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Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving apocrine glands of the skin. It carries out an important burden on the daily life of the patient. Unfortunately, it presents a major concern for medical care management in the absence of clear guidelines for proper medical and surgical treatment. Hence, we report a case of concomitant axillary and perianal HS. We opted for surgical management using a novel technique, which proved efficacy for a year of follow-up recurrence free.

Highlights • The spleen is normally located in the left hypochondriac region just underneath the 9th to 11th intercostal spaces. • Splenoptosis, wandering spleen or floating spleen, is a rare entity in which the spleen migrates from its normal position. • The diagnosis is confirmed by imaging modalities. • The only definitive treatment is surgical intervention., Background Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. Case presentation In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

Highlights • Adrenal incidentalomas are tumors found accidentally by imaging. • Hemangiomas are quite rare and in certain cases their surgical intervention should never be overlooked. • Embolization is primarily implied but one should never neglect the failure rate and the need for surgical intervention. • There are 4 types of AH: cavernous hemangioma, venous hemangioma, capillary type hemangioma, and mixed hemangioma. • To our knowledge, our case has the largest size of an AH being reported in the literature with a 17 cm., Introduction Adrenal incidentalomas are tumors found accidentally by imaging. Among the incidentalomas, hemangiomas are quite rare and in certain cases their surgical intervention should never be overlooked. Presentation of case We present a case of 70 years old Lebanese female with an adrenal tumor presented as syncope found to have anemia on presentation and a bleeding 17 cm adrenal tumor on imaging. Patient had workup to rule out functioning adrenal tumors and decision to excise the tumor was taken after failure of embolization. Pathology report denied malignancy despite of the huge size and was in favor of hemangioma. Conclusion Adrenal hemangiomas are rare and they rarely present as syncope. Attention to such a life-threatening condition should be sustained. Embolization is primarily implied but one should never neglect the failure rate and the need for surgical intervention.

Highlights • Adenomyoepithelioma is a rare tumor of the breast characterized by a biphasic proliferation. • Variable spectrum of behavior ranging from benign to malignant, with tendency to local recurrence. • Combine sentinel lymph node dissection (SLND), with simple mastectomy. • Hematogenous spread is the more common means of spread. • Adjuvant chemotherapy for malignant AME cases is recommended., Background Adenomyoepithelioma is a rare tumor of the breast characterized by a dual/biphasic proliferation of two cell populations: the epithelial cells and the myoepithelial cells. The first case was reported in 1970. The majority of the cases are benign, but few malignant cases were reported in literature. Case presentation A case of a 66-year-old lady presenting with an asymptomatic breast mass, of 18 × 17 × 15 mm size with irregular borders and negative metastatic workup. The patient was operated for wide local excision of the tumor, with a confirmed negative margins intraoperatively. The final pathology was Adenomyoepithelioma. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of breast mass.

Highlights • Duodenal diverticula is mostly found incidentally and it rarely complicates by perforation. • Treatment is only indicated in complicated duodenal diverticula. • Micro perforation in the absence of systemic signs are better treated with conservative management. • Among surgical options diverticulectomy and single layer closure was performed. • Other surgical intervention could involve segmental duodenectomy or pylorus-preserving duodeno-pancreatectomy., Introduction Duodenal Diverticula is not uncommon and it is mostly found in the 2nd part of the duodenum. Despite the fact that it is mostly found incidentally, it can complicate however it rarely complicates by perforation. Treatment is indicated only in complicated cases and it is divided into conservative and surgical arms. Presentation of case It is a case of 78 years old Lebanese female that was diagnosed intra-operatively with a perforated duodenal diverticulum after presenting with post prandial abdominal pain, distention and pneumoperitoneum on imaging. Our case was consistent with previous reports where the diverticulum occurred in the second part of the duodenum. We opted for primary resection of the diverticulum and over-sewing. Moreover, patient had an uneventful post-operative course and progressed gradually to be discharged on day 10. Conclusion Our case aims to draw attention to a rare complication of duodenal diverticula and to widen the differential diagnosis of pneumoperitoneum thus concluding about the better treatment option. Previous reports show that proper management is still a controversial topic; however surgical approach is indicated in case of systemic signs.

Highlights • CAP can be a challenging diagnosis, with a presentation of acute abdominal pain mimicking a surgical abdomen. • In pediatric patients pneumonia is considered as the main extra-abdominal cause of acute abdominal pain. • Abdominal Pain mimics is an entity by itself with a vast differential diagnosis. • Acute abdomen requires precise and rapid diagnosis and treatment to avoid an increase in mortality. • Laparoscopy is safe and effective in setting the diagnosis., Introduction Community acquired pneumonia usually presents with typical clinical and radiological signs allowing for a quick diagnosis. Nevertheless, pneumonia can infrequently mimic acute abdominal pathologies, leading to invasive unnecessary procedures. Presentation of case We report a case of a 44-year-old man, previously healthy, admitted with a diagnosis of a surgical abdomen, investigated with an exploratory laparoscopy after inconclusive imaging and failure of improvement. Clinical evolution revealed the diagnosis of pneumonia. Discussion Community acquired pneumonia is a frequently encountered condition. While its clinical presentation is usually related to the respiratory system, extrapulmonary manifestations, including abdominal pain in the pediatric population, are well documented. However, solely severe acute abdominal pain, being as the major presentation, without respiratory symptoms or radiological signs is very rarely reported. Conclusion Community acquired pneumonia can sometimes be a challenging diagnosis. Acute abdominal pain mimicking a surgical abdomen is an infrequent presentation but can confuse physicians when no radiological or clinical signs of pneumonia are present.

