Müllerian duct cyst (MDC) is an uncommon congenital lesion arising from incomplete regression of the paramesonephric duct. It typically presents as a midline pelvic cystic lesion and is often asymptomatic, making preoperative diagnosis challenging. We report the case of a 37-year-old woman who was admitted in 2024 for evaluation of an incidentally discovered pelvic cystic lesion. Pelvic magnetic resonance imaging (MRI) revealed a well-circumscribed, non-enhancing posterior pelvic cystic lesion. Laparoscopic resection of the cyst was performed, and intraoperatively, dense adhesions were noted between the cyst, the posterior uterine wall, and the posterior peritoneum. Histopathological examination confirmed the diagnosis of MDC and revealed coexisting endometriosis in the adherent posterior peritoneum. This case highlights the importance of considering MDC in the differential diagnosis of pelvic cystic lesions in women, as well as the potential coexistence of endometriosis.

Complicated cholelithiasis remains a frequent challenge in emergency general surgery because acute severe cholecystitis, gallbladder empyema, gangrenous inflammation, dense adhesions, and Mirizzi syndrome may distort biliary anatomy and increase the risk of conversion, morbidity, and bile duct injury. This integrative literature review analyzed evidence on laparoscopic cholecystectomy in patients with complicated gallstone disease, focusing on surgical outcomes, technical difficulties, intraoperative and postoperative complications, conversion predictors, recovery time, and perioperative strategies. The reviewed literature indicates that early laparoscopic cholecystectomy is generally effective and safe when performed with strict adherence to operative safety principles, especially the Critical View of Safety and timely use of bailout strategies. Male sex, advanced age, delayed presentation, severe inflammation, gallbladder wall thickening, empyema, gangrene, Mirizzi syndrome, obesity, diabetes, and previous upper abdominal surgery are associated with greater operative difficulty and higher conversion risk. Subtotal cholecystectomy, fundus-first dissection, intraoperative imaging, conversion, and drainage should be considered safety measures rather than technical failure. Enhanced Recovery After Surgery protocols may reduce pain, nausea, length of stay, and functional delay when adapted to disease severity. Laparoscopic cholecystectomy remains the preferred approach in complex cholelithiasis when supported by surgical judgment, structured training, and individualized recovery pathways.

Tracheobronchial injuries (TBI) are rare but potentially life-threatening complications of esophagectomy, with significant morbidity and mortality. This narrative review examined the incidence, risk factors, diagnostic methods, and management strategies for TBI following esophagectomy. A PubMed search was conducted for relevant studies published between 1978 and 2024 using terms related to tracheal injury and esophagectomy. Forty-five articles met the inclusion criteria. The incidence of TBI ranged from 0.4 to 3.5% in transhiatal esophagectomy (THE) and 0 to 2.67% in transthoracic esophagectomy (TTE). Identified risk factors included dense tumor adhesions, neoadjuvant chemoradiation, blunt esophageal dissection, and double-lumen endotracheal tube use. Diagnosis was primarily via bronchoscopy and imaging. Small, stable injuries were managed conservatively, while larger defects required surgical repair, often with muscle flap or synthetic reinforcement. Early intraoperative recognition and repair are key to improving outcomes, but mortality is high in cases of delayed diagnosis. This review emphasizes the importance of meticulous surgical technique, vigilant intraoperative monitoring, and individualized treatment strategies to minimize complications in high-risk patients.

Mediastinal teratomas are germ cell tumors that most commonly arise in the anterior mediastinum. Although often asymptomatic and discovered incidentally, larger lesions may produce compressive respiratory symptoms. Trichoptysis is a rare but highly suggestive presentation. A 45-year-old woman presented with an 8-month history of chronic dry cough without dyspnea, sputum production, hemoptysis, or systemic symptoms. Chest radiography revealed a mediastinal opacity. Contrast-enhanced computed tomography (CT) of the chest showed a heterogeneous predominantly low-density mass in the left superior mediastinum with peripheral enhancement, inflammatory fat stranding, and mediastinal lymphadenopathy, raising concern for mediastinal abscess versus neoplasm. On the day of surgery, the patient recalled a prior episode of cough associated with expectoration of yellowish hair-like strands. Left posterolateral thoracotomy revealed a well-encapsulated anterior mediastinal mass densely adherent to the pericardium and left upper lobe. The lesion was excised en bloc with wedge resection of the adherent upper-lobe parenchyma. Histopathologic examination confirmed a mature mediastinal teratoma. Trichoptysis is an uncommon but strongly suggestive symptom of teratoma with airway communication. Imaging may be misleading when inflammatory changes are present, mimicking infection. Complete surgical excision remains the definitive treatment, and thoracotomy may be preferred when dense adhesions or lung involvement is anticipated. Anterior mediastinal teratoma should be considered in patients with mediastinal masses and chronic cough, particularly when trichoptysis is reported. Complete resection offers excellent outcomes.

