High-grade appendiceal mucinous neoplasm (HAMN) is an uncommon epithelial neoplasm of the appendix, and it is a median risk lesion that can be placed between benign low-grade appendiceal mucinous neoplasm (LAMN) and malignant adenocarcinoma. The diagnosis can be both incidental during surveillance imaging or clinically similar to acute appendicitis, which presents as pain in the right lower quadrant, or local pressure on adjacent organs. It carries the potential to progress to cancer if left untreated. Our aim is to review the literature and to report this rare tumor with outlining its clinical presentation, histologic features, and management. A 50-year-old man with end-stage renal disease (ESRD) on hemodialysis underwent evaluation for kidney transplantation. A noncontrast CT abdomen revealed an incidental appendiceal mass during routine pretransplant imaging. The patient was asymptomatic with no gastrointestinal complaints. We performed a robotic appendectomy with partial cecectomy. The size of the mass was 10 × 5.5 × 3.5 cm. Pathology confirmed HAMN limited to the appendix, stage pTis (HAMN), with a negative margin and negative lymph nodes involvement pN0. The patient recovered well, and he will be monitored for recurrence while awaiting the renal transplant. HAMN is a recently recognized diagnosis. It can progress to an aggressive nature if left untreated. A standard appendectomy is performed for appendix limited lesions with right hemicolectomy in the presence of invasive characteristics. A comprehensive screening and vigilant clinical evaluation are essential before transplantation.
To describe the presentation and management of a symptomatic Müllerian duct abnormality in a teenager and propose an evidence based clinical decision-making tree on when to treat based on a thorough literature review. A 17-year-old nulligravid woman presented with a 5-year history of menorrhagia, dysmenorrhea and pelvic pain with medical history significant for a congenitally absent left kidney and ureter. Pelvic ultrasound suggested a bicornuate uterus, but a pelvic MRI with/without contrast diagnosed her with a unicornuate uterus with a noncommunicating left rudimentary horn containing hematometra. The patient underwent surgical intervention with vaginoscopy, hysteroscopy, and eventually laparoscopic resection of left rudimentary horn, left salpinectomy, and an appendectomy which confirmed endometriosis. The patency of the right fallopian tube was confirmed with chromotubation and the patient's reproductive potential was maintained. Postoperatively, the patient was symptom free and started on hormonal suppression for endometriosis. Based on this case and a thorough literature review we propose a clinical evidence based clinical decision-making tree on how to approach and treat mullerian abnormalities. Müllerian duct anomalies require individualized management for symptom relief, prevention of complications, and preserving reproductive potential. Our clinical decision-making tree provides a guide for clinicians. Further research is needed to optimize long term outcomes of these rare conditions.
Transient bradycardia and asystole are recognized complications of insufflation during laparoscopic surgery due to acute peritoneal stretch triggering vagal mediated reflexes. This reaction has been attributed primarily to elevated intraabdominal pressure (IAP) with less attention given to the potential role of carbon dioxide (CO2) flow rate, access modality, and port diameter. Here, we report the case of a 34-year-old male undergoing a robotic cholecystectomy due to gallstone hepatitis. After initial abdominal access was obtained using a Veress needle, pneumoperitoneum was established at a target pressure of 15 mmHg through an 8-mm trocar at a flow rate of 40 L/minute. Upon transition to trocar insufflation, the patient developed transient asystole at the time of insufflation lasting approximately 2-3 seconds, followed by sinus bradycardia. Insufflation was immediately discontinued, and glycopyrrolate and ephedrine were administered in response. The patient's heart rate returned to his baseline shortly after deflation with the entire episode lasting less than 1 minute. Pneumoperitoneum was then re-established at a lower flow rate and pressure without recurrence of bradyarrhythmia. Although the target pressure was within standard operative guidelines, the high initial flow rate and large initial trocar size may have distended the peritoneum to a greater extent quicker, thus inducing a larger vagal response. The immediate onset, rapid reversibility with deflation, and absence of recurrence following slower insufflation support a rate-dependent stretch mechanism rather than the effect of absolute IAP alone.
