CRSLS : MIS case reports from SLS最新文献

Background: Uterine sarcoma is a rare mesenchymal malignancy, and its preoperative diagnosis presents significant challenges, often resulting in the so-called occult sarcoma following surgery, based on the pathological diagnosis. Embryonal rhabdomyosarcoma of the female genital tract most commonly presents in pediatric patients and occurs in the uterine cervix. A pure uterine embryonal rhabdomyosarcoma presenting in an older adult patient is exceedingly rare. Due to its overall poor prognosis, early recognition of this unusual entity is crucial for patient care.

Case: A 57-year-old woman presented with a single uterine mass and intermittent bleeding over the past 4-5 years. Office endometrial biopsies, conducted twice by other providers, reported either normal endometrium or inconclusive results; therefore, she was diagnosed and managed as having uterine fibroids for the past 3 years. Given the high suspicion of uterine malignancy, we counseled the patient with a plan for an abdominal hysterectomy and bilateral salpingo-oophorectomy. Meanwhile, we performed another endometrial biopsy under sedation to obtain an adequate and accurate specimen. This biopsy revealed high-grade malignancy, leading to the diagnosis of uterine embryonal rhabdomyosarcoma following the hysterectomy. She is currently undergoing chemotherapy with docetaxel and gemcitabine.

Conclusion: Since there is no reliable laboratory or imaging study for preoperative diagnosis of uterine sarcoma, a high index of clinical suspicion is of the utmost importance to decrease the occurrence of occult uterine sarcoma, which is extremely difficult to differentiate from benign uterine fibroids.

Background: Congenital hyperinsulinism (CHI) is a heterogeneous genetic disease characterized by increased insulin secretion, in which dysregulation of insulin secretion by pancreatic β cells causes persistent hypoglycemia in neonates and infants. Babies diagnosed with CHI require preferentially minimal invasive surgical treatment with near-total pancreatectomy (NTP).

Material and methods: CHI was treated with robotic-assisted laparoscopy (RAL).

Results: The authors present an unreported case of CHI in an infant less than 10 kg, which was submitted to NTP treated by RAL. The procedure was performed with 3 arms of Da Vinci robot using adaptable size of trocars and the surgery was well succeeded.

Conclusions: The RAL is a challenge in pediatric pancreatic surgery to CHI due to the size of the trocars. To our knowledge, this is the first case reported in the English literature of an infant weighing less than 10 kg having been submitted to NTP by RAL.

Introduction: Leiomyoma with bizarre nuclei (LBN) is a leiomyoma variant that can be associated with fumarate hydratase (FH) deficiency. Germline pathogenic variants in the FH gene are linked to hereditary leiomyomatosis and renal cell carcinoma (HLRCC), which presents with cutaneous leiomyomata, aggressive renal cell carcinomas (RCCs), and symptomatic uterine leiomyomas.

Case description: A 22-year-old nulligravida female presented with multiple uterine fibroids, heavy menstrual bleeding and pelvic pain, lasting over two years. The patient subsequently underwent laparoscopic myomectomy. Histological analysis of the leiomyomas indicated the presence of bizarre nuclei. Immunohistochemical studies confirmed FH deficiency, characterized by loss of FH expression and overexpression of S-(2-succino)-cysteine (2SC). Genetic testing revealed a likely pathogenic variant (c. 1176_1181delTGCTGT) in the FH gene.

Discussion: Due to potentially devastating consequence and the occult nature of RCCs, the discovery of LBN should be followed with further investigation for HLRCC.

Cholecystectomy, the surgical removal of the gallbladder, is a common abdominal operation often performed laparoscopically due to its minimally invasive nature. Despite its safety and efficacy, rare complications such as gallstone retention outside the biliary system can occur. One unusual complication is the migration of gallstones into the thoracic cavity, potentially causing severe outcomes like pleural effusion, empyema, or bronchopleural fistula, which present diagnostic challenges due to their rarity and varied symptoms. Advanced imaging techniques are essential for diagnosis, while treatment ranges from conservative management for asymptomatic cases to surgical intervention for significant complications. This report details the case of an 80-year-old male who presented with epistaxis and hemoptysis, later found to have a retained thoracic gallstone postcholecystectomy. Despite initial normal imaging and clinical improvement, further investigation revealed a gallstone eroding through the diaphragm into the thoracic cavity. The patient underwent successful thoracoscopic removal of the stone but experienced a prolonged hospital stay due to complications, including atrial fibrillation exacerbation, hemothorax, and lower extremity ischemia. The report underscores the diagnostic complexities of intrathoracic gallstone migration and the severe complications that can arise. A high index of suspicion is necessary for patients with persistent respiratory symptoms following cholecystectomy, and timely imaging and surgical intervention are crucial to minimize morbidity.

Introduction: Internal herniation under the external iliac vasculature is a rare cause of small bowel obstruction, however an increasing number of cases have been reported in recent years.

Presentation of the case: We report a case of 74-year-old male patient who presented with diffuse abdominal pain. He had undergone robot-assisted laparoscopic prostatectomy 4 months earlier. Computed tomography showed signs of internal herniation under the right external iliac vessels. The patient was operated laparoscopically with small bowel resection and peritoneal flap.

Conclusion: Internal herniation under external iliac vessels is a rare and challenging condition. Operation can be performed well with both laparotomy and laparoscopy. We suggest closing peritoneal defects during index operation and strongly recommend defect closure after an episode of internal herniation.