Background: Posterior ankle pain has varied etiologies, with sural nerve (SN) entrapment contributing to posterolateral ankle discomfort. The SN is a pure sensory nerve that innervates the lateral ankle and foot up to the fifth metatarsal. Although SN pathologies are known, specific clinical features and management of neuropathy affecting the lateral calcaneal branch of the sural nerve (LCBSN), which supplies the lateral heel, are less defined. This condition is often exacerbated by repetitive ankle dorsiflexion in sports or external compression from tight footwear. We hypothesized that LCBSN lesions cause a distinct pattern of heel pain that is uniquely aggravated by ankle dorsiflexion or shoe contact, thereby distinguishing this entity from other causes of posterior ankle pain. Methods: This retrospective case series included 23 patients. We reviewed records of 23 patients presenting with posterolateral ankle pain and localized LCBSN tenderness. Key diagnostic features included pain aggravation with ankle dorsiflexion or shoe contact, lacking motor deficits. Diagnosis was primarily confirmed by immediate, significant pain relief after local anesthetic injection around the LCBSN. Symptom severity (0-4 scale) and American Orthopaedic Foot & Ankle Society (AOFAS)-hindfoot scores were assessed at 1 month and 1 year post-treatment. Surgical intervention was performed for recurrent pain after 6 months of conservative management. Results: Improvement ( P < .05) in both symptoms and AOFAS-hindfoot scores was observed at 1-month and 1-year follow-ups. Six patients required surgical treatment for recurrent symptoms. Pathologic findings included arterial wall thickening with dense perineural adhesions and scarring (3 cases), neuroma formation (2 cases), and nerve entrapment due to adhesions (1 case). Conservative treatment was effective for the remaining patients. Conclusion: Accurate and timely diagnosis of LCBSN lesions is crucial for effective treatment and enabling prompt return to sports activities. A diagnostic, small volume local anesthetic injection may serve as a practical diagnostic adjunct and an initial therapeutic measure for this clinically significant condition.

Cauda equina neuroendocrine tumor (CENET) is a rare spinal neuroendocrine tumor, and its coexistence with superficial siderosis (SS) is even more rare. CENETs are usually small and most commonly located below L2, and their imaging often overlaps with that of myxopapillary ependymomas or schwannomas, thus complicating their preoperative differentiation. The coexistence of SS and intratumoral fluid-fluid level (FFL) in CENET has not been documented. The authors describe a giant thoracolumbar CENET (T12-L3) with intracranial SS in a patient with progressive paraparesis and bladder dysfunction. MRI revealed a hypervascular intradural extramedullary mass with an intratumoral FFL and neuraxial hemosiderin deposition, suggesting recurrent hemorrhage. Because of dense cauda equina adhesions, function-preserving subtotal resection was performed under intraoperative neurophysiological monitoring, resulting in marked neurological improvement. In CENETs, the coexistence of SS, intratumoral FFL, and marked hypervascularity on preoperative imaging may indicate a chronic hemorrhagic phenotype with severe adhesions to the cauda equina, particularly in large multisegmental tumors. In such cases, nerve-sparing subtotal resection planned with preoperative vascular assessment and performed under intraoperative neurophysiological monitoring can be an appropriate strategy to balance tumor control with preservation of neurological function when safe dissection planes are limited. https://thejns.org/doi/10.3171/CASE251015.

