Theodoros Piperos

Clinical significance of de Garengeot's hernia: A case of acute appendicitis and review of the literature

INTRODUCTION The presence of the appendix in a femoral hernia sac is known as de Garengeots hernia. We report a rare case of an elderly woman with femoral hernia appendicitis and discuss the surgical pitfalls and considerations through a literature review. PRESENTATION OF CASE An 83-year-old woman presented with fever and right lower quadrant abdominal pain. Clinical examination revealed a femoral hernia. Ultrasonography confirmed bowel was present in the hernia sac. In the operation room, an acutely inflamed appendix was recognized within the sac. The patient underwent appendectomy and hernia repair with sutures. DISCUSSION Acute appendicitis within a femoral hernia is rare and multiple dilemmas exist regarding its treatment. An incision below the inguinal ligament is a reasonable choice in order to access the hernia sac. A mesh should be placed in non-infectious appendectomy while herniorrhaphy is preferred in cases of appendicitis. CONCLUSION The presence of the vermiform appendix in a femoral hernia sac is rare but the surgeon should be aware of this clinical entity. Prompt diagnosis and appropriate surgical treatment is the key to avoid complications.

Subcutaneous Splenosis of the Abdominal Wall: Report of a Case and Review of the Literature

Splenosis is a common benign condition that occurs after splenic rupture via trauma or surgery. The mechanism behind splenic cell autotransplantation begins with the splenic rupture, either from trauma or surgical removal. Splenosis is usually found incidentally and, unless symptomatic, surgical therapy is not indicated. Subcutaneous splenosis is an extremely rare form of splenosis, mostly observed in abdominal surgical scars. We report a case of subcutaneous splenosis, as well as a comprehensive review of the literature. In our case, a 43-year-old woman who had splenectomy after traumatic splenic rupture at the age of 7 years old presented for plastic reconstruction of her postoperative scar. Upon surgery, two asymptomatic subcutaneous nodules were incidentally discovered. The presence of splenic tissue was confirmed by the histological study. The nodules were not excised, as the patient was not symptomatic.

Congenital peritoneal encapsulation of the small intestine: A rare case report

Highlights • Be aware of the rare occasion of PE in patients with intestinal obstruction without other etiological factors.• Preoperative diagnosis of PE may be impossible.• Management of PE in case of intestinal obstruction requires urgent surgery.

Left-sided gallbladder (Sinistroposition) encountered during laparoscopic cholecystectomy: A rare case report and review of the literature

Highlights • LSG is a peculiar anatomical variation that is difficult to be identified preoperatively.• LSG is associated with anatomical anomalies that may lead to intra-operative injuries.• Safe laparoscopic cholecystectomy is feasible by placing the patient to left-side up position for better exposure of the operative field.

Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature

Highlights • Aberrant subvesical bile ducts are a rare anatomical variation defined as a network of bile ducts located in the peri-hepatic tissue of the gallbladder fossa.• Their injury is almost inevitable and it leads to bile leakage, which is a life-threatening complication of laparoscopic cholecystectomy.• Meticulous operative technique and detailed exposure of the operative field is the cornerstone of a safe laparoscopic cholecystectomy, when surgeons encounter this rare anatomical variation.

The ligament of Parks as a key anatomical structure for safer hemorrhoidectomy: Anatomic study and a simple surgical note

Hemorrhoids are a common anal disorder which affects both men and women of all ages. One out of ten patients with hemorrhoidal disease, requires surgical treatment. Unfortunately though, hemorrhoidectomy is closely related to complications that can be present early or late postoperatively. In the present manuscript, the safe surgical technique which emphasizes to the identification of the key anatomical structure of the ligament of Parks (Trietzs muscle) is adequately described. A total of 200 patients with grades III and IV hemorrhoids, underwent Milligan-Morgan or Fergusons hemorrhoidectomy. The mucosal ligament of Parks was identified to all patients and was used as a key anatomical structure through the excision of the hemorrhoids. Its identification guides surgeons during the operation and reduces the major problem of postoperative complications. Finally, since the mucosal ligament of Parks represents a constantly identifiable landmark, it allows simple and reliable identification of the internal sphincter muscle and minimizes the probability of postoperative complications.

Abnormal distance of the extralaryngeal bifurcation point of the recurrent laryngeal nerve from the cricothyroid joint

Abstract The extralaryngeal bifurcation point of the recurrent laryngeal nerve (RLN) is typically located in a mean distance of 0–2 cm from the cricothyroid joint (CTJ). In the presented case though, the left RLN was unexpectedly identified bifurcating in a mean distance of 7 cm from the left CTJ in a young woman with multinodular goiter during total thyroidectomy. The RLN was carefully exposed throughout its course for the avoidance of iatrogenic injury of the nerval structure. The operation was uneventful. The present manuscript aims to highlight a scarce anatomic variation and its implications for thyroidectomy. Rare anatomic variations of the RLN such as the presented one encumber thyroid surgery and represent a severe risk factor of RLN injury. Meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to an injury-free thyroid surgery.

Middle colic vein draining to splenic vein: a rare anatomic variation encountered during a right hemicolectomy

Abstract Right or subtotal colectomy either open or laparoscopic may be a challenging operation owing to technical difficulties. One of these, is to identify a safe and adequate dissection plane, ligating and dissecting lymph nodes around middle colic vessels. The purpose of this study was to depict a rare anatomic variation of middle colic vein (MCV) draining to splenic vein. We report the case of a 55-year-old male patient, who was subjected to a right hemicolectomy for an adenocarcinoma in the ascending colon. During dissecting the transverse mesocolon from the greater omentum, for complete mesocolic excision (CME), we encountered that the MCV drained in the splenic vein. With respect of this rare anatomic variability, CME was completed without hemorrhage. Our aim is to depict that deep knowledge of MCV anatomy and its variations is of paramount importance to achieve CME and to avoid dangerous or massive bleeding.

Anatomic variation of the relation between the inferior mesenteric artery and the bifurcation point of abdominal aorta during lower anterior resection: A rare case report

Highlights • Anatomic variations of the origin of IMA and of its relationship with the AA are of paramount clinical importance as regards to diagnosis and surgical treatment.• Such variations might encumber high ligation of the IMA during surgery for rectal cancer, with subsequent implications or may pose a major risk factor of accidental injury and hemorrhage.• Such anatomic variations of the origin of the IMA and its relationship with AA, may be actually more common, than described in the literature.

Anomalous origin of the right colic artery from the right gastroepiploic artery during complete mesocolic excision: a rare case report

Abstract Complete mesocolic excision (CME) is a standardized surgical procedure for colonic cancer that requires ample knowledge of the anatomical patterns of the colic arteries. Variations of the colic vessels encumber both surgical and endovascular techniques. In the presented case below, the right colic artery was incidentally detected emerging from the right gastroepiploic artery, during CME. Surgeons should be always aware of this variation in order to perform safe abdominal surgeries and sufficient resection of the regional lymph nodes with a view to minimizing the probability of recurrence of disease when encountering colonic cancer.