Transabdominal Minimally Invasive Repair of a Left Chronic Traumatic Diaphragmatic Hernia.

Although the exact incidence of traumatic diaphragmatic hernia (TDH) is unknown, it can carry significant morbidity if not treated promptly. TDH is thought to be more common in penetrating thoracoabdominal trauma compared to blunt trauma. The left side is thought to be more commonly affected than the right due to the protective effects of the liver on the right hemidiaphragm in trauma. Although large defects are evident on CT imaging and the detection rate is improved with higher resolution CT scanners, smaller ruptures may require laparoscopy for definitive diagnosis if there is a high index of suspicion. In this case report, we present a case of a missed left TDH on CT imaging, with eventual herniation of the omentum and stomach. Although TDH traditionally is approached via thoracotomy or laparotomy, we demonstrate that a transabdominal minimally invasive approach with robot-assisted laparoscopic repair is a viable option, with the potential to reduce the morbidities associated with the open approach.

Subcutaneous Infiltration of Indocyanine Green From a Malpositioned Intravenous Catheter.

Indocyanine green (ICG) is a water-soluble, iodine-containing molecule with a wide variety of applications in various fields of medicine. In this paper, we report an adverse event of ICG infiltration into subcutaneous tissue from a malpositioned intravenous (IV) catheter. Although ICG can be injected intradermally and subcutaneously for sentinel lymph node biopsy in breast cancer surgery, no reports exist regarding inadvertent infiltration from an IV catheter. It is our objective to provide an example should this unfortunate event occur in other populations, to describe the timing of resolution from infiltration, and to provide recommendations for future occurrences. In this case, the discoloration from infiltration became apparent on postoperative day one and had resolved completely at the time of the follow-up appointment on postoperative day 18.

Appendiceal Goblet Cell Adenocarcinoma Case Report and Review of the Literature.

Acute appendicitis is a common presentation to the emergency department. The common pathogenesis thereof relates to obstruction of the appendiceal lumen by an appendicolith, which leads to an increase in intraluminal and intramural pressure. This is followed by distension of the appendix, subsequent small vessel occlusion and lymphatic stasis, and appendiceal wall ischemia and necrosis, eventually leading to rupture if not treated. Occasionally tumors at the base of the appendix can lead to appendicitis via the same process as an appendicolith. Goblet cell adenocarcinoma (alternatively named goblet cell carcinoid) is amongst the most rare appendiceal tumors, with a reported incidence rate of 0.05 cases per 100,000 population per year in the United States. These tumors contain features of both neuroendocrine tumors as well as adenocarcinomas, but behave more similarly to adenocarcinomas. Consensus regarding management of these tumors is lacking, likely due to the rarity of the disease. In this paper, we present a case of appendiceal goblet cell adenocarcinoma causing appendicitis and review the literature regarding these rare epithelial tumors.

Diaphragm Disease of the Small Bowel Presenting With Intussusception.

Diaphragm disease of the small bowel is an uncommon condition with nonspecific symptoms, which causes strictures of the small bowel associated with non-steroidal anti-inflammatory drug (NSAID) use. Due to the nature of the disease process and the strictures it can form, patients often present with a clinical picture suggestive of small bowel obstruction, and the true diagnosis is not confirmed until histopathological examination.  In this article, we present the case of a 73-year-old female with chronic NSAID use and gastrointestinal complaints who had undergone multiple endoscopic procedures which failed to identify the cause of her symptoms. Further investigation with video capsule endoscopy and CT enterography led to a diagnosis of intussusception believed to be caused by a small bowel mass. Retention of the video capsule endoscope prompted the decision to undertake diagnostic laparoscopy with push endoscopy and direct visualization of a string of small bowel strictures in the area of intussusception. This characteristic appearance of the bowel was then confirmed by pathology as diaphragm disease lesions. Diagnosis of this disorder is difficult due to its rarity and common symptoms that make other disease processes seem more probable. Early diagnosis can prompt counseling on cessation of NSAID use and interventions to decrease the risk of complications that may require surgical intervention. Physicians should be able to recognize diaphragm disease of the small bowel as a differential in patients presenting with obstructive bowel symptoms and even rare cases of intussusception in the setting of chronic NSAID use.

Umbilical Hernia Containing Appendicitis.

Umbilical hernia is a common cause for patient presentation to the surgeon, often on a nonemergent basis for a bulge at or lateral to the umbilicus but occasionally under emergency circumstances for pain or bowel obstruction when the hernia contents become incarcerated or strangulated. Risk factors for umbilical hernia include female gender, obesity, and ascites. A defect in the abdominal wall fascia at the umbilicus allows the preperitoneal adipose tissue, omentum, or small or large bowel to protrude through the defect. Rarely described is herniation of the appendix through an umbilical hernia, though appendix-containing femoral hernia (de Garengeot hernia) and appendix-containing inguinal hernia (Amyand hernia) are more common. There are 10 available case reports in the medical literature that describe an appendix-containing umbilical hernia; in this case report, we present the 11th case report of appendicitis within an umbilical hernia.