Severe intrapericardial adhesions, regardless of their etiology, represent a major challenge in cardiac surgery. Such adhesions increase the risk of cardiac injury, excessive bleeding, and technical difficulty in establishing cardiopulmonary bypass, thereby necessitating meticulous preoperative planning and careful intraoperative management. Herein, we report a 74-year-old female patient who required cardiac surgery in the presence of severe pericardial adhesions. Echocardiography demonstrated severe mitral regurgitation due to P3 prolapse, accompanied by progressive left atrial enlargement. Preoperative imaging findings suggested the presence of dense pericardial adhesions; therefore, a median sternotomy was selected with careful surgical planning. The patient underwent mitral valve repair with artificial chordae implantation and annuloplasty, along with concomitant tricuspid valve repair. Intraoperatively, extensive intrapericardial adhesions were confirmed, requiring cautious and meticulous dissection to avoid cardiac injury. The postoperative course was uneventful, and mitral regurgitation improved to a minimal degree. The patient was discharged on postoperative day 12 and remained free from heart failure symptoms during follow-up. Severe pericardial adhesions can substantially increase the complexity and risk of cardiac surgical procedures, irrespective of the underlying cause. Accurate preoperative assessment, anticipation of technical difficulties, and selection of an appropriate surgical strategy are crucial for ensuring procedural safety and achieving favorable surgical outcomes.

Radical prostatectomy after rectal cancer surgery: surgical challenges and technical strategies \u2013 a case series

To describe a novel staged surgical approach using short-term intraocular perfluorocarbon liquid (PFCL) tamponade to facilitate spontaneous posterior vitreous detachment (PVD) formation in a case of traumatic retinal detachment (RD) with dense vitreoretinal adhesion. A 36-year-old male presented with light perception vision in the right eye two weeks after scleral repair of a ruptured globe caused by a projectile nail. B-scan ultrasonography showed dense vitreous and subretinal hemorrhage with a total open-funnel RD. A 25-gauge pars plana vitrectomy (PPV) was performed, revealing a total RD, subretinal hemorrhage and a strongly adherent posterior hyaloid that could not be safely detached. PFCL was used to flatten the retina, displace subretinal hemorrhage, and maintain the retina flattened. The patient was instructed to maintain a face-up position, and PFCL removal was planned 10 days later. At the second surgery, the posterior hyaloid had spontaneously detached, allowing complete hyaloid removal and retinal reattachment with PPV, endolaser, and silicone oil tamponade. The retina remained attached under silicone oil which was removed 9 weeks later. At 9 months post silicone oil removal the retina remained attached and best-corrected visual acuity improved to 20/60. Unlike previously described intraoperative PFCL-assisted methods to flatten the retina, this technique uses PFCL's density and surface tension to generate gentle shear forces over time, passively inducing PVD while maintaining macular attachment. This approach offers an alternative for complex traumatic RDs with dense vitreoretinal adhesion.

Benign biliary strictures are an uncommon but significant complication following hepatobiliary surgeries, most often seen after cholecystectomy or biliary-enteric anastomosis. While Roux-en-Y hepaticojejunostomy is the standard surgical treatment for high bile duct strictures, recurrence of the stricture remains a complex problem, especially when the anatomy is distorted by fibrosis or previous surgery or when it presents as cholangitis episodes very late after surgery. Revision surgery in these cases is challenging, and timely recognition and resource-appropriate interventions are key to optimal outcomes. We describe a case series of seven patients who underwent revision surgery for recurrent benign biliary strictures following Roux-en-Y hepaticojejunostomy. Three patients were found to have high-level strictures (Strasberg E4) at the time of revision surgery. While most patients were managed with standard surgical techniques, in one of these patients, dense adhesions and scarring made ductal identification nearly impossible, where intraoperative ultrasound-guided biliary catheter placement was used as a salvage technique to localize the biliary ducts transhepatically, creating a neo-hepaticojejunostomy. All patients had a satisfactory recovery, with resolution of jaundice and normalization of liver function over a follow-up period of one year. Revision surgery for recurrent benign biliary strictures after Roux-en-Y hepaticojejunostomy remains technically demanding due to altered anatomy and fibrosis, where it becomes difficult to differentiate structures. Careful preoperative planning, meticulous intraoperative dissection, flexible surgical strategies, and multidisciplinary cooperation and planning are essential for successful reconstruction and favorable outcomes.

