Retained Surgical Items in Inguinal Canal: A Case Report and Literature Review

BACKGROUND:

Retained surgical items (RSI) are rare medical challenges with serious complications and medicolegal implications. Knowledge and preventive measures for these rare events are currently not sufficient to limit their increasing incidence. Gauzes and sponges constitute most of RSI. Forceps, needles and pins may be found too. Diagnosis of these events is challenging and often missed due to nonspecific clinical findings.

PRESENTATION OF CASE:

We present here a 49-year-old patient who presented to the clinic with a history of chronic scrotal sinus on the same side of a repeatedly repaired inguinal hernia 4 months before admission. He underwent exploration of the inguinal canal as elective surgery. Exploration of the inguinal canal revealed missed surgical gauze left during the previous hernia repair. The gauze was removed, and the inguinal canal was repaired. The postoperative period was uncomplicated.

CONCLUSION:

Retained surgical items are completely preventable near-events. Although they are rare entities, clinicians must have a high index of suspicion for any postoperative, in patients presenting with pain, sinus or palpable masses.

A foreign body in inguinal canal: A case report

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Bladder hernias are rare incidents that are mostly discovered intraoperatively.

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Diagnosis must be made preoperatively to avoid risk of injuring the bladder.

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High index of suspicion for bladder hernia is vital in elderly males with urinary or intestinal symptoms.

Introduction

Inguinal bladder hernias are rare incidents accounting for 1–3% of all inguinal hernia. Most of those cases are discovered intraoperatively accounting for the high incidence of bladder injuries during the repair. Symptoms can be variable depending on the size of the herniated bladder.

Presentation of case

We present here a 70 years old obese male patient, with history of CVA & on regular Aspirin ingestion. He presented to the ER as a case of intestinal obstruction due to suspicion of strangulated inguinal hernia based on an unclear Ultrasound picture. He underwent an emergency exploration of the hernia where the balloon of a Foley’s catheter was found inside a diverticulum of the urinary bladder, herniated through an Ogilvie hernia.

Discussion

Ogilvie hernia is a rare incident that happens mostly in elderly males. The herniated part contains prevesical fat, bladder andor loops of intestines. Diagnosis must be made preoperatively through CT scan or Cystourethrogram. First line management involves surgical reduction of the bladder and hernia repair. Resection of the herniated part is generally limited to necrotic tissues.

Conclusion

Surgeons must have high index of suspicion for elderly obese males with inguinal hernias and urinary or intestinal obstruction symptoms. Careful preoperative planning must be made to avoid repair associated bladder injuries.

Testicular seminoma metastasis to duodenum. Misdiagnosed as primary duodenal tumor

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Testicular cancers are the most common malignancies in men aged 15–35 years.

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Testicular malignancies rarely metastasize to retroperitoneum and involve upper gastrointestinal tract.

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Testicular cancers may cause upper gastrointestinal tract complications, including: ulceration of bowel mucosa, hemorrhage and intestinal obstruction.

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Radical orchiectomy, followed by chemo-radiotherapy is the standard treatment of testicular malignancies.

Introduction

Testicular cancer is the most common malignancy in Males aged 15–35 years. Its incidence comprises 0.8% of all Male cancers worldwide, with a mortality rate of 0.1%. Rarely it metastasizes to the retroperitoneum and invades upper gastrointestinal tract (GIT). Complications like intestinal obstruction, hemorrhage, and perforation are usually present.

Presentation of case

We report a 30 year-old male, presented to GIT unit with severe anemia due to upper GIT bleeding. Esophagogastroduodenoscopy (OGD) documented duodenal growth. Histopathology findings of biopsy taken from the growth revealed, moderately differentiated adenocarcinoma of duodenum. Abdominal computed tomogram (CT) scan showed retroperitoneal mass which could be primary duodenal tumor or para − aortic lymph node. The patient was referred to surgery unit for pancreatico − duodenectomy with the diagnosis of primary duodenal malignancy. In Surgery unit, a left testicular mass was discovered. Ultrasound revealed suspicious mass in left testis. Review of duodenal biopsy (by another pathologist) was asked for. Duodenal metastatic seminoma was the diagnosis which was confirmed by immunohistochemical Stains (that was not done before). Left testicular biopsy showed testicular seminoma .Patient was treated by high inguinal orchiectomy followed by chemotherapy. One year, later the patient had no GIT symptoms, was not anemic and started to put on weight. Follow up endoscopy showed no evidence of tumor in duodenum. There was no evidence of retroperitoneal growth by follow up CT scan.

Discussion

Testis lymphatic drainage is through para aortic lymph nodes .These are in contact with GIT. When testicular malignancy metastasizes to retroperitoneum it may invade GIT causing confusion whether symptoms are primarily from GIT, or they are primarily extra intestinal.

Conclusion

High index of suspicion for testicular seminoma must be raised when treating young males with GIT complications like hemorrhage. Testicular seminoma is the most common solid tumor at this age. Sometimes it is the cause behind this complication.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.