Highlights • Liposarcomas are a malignant transformation of fat tissue, found in two major subtypes according to their differentiation. • Enhanced CT is essential for diagnosis and confirmed by percutaneous large core needle guided biopsies. • Surgery remains the standard practice in treating non-metastatic liposarcomas. • No clear definition for giant liposarcoma, Only 52 cases reported between 1998 and July 2020. • Our patient has the longest reported follow up in the literature of 10 years, with 3 operations and 3 recurrences., Introduction This case is of a patient with a recurrent giant retroperitoneal liposarcoma, followed-up and operated multiple times over 10 years. We report this case because of its rarity and review all previous articles reporting “Giant Retroperitoneal Liposarcoma” in the English literature. Case description A 70 years old man presented to our clinic for dizziness and fatigue. He was incidentally found to have a large retroperitoneal mass filling all the length of the abdominal cavity and shifting all intraabdominal viscera and kidney to the left side. En bloc excision of a 50 × 30 × 18 cm, 9 kg tumor was performed. Final pathology revealed a well-differentiated liposarcoma. Five years later, the patient was reoperated for recurrence and a well-differentiated liposarcoma was excised in 2 pieces (the biggest measuring 14 × 11 × 7 cm) along with the appendix. Four years later the patient was operated on again for a second recurrence, and again a well-differentiated liposarcoma (16 × 10 × 7 cm) extending into the right inguinal canal was excised. One year thereafter, the patient was diagnosed with a third recurrence (22 × 12 cm). Discussion Retroperitoneal Liposarcomas are rare tumors, presenting with different histological differentiation. They are diagnosed using multiple imaging modality, mainly CT scan, and it is confirmed by percutaneous large core needle biopsy. R0 Surgical excision remains the proper treatment for non-metastatic tumors, which may necessicate multiorgan resection. They rarely grow to reach a large size and be labled as “Giant Retroperitoneal Liposarcoma”.

Highlights • The small intestine is an essential constituent of the digestive system and plays a major role in the absorption of nutrients. • Acute mesenteric ischemia remains an emergency case. • Failure to adapt and the inadequate nutritional supply result in Short bowel syndrome. • A minimal indispensable length is required for nutritional autonomy. • Parenteral Nutrition still presents a pertinent problem of complications, charges and impairment in quality of life., Introduction The small bowel is an essential organ for maintaining adequate nutrition. Decrease in length could be associated with malnutrition and may require that the patient receives parenteral nutritional support. We report a case of a 59-year-old man who survived32 years with a short bowel of 35 cm length without any parenteral nutrition. Case presentation A 59-year-old gentleman, with a history of hypercoagulable state, presented for severe abdominal pain and obstipation of one day's duration. Upon presentation, the patient was hemodynamically unstable, with abdominal guarding and tenderness upon physical examination. Laboratory studies showed metabolic acidosis with leukocytosis and electrolyte disturbances, and an abdominal CT scan showed thickening of the sigmoid and multiple air-fluid levels. The patient was operated urgently for suspicion of mesenteric ischemia, however, he was found intraoperatively to have a very short dilated small bowel with jejunotransverse anastomosis. Discussion The necessity for surgical resection of the small bowel can arise for a sum of reasons. However, the removal of a big amount of small bowel may not be adaptive and appropriate digestion will no more be possible. In the aftermath of the resection, patients require parenteral nutrition for a certain period after which they may switch to enteral and oral nutrition, and subsequently intestinal adaptation by thickening and growth of the remaining intestinal villi. Conclusion Patients with a short bowel, particularly those surgically removed, can survive even with a very short remaining bowel length, as a result of intestinal adaptation, nutrition enhancement, and elimination of parenteral nutrition.

