Case Of Intestinal Obstruction Research Articles

Determining the optimal distal resection margin in rectal cancer patients by imaging of large pathological sections: An experimental study.

To determine the distal resection margin in sphincter-sparing surgery in patients with low rectal cancer based on imaging of large pathological sections. Patients who underwent sphincter-sparing surgery for ultralow rectal cancer at Guangxi Medical University Cancer Hospital within the period from January 2016 to March 2022 were tracked and observed. The clinical and pathological data of the patients were collected and analyzed. The EVOS fluorescence automatic cell imaging system was used for imaging large pathological sections. Follow-up patient data were acquired mainly by sending the patients letters and contacting them via phone calls, and during outpatient visits. A total of 46 patients (25 males, 21 females) aged 27 to 86 years participated in the present study. Regarding clinical staging, there were 9, 10, 16, and 10 cases with stages I, II, III, and IV low rectal cancer, respectively. The surgical time was 273.82 ± 111.51 minutes, the blood loss was 123.78 ± 150.91 mL, the postoperative exhaust time was 3.67 ± 1.85 days, and the postoperative discharge time was 10.36 ± 5.41 days. There were 8 patients with complications, including 3 cases of pulmonary infection, 2 cases of intestinal obstruction, one case of pleural effusion, and one case of stoma necrosis. The longest and shortest distal resection margins (distances between the cutting edges and the tumor edges) were 3 cm and 1 cm, respectively. The minimum length of the extension areas of the tumor lesions in the 46 images of large pathological sections was 0.1 mm, and the maximum length was 15 mm. Among the tumor lesions, 91.30% (42/46) had an extension area length of ≤5 mm, and 97.83% (45/46) had an extension area length of ≤10 mm. The length of the extension zone was not related to clinical pathological parameters (P > .05). In the vast majority of cases, the distal resection margin was at least 1 cm; thus, "No Evidence of Disease" could have been achieved. Additional high-powered randomized trials are needed to confirm the results of the present study.

A case of acute intestinal obstruction caused by Burkitt’s lymphoma

Acute intestinal obstruction is a multifactorial disease. Its causes may be intra-abdominal adhesions, volvulus, bezoar, gallstones, foreign bodies, intestinal tumors, etc. In rare cases, acute intestinal obstruction may be associated with intussusception, which is relatively rare in adults. The purpose of this work is to demonstrate a clinical case of acute small bowel obstruction caused by Burkitt lymphoma. During treatment for a herpetic infection, the patient underwent surgical treatment — ileostomy because of acute intestinal obstruction. In the postoperative period, the patient was hospitalized due to intestinal bleeding; during diagnostic colonoscopy, intussusception of the ileum into the ascending colon was detected; diagnostic laparoscopy, laparotomy, right-sided hemicolectomy with resection of the greater omentum, restoration of intestinal continuity with elimination of the stoma,and formation of an anastomosis were performed. The material obtained intraoperatively was sent for pathomorphological examination, including the method of fluorescent hybridization, which revealed a rearrangement of the 8th chromosome in the region of localization of the MYC gene in tumor cells, and a diagnosis of Burkitt lymphoma was established. The oncological council determined the chemotherapy treatment protocol. According to the literature, Burkitt lymphoma can debut in the cutaneous form, and it is necessary to carry out a differential diagnosis, including chickenpox. There is currently no information about intestinal complications occurring in the cutaneous form of Burkitt lymphoma. It is possible that in the described case, the initially established diagnosis of herpetic infection was incorrect, and Burkitt lymphoma occurred in the cutaneous form.

