Open Access Case Report

Obturator Hernia in a Male Patient; A Rare Entity: A Case Report

Rishi Kumar Agrawal, Priti Agrawal, Jyotirmay Chandrakar, Pankaj Motghhare

Asian Journal of Case Reports in Surgery, Page 21-26

Introduction: Obturator hernia (OH) is rare accounting for 0.05 – 0.4 % of all abdominal hernias. It is a diagnostic challenge because the signs and symptoms are non-specific. We report a case of OH which was diagnosed during laparoscopic left inguinal hernioplasty and is very rare because it occurred in male, on left side and with associated benign prostatic hypertrophy.

Case Report: Our patient 60 years old male, admitted with history of chronic lower abdominal pain, lump in left groin area which reduced in size after rest and aggravated on coughing and doing heavy work. On local examination, left inguinal hernia was present and was reducible. Patient was taken for laparoscopic transabdominal preperitoneal (TAPP) hernioplasty procedure. On laparoscopy after reducing the contents of inguinal hernia associated OH was seen.

Discussion: Loss of body fat and increase in intrabdominal pressure are the major factors that lead to the development of hernia. The commonest content of the sac is ileum with about 50% being of the Richter’s type. We suggest that laparoscopic hernia surgeries are superior to open methods. In open surgeries, we can only address direct and indirect inguinal hernia whereas during laparoscopy, we can find and treat direct, indirect, femoral and OH simultaneously. In our case, OH was detected incidentally, had it been open surgery this would have remain undiagnosed and lead to future morbidity.

Conclusion: OH is very rare and difficult to diagnose. Laparoscopic hernia surgeries can detect asymptotic OH and repair can be easily done either by simple suture closure or mesh placement. TAPP is procedure of choice for strangulated OH.

Open Access Case Study

Papillary Adenocarcinoma of the Gallbladder: A Case Report

Erwin Syarifuddin, Teddy Agung Saputra, Gabriele Jessica Kembuan

Asian Journal of Case Reports in Surgery, Page 1-7

Gallbladder carcinoma is a rare cancer often originally diagnosed as other benign gallbladder ailments. Early diagnosis is difficult due to lack of symptoms and half of all cases are only incidentally found during surgery. Unlike adenocarcinoma, the most common pathologic subtype of gallbladder cancer; papillary adenocarcinoma is found in only 3-5% of gallbladder cancer cases and has a tendency for exophytic growth and early manifestation of obstructive symptoms. We present a case of a female presenting with complaints and signs suggestive of choledocholithiasis. However, during surgery, a gallbladder tumor and empyema were discovered, with tumor invasion into the bile duct and the pancreas. The patient subsequently underwent open cholecystectomy and total resection of the gallbladder. Pathologic examination subsequently showed papillary adenocarcinoma subtype of gallbladder carcinoma.

Open Access Case Study

Unusual Presentation of Emphysematous Pyelonephritis (EPN): "Double trouble" A Case Report

Abdul Malek Mohamad, Sarmukh Singh A/L Charanjit Singh, Azmi Hassan

Asian Journal of Case Reports in Surgery, Page 8-13

Introduction: Emphysematous Pyelonephritis (EPN) is a possibly life-threatening condition that is usually present as sepsis. Delay in identifying the disease may lead to detrimental outcomes, even mortality. The present study reports a case of incidental finding of an EPN in a perforated viscus patient. Studies also advocate the minimally invasive approach of percutaneous drainage with antibiotics in asymptomatic EPN patients. Historically, EPN was managed by nephrectomy or open drainage along with antimicrobial therapy but resulted in high mortality of 40-50%. Introduction of percutaneous drainage had shown better outcome compared to nephrectomy.

Case Presentation: A 63-year-old gentleman, with underlying Diabetes Mellitus (DM), initially presented with a sudden onset of severe generalized abdominal pain and distension. Examination revealed peritonitic abdomen. Erect CXR revealed air under the diaphragm suggestive of perforated hollow viscus. Patient underwent exploratory laparotomy with intraoperative findings of perforated prepyloric gastric ulcer that managed with modified Graham patch. Besides, there was also huge retroperitoneal mass. Post operatively, patient subjected for abdominal and pelvic CT that revealed right EPN. It was managed with antibiotic and percutaneous drainage. Patient was responded and recovered.

Conclusion: EPN is a fatal disease that requires early detection with a high index of suspicion particularly in patients with signs of sepsis and pyelonephritis. Although it is rare, in subjects with pneumoperitoneum and the presence of pathology over renal area, EPN should be one of the differential diagnosis. In this case, it is possible that the presence of EPN poses stress to the patient leading to development of perforated viscus.

Open Access Case Study

Recurrent Dermatofibrosarcoma Protuberans of Head and Neck: A Rare Case Report

Richa Mehra, Munish Kumar Saroch, Amit Saini

Asian Journal of Case Reports in Surgery, Page 14-20

Dermatofibrosarcoma protuberans (DFSP) is an uncommon neoplasm of dermis involving head neck region. This tumour is slow growing and has very high potential for local recurrence with less risk of metastasis. It is a very rare neoplasm of the dermis layer of the skin [1] and is classified as a cutaneous soft tissue sarcoma [1]. It accounts for approximately 1–2% of all soft-tissue sarcomas. About 85% to 90% of DFSPs are low-grade tumours. The remaining 10–15% exhibit a high-grade fibrosarcomatous component and are considered high-grade lesions associated with a higher risk of metastasis [2]. We report a case of 46 years old male patient who presented with third episode of DFSP. The first episode was on right side of fore head, the second one was on right frontoparietal region and latest lesion was on right preauricular region and right pinna. On all the three occasions the recurrence was away from primary site.

Open Access Case Study

Large Pelvic Abscess in a Young Female Presenting as Urinary Retention. A Case Report

Priti Agrawal, Rishi Agrawal, Pankaj Motghhare, Anand Bansal, Jyotirmay Chandrakar

Asian Journal of Case Reports in Surgery, Page 27-34

Introduction: The pelvic abscess is a circumscribed collection of infected exudates.  In young women, a pelvic abscess occurs as one of the complications of pelvic inflammatory disease. The incidence of pelvic abscess is less than 1 % in a patient undergoing obstetric and gynaecological surgeries. Here we report a case of large pelvic abscess in a young female patient who presented with severe backache, urinary retention and abdominal pain and remained afebrile throughout the course of her illness.

Case Presentation: Our patient young female 30 years in age, presented with complaints of inability to pass urine for 4 hours with severe backache and abdominal pain. She had undergone tubectomy operation 4 years back. She had no history of vaginal discharge, fever, loss of appetite, weight loss or severe abdominal pain. Ultrasonography revealed large pelvic abscess measuring 13.18 x 13.84 x 13.91cm, volume-1328cc with homogenous internal echoes and thick wall. Laparotomy was done, dense intestinal and omental adhesions with the abscess wall removed. About 1.5 litres of pus drained from the abscess cavity. Pelvic ultrasound is the method of choice to evaluate a pelvic mass as it differentiates between fluid filled lesion and solid lesion, is inexpensive. Laparotomy with drainage of the abscess and lavage of the cavity is the mainstay of the treatment.

Conclusion: Our patient had non-specific symptoms. She remained afebrile throughout the course of illness and recovery. Surgical drainage and adhesiolysis through laparotomy gave her complete recovery.