Cameron ulcers are linear erosions or ulcerations in the setting of large hiatal hernias with potential to lead to life-threatening complications. We report a rare complication of a Cameron ulcer in the setting of an incarcerated paraesophageal hernia with gastric volvulus. An 84 year old female presented in shock from gastric perforation. Imaging demonstrated significant pneumoperitoneum, free fluid, and a large incarcerated paraesophageal hiatal hernia with gastric volvulus. The patient underwent diagnostic laparoscopy revealing a perforated Cameron ulcer with subsequent laparoscopic reduction of incarcerated parasesophageal hiatal hernia, repair of Cameron ulcer perforation, and abdominal washout. Postoperative course was complicated by multiple intra-abdominal collections, mediastinitis, venous thromboses, choledocholithiasis, and persistent leak from gastric perforation, ultimately transitioning her care to comfort measures only. This case highlights a rare but severe manifestation of Cameron ulcers and underscores the importance of early recognition of complications associated with large paraesophageal hernias.
Completely isolated intestinal duplication cysts are rare congenital lesions that lack continuity with the gastrointestinal tract and have an independent vascular pedicle. Their presentation beyond infancy and distinction from mesenteric or omental cysts can be challenging, particularly when only noncontrast imaging is available. We report the laparoscopic resection of a giant isolated intestinal duplication cyst in a 10-year-old boy who presented with abdominal distension and pain. Noncontrast computed tomography demonstrated a large cystic lesion occupying the pelvis and lower abdomen, initially interpreted as a mesenteric cyst. Laparoscopic exploration revealed a giant unilocular cyst without macroscopic communication with the bowel, supplied by a single vascular pedicle traversing the diaphragm from the thoracic cavity. The pedicle was clipped and divided, and the cyst wall was completely excised and retrieved in an endoscopic specimen bag without intestinal resection. Histopathologic examination showed a fibrous cyst wall with a well-organized double layer of smooth muscle and complete mucosal ulceration replaced by chronic inflammatory granulation tissue with multinucleated giant cells and cholesterol clefts, consistent with an enteric inclusion (duplication) cyst. The postoperative course was uneventful, and the patient remained asymptomatic at two months of follow-up. This case illustrates that completely isolated intestinal duplication cysts may present in older children and mimic mesenteric cysts, and that laparoscopic resection allows definitive diagnosis while preserving intestinal continuity.
Colovaginal fistula (CVF) is a rare, late complication of laparoscopic sacrocolpopexy that significantly impairs quality of life. We report a case occurring 9 years postoperatively to highlight its presentation and management. A G3P3 woman in her seventies presented with yellow, foul-smelling vaginal discharge 9 years after laparoscopic total hysterectomy with sacrocolpopexy. Colonoscopy revealed a rectovaginal fistula; histology excluded diverticular disease. A multidisciplinary team performed laparoscopic removal of the eroded mesh and sigmoid resection with primary anastomosis. At 1-year follow-up the vagina was completely healed and the patient reported no further abnormal discharge. CVF may arise almost a decade after sacrocolpopexy. A high index of suspicion, prompt multidisciplinary surgery and long-term surveillance are essential for optimal outcomes.
Disseminated peritoneal leiomyomatosis (DPL) is a rare condition characterized by multiple peritoneal and subperitoneal nodules composed of smooth muscle cells. Although it has been associated with iatrogenic dissemination following uncontained power morcellation, it may also arise spontaneously. A 46-year-old G1P1 woman with no history of prior myomectomy or morcellation presented with lower abdominal pain and urinary symptoms. Pelvic magnetic resonance imaging (MRI) revealed a lobulated leiomyomatous uterus. She elected to undergo total laparoscopic hysterectomy. Intraoperatively, multiple nodules were unexpectedly identified on the omentum, pelvic peritoneum, and intestinal serosa. Total laparoscopic hysterectomy with bilateral salpingectomy, complete omentectomy, and pelvic peritonectomy was performed. Given the absence of a preoperative diagnosis and prior discussion of risks, a deliberate decision was made to leave the intestinal serosal nodules in situ. The uterus was extracted via contained (in-bag) power morcellation. Histopathological analysis confirmed leiomyoma without atypia. The patient had an uneventful recovery and was discharged within 24 hours. Following incomplete resection, a management plan with periodic imaging surveillance was adopted. One-year follow-up MRI demonstrated stable residual nodules with no features suggestive of malignancy. This report highlights that DPL can occur in patients without a history of morcellation and that preoperative diagnosis remains challenging. Laparoscopy appears to be an effective approach for both diagnostic confirmation and staged management. Decisions regarding extensive resection should consider surgical risk, the high recurrence rate, and the relatively low risk of malignant transformation. Contained power morcellation remains an important preventive strategy.