A STUDY ON INTESTINAL OBSTRUCTION REGARDING ITS EPIDEMIOLOGY, ETIOLOGY AND MANAGEMENT IN A PERIPHERAL MEDICAL COLLEGE

Objectives: The intestinal obstruction is a widespread emergency problem in our surgical practice day by day. It is a significant cause of morbidity and mortality in our health system. It is caused by adhesions, hernias, malignancies, endometriosis, inflammatory bowel disease stenosis, intussusception, and others. Our research aims to identify the etiology, epidemiology, and clinical presentations of the pathology so that we can manage the disease as early as possible for better outcomes in our peripheral institution. Methods: The study was performed on 100 cases of the age group 12–76 years admitted in the surgical ward of Midnapore Medical College and Hospital, Paschim Medinipur (W.B.) from December 2016 to June 2018. Cases of acute intestinal obstruction who underwent operation were included in our research to establish the pathology of intestinal obstruction. Results: In our study, the incidence of acute intestinal obstruction is 1.6% of total surgical cases. Maximum patients (25%) were in the age group 51– 60 years. The most common cause of intestinal obstruction was obstructed/strangulated hernia (40%). The most common symptoms were pain abdomen (88%), abdominal distension (84%), and vomiting (78%). An X-ray revealed presence of air-fluid levels in 75% of patients. The overall mortality rate was 10%. Conclusion: The morbidity and mortality of intestinal obstruction are dependent on early diagnosis, prompt resuscitation, and proper management. The critical determinants of the morbidity are age of the patient, duration of the disease, existing comorbidity, and delay in treatment. X-ray in erect view is an essential mode of diagnostic method and obstructed hernia is the most common etiology of obstruction in our research study.

Small bowel obstruction caused by transmesosigmoid internal hernia

Internal hernia is an uncommon occurrence contributing to intestinal obstruction, posing diagnostic challenges. Among the infrequent manifestations, one noteworthy type is associated with the sigmoid colon, categorized into three subtypes: inter-sigmoid, trans-mesosigmoid, and intra-mesosigmoid. We present a case of a 48-year-old female who presented with small bowel obstruction as an emergency. CT showed intestinal obstruction with translational point at mid jejunum without any mass identified. At laparotomy we identified an internal hernia in the sigmoid mesocolon with full thickness mesentery defect (transmesosigmoid), bowel was viable and reduced where the defected was closed. Early identification of internal hernia and early management prevent mortality and morbidity; sigmoid related hernia is rear type of internal hernia. Most internal hernia diagnosed during laparotomy searching for case of acute intestinal obstruction.

An ingestible self-propelling device for intestinal reanimation.

Postoperative ileus (POI) is the leading cause of prolonged hospital stay after abdominal surgery and is characterized by a functional paralysis of the digestive tract, leading to symptoms such as constipation, vomiting, and functional obstruction. Current treatments are mainly supportive and inefficacious and yield acute side effects. Although electrical stimulation studies have demonstrated encouraging pacing and entraining of the intestinal slow waves, no devices exist today to enable targeted intestinal reanimation. Here, we developed an ingestible self-propelling device for intestinal reanimation (INSPIRE) capable of restoring peristalsis through luminal electrical stimulation. Optimizing mechanical, material, and electrical design parameters, we validated optimal deployment, intestinal electrical luminal contact, self-propelling capability, safety, and degradation of the device in ex vivo and in vivo swine models. We compared the INSPIRE's effect on motility in models of normal and depressed motility and chemically induced ileus. Intestinal contraction improved by 44% in anesthetized animals and up to 140% in chemically induced ileus cases. In addition, passage time decreased from, on average, 8.6 days in controls to 2.5 days with the INSPIRE device, demonstrating significant improvement in motility. Luminal electrical stimulation of the intestine via the INSPIRE efficaciously restored peristaltic activity. This noninvasive option offers a promising solution for the treatment of ileus and other motility disorders.

Myomectomy with ArtiSential fully articulating laparoscopic instruments: A prospective multicenter study.

ArtiSential, a class of innovative laparoscopic instrument, has been developed to overcome the limitations of conventional laparoscopic surgery by enabling free, 360°-unrestricted movement of the wrist joint, as in robotic surgery. The aim of the present study was to describe the initial experiences with these devices in myomectomy and to report the surgical outcomes. A total of 77 women undergoing laparoscopic or robotic myomectomy between January 2021 and June 2022 were included in this multicenter prospective study. The ArtiSential instruments used by the surgeons were those chosen according to their respective preferences. The baseline characteristics, surgical outcomes, trocar placement options, and operator survey results were scrutinized. The mean age of the patients was 39.9 ± 6.3, and the mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was 22.4 ± 3.4 kg/m2 ; 46.8% of the patients underwent robotic surgery, while 53.2% underwent laparoscopic surgery. The number of removed myomas was 3.3 ± 3.0, the size of the largest myoma was 7.1 ± 2.3 cm, and the operative time was 130.0 ± 54.0 min. No transfusions or laparotomy conversions were required. Other than one case of ileus, there were no postoperative complications. In most cases, the instruments were inserted through the umbilicus trocar, and the fenestrated forceps, needle holder, and bipolar fenestrated forceps, in that order, were frequently employed. According to a surgeon survey, 29.9% moderately or strongly agreed that the ArtiSential devices utilized were more convenient than conventional laparoscopic instruments, while only 9.7% moderately or strongly agreed that they were more convenient than robotic instruments. Myomectomy as performed with an ArtiSential instrument seems to be feasible and safe. Further studies are necessary in order to comparatively assess the outcomes and potential benefits of ArtiSential, robotic, and conventional laparoscopic myomectomy.