Introduction and Importance: Tuberculous aneurysm of the ascending aorta is extremely rare and life-threatening, particularly in elderly patients. Early recognition and appropriate surgical management are essential to prevent fatal rupture. Case Presentation: An 84-year-old man presented with hemoptysis and chest tightness. Computed tomography revealed a saccular aneurysm of the ascending aorta with sternal erosion. During surgery, the aneurysm showed a caseous appearance with dense adhesions and infiltration into adjacent tissue. Frozen section demonstrated granulomatous inflammation suggesting tuberculous aortitis, which was later confirmed by postoperative Xpert MTB/RIF assay. A double-layer aortic repair was performed using an inner bovine pericardial patch and an outer Gelweave graft. The patient recovered well under antituberculous therapy and remained stable at 7-month follow-up. Clinical Discussion: Tuberculous aortitis in elderly patients is challenging due to degenerative aortic wall changes and hypertension. Intraoperative frozen section combined with gross findings played a key role in guiding the surgical strategy. The double-layer repair provided infection control and mechanical durability, consistent with current literature supporting biologic–synthetic hybrid reconstruction in infected aneurysms. Conclusion: A tuberculous aneurysm of the ascending aorta should be considered in atypical cases presenting with hemoptysis. In elderly patients with degenerative aortic walls and hypertension, double-layer repair offers effective infection control and durability when combined with appropriate antituberculous therapy. Early diagnosis and tailored surgical planning are crucial for favorable outcomes.

The right innominate interarteriovenous lymph nodes (RIAVLN) represent a distinct nodal group situated between the right innominate artery and vein. This area lies outside the conventional level VI-VII boundaries in thyroid carcinoma surgery and is seldom addressed in standard guidelines. Metastasis in this region is difficult to detect and surgically challenging due to its proximity to major vascular structures. This study aimed to analyze the clinical characteristics and surgical management of RIAVLN metastasis in patients with thyroid carcinoma. We retrospectively reviewed 103 patients with thyroid carcinoma who underwent RIAVLN dissection between July 2017 and January 2024. All patients had preoperative contrast-enhanced CT scans suggesting nodal metastasis in this region. Demographic data, tumor subtype, surgical approach, and pathological findings were analyzed. The surgical technique emphasized cervical exposure of the carotid sheath, mobilization of the common carotid artery, and careful dissection of the interarteriovenous space, with partial sternotomy reserved for cases with severe adhesion or bleeding risk. The mean patient age was 39.9 ± 12.3 years (range, 18-68), with 42 males and 61 females. The cohort included 24 primary papillary, 63 recurrent papillary, 2 primary medullary, and 13 recurrent medullary thyroid carcinoma cases. Overall, 93 patients (90.3%) were successfully treated via a transcervical approach, while 10 (9.7%) required partial sternotomy. The mean number of RIAVLN dissected was 3.1 ± 2.9, and metastasis was confirmed in 77 patients (74.8%). The mean number of metastatic nodes among positive cases was 1.5 ± 2.4, with extranodal extension observed in 12 patients (11.7%). No major vascular injury or operative mortality occurred. RIAVLN metastasis is relatively common in recurrent thyroid carcinoma and represents an anatomically unique nodal group not covered by traditional classifications. In most cases, complete clearance can be safely achieved through a transcervical approach. Partial sternotomy should be reserved for patients with dense adhesions or high bleeding risk. Recognition of this region as a potential site of recurrence and mastery of its surgical anatomy are crucial for achieving optimal oncologic outcomes in thyroid cancer surgery.

Encapsulating peritoneal sclerosis: a three-case series highlighting diagnostic challenges and surgical managements

Primary cystadenocarcinoma of the mesentery is an extremely rare malignant cystic epithelial tumor and represents the malignant spectrum of mesenteric mucinous cystic neoplasms. Due to its rarity, fewer than 25 cases have been reported in the literature, and the clinical characteristics, diagnostic features, and optimal management strategies remain poorly defined. Patients usually present with nonspecific symptoms related to mass effect, including abdominal pain, abdominal distension, nausea, vomiting, constipation, or a palpable abdominal mass, often mimicking ovarian or gastrointestinal tumors. Preoperative diagnosis is particularly challenging because radiological findings are not pathognomonic and tumor markers have limited diagnostic value. We report a rare case of primary mesenteric cystadenocarcinoma in a 20-year-old female who presented with progressive abdominal distension, abdominal pain, nausea, vomiting, constipation, and exertional shortness of breath. Clinical examination revealed a large abdominal mass. Contrast-enhanced positron emission tomography–computed tomography demonstrated a large lobulated abdominopelvic mass with internal septations and heterogeneous enhancement, producing significant mass effect including bilateral ureteric dilatation and hydronephrosis. However, the exact origin of the lesion could not be determined preoperatively. Exploratory laparotomy revealed a large cystic mass arising from the mesentery with dense adhesions to the colon. Complete surgical excision was performed without rupture. Histopathological examination confirmed papillary mucinous cystadenocarcinoma of mesenteric origin. This case highlights the diagnostic difficulty associated with mesenteric cystic malignancies and emphasizes that complete surgical excision remains essential for definitive diagnosis and management.