Olanzapine as a cause of necrotizing pancreatitis is very rare. Unheard of in the literature is the development of a pancreatico-pleural fistula following olanzapine induced necrotizing pancreatitis requiring minimally invasive pancreatectomy to resolve the disease. This report seeks to publish the history, findings and strategies used to resolve this extremely unique case. A 53-year-old male presented with over a year of chronic abdominal pain. He was diagnosed with pancreatitis. His presentation worsened, leading to necrosis, peripancreatic fluid collections and ultimately a pancreatico-pleural fistula. Despite a low-fat diet, confirmation of alcohol abstinence, absence of gallstones, pancreatic duct stenting, peritoneal and pleural drainage, the fistula persisted and his weight loss worsened. Hepatobiliary surgery was consulted, performed a successful minimally invasive pancreatectomy. His drains were removed sequentially and at final follow up was free of symptoms, regaining weight. Olanzapine as a cause of acute necrotizing pancreatitis is rare. For it to result in necrosis, peripancreatic fluid collections and a pancreatico-pleural fistula is even rarer. This case failed to resolve with nonsurgical management. Robotic technology combined with appropriate endoscopic, interventional radiologic and nutritional therapy resolved this case, highlighting strategies that will be useful to physicians and their patients, as well as being of great interest.
Fluorescence-guided surgery (FGS) utilizing near-infrared (NIR) technology is a powerful technique for enhancing intraoperative visualization and safety. The Endolumik Gastric Calibration Tube (EGCT) is a novel device integrating NIR LEDs and fluorescence-guided measurement markings to support key steps in bariatric procedures. We demonstrate the utilization of the EGCT in a laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure for a 55-year-old female patient with a BMI of 45 kg/m2 and obesity-related comorbidities. The 40 French EGCT was employed with NIR visualization to facilitate gastric decompression, pouch sizing, gastrojejunostomy calibration, and leak testing. The integrated 2 cm-spaced LED lights and black stripes enabled real-time gastric pouch measurement and provided precise anatomic calibration. The surgery was performed in 187 minutes without complications. At the 30-day follow-up, there was no morbidity and patient BMI was 41 kg/m2. This case highlights the feasibility of fluorescence-guided calibration during gastric bypass and its potential to support intraoperative workflows. The EGCT served as a multifunctional device for gastric suction, gastric calibration, and leak testing; it enhanced the visibility of gastric architecture and helped standardized gastric pouch construction. Further investigation is required to evaluate the device's impact on safety and other clinical outcomes.
Robotic liver resection is a valuable alternative to both open and laparoscopic techniques. We report a case of hepatocellular carcinoma (HCC) located in the caudate lobe, and the tumor was successfully resected with a robotic approach. When performed by experienced surgeons, robotic resection can be a technically sound and an oncological appropriate option for selected patients with complex hepatic tumors. A 70-year-old man with a history of chronic hepatitis C infection, compensated cirrhosis, cholelithiasis, type 2 diabetes mellitus, and hypertension was referred to our transplant and hepatobiliary center following an incidental liver lesion finding during routine surveillance imaging. He was asymptomatic and his family history was notable for HCC. Physical examination and laboratory investigations were unremarkable. Abdominal ultrasound demonstrated a 4.6 cm hypoechoic mass in the caudate lobe, and cholelithiasis. Magnetic resonance imaging demonstrated a 4.2 × 4.0 cm lesion in segment one with arterial enhancement and washout. Triphasic contrast-enhanced computed tomography (CT) showed a 5 × 4.2 × 4 cm hypervascular mass, and esophagogastroduodenoscopy showed mild gastritis. A CT-guided needle biopsy from uninvolved right hepatic lobe revealed chronic hepatitis C and fibrosis. Metastatic workup was unremarkable. Robotic-assisted caudate lobectomy with cholecystectomy was performed with the da Vinci-5 robotic platform. The pathological report of the resected mass confirmed HCC with negative margins. This case highlights the safety of robotic resection for HCC in the caudate lobe. With proper patient selection and more clinical experience, it is becoming a widely accepted option.