P675 Comparative efficacy of Infliximab, Adalimumab, and Ustekinumab in patients with biologics naive Crohn's disease：a retrospective observational single-center study

Abstract Background The number of biologics available for Crohn's disease (CD) has increased dramatically, but there is no established standard of selection and few direct comparisons of efficacy among the agents. In this study, we compared the efficacy of infliximab (IFX), adalimumab (ADA), and ustekinumab (UST) in biologics naive CD patients. Methods A retrospective analysis of clinical data from CD patients who received IFX, ADA, and UST as 1st biologics during the period 2014-2023 was performed. Results Of 137 CD patients, 8 patients who received IFX, 17 patients who received ADA, and 10 patients who received UST as 1st biologics were included. Patient background (IFX/ADA/UST group) was as follows: median age was 32/21/22 years, median disease duration was 1/2/2 years, median HBI was 5/6/6, median SES-CD was 9/6/9, median CRP was 1.59/0.49/1.03 mg/dl, median albumin was 3.7/4.3/4.2 g /dl. Prednisolone or budesonide was concomitantly administered at induction in 5 (62.5%)/4 (23.5%)/0 (0%) patients.The cumulative remission rate (IFX/ADA/UST group) was 62.5%/58.8%/85.7% at 52 weeks after biologics induction in all patients, with a higher rate in the UST group. The steroid-free remission rates at 52 weeks (IFX/ADA/UST group) were 50.0%/58.8%/90.0%, which were higher in the UST group. For patients with HBI≥5 at the biologics induction, the remission rate after 8/16 weeks was 83.3% (5/6)/66.7% (4/6) in the IFX group, 54.5% (6/11)/63.6% (7/11) in the ADA group and 75.0% (6/8)/100% (8/8) in the UST group. There were no significant differences among all groups. Regarding adverse events, one case of skin rash and one case of dizziness were observed in the IFX group, one case of skin rash was observed in the ADA group, and no adverse event was observed in the UST group. One case of intestinal obstruction occurred in the IFX group and two cases in the ADA group, but not in the UST group. Conclusion Induction of UST in biologics naive CD patients may be as effective as anti-TNFα antibodies.

Etiology of Intestinal Obstruction - Correlation between Pre-operative and Per-operative Findings with Histopathology

Background: Intestinal obstruction is one of the most common causes of acute abdomen and often requires surgical intervention. However, pre-operative and per-operative diagnosis often do not correlate with postoperative histopathology done in suspected cases. Therefore, the study was designed to identify the etiology of intestinal obstruction correlating to pre-operative and per-operative findings with postoperative histopathological findings in suspected cases. Methods: A cross sectional study was conducted at the department of General Surgery, Mymensingh Medical College & Hospital, Mymensingh for 18 months following ethical approval from Institutional Review Board (IRB) of Mymensingh Medical College. During the study period, all patients with suspected intestinal obstruction admitted in Department of Surgery were included based on selection criteria. Total 103 patients were assessed in pre-operative and per-operatively. Histopathological examination was done in suspected cases where diagnosis could not be confirmed without histopathology. Data collection was done with a data collection form. After collection of all the required data, final analysis was carried out by using the SPSS version 21.0. Results: Among 103 cases of intestinal obstruction, mean age was 45.50±14.37 SD (years) with male female ratio-1.78:1. About 66% came from rural areas and 34% were from urban areas. Abdominal pain was the commonest symptom present among the cases which was observed in 91.3% cases. Others common symptoms were vomiting, abdominal distension absolute and relative constipation in 72.8%, 69.9%, 12.6% and 63.1% cases respectively, while abdominal tenderness was the commonest sign present in all cases. Among study population, 68.9% was small bowel obstruction and 31.1% was obstruction in large bowel. According to per-operative findings 22.3% cases were suspected as malignant. Finally 24.3% cases were proved as malignant in subsequent histopathological examination and 75.7% cases

