Abdelali Guellil

Introduction and importance: An obturator hernia is a rare condition accounting for less than 1% of abdominal wall hernias. Due to its deep pelvic location and nonspecific clinical presentation, it is frequently misdiagnosed, most often as an inguinal hernia. Delayed or incorrect diagnosis may result in bowel ischemia and perforation. Case presentation: We report the case of a 61-year-old man who underwent emergency open surgery at another institution for a presumed strangulated right inguinal hernia with placement of prosthetic mesh. No operative report was available regarding intraoperative findings, bowel assessment, or mesh positioning. Eight days later, the patient presented with progressive abdominal distention, respiratory distress, and extensive subcutaneous emphysema involving the cervical and thoracic regions. A CT scan demonstrated pneumoperitoneum, bilateral pneumothorax, pneumomediastinum, and an incarcerated obturator hernia with small-bowel ischemia and a suspected perforation. Emergency laparotomy revealed a perforated ileal loop associated with extensive fecal contamination tracking through fascial planes in proximity to the previously placed mesh. Segmental bowel resection with double stoma, obturator defect closure, and drainage were performed. The postoperative course was favorable. Clinical discussion: This case illustrates several rare and clinically relevant issues: (1) an obturator hernia mimicking an inguinal hernia; (2) a complex postoperative course with bowel perforation in the context of recent mesh repair; and (3) extensive subcutaneous fecal emphysema with thoracic extension. However, in the absence of operative documentation from the initial surgery, it remains impossible to determine with certainty whether the obturator hernia was initially unrecognized, whether ischemia evolved secondarily, or whether the perforation occurred independently in the postoperative period. This uncertainty highlights the importance of caution in attributing postoperative complications to a single causal mechanism when complete clinical data are unavailable. Conclusion: Obturator hernia remains a diagnostic challenge in emergency surgery. In cases of persistent postoperative obstruction after groin hernia repair, alternative diagnoses should be considered. This case also underlines the importance of complete operative documentation and close postoperative follow-up. Subcutaneous fecal emphysema represents an exceptionally rare but severe manifestation of gastrointestinal perforation.

Introduction and importance: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the digestive tract. While they usually arise in the stomach or small intestine, primary involvement of the hepatic round ligament is exceedingly rare. The synchronous coexistence of such an unusual GIST with colorectal adenocarcinoma (CRC) represents a major diagnostic and therapeutic challenge. Case presentation: We report the case of a 66-year-old man admitted with acute intestinal obstruction associated with epigastric pain and abdominal distension. Contrast-enhanced computed tomography revealed two intra-abdominal masses associated with multiple hepatic nodules. Exploratory laparotomy identified a tumor arising from the hepatic round ligament, a necrotic mesenteric mass causing bowel obstruction, and multiple suspicious liver nodules. Surgical management included en bloc resection of the round ligament tumor, biopsies of the mesenteric and hepatic lesions, and a proximal ileostomy. Histopathological examination demonstrated a high-grade spindle-cell GIST of the round ligament, positive for CD117, DOG1, and CD34, with a high Ki-67 proliferation index, confirming its independent mesenchymal lineage. Concurrently, the mesenteric and hepatic lesions corresponded to metastatic, moderately differentiated colorectal adenocarcinoma expressing CK20 and CDX2. Postoperative colonoscopy confirmed a primary sigmoid colonic tumor, establishing an indisputable diagnosis of two completely independent synchronous primary malignancies. Clinical discussion: This case highlights the diagnostic complexity of synchronous abdominal malignancies. Imaging findings alone were insufficient to distinguish metastatic dissemination from two separate primary tumors. Rigorous histopathological and immunohistochemical characterization of each suspicious lesion was therefore crucial because therapeutic strategies differ substantially between GIST and metastatic colorectal adenocarcinoma. The rarity of round ligament GISTs further contributes to the originality of this observation. Conclusion: Primary GIST of the hepatic round ligament is exceptionally rare. Its synchronous association with metastatic colorectal adenocarcinoma has not been previously reported. This case emphasizes the importance of systematic histological evaluation of atypical lesions and multidisciplinary management to optimize therapeutic decision-making.

