Mohamed Tarchouli

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: a case report

IntroductionGiant inguinoscrotal hernias are extremely rare nowadays, but they may still be encountered after years or even decades of neglect. Such hernias containing both bowel loops and urinary bladder have not been reported in the medical literature to date, to the best of our knowledge.Case presentationWe report a case of a 65-year-old Moroccan man who presented with giant right-sided and long-standing inguinoscrotal hernia with compromised quality of life due to walking difficulties and sexual discomfort. Computed tomography revealed a voluminous hernia sac containing small and large bowel loops, greater omentum, and urinary bladder. Surgical repair was done through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy.ConclusionsGiant inguinoscrotal hernia containing intestinal segments and urinary bladder is a challenging surgical disease. A Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible in such cases.

Analysis of prognostic factors affecting mortality in Fournier’s gangrene: A study of 72 cases

INTRODUCTION Fourniers gangrene is a rapidly progressing necrotizing fasciitis of the perineum and genital area associated with a high mortality rate. We presented our experience in managing this entity and identified prognostic factors affecting mortality. METHODS We carried out a retrospective study of 72 patients treated for Fourniers gangrene at our institution between January 2005 and December 2014. Patients were divided into survivors and non-survivors and potential prognostic factors were analyzed. RESULTS Of the 72 patients, 64 were males (89%) and 8 females (11%), with a mean age of 51 years. The most common predisposing factor was diabetes mellitus (38%). The mortality rate was 17% (12 patients died). Statistically significant differences were not found in age, gender, and predisposing factors, except in heart disease (p = 0.038). Individual laboratory parameters significantly correlating with mortality included hemoglobin (p = 0.023), hematocrit (p = 0.019), serum urea (p = 0.009), creatinine (p = 0.042), and potassium (p = 0.026). Severe sepsis on admission and the extent of affected surface area also predicted higher mortality. Others factors, such as duration of symptoms before admission, number of surgical debridement, diverting colostomy and length of hospital stay, did not show significant differences. The median Fourniers Gangrene Severity Index (FGSI) was significantly higher in non-survivors (p = 0.002). CONCLUSION Fourniers gangrene is a severe surgical emergency requiring early diagnosis and aggressive therapy. Identification of prognostic factors is essential to establish an optimal treatment and to improve outcome. The FGSI is a simple and valid method for predicting disease severity and patient survival.

Giant adrenal hemangioma: Unusual cause of huge abdominal mass

Adrenal hemangioma is an extremely rare benign and non-functioning neoplasm of the adrenal gland. We report a case of a 71-year-old woman admitted for intermittent abdominal pain and abdominal distension associated with vomiting and chronic constipation for 5 years. Physical examination revealed a large abdominal mass. Both computed tomography scan and magnetic resonance imaging suggested hemangioma in the right lobe of the liver. Laboratory examinations and tumour markers were within normal limits, except for hypochromic microcytic anemia. The mass was removed intact by conventional surgery and histopathology revealed a cavernous hemangioma of the adrenal gland with no signs of malignancy. Surgical resection was curative, with no recurrence at the 2-year follow-up.

Intestinal intussusception in a young women: unusual cause and specific management

BackgroundIntussusception in adults is a rare cause of abdominal pain that is often associated with organic pathology. We describe a case of ileocolic intussusception revealing a cecal adenocarcinoma in a young woman successfully managed by laparoscopic-assisted surgery adhering to oncological principles.Case presentationA 30-year-old woman with a family history of colon adenocarcinoma in a young brother presented to our emergency department with a 2-month history of intermittent colicky abdominal pain accompanied by nausea and vomiting. Physical examination showed a palpable mass in the right lower quadrant of the abdomen. Computed tomography showed a 3-layered structure giving the characteristic target-shaped appearance in the ascending colon, highly suggestive for an ileocolic intussusception associated with right colic parietal thickening and an adjacent lymphadenopathy.Patient was planned for laparoscopic exploration and eventually definitive surgery. Intra-operatively, we found an ileocolic intussusception with thickening of the colic wall and slight proximal intestinal dilation. Multiple lymphadenopathies along the ileocecal artery were observed. Laparoscopic right hemicolectomy was performed following strict oncologic principles with “en bloc resection” and lymphadenectomy given the risk of an underlying malignancy. Considering this risk, previous reduction of the invaginated segments was not attempted and primary extracorporeal anastomosis was performed using manual sutures.Macroscopic examination of the resected specimen revealed a tumor mass of the caecal wall .The histological analysis identified a moderately differentiated tubular adenocarcinoma invading the serosa (T3) without permeation of the lymphatic or venous capillaries .No lymphatic metastasis of 28 nodes removed was seen. Postoperative course was uneventful and patient was discharged 5 days after surgery.Postoperative chest, abdomen, and pelvis CT scan were normal .Therefore, tumor is classified as stage II A (T3N0 M0).There was loss of MLH2 and MSH6 protein expression on immunohistochemistry findings reflecting a microsatellite instability phenotype, and the patient was followed up without adjuvant chemotherapy.ConclusionIleocolic intussusception rarely revealed a cancer in young adults. Laparoscopic surgery has a special interest in the diagnosis and treatment in this pathology. Oncogenetic consultation should be required in malignant lesion.