Intestinal Obstruction Due to Ileotransverse Anastomosis Stenosis Secondary to Crohn's Disease: A Case Report

Introduction: Crohn's disease is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. This report explores a case of intestinal obstruction resulting from stenosis of ileotransverse anastomosis, secondary to Crohn's disease. Epidemiology: The macroscopic features of Crohn's disease vary, including patchy inflammation, ulcers, and stenosis. Stenosis is a common occurrence, particularly in the terminal ileum, affecting 30-40% of individuals with Crohn's disease. OBJECTIVE: To describe a clinical case of intestinal obstruction due to ileotransverse anastomosis stenosis secondary to Crohn's disease, aiming to recognize its behavior and determine surgical management in patients with a high suspicion of this condition. Patient and Method: A 35-year-old female diagnosed with ankylosing spondylitis, recent Crohn's disease, and intestinal obstruction. Surgical history includes exploratory laparotomy, right hemicolectomy, and ileotransverse anastomosis due to acute appendicitis. Current symptoms led to surgical exploration, revealing extensive adhesions and stenosis at the anastomosis. Results: The patient underwent resection of the affected intestinal segment and the creation of a terminal ileostomy, successfully resolving the obstruction. Comprehensive preoperative evaluation, diagnostic confirmation through imaging, and appropriate surgical intervention played critical roles in achieving a positive outcome. Discussion: The discussion emphasizes the complexities associated with Crohn's disease surgery, highlighting common complications such as infection, fistulas, and anastomotic stenosis. The case underscores the need for a cautious surgical approach and the importance of early consideration of Crohn's disease in patients with intestinal obstruction. Conclusions: This case report underscores the significance of recognizing Crohn's disease in patients presenting with intestinal obstruction. Appropriate surgical management, though challenging due to the heightened risk of complications, is essential for improving treatment outcomes. A comprehensive approach, from timely diagnosis to surgical intervention, is crucial for effectively addressing Crohn's disease manifestations and enhancing patient quality of life.

Unveiling new patterns: A surgical deep learning model for intestinal obstruction management.

Swift and accurate decision-making is pivotal in managing intestinal obstructions. This study aims to integrate deep learning and surgical expertise to enhance decision-making in intestinal obstruction cases. We developed a deep learning model based on the YOLOv8 framework, trained on a dataset of 700 images categorised into operated and non-operated groups, with surgical outcomes as ground truth. The model's performance was evaluated through standard metrics. At a confidence threshold of 0.5, the model demonstrated sensitivity of 83.33%, specificity of 78.26%, precision of 81.7%, recall of 75.1%, and mAP@0.5 of 0.831. The model exhibited promising outcomes in distinguishing operative and nonoperative management cases. The fusion of deep learning with surgical expertise enriches decision-making in intestinal obstruction management. The proposed model can assist surgeons in intricate scenarios such as intestinal obstruction management and promotes the synergy between technology and clinical acumen for advancing patient care.

Occlusion By Transmeso - Internal Hernia Congenital Sigmoid: About A Case

Internal hernia through a meso-sigmoid defect or hernia Transmesosigmoid is a rare cause of acute intestinal obstruction. Its diagnosis is most often made intraoperatively. Knowledge of its clinical particularities makes it possible to consider the preoperative diagnosis. We present 1 case of acute intestinal obstruction caused by a hernia Transmesosigmoid congenital in 1 adults. We discuss the clinical particularities of this rare form of internal hernia.

Case of intestinal obstruction by gravel in red-eared slider (Trachemys scripta elegans) solved with medicamentous therapy

Red-eared sliders (Trachemys scripta elegans) are often kept as pets, even though their sale is prohibited in many countries due the invasiveness of this species. This report describes a case of a 4-year-old red-eared slider that presented with a month-long history of lethargy and unwillingness to go into the water and was unsuccessfully treated with antibiotics and corticosteroids. Upon clinical and radiological examination, it was discovered that the patient was suffering from intestinal obstruction caused presumably by gravel stones. Medicamentous therapy consisting of meloxicam, lactulose and Ringer?s solution for reptiles was then started and the turtle managed to pass all the ingested stones via the alimentary tract. Control radiological examination has shown no signs of high-density structures in the lumen of the intestines, and the turtle has made a full recovery. With enterotomy often being considered indicated in chelonians suffering from intestinal obstruction caused by gravel, this is, to the best of the authors? knowledge, the first reported case of this kind resolved solely with medicamentous therapy in a red-eared slider.

