Patient-tailored management of an asymptomatic massive substernal goiter presenting as brachiocephalic vein occlusion. Report of a case and review of sternotomy indications.

INTRODUCTION: Substernal goiters are characterized by the protrusion of at least 50% of the thyroid mass below the level of the thoracic inlet. Still their definition is controversial. CASE PRESENTATION: The case refers to a 44year old male who presented to our department due to swelling and a feeling of 'heaviness' of his left upper extremity for the past 6 months. CT scan revealed a massive substernal goiter extending to the great vessels. Intraoperatively, a median sternotomy was performed due to the size of the gland and the close adhesion of the isthmus and lower left thyroid lobe to the brachiocephalic vein. Resection of the gland revealed the vein to have a cord-like shape, leading to reduced venous return and upper extremity symptoms. Recovery was uneventful for the patient who was discharged on the 7th postoperative day. DISCUSSION: While most substernal goiters can be surgically managed through a cervical incision, there are cases in which a median sternotomy is indicated. Those cases include excessive gland size, thoracic pain, ectopic thyroid tissue and the extent of the goiter to the aortic arch. Median sternotomy is associated with a number of intra and postoperative complications, although when performed by an experienced surgeon, mortality and morbidity rates along with long-term recovery are not affected. CONCLUSSION: The lack of a uniform definition and variety of indications, lead to a patient-tailored approach regarding the execution of sternotomy during surgical management of massive substernal goiters.

Intra-abdominal myositis ossificans in an asymptomatic patient during closure of a Hartmann's colostomy.

Intra-abdominal myositis ossificans, also known as heterotopic mesenteric ossification, defines the formation of bone-like lesions inside the abdominal cavity. It is a rare medical condition, usually following abdominal surgery or trauma. A 55-year-old male presented for closure of a Hartmann's colostomy, created 6 months ago because of sigmoid adenocarcinoma. Intraoperative findings consisted of an elongated bone-like lesion attached on the peritoneum and protruding inside the abdominal cavity, while two more stiff calcified nodules were found in the mesocolon. All lesions were excised. The presence of a hard consistency sigmoid stump led to cancelation of the operation. Heterotopous bone formation constitutes a challenging surgical condition, since its clinical presentation is innocuous and repetitive surgery acts a stimuli for additional bone creation. Computed tomography scan plays a major role in its diagnosis, while nonsteroidal anti-inflammatory drugs and cimetidine are helpful in preventing further recurrence of the disease.

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

INTRODUCTION: Inguinal 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 CASE: A 77year 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. DISCUSSION: Giant 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. CONCLUSION: Preoperative management and the correct surgical plan depending on the case are key elements in the successful treatment of this rare surgical entity.