We present a rare morphological variant of a colonic polyp observed during a routine screening colonoscopy. A 62-year-old male with known chronic obstructive pulmonary disease (COPD) and benign prostatic hyperplasia (BPH) was found to have a bridge-shaped polyp in the sigmoid colon. The polyp was successfully resected via snare polypectomy following submucosal adrenaline injection. Histopathological analysis revealed the lesion to be a hyperplastic polyp. To our knowledge, bridge- or horseshoe-shaped hyperplastic polyps have not been previously reported in the literature.
The urachus is a vestigial remnant of the allantois which naturally degenerates after birth. Failure of closure of the urachus can result in urachal malformations, with the most common being a urachal cyst. Diagnosing a urachal cyst is challenging due to its diverse presentations, often leading to misdiagnosis. Although they are often asymptomatic, urachal cysts can be significant because they can lead to complications. We report a late preterm male infant born at 36 weeks + 5 days, in whom an antenatal anomaly scan revealed a unilocular intra-abdominal cyst adjacent to the bladder. Postnatal ultrasound kidney, ureter, and bladder (KUB) at 3 days of age demonstrated a cystic structure anterior and superior to the bladder, accompanied by mild bilateral hydronephrosis. A voiding cystourethrogram (VCUG) at 2 weeks revealed a cystic mass connected to the bladder by a fistulous tract, raising differential diagnoses of urachal cyst, bladder diverticulum, or incomplete bladder duplication. At 2 months, diagnostic cystoscopy and laparoscopy were performed. Cystoscopy showed a small opening at the bladder dome, while laparoscopy identified a 5 × 5-cm cyst extending from the bladder dome to the umbilicus. The cyst was excised laparoscopically, and bladder repair was completed. Histopathology revealed benign urothelium with mild chronic inflammation and a muscular wall, suggestive of a urachal diverticulum. Postoperative recovery was uneventful, and follow-up imaging demonstrated normal bladder morphology and renal function. Our case supports the efficacy of diagnostic and therapeutic laparoscopy in accurately diagnosing urachal anomalies, aiding in treatment decisions, and preventing future complications.
Small bowel obstruction is a common surgical problem. Volvulus as a cause of obstruction is rare, and duodenal volvulus has only been described in case reports. A 60-year-old male presented with abdominal pain and emesis in the setting of significant weight loss. He was identified to have a spontaneous duodenal volvulus with massive gastric outlet obstruction, due to superior mesenteric artery (SMA) syndrome. He underwent laparoscopy with successful reduction of the volvulus and creation of a duodenojejunostomy. Here we review all published cases of duodenal volvulus and present the first case of duodenal volvulus in the setting of SMA syndrome, treated with a minimally invasive approach.
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.
Intussusception occurs when one segment of bowel invaginates into an adjacent segment of bowel from a lead point. Literature suggests a nonpathological lead point attributed to adult intussusception: marijuana. This report describes a unique presentation of intussusception in a patient with a history of previous surgical intervention and marijuana use. We report a 33-year-old male with a history of surgically treated intussusception and 12 years of marijuana use, who presented to the emergency department (ED) twice with nausea, vomiting, and abdominal pain. After imaging revealed intussusception, the patient underwent multiport-robot-assisted small bowel resection. The patient had no complications and was discharged after 6 days. Intussusception can be deadly if not caught early. The use of marijuana can mislead clinicians due to similar appearing presentations. This case highlights the importance of a comprehensive patient history for abdominal pain. Additionally, it suggests placing intussusception higher in the differential for marijuana users.