A Case of Mechanical Intestinal Obstruction Combined with Hepatic Portal Vein Gas Accumulation

A Case of Mechanical Intestinal Obstruction Combined with Hepatic Portal Vein Gas Accumulation

Internal Hernias: Diagnosis and Management

Introduction: Internal hernias are rare, with an overall incidence of less than 1%. They account for 0.5 to 5.8 % of cases of intestinal obstructions. If left untreated, their overall mortality exceeds 50 % in cases of strangulation. The aim of this work is to report 04 new cases of different types of internal hernias and to review the literature on the circumstances of occurrence, discovery, and therapeutic modalities for internal hernias. Observations: We report four (04) observations concerning different types of internal hernias: (02 peri-cecal internal hernias, one hernia through the Winslow's hiatus, and one supra-vesical internal hernia), all revealed by clinical presentations of acute intestinal obstructions and confirmed by preoperative CT scan. Our patients (03 men and 01 woman) have an average age of 63 years. All 04 cases were operated on urgently, with 03 undergoing laparotomy and 01 undergoing laparoscopy. The procedure performed is the reduction of the hernia (viable strangulated small bowel loops) with closure of the hernial orifice to prevent recurrences. Postoperative courses were uneventful in all four patients. The average length of hospital stay is 02 days. After a follow-up ranging from 02 years to 08 years, no recurrence was observed. Conclusion: Internal hernias are rare and should be considered in cases of acute intestinal obstruction, especially in patients without abdominal surgical history or trauma. Laparotomy remains the most commonly used surgical approach, but laparoscopy is increasingly reported in recent publications.

A prospective observational study on etiology and management influencing outcome in operatively managed cases of acute intestinal obstruction in adults

Background: Acute intestinal obstruction (IO) is an important cause for acute abdomen in surgery which presents as abdominal pain, vomiting, distension, and constipation depending on the level and extent of obstruction of gastrointestinal tract. Early diagnosis of acute IO with understanding of various etiologies, use of better diagnostic techniques, and skillful operative management and good postoperative care, carries a good outcome. Aims and Objectives: The objective of the study was to find out the prevalence of various etiologies of acute IO and to study the various post-operative morbidity and mortality. Materials and Methods: This was a hospital-based observational study in the Department of General Surgery of Calcutta National Medical College and Hospital among patients with a diagnosis of acute IO during the study period of December 2016-April 2018. Results: Acute IO commonly affects male with a male: female ratio 7:3 and the most common occurrence in the age group of 40–59 years (30%). The most common etiology was obstructed/strangulated hernia (36%), followed by large bowel neoplasm (18%), adhesion (16%), intestinal tuberculosis (12%), and volvulus (10%). The most common surgical procedure performed was the resection of gangrenous bowel and creation of stoma (30%), followed by prosthetic repair of hernia (28%). The mortality rate of the present study was 12%. The morbidity rate was 46%attributing mainly to respiratory complications (30.4%) and surgical site infections (26.08%). Conclusion: This study demonstrates that the pattern of IO differs from the Western world with obstructed hernias being the most important cause and also emphasizes the fact that intestinal tuberculosis assumes a prominent role.

Case report of metastatic colorectal cancer associated with <i>KRAS</i> A146V and A59G mutations

In colorectal cancer (CRC) in addition to the most common mutations in the second exon of KRAS, there are rarer mutations that are not well understood as prognostic markers.Description of cases. We describe two clinical cases of moderately differentiated adenocarcinoma (low-grade, G2), which manifested a complicated course in a 67-year-old woman – intestinal obstruction (case 1) and in a 62-year-old man – paratumorous abscess (case 2). Both cases were characterized by the development of regional and distant metastases (liver, brain) and a short relapse-free period. We found rare sporadic mutations of KRAS A146V and A59G with microsatellite stability and no mutation in the V600 BRAF site.Discussion. In the presented case 1, the KRAS A146V mutation was detected, the frequency of its detection in our practice of testing 2103 cases of CRC was 0.48%. Case 2 shows the extremely rare A59G mutation. Among the patients with CRC we studied, we found mutations in codon 59 in only two, which amounted to 0.095%. Both rare mutations represent separate molecular subgroups of CRC, characterized by an unfavorable clinical outcome and requiring the development of special treatment regimens.

