An unusual case report of a subhepatic appendix and an interlobar hepatic bridge in a patient with acute cholecystitis.

A subhepatic appendix and an interlobar hepatic bridge are both rare anatomical variants. To find both entities in the same patient at the time of a laparoscopic cholecystectomy makes for a unique case report. Subhepatic appendicitis has a reported incidence of 0.08%, and there have been only published three case reports of an interlobar hepatic bridge. Their lack of involvement in acute cholecystitis facilitated an easier dissection process and prevented serious complications to the liver or the right hemi-colon.

A rare case report of pigment gallstones and a concomitant gastric gastrointestinal stromal tumour.

Gastric gastrointestinal stromal tumours (GISTs) with cholelithiasis in the English literature are quite rare with a few published case reports. Their concurrent surgical management has also been debated as the clinical symptoms are often ascribed to one of the pathologies. All case reports to date have reported on cholesterol cholelithiasis. We would like to present a first case report of pigment cholelithiasis and a gastric GIST and their concurrent laparoscopically management. This was facilitated due to the patient's request to deal with both pathologies as well as the nebular signs concerning the symptoms that she presented with. We were able to undertake the dual surgeries without compromising her oncological outcomes.

Parietal peritoneal lipomas: a first case report of two lipomas of the parietal peritoneum.

Parietal peritoneal lipomas are a rare surgical entity with seven case reports in the published literature. Their aetiology remains nebulous and includes theories such as misplaced embryonic tissue, adipose hyperproliferation, trauma and fat herniation or excessive obesity. This is the first case report in the literature with two parietal peritoneal lipomas incarcerated in an umbilical hernia. We strongly advocate for an international rare tumour registry, given the sparsity of data on these tumours and their possible malignant potential, which we believe would help potentiate an effective treatment protocol for future cases.

De novo adolescent gastric carcinoma: a first case report in Saskatchewan, Canada.

Adolescent gastric cancers are extremely rare with a reported incidence of 0.05-0.10% in North America. We present a de novo case of gastric carcinoma in a 17-year-old teenager with no concomitant family history or risk factors. His main clinical presentation included anaemia and melaena stools. Despite an extensive clinical workup that included a diagnostic laparoscopy, the tumour was deemed surgically irresectable, and he was started on a palliative chemotherapy protocol at the local paediatric oncology centre. He demised 7 months later. This is the first recorded case of an adolescent gastric cancer in Saskatchewan, Canada. This case highlights the need for an international tumour registry to document and investigate rare adolescent gastric malignancies and thereby potentiate a possible cure through the pooling of limited resources.

Massive gallstone in an asymptomatic Indigenous Canadian male: Case report and literature review.

INTRODUCTION: Gallstones are present in 10-15% of North Americans, but only 20% become symptomatic. This case report describes a patient with a 7.5 cm gallstone detected incidentally while being investigated for cardiac pathology. This is the first report in the English literature of a stone this size that has remained clinically asymptomatic. This work is reported in line with the SCARE criteria. CASE REPORT: The patient was a 71-year-old Indigenous Canadian male, with atrial fibrillation. His cardiologist ordered a CT scan of his chest, which incidentally identified a large gallstone. He was referred to surgery for asymptomatic cholelithiasis. An uncomplicated laparoscopic cholecystectomy was performed. Final pathology showed a 7.5 cm gallstone with features of chronic cholecystitis. DISCUSSION: The patient's ethnicity and gallstone size placed him at increased risk for gallbladder cancer, gallstone fistulization and perforation. We reviewed the literature for asymptomatic patients who may benefit from cholecystectomy: transplant recipients and those with hemolytic disorders. Laparoscopic cholecystectomy is not currently indicated in diabetics and bariatric surgery patients. CONCLUSION: This case report shows that there are asymptomatic patients with massive gallstones. A review of their history, risk factors for malignancy and future gallstone related complications must be carefully weighed and discussed prior to deciding on surgical versus expectant management.

Acute appendicitis with four appendicoliths: a first case report in the English literature.

This is an extremely rare presentation of multiple appendicoliths in one appendix. Multiple appendicoliths as well as appendicoliths larger than 5 mm have been implicated in severe appendicitis as well as perforation and gangrene of the appendix. There is no known correlation with appendicular malignancy. The controversy arises in the surgical management of asymptomatic patients. There is emerging evidence that justifies an elective appendicectomy in asymptomatic patients.

A case report of a double port site hernia and their laparoscopic repair with intra corporeal suturing of the hernia necks and an underlay mesh repair.