Bariatric surgery is the most effective treatment option for patients with refractory morbid obesity to help facilitate weight-loss and reduce long-term metabolic morbidity and mortality. Over 200,000 procedures are performed annually in the United States with sleeve gastrectomy being the most common surgical approach. However, the growing popularity of surgical bariatric interventions has led to an increase in incidental findings of gastrointestinal neoplasms in intraoperative specimens. We report our experience performing a robotic sleeve gastrectomy in a 58-year-old woman who was later found to have a gastrointestinal stromal tumor (GIST) with positive immunohistochemical marking.

Introduction: Internal abdominopelvic hernias, whether congenital or acquired, are a rare cause of acute small bowel obstruction. Symptoms range from recurrent abdominal pain to acute obstruction, which can lead to severe complications like bowel ischemia, perforation, or death if untreated. Diagnosis is often difficult due to variable symptoms, but prompt surgical intervention is crucial to prevent life-threatening outcomes.

Case description: We treated a 42-year-old female airline cabin crew member who presented with colicky abdominal pain, bilious vomiting, and lower abdominal tenderness. Her abdominal computed tomography (CT) scan showed small bowel obstruction with loops of small bowel predominantly in the left lower abdomen. She had a history of a single episode of similar abdominal pain many years prior, which resolved spontaneously. The rest of her history was unremarkable. She received nonoperative management initially, but due to persistent abdominal pain and vomiting, a diagnostic laparoscopy was done. The diagnostic laparoscopy showed congested but viable small bowel herniating into a peritoneal defect through the lateral part of left broad ligament at the lateral pelvic wall into the retroperitoneum. The hernia was reduced, and the defect was repaired. Postoperatively, she had an uncomplicated recovery.

Discussion: Internal hernia is an important differential diagnosis in patients presenting with an acute abdomen, especially with a history of recurrent small bowel obstructions, regardless of surgical history. Physicians need to have a high index of suspicion to diagnose and treat this condition without delay, preventing morbidity and mortality in this patient group.

Introduction: Benign prostatic hyperplasia (BPH) affects a significant proportion of aging males, often requiring surgical intervention when conservative treatments fail.

Case description: This case report details the management of a 58-year-old male with severe lower urinary tract symptoms and a markedly enlarged prostate, presenting with bladder stones and persistent obstruction despite medication. The patient underwent an open simple prostatectomy but developed bladder neck contracture and recurrent urinary retention, necessitating a suprapubic cystostomy. Following this, a robotic-assisted approach was chosen to address the complex contracture. The surgical strategy involved a vertical posterior bladder incision, after guide wire was visualized a bladder stone was removed, resection of inflammatory tissue, and a novel 360-degree running suture with 3-0 thread for bladder neck reconstruction. This approach was followed by closure with a double-layer running suture using 3-0 V-Lock material. The patient showed significant improvement in urinary flow and symptom resolution postoperatively, with no residual contracture detected on follow-up imaging.

Discussion: This report highlights the effectiveness of the robotic-assisted technique and the innovative use of the 360-degree running suture for managing challenging bladder neck contractures, marking a novel application in surgical practice.

Background: Obesity is an alarmingly increasing global public health issue. Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery owing to its simplicity, effectiveness, and low complication rates. The complications can be classified as early or late, with fistula formation being one of the most severe complications. Here, we report a rare gastrobronchial fistula (GBF) that presented 12 years post LSG.

Case presentation: A 34-year-old woman who underwent LSG in 2011 was referred to our institution. The patient complained of recurrent upper respiratory tract infections, nausea, and vomiting. Abdominal computed tomography (CT) with oral contrast showed abnormal fistulous communication between the fundus and left lung. Conservative management was initiated but failed multiple times. After counseling the patient on the surgical options, she underwent fistula removal and primary repair of the fundus with a healthy omental wrap and an omental diaphragmatic flap. She tolerated the procedure well, recovered uneventfully, and was discharged on postoperative day 7.

Conclusion: GBF diagnosis is challenging. Imaging studies, such as CT and radiography with contrast and endoluminal diagnosis with esophagogastroduodenoscopy (EGD), bronchoscopy, and bronchial secretion analysis, aid in the diagnosis. GBF management requires a multidisciplinary team. Patients should be initially offered conservative management with the understanding that reoperation would be the only option if failure is seen for 3 months.

Introduction: Acute appendicitis and acute cholecystitis are two of the most commonly encountered surgical entities. Multiple hypotheses are behind their coexistence, which include pathogen predilection, and mucosal ischemia inducing portal vein bacteremia as the management of uncomplicated acute cholecystitis and acute appendicitis is surgical, for which a single operation for synchronous presentation is effective. Here, we report a case with coexistent acute cholecystitis and acute appendicitis managed at our institution.

Case/technique description: A 30-year-old female presented with right upper quadrant abdominal pain for four days. The pain was radiating to the right shoulder, not related to fatty foods, associated with vomiting, anorexia, and burning micturition. On examination, she was vitally stable and afebrile with soft nondistended abdomen, a negative Murphy's sign, right lower quadrant rebound tenderness, and suprapubic tenderness. Laboratory tests showed leukocytosis (17.59 × 10⁹) and high ALT (40 IU/L) and AST (32.5 IU/L). Ultrasound showed a distended gallbladder with two echogenic intraluminal nonshadowing echogenicity, the largest measuring 0.57 cm. Due to the vague presentation we elected to go for computed tomography of the abdomen which showed a distended gallbladder with adjacent fat stranding, subhepatic appendix with distended tip and no surrounding fat stranding. She underwent diagnostic laparoscopy with cholecystectomy and appendectomy. The patient had an uneventful postoperative course and was discharge home on day 1.

Conclusion: We aim to shed light on the rare, but possible, synchronous coexistence of these diseases, raise the index of clinical suspicion. Management options for synchronous presentation can follow their asynchronous guidelines such as Tokyo and WSES.