ABSTRACTObjective:Acute calculous cholecystitis is one of the most common surgical infectious disease emergencies worldwide. Early laparoscopic cholecystectomy (LC) is the definitive treatment, but severe inflammation often leads to technical difficulty and increased intraoperative adverse events. This study evaluated preoperative gallbladder wall thickness (GWT) on ultrasound as a simple, objective predictor of difficult LC in acute calculous cholecystitis.Methodology:A prospective cross-sectional study was conducted in the Department of Surgery, Aga Khan University Hospital, Karachi, from May to November 2022. Consecutive adult patients (18–60 years) with ultrasound-confirmed acute calculous cholecystitis undergoing LC within 96 hours of symptom onset were included (n=116). GWT was classified as normal (≤3 mm), moderate (3.1–7 mm), and severe (>7 mm). Intraoperative adverse events recorded were operative time >90 minutes, distended gallbladder requiring aspiration, dense adhesions, conversion to open procedure, and drain placement.Results:Mean GWT was 3.44 ± 1.79 mm. Severe thickening (>7 mm) was present in six patients (5.2%) and was highly significantly associated with prolonged operative time (p<0.001), need for gallbladder aspiration (p<0.001), conversion to open cholecystectomy (p<0.001), and subhepatic drain placement (p<0.001). Dense adhesions showed a strong trend (p=0.069).Conclusion:Severe preoperative gallbladder wall thickening (>7 mm) is a powerful, reproducible marker of intense inflammation and can predicts difficult laparoscopic cholecystectomy in acute infectious cholecystitis. Routine reporting of GWT allows accurate risk stratification, facilitates early involvement of experienced surgeons, reduces conversion rates, and optimizes outcomes in this common infectious surgical emergency – making it a practical and cost-effective surgical solution, especially in low-middle-income settings.

Gastrointestinal fistulas in children are rare, and the coexistence of a jejunocecal and gastric ascending colon fistula is exceptional. To our knowledge, no instance of this fistula combination has been reported previously. These patients present with nonspecific symptoms, which may lead to delayed or missed diagnoses. We evaluated a 12-year-old boy with a 3-year history of intermittent nausea and vomiting, and a weight loss of 30 kg. Initially, he was managed as for gastroenteritis; however, his response was minimal. Further investigation included endoscopy and contrast radiography; these studies identified an abnormal communication between the stomach and colon; however, the exact anatomy remained elusive. Laparoscopy identified two fistulae: one between the greater curvature of the stomach and the ascending colon, and another between the jejunum and the cecum. The operation was converted to open due to dense adhesions. Resection of the fistulous tracts and repair (stomach) or anastomosis (small intestine and colon) were performed. Histopathology showed chronic inflammation with mucosal metaplasia but no evidence of malignancy. Retrospectively, the patient and family recalled prior play with magnets, but ingestion could not be confirmed. In children with chronic symptoms, such as recurrent diarrhea with weight loss, a gastrointestinal fistula should be considered. Use of contrast radiography and endoscopy, together with clinical correlation, may prevent misdiagnosis and delayed in treatment.

