

A Huge Primary Retroperitoneal Diffuse Large B-cell Lymphoma: A Case Report

Retroperitoneal diffuse large B-cell lymphoma (DLBCL) is generally rare and often presents with late symptoms. A 60-year-old female presented with abdominal pain for 3 days with associated symptoms of altered bowel habits and constitutional symptoms. Physical examination was unremarkable. The blood investigations were generally within normal limits except for a 10-fold rise in serum CA-125. Transabdominal ultrasonography revealed an ill-defined lesion, with a cystic component within, at the inferior pole of the spleen. Computed tomography scan showed a large lobulated soft tissue tumour in the left retroperitoneal space with local infiltration to adjacent organs with multiple subcentimeter para-aortic and aortocaval lymph nodes. Laparotomy revealed a locally advanced retroperitoneal tumour measuring 10 x 10cm in size. The left retroperitoneal tumour was resected en-bloc with the left kidney, the spleen, the distal part of the pancreas and a part of the left diaphragm. Histopathological examination of the retroperitoneal tumour revealed a DLBCL (germinal centre type) as CD10, CD20, and BCL-6 were positive among all the markers, confirming the final diagnosis. She was started on CHOP regimen chemotherapy and is currently well. A complete en-bloc resection of the retroperitoneal lymphoma is recommended in fit patients with resectable retroperitoneal tumours. The decision between core needle biopsy and surgical resection should be made on a case-by-case basis following a multidisciplinary team approach discussion to achieve the best outcome for these patients