INTRODUCTION: Port site hernias (PSH) are a potential postoperative complication in laparoscopic surgery. It is difficult to estimate their true incidence given the descrepancy in published reports. PRESENTATION OF CASE: This is a case report of a 42-year-old lady who developed two separate PSH requiring a laparoscopic repair. This is also the first reported case of multiple PSH in a single patient in the English literature. DISCUSSION: This report highlights the need for further research in establishing well defined incidence rates in order to properly discuss future surgical risks when consenting a patient for laparoscopic surgery. It is our belief that future research should be directed towards determining the risk associated with different trocar types, in the setting of various premorbid patient factors, to help surgeons decide on relevant instrument use and the most appropriate closure for port sites. CONCLUSION: The growing incidence of PSH has brought about significant changes in the practice of laparoscopic surgery which behoves us as practicing clinicians to stay abreast of these changes so as to decrease the incidence of PSH.

Case series of two falciform ligament incisional hernias and their laparoscopic repair.

Incisional hernias involving the falciform ligament have only been reported in two case reports in the English literature. This is the first reported case series of two falciform ligament incisional hernias. Both patients had undergone a prior cholecystectomy. Laparoscopic transabdominal pre-peritoneal repair was performed with an uneventful recovery in both patients. In the previously published reports both patients underwent an open herniorrhaphy with an underlay mesh repair. These are the first two documented laparoscopic repairs of a falciform ligament incisional hernia. The laparoscopic repair also included intra-corporeal suturing of the hernia necks with a non-absorbable suture. We extrapolated this data from the component separation technique which reconstituted the abdominal musculature in their normal anatomical position resulting in a reduced hernia recurrence rate.

Laparoscopic herniorrhaphy of bilateral inguinal herniae and an incidental Spigelian hernia with intra corporeal suturing of the Spigelian hernia neck: A case report.

INTRODUCTION: A Spigelian hernia is a rare type of abdominal wall hernia occurring in an area of congenital or acquired defect. These hernias occur in an area called the Spigelian zone and are interparietal making for a difficult diagnosis on clinical exam. PRESENTATION OF CASE: A 74-year-old female presenting with bilateral inguinal herniae and a left sided Spigelian hernia. The repair was done laparoscopically with an intra-corporeal suture closing the Spigelian hernia neck. Her recovery was uneventful. DISCUSSION: The aetiology of Spigelian herniae remains nebulous. Due to their rarity and evasive nature on clinical exam, ultrasound imaging has become the first line in diagnosis. Open herniorrhaphy is still the most common technique, but laparoscopic repair is becoming more commonplace in the surgical armamentarium. CONCLUSION: Spigelian herniae are rare with non specific symptoms. We present the first case report of a laparoscopic repair of bilateral inguinal herniae and a left sided Spigelian hernia with intra-corporeal suturing of the Spigelian hernia neck.

Abdominal wall extra-adrenal myelolipoma, a case report and review of the literature.

Extra-adrenal myelolipomas (EAMLs) are extremely rare soft tissue tumours that constitute <15% of all myelolipomas. We present a 70-year-old patient with a midline swelling of the anterior abdominal wall. It was clinically diagnosed as an incisional hernia, though the computerized scan indicated an internal hernia. During laparoscopy a soft tissue tumour of the abdominal wall was identified and excised. Pathology confirmed an extra-adrenal myelolipoma of the anterior abdominal wall through the presence of adipocytes and trilineage haematopoetic cell lines. EAMLs are rare mesenchymal soft tissue tumours with less than a hundred cases reported in the English literature. Pathological diagnosis shows the presence of mature adipocytes as well as myeloid and erythroid cell lines. This is the first case report of an EAML of the anterior abdominal wall. This case report is made even more rare as it is present in a male patient.

Elasto fibroma Dorsi: a case report of bilateral tumours and excision of the symptomatic lesion in a male patient.

Elasto fibroma dorsi is a rare tumour of the shoulder girdle that usually arises at the infra scapular area. We present a 57-year-old male with a soft tissue swelling on his right infra scapular area of 6 months duration. It was a painless lesion which caused him discomfort while sleeping. Preoperative imaging revealed bilateral tumours but the left tumour was impalpable. The surgery itself was uneventful but post-operatively he developed a haematoma which was managed conservatively Elasto fibroma is a benign pseudo tumour of the shoulder girdle. It's aetiology is tied in to repetitive trauma of the shoulder girdle resulting in a pseudo tumour at the infra scapular area. Magnetic resonance imaging is the diagnostic modality of choice and is pathognomic in the presence of bilateral infra scapular tumours. Treatment is usually conservative and tissue diagnosis is essential as it can mimic a soft tissue sarcoma radiologically.

Case report of a littoral cell angioma of the spleen and accessory spleens: A benign vascular tumour.

