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An 83-year-old woman underwent an elective perineal proctosigmoidectomy (Altemeier procedure) for a rectal prolapse. On postoperative day 1, the patient presented with impressive subcutaneous emphysema involving the chest, neck and face without any other symptoms. A CT scan showed free air in the retroperitoneum, the intraperitoneal cavity, the mediastinum and a subcutaneous emphysema of the neck and the face. Air was also found around the coloanal anastomosis and an anastomotic leak was proven by rectal contrast agent. In this situation, a rectoscopy followed by a laparoscopy were immediately performed. The leak could not be visualised. Peritoneal lavage and drainage, followed by protective sigmoidostomy were carried out. After surgery, the follow-up was uneventful except a persistent but asymptomatic leak with a presacral cavity. The coloanal dehiscence was later proven in rectoscopy. Although sutured, it is still present and colostomy closure will eventually be possible in a few months., (2014 BMJ Publishing Group Ltd.)

Internal hernia after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery can lead to acute small bowel obstruction or chronic recurrent abdominal pain. We present two cases of internal hernias after antecolic antegastric LRYGB. Both patients presented to the emergency room with acute diffuse abdominal pain. Other than that, a physical examination and routine laboratory workup did not reveal any pathological finding. An abdominal CT was performed in both cases. It showed mesenteric torsion as a sign of internal hernia in one case, but remained inconclusive in the other patient. Immediate diagnostic laparoscopy was performed in both cases. Intraoperatively, both patients revealed an internal hernia, where the common channel herniated through the mesojejunal space. The conversion to upper median minilaparotomy was necessary for hernia reduction in both cases. No bowel resection was required and both patients recovered fully.

A 90-year-old woman presented with abdominal pain and vomiting. Initial investigations revealed diffuse abdominal tenderness and fever, combined with leucocytosis and marked elevation of C reactive protein levels. Abdominal CT demonstrated segmental bowel wall thickening in the jejunum near the tip of a ventriculoperitoneal (VP) shunt, which had been placed 17 years before because of hydrocephalus. Pneumobilia was present but no ectopic gallstone was detected at the initial analysis and there were no signs of mechanical ileus. Immediate laparoscopy was performed to exclude small bowel ischaemia. Owing to purulent ascites the VP shunt was externalised, supposing VP shunt infection with reactive jejunitis to be the main problem. Antibiotic treatment was then administered and the remaining part of the shunt was removed 6 days later. However, clinical signs of intestinal obstruction have been aggravated. Therefore, a laparoscopy was repeated 3 days later and a gallstone ileus was diagnosed. After enterolithotomy through a minilaparotomy, the patient was fully recovered.