Diaphragmatic rupture is a rare but potentially life-threatening injury that can result from blunt or penetrating trauma. Timely diagnosis is critical to prevent serious complications, yet clinical and radiological assessments are often inconclusive. We report the case of a 39-year-old male patient who sustained blunt thoracoabdominal trauma in a motor vehicle accident. The patient presented with respiratory distress and generalized abdominal tenderness. Imaging revealed a left diaphragmatic defect with herniation of abdominal organs into the thoracic cavity. The patient underwent diagnostic laparoscopy, which confirmed an 8 × 5 cm defect in the left diaphragmatic dome with herniation of the stomach and omentum. The herniated organs were reduced, and the defect was repaired tension-free using intracorporeal 0-silk sutures. A 28-Fr intercostal drainage tube and a 12-Fr abdominal drain were placed. The postoperative course was uneventful. A chest x-ray on postoperative day one confirmed normal diaphragm position and re-expansion of the lung. The patient recovered without complications. Laparoscopy provides a minimally invasive and effective diagnostic and therapeutic option for diaphragmatic rupture following blunt trauma. In appropriately selected cases, it offers favorable outcomes with reduced morbidity.
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). CHI was treated with robotic-assisted laparoscopy (RAL). 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. 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.
The incidence of obesity nationwide has led to an increase in both medicinal and surgical interventions, with recent studies indicating a drop in obesity prevalence for the first time in over a decade. Laparoscopic Roux-en-Y gastric bypass remains one of the most commonly performed bariatric procedures in the United States, accounting for about 22% of all bariatric surgeries in 2022. While considered a safe procedure, gastric bypass results in an anatomic configuration that poses a unique challenge from both a surveillance and interventional standpoint. The gastric remnant, biliopancreatic (BP) limb, and extrahepatic biliary tree are not readily accessible vis-à-vis esophagogastroduodenoscopy and thus require a novel approach for evaluation. Symptomatic small bowel diverticula are by themselves a rare entity. When present in the gastric bypass patient, this combination makes for a uniquely challenging case for both diagnosis and management. Surgical exploration with or without intraoperative endoscopy may be the only modality for both localization and management of symptomatic small bowel diverticula in this patient population.
Splenic cysts are rare lesions that are classified as either true (primary) or false (secondary) cysts based on their epithelial lining. The pathogenesis of primary splenic cysts is not well understood, and several hypotheses have been proposed, including the Mesothelial invagination theory, which postulates that during development, the mesothelial lining invades along with the capsule. As the lining has a pluripotent nature, it has the propensity to undergo metaplasia and secretion of fluid, leading to the formation of cysts. A 12-year-old female patient presented with a visible upper abdominal, painless cystic lesion, underwent blood tests and radiological diagnostic tools, such as abdominal ultrasound and computed tomography (CT) scan, but no definite diagnosis could be reached. Ultrasound-guided aspiration of the cyst was done, followed by explorative laparoscopy with total excision of the cyst (which was found to originate from the spleen), accompanied by partial splenectomy. The cyst was diagnosed as a benign primary mesothelial cyst of the spleen by histopathology. The patient experienced an uneventful postoperative period and showed no recurrence during follow-up. A significant challenge for surgeons in terms of diagnosis, surgical planning, and managing intraoperative surprises is the difficulty in detecting the origin and nature of a large abdominal cyst, despite the availability of highly sophisticated diagnostic tools. Minimally invasive partial splenectomy in the pediatric age group is a feasible surgical intervention.
Pneumoperitoneum in infancy raises concern for visceral perforation and resultant urgent surgical exploration. However, benign pneumoperitoneum-defined as free intraperitoneal air without gastrointestinal perforation-can occur rarely, especially in infants with chronic ventilatory dependence. We present an unusual case of an 8-month-old infant with severe bronchopulmonary dysplasia (BPD), tracheostomy, and gastrostomy-tube dependence, with radiographic evidence of pneumatosis intestinalis and free intraperitoneal air. Diagnostic laparoscopy was performed which identified air within the mesentery of the small and large intestine, without evidence of true pneumatosis, perforation, inflammation, or ischemia. The patient recovered from their surgery uneventfully without any complications. This case highlights the importance of recognizing benign pneumoperitoneum, particularly in medically complex ventilator-dependent pediatric patients, and emphasizes the role of diagnostic laparoscopy as a valuable tool to confirm bowel integrity, preventing unnecessary laparotomy.