INTRODUCTION: Littoral- cell angioma (LCA) is a rare benign vascular tumour of the spleen. There have been less then 80 cases reported in the literature. Recent reports have described it to be a malignant lesion with congenital and immunologic associations. We report a case of LCA of the spleen. PRESENTATION OF CASE: A 52 -year-old male patient was admitted to hospital with a three month duration of intermittent upper abdominal pain and nausea. Imaging studies, including computer tomography (CT) and magnetic resonance imaging (MRI), showed multiple lesions in the spleen as well as in the accessory spleens. An open splenectomy was performed and his post-operative recovery was uneventful. DISCUSSION: Littoral cell angioma of the spleen is a benign vascular tumour that has been infrequently reported in the English literature. While it does have malignant potential, the vast majority are benign. Diagnosis depends on the expression of endothelial markers like CD31 and histiocytic markers like CD68.Malignant potential is enhanced by the presence of splenomegaly as well. CONCLUSION: This rare condition is made even more rare by the presence of the tumour in the two accessory spleens as well.

An intestinal carcinoid causing transient jejunal intussusception in an adult-A case report.

INTRODUCTION: Transient jejunal intussusception in an adult is a rare clinical finding as reported in the English literature. The diagnosis is usually a matter of exclusion given the extremely rare nature of this medical condition. PRESENTATION OF THE CASE: A young female presented to our hospital with abdominal pain and distention of six months duration. The episodes were intermittent in nature and resolved with conservative management. The aetiology remained obscure until a computerized tomography(CT) scan diagnosed a small bowel intussusceptionIntraoperatively a small bowel tumour was identified and resected. Pathology confirmed an intestinal carcinoid of the small bowel with no evidence of metastatic disease. DISCUSSION: Transient jejunal intussusception is a rare finding with only eight reported cases in the English literature. All previously reported cases have been ascribed to benign aetiologies and to our knowledge this is the first case of a malignancy causing transient jejunal intussusception. The management is usually conservative unless an actual cause for the intussusception can be ascertained. The diagnosis is usually one of exclusion and CT scan remains the gold standard in eliciting a diagnosis. CONCLUSION: Transient jejunal intussuception in adults is an extremely rare pathological condition and the diagnosis is usually entertained as a matter of exclusion.

Superior Mesenteric Artery Syndrome: A Case Report of Two Surgical Options, Duodenal Derotation and Duodenojejunostomy.

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction and its management is usually conservative with nasojejunal feeding. The pathophysiology entails the loss of the fat pad between the superior mesenteric artery and the abdominal aorta. This reduces the angle between the two vessels to less than 20 degrees with the resultant compression of the third part of the duodenum. The surgical management is usually a laparoscopic duodenojejunostomy. The two cases in our series had two different surgical procedures with good outcomes in both patients. The surgical management of each patient should be determined on its own merits irrespective of the standard of care.

Laparoscopic repair of an incarcerated femoral hernia.

INTRODUCTION: A femoral hernia is a rare, acquired condition, which has been reported in less than 5% of all abdominal wall hernias, with a female to male ratio of 4:1. PRESENTATION OF CASE: We report a case in a female patient who had a previous open inguinal herniorrhaphy three years previously. She presented with right sided groin pain of one month duration. Ultrasound gave a differential diagnosis of a recurrent inguinal hernia or a femoral hernia. A transabdominal preperitoneal repair was performed and the patient made an uneventful recovery. DISCUSSION: Laparoscopic repair of a femoral hernia is still in its infancy and even though the outcomes are superior to an open repair, open surgery remains the standard of care. The decision to perform a laparoscopic trans abdominal preperitoneal (TAPP) repair was facilitated by the patient having previous open hernia surgery. The learning curve for laparoscopic femoral hernia repair is steep and requires great commitment from the surgeon. Once the learning curve has been breached this is a feasible method of surgical repair. This is demonstrated by the fact that this case report is from a rural hospital in Canada. CONCLUSION: Laparoscopic femoral hernia repair involves more time and specialized laparoscopic skills. The advantages are a lower recurrence rate and lower incidence of inguinodynia.

Gallbladder duplication.

INTRODUCTION: Gallbladder duplication is a rare congenital malformation that occurs in about one in 4000 births. Congenital anomalies of the gallbladder and anatomical variations of their positions are associated with an increased risk of complications after laparoscopic cholecystectomy. PRESENTATION OF CASE: We report the case of a double gallbladder in a fifty-six year old man. He presented with recurrent episodes of biliary colic. Pre-operative imaging confirmed the diagnosis. He subsequently underwent surgery for biliary colic. DISCUSSION: Inspection of the resected gallbladder specimen showed that it consisted of two chambers with a single cystic duct, which communicated through a common ostium. Both chambers had cholelithiasis. There were two cystic arteries as well. Duplication of the gallbladder has an incidence of approximately 1: 4000. However, the exact incidence of this rare anomaly cannot be accurately assessed, since the only cases which have been identified are those that became symptomatic or were encountered as incidental findings during surgery, imaging studies or at autopsy. CONCLUSION: Duplication of the gallbladder is a rare congenital abnormality, which requires special attention to the biliary ductal and arterial anatomy. Laparoscopic cholecystectomy with intraoperative cholangiography is the appropriate treatment in a symptomatic gallbladder. The removal of an asymptomatic double gallbladder remains controversial.