Epicardial access for ventricular tachycardia (VT) ablation is challenging in patients with prior cardiac surgery or dense pericardial adhesions. Although carbon dioxide (CO₂) insufflation has been used to improve visualization, concerns remain regarding its hemodynamic and electrophysiological effects. We report the first clinical use of helium to facilitate epicardial access in three patients undergoing VT ablation. All patients had ischemic cardiomyopathy, prior coronary artery bypass grafting, and failed or incomplete endocardial ablation. Helium was delivered into the pericardial space via a coronary venous microcatheter connected to an intra-aortic balloon pump (IABP) console, allowing controlled insufflation and continuous hemodynamic monitoring. Helium insufflation resulted in rapid separation of the pericardial layers, clear visualization of adhesion-free regions, and safe epicardial puncture in all cases. Epicardial mapping and radiofrequency ablation were successfully completed, achieving VT non-inducibility without hemodynamic compromise, defibrillation related issues or procedural complications. Helium insufflation using an IABP console enabled safe and effective epicardial access in patients with complex pericardial anatomy and prior cardiac surgery. As a physiologically inert, low-viscosity, and widely available gas, helium represents a practical alternative to CO₂ for challenging epicardial VT ablation procedures and merits further evaluation in larger studies.

Laparoscopic retrograde hysterectomy (LRH) represents an innovative minimally invasive approach for managing complex pelvic pathology where conventional techniques are contraindicated. This review synthesizes current evidence regarding its techniques, indications, and outcomes. LRH employs a strategic caudal-to-cephalad dissection, prioritizing early identification of ureters and uterine vessels before addressing fundal attachments. Primary indications include severe endometriosis with obliterated cul-de-sac, large uterine size (>300 g), multiple previous surgeries with dense adhesions, and distorted pelvic anatomy. Outcomes demonstrate significant advantages, including reduced conversion rates to laparotomy (0-2.9%), acceptable operative times (66-285 minutes), minimal blood loss (79-450 mL), and short hospital stays (two to six days). The technique maintains low complication rates (2.2-4.7%) despite challenging conditions. However, LRH requires advanced laparoscopic skills and has a substantial learning curve (~65 cases). Widespread adoption necessitates structured training programs and further comparative studies. LRH effectively expands minimally invasive options for complex gynecological surgery, demonstrating particular utility in frozen pelvis scenarios while preserving the benefits of laparoscopy.

Extraperitoneal tubeless umbilical cutaneous ureterostomy is a useful urinary diversion technique for patients with shortened ureters or high risk of upper urinary tract recurrence. However, radical nephroureterectomy following this diversion has not been previously reported. A 67-year-old man underwent radical cystoprostatourethrectomy with extraperitoneal tubeless umbilical cutaneous ureterostomy for high-risk urothelial carcinoma with bilateral ureteral shortening. Twenty-four months later, left-sided upper tract urothelial carcinoma was diagnosed, and laparoscopic left radical nephroureterectomy was performed. Although dense adhesions necessitated partial small-bowel resection, complete nephroureterectomy was achieved without major complications. To the best of our knowledge, this is the first report of radical nephroureterectomy performed after umbilical cutaneous ureterostomy. This urinary diversion may represent a reasonable option for selected patients at high risk of upper urinary tract recurrence.

Retained surgical foreign bodies are underreported due to legal concerns. They may remain asymptomatic or cause acute complications with nonspecific imaging findings, leading to delayed diagnosis. Awareness in previously operated patients is essential, and their impact has driven preventive measures such as standardized counts, detection technologies, and surgical checklists. A 38-year-old woman with prior urologic and gynecological surgeries presented with 3 days of left flank pain, fever, nausea, and vomiting. Imaging revealed a large heterogeneous abdominal mass. Exploratory laparoscopy identified a cystic lesion with dense adhesions to the abdominal wall, small bowel, and sigmoid colon. Adhesiolysis exposed purulent material and a retained foreign body. The lesion and foreign body were removed, bowel defects were repaired, and the abdomen was irrigated. The postoperative course was uneventful, and the patient was discharged on day 6. The second case is a 68-year-old man with cardiovascular comorbidities and a remote history of pulmonary tuberculosis who was followed for an asymptomatic 6 cm anterior mediastinal mass. Due to suspected malignancy, thoracoscopic resection was performed. Intraoperatively, dense fibrosis was found, and conversion to a utility thoracotomy was required. Opening the mediastinal pleura revealed purulent material and a retained surgical gauze. Removal caused significant bleeding from vessel erosion, which was controlled with packing, vascular clamping, and suturing. The cases demonstrate that retained surgical items are preventable "never events" with significant clinical, ethical, and legal consequences. They often present with nonspecific symptoms and delayed diagnosis, requiring reoperation. Despite standard precautions, human and procedural factors persist, emphasizing the need for improved surgical safety culture, advanced prevention strategies, and meticulous reintervention techniques.