Internal-mesocolic hernia after laparoscopic left colectomy report of case with late manifestation.

INTRODUCTION: In contrast to right colectomy, closure of the mesocolic gap after laparoscopic left colectomy is not practiced, and reports of small gut herniation through this gap are scarce. PRESENTATION OF CASE: A 73 year old male was admitted as an emergency with symptoms and clinical signs, suggesting obstruction of the small bowel. Abdominal imaging, including computed tomography confirmed the diagnosis. The patient had undergone laparoscopic left colectomy for cancer, three years ago. At laparotomy small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis. The small bowel loops were reduced and their viability was ascertained. Because of an iatrogenic perforation of the colon at the anastomosis during small bowel loops mobilization, the colon was temporarily exteriorized in the form of a double barrel colostomy. The postoperative course was uneventful. DISCUSSION: Very few cases have been reported in the liteature indicating the need of sutuing the mesenterium. Despite the limited numbe of the reported cases, there is clearly a risk of intenal hernia after laparoscopic left colectomy. CONCLUSION: Although rare internal hernia after laparoscopic left colectomy may occur, and this brings forward the question of mesocolic gap closure.

Successful management of a combined abdominal and thoracic trauma with rectal impalement: report of a case.

Introduction. Combined abdominal and thoracic impalement injuries are a rare form of penetrating trauma. Nowadays, they occur more frequently as an accident and not so often as a deliberate violent action. Case Report. A 35-year-old man was admitted to our emergency department with chest pain and respiratory distress after he had reportedly slipped in his bathtub. Abdominal and thoracic imaging, including computed tomography (CT), confirmed a right-sided pneumothorax and a liver laceration without bleeding or further endoperitoneal trauma. A chest tube was placed. During his hospitalization in the first 24-hour period, he complained of abdominal and right shoulder pain accompanied by fever. A new abdominal and thoracic CT scanning revealed a rupture of the rectosigmoid, a rupture of right hemidiaphragm, and a foreign body in the thoracic cavity. The patient admitted that a broomstick was violently placed through his rectum, and he underwent a thoracotomy with an exploratory laparotomy. The foreign object was removed, the diaphragmatic rupture was repaired, and a Hartmann's procedure was performed. The postoperative course was uneventful. Conclusion. In cases of combined thoracoabdominal trauma, high index of suspicion is required when medical history is misleading and the injuries are not obvious immediately. A coordinated team effort in a well-organized trauma center is also very important.

Medical management of acute type a aortic dissection in association with early open repair of acute limb ischemia may prevent aortic surgery.

BACKGROUND: Acute type A aortic dissection (AAAD) is a cardiovascular emergency with a high potential for death. Rapid surgical treatment is indicated to prevent fatal complications. Aggressive appropriate medical management starts at first suspicion and is essential to prevent exacerbation or rupture of the dissection. Despite improved surgical techniques, perioperative care and the development of specialized cardiovascular centers, mortality remains high. Organ ischemia is a catastrophic manifestation of aortic dissection, demanding acute surgical intervention in specialized cardiovascular centers. CASE REPORT: We present the case of a 62-year-old man with isolated acute limb ischemia due to an acute type A aortic dissection treated in a regional general hospital, without a specialized cardiovascular service, with immediate open malperfusion repair and aggressive medical management. The patient did not undergo further surgical aortic repair, and after a 30-month follow-up he remains symptom free and in good clinical condition, suggesting that although aortic surgery remains the gold standard for treatment of acute Type A dissection, appropriate medical management and early malperfusion repair may offer an initial limb- or life-saving procedure. CONCLUSIONS: This staged approach gives clinicians more time to properly evaluate and transfer the patient to a specialized cardiovascular center, and in some cases may even offer a definite treatment.