Introduction: Kasabach–Merritt phenomenon (KMP) is a life-threatening consumptive coagulopathy that occurs in association with vascular lesions. Although classically described in children with kaposiform hemangioendothelioma, its occurrence in adults with giant hepatic hemangiomas is exceedingly rare and carries a high mortality rate. Case presentation: A 42-year-old female presented with acute right upper quadrant pain. Triple-phase CT revealed an 11 cm giant hepatic hemangioma involving segments VII and VIII with classical peripheral nodular enhancement. Laboratory investigations showed critical thrombocytopenia (platelets: 6000/mm ³ ), anemia (Hb: 7 g/dL), prolonged coagulation (INR: 1.9), hypofibrinogenemia (fibrinogen: 0.9 g/L), and markedly elevated D-dimer (>8000 ng/mL), confirming consumptive coagulopathy. Despite aggressive transfusion, thrombocytopenia remained refractory. The patient developed a fatal spontaneous cerebral hemorrhage prior to any surgical intervention. Clinical discussion: Giant hepatic hemangiomas may act as sequestration reservoirs, producing a systemic consumptive coagulopathy analogous to KMP. The failure of transfusion in this case illustrates the “consumptive sink” effect. Early surgical or endovascular intervention represents the only definitive approach and should not be deferred in favor of hematological stabilization alone. Conclusion: Adult KMP in the setting of a giant hepatic hemangioma is a surgical emergency. The consumptive sink effect renders preoperative stabilization alone insufficient, underscoring a critically narrow window for intervention.

Introduction and importance: Primary tumors of the seminal vesicles are extremely rare, and among these, cystadenomas are benign tumors that can grow to considerable size, mimicking malignant pelvic masses. The rarity and non-specific presentation of these tumors make preoperative diagnosis particularly challenging, often leading to delays and complex surgical scenarios. We present a case of a giant seminal vesicle cystadenoma to highlight its unusual presentation, diagnostic complexity, and management. Case presentation: An 80-year-old man, classified as ASA II (body mass index 20 kg/m ² ), presented with a 3-month history of a large abdominopelvic mass associated with abdominal pain, urinary disturbances, and significant weight loss. Social and surgical histories were unremarkable. Physical examination and abdominopelvic CT scan revealed a massive multiloculated cystic mass measuring 297 × 180 mm in the retrovesical space, displacing adjacent organs. Despite an elevated prostate specific antigen (PSA) (90.36 ng/mL), malignancy was not confirmed, and prostate biopsies were performed and demonstrated benign prostatic hyperplasia without evidence of carcinoma. The patient underwent exploratory laparotomy (favored over minimally invasive surgery due to tumor size) and en bloc resection of the mass with the sigmoid colon and upper rectum due to dense adhesions. Histopathological examination confirmed a seminal vesicle cystadenoma with negative surgical margins (R0 resection), positive for estrogen and progesterone receptors. At 12-month follow-up, PSA had normalized, and the patient remained recurrence free. Clinical discussion: Seminal vesicle cystadenomas are rare, and their non-specific symptoms and presentation as a giant mass necessitate a high index of suspicion. Imaging, particularly pelvic magnetic resonance imaging, is crucial for characterization, but definitive diagnosis rests on histopathology. Complete surgical resection is the mainstay of treatment, often requiring a laparotomy for large, adherent tumors, as in our case. Despite the size and complex resection, the prognosis is favorable after complete excision, but regular follow-up is recommended. Conclusion: This case underscores the rarity and diagnostic difficulty associated with giant seminal vesicle cystadenomas, emphasizing the need to include them in the differential diagnosis of pelvic masses in men. A multidisciplinary approach and appropriate, complete surgical excision are critical for effective management and a good patient outcome.