Acute Intestinal Occlusion by Ileo-Sigmoid Node: About a Case

The ileosigmoid node is a rare surgical emergency. We report a case of intestinal obstruction by ileosigmoid node that occurred in a young adult patient himself accompanying another patient. Management was early and confirmation was intraoperative.

The Rigler’s triad: a case of gallstone ileus

Rigler’s triad is an extremely rare syndrome that accounts for 4% of all cases of small intestinal obstruction (SBO). This illness is distinguished by three clinical and radiological features: pneumobilia, a severe intestinal blockage, and an abnormally placed gallstone in the gallbladder. An 84-year-old woman arrives at the Emergency Department with symptoms of SBO. The CT scan is essential for detecting the trio. An emergency laparoscopy with an enterotomy and gallstone extraction was conducted successfully. The Rigler’s triad should be suspected in elderly individuals with a history of gallstones in the gallbladder, especially in the emergency scenario. Large and solitary gallstones in the gallbladder that are asymptomatic should be candidates for cholecystectomy. In conclusion, this case is a very didactic instance, particularly because of the crisp CT images that can assist surgeons in identifying gallstone ileus and the mini-invasive method that can also benefit in an emergency context.

Intussusception-induced acute abdomin caused by a giant lipoma in the transverse colon: a rare case report.

The authors present a case of a 48-year-old male who presented to the emergency department suffering from severe abdominal pain. Following examination and investigations, a giant lipoma (GL) in the transverse colon was identified via ultrasound which showed the classical "target sign" Intussusception among adults is unusual as it accounts for only 1% of bowel obstruction cases. Being colo-colonic makes it even more unlikely since it occurs only in 17% of intestinal obstruction cases. GLs exceeding 5cm in size can present with a variety of symptoms. Intussusception is an uncommon presentation of a GL. Preoperative diagnosis of GL-induced intussusception is highly improbable and surgical resection is the treatment of choice. Despite the dominance of the asymptomatic presentation of lipomas, considering its diagnosis in the case of an intussusception-induced acute abdomen should cross physicians' minds.

A clinical case of small intestinal intussusception caused by metastatic melanoma

Intestinal obstruction is observed in about 9.0 % of patients with acute surgical pathology of the abdominal cavity. The disease occurs at any age, but more often between 25–50 years. Mixed intestinal obstruction is only 3–7 %. The most common form of mixed intestinal obstruction is intestinal invasion. The most common cause of intussusception in adults is an intestinal tumor. Early diagnosis and the optimal amount of surgical treatment are the main components of successful treatment of the patient.
 Aim: to familiarize practitioners with a rare case of intestinal obstruction in adults and its management strategies in a surgical hospital.
 Materials and methods. The patient was treated in the surgical department of the Communal Non-Profit Enterprise “City Hospital No. 7” Zaporizhzhia City Consul. The patient underwent preoperative preparation and surgical intervention.
 Results. The patient underwent an emergency median laparotomy under total intravenous anesthesia with artificial lung ventilation. During the examination of the abdominal cavity, multiple distended loops of the small intestine were visualized. During the revision, at a distance of 1.5 meters from the ligament of Treitz, a volumetric formation of the small intestine of dense-elastic consistency, represented by small-intestinal invasion, up to 10 cm long, was detected. The proximal sections of the small intestine are distended, light purple in color. The sections of the small intestine that were distal to the site of invasion were inflamed. Manual disinvagination of the small intestine was performed. The visual examination showed that the intestine was viable. There was a tumor was found on the antrumeral margin, measuring 1.8 × 2.5 cm, dense in consistency, finely tuberculated, dark purple heterogeneous in color, infiltrating and deforming the wall of the small intestine. Resection of the invaded area of the small intestine with the tumor was performed with the imposition of a small-small intestinal anastomosis “side to side” with two-row nylon sutures.
 Conclusions. In this clinical case, it was possible to establish the final diagnosis and determine further surgical strategy only intraoperatively. Only early diagnosis of melanoma will allow avoiding the complications identified in this patient.