Primary Desmoid-Type Fibromatosis of the Mesentery: Report of an Unusual Tumor Localization

Since their initial description in 1832, desmoid tumors have been reported to occur in every part of the body. The mesentery is a very rare localization of this lesion [1, 2]. Mesenteric desmoid-type fibromatosis is under-recognized and often subject to misdiagnosis. It is a locally aggressive mesenchymal neoplasm of the mesentery and adjacent tissues that lacks the capacity to metastasize but shows a high risk of local recurrences. It can occur spontaneously or after surgical trauma. A small percentage of patients are affected byGardner syndrome. Mesenteric desmoid-type fibromatosis (DF) has characteristic morphologic features that are similar to those of fibromatosis elsewhere [1, 3]. This report treats a very rare case of primary giant mesenteric desmoid-type fibromatosis, highlighting clinicopathological features and differential diagnostic problems.

Un cas rare de pneumopéritoine spontané massif: à propos d’une observation

Le pneumopéritoine spontané est une affection rare caractérisée par la présence d’un épanchement d’air libre dans la cavité péritonéale en l’absence de toute cause évidente, nous rapportons une observation d’un pneumopéritoine massif de découverte scanographique dont l’exploration clinique, biologique, radiologique et cœlioscopique n’a aboutie a aucune étiologie décelable. Cette observation met le jour sur une entité clinique rarement vue dans notre pratique constituant un véritable piège diagnostic, sa connaissance éviterait des laparotomies blanches inutiles et surtout agressives pour nos patients. La cœlioscopie semble être un moyen chirurgical peu invasif pour les formes douteuses et permet un diagnostic visuel en éliminant une perforation d’organe creux.Spontaneous pneumoperitoneum is a rare disorder characterized by the presence of free air in the peritoneal cavity, in the absence of any obvious cause. We here report the case of a patient with massive pneumoperitoneum, detected by scan, in whom clinical, biological, radiological and laparoscopic examinations showed no detectable etiology. This case study describes a clinical entity rarely seen in our practice constituting a real diagnostic trap; accurate knowledge about the disease would avoid unnecessary and especially aggressive laparotomies revealing no signs of perforation. The laparoscopy seems to be a minimally invasive surgical procedure for doubtful cases allowing visual diagnosis by eliminating hollow organ perforation.

An unusual localization of retroperitoneal paraganglioma: a case report.

Paragangliomas are rare tumors arising from extra-adrenal chromaffine tissues. The diagnosis of non-functional retroperitoneal paraganglioma and its surgical management can be difficult. We report a case of a retroperitoneal paragangliomaof an unusual localization that renders the surgery more challenging. A 40 year-old woman presented to our department with a four-month history of upper quadrant pain with no vomiting, no fever, nor jaundice. Physical examination was normal. Ultrasonography showed a retro duodenal homogenous mass and computed tomographyscan showed a well-circumscribed round mass of heterogeneous density, which was in close contact with the aorta and the left kidney vein. Laboratory tests were normal. The patient underwent surgical management. The surgical exploration found a retroperitoneal tumor that was encapsulated and showing intimate contact with the abdominal aorta. We performed a complete resection of the tumor. Histological examination of the surgical specimen revealed a paraganglioma. The post operative course was uneventful. Paragangliomas are rare tumors. They can be asymptomatic for a long time and thus be diagnosed at late stage. A follow-up of patients is then essential. Surgical treatment is the only radical treatment and should be performed even in paragangliomas in close contact with the great vessels.