Highlights • Bouveret’s syndrome is a rare entity which takes part of the gallstone ileus entities. • There are no standardized recommendations for workup and management, and there is a high chance of misdiagnosis. • In front of its vague presentation, various differential diagnosis should be taken into consideration. • The diagnosis is usually confirmed by CT scan, showing the fistula and Rigler’s Triad. • Surgery is most of the times the definitive treatment., Introduction This report is a case of proximal gastric outlet obstruction, misdiagnosed after esophagogastroduodenoscopy as invasive pancreatic malignancy. We report this case because of its rarity and to encourage physicians to take this etiology into consideration as part of differential diagnosis. Presentation of case We present a case of 88 year-old lady presenting for 3 days history of post-prandial coffee ground vomiting associated with obstipation, misdiagnosed as pancreatic malignancy with duodenal invasion after outpatient gastroscopy. The proper diagnosis was confirmed by CT Scan which revealed the presence of large calculi with aerobilia and gastric stasis. Surgery done to extract two impacted large gallstone of 2 × 2 × 1 and 6 × 3.5 × 3 cm followed by cholecystectomy, closure of fistulae, gastrojejunsotomy and vagotomy. Discussion Bouveret Syndrome is referred to as rare presentation of gastric outlet obstruction by passage of large gallstone through a fistula between the gallbladder and proximal gastrointestinal tract. It has a vague presentation, and can be misdiagnosed due to non-specific symptoms. The diagnosis is usually confirmed by a CT scan and it is treated surgically most of the time. Conclusion Bouveret syndrome is a rare entity, and should be taken into consideration as a differential diagnosis in front of proximal gastric outlet obstruction.

Highlights • Gastric stenosis is seldom encountered in adult patients. Suicide attempt should be considered as differential diagnosis. • Multiple etiologies results in gastric stenosis. They do not usually cause acute gastric obstruction. • Both acidic and alkaline chemicals are implicated. • 4th type of gastric strictures is the “Linitis-Plastica-like” appearance. • The management of caustic gastritis ranges from supportive to surgical treatment., Introduction This report is a case of a suicide attempt by bleach ingestion. mistaken for gastric cancer after oral contrast studies and esophagogastroduodenoscopy. We report this case to encourage physicians to take this etiology into consideration as part of differential diagnosis especially in front of a secretive patient. Presentation of case We report a case of a 38-year-old lady admitted for an acute onset of symptoms leading to a diagnosis of antral stenosis. Further workup which included endoscopic and surgical biopsies failed to reveal an underlying malignancy. After 24 days of inconclusive inpatient investigations, and due to failure of conservative treatment, distal gastrectomy was performed. Final pathology also revealed an absence of any signs of malignancy, and reported only inflammatory changes. One month after discharge, the patient confessed that she had attempted suicide by ingestion of corrosive agents before the symptoms started and wanted to keep the incident as a secret. Discussion Gastric stenosis is seldom encountered in adult patients, however, it can occasionally result secondary to gastric ulcer disease, malignancies, foreign body ingestion, certain drugs or chemicals, or after endoscopic or surgical interventions. These etiologies do not usually cause acute gastric obstruction, and usually follow a more indolent course. Identification of an underlying etiology is mandatory to determine the proper medical or surgical treatment to relieve the obstructive symptoms. Conclusion We report this bizarre case to encourage physicians to keep this etiology in mind in otherwise unexplained gastric stenosis.

Highlights • CAIS is a rare sexual development disorder with X-linked recessive inheritance. • Usually present with primary amenorrhea, inguinal hernias and with near normal female external genetalia. • Testosterone levels are equal or higher than in male. Different imaging types together with karyotyping are crucial in diagnosing. • Treatment debates include prepubertal or postpubertal Gonadectomy. • CAIS must be suspected in any case of young females with bilateral inguinal hernias., Introduction Complete Androgen Insensitivity Syndrome (CAIS) is a rare sexual development disorder with X-linked recessive inheritance. It is prevalent in 1:20400 to 1:99000 of female phenotypes, yet characterized by an XY genotype. Cases of CAIS usually present with primary amenorrhea together with unilateral/bilateral inguinal hernias. Case presentation A previously healthy 19 year old sexually inactive girl presents to our clinics for delay in menarche and bilateral palpable inguinal masses 3 years ago. She has normal female habitus, tanner stage 3 and external female genetalia with sparse pubic hair. She has a family history of 2 aunts (mother side) having infertility with Bilateral inguinal hernias surgery. Hormonal tests showed male range testosterone levels. MRI showed bilateral inguinal masses with Mullerian structures agenesis and a misdiagnosis of Mayer-Rokitansky-Küster-Hauser syndrome (MRHKS) was interpreted. While karyotype showed XY genotype. She is then planned for bilateral orchiectomy. Final pathology of the 2 specimens taken showed testicular tissue correlating with CAIS. Discussion CAIS patients presents with near normal female external genetalia, absence of Mullerian structures, taller status than regular females and testosterone levels equal or higher than male levels. Different imaging types together with karyotyping are crucial in diagnosing and differentiating CAIS from other entities such as MRHKS and Swyer syndrome. Treatment debates include prepubertal or postpubertal gonadectomy correlating with the age related malignancy rate and site of testis followed by Hormonal replacement therapy. CAIS management needs a multidisciplinary approach and decisions by the patient or his family sometimes. Conclusion CAIS must be suspected in any case of young females with bilateral inguinal hernias as in our case, and precise diagnostics tests such as MRI and Karyotyping must be done followed by biopsy or excision for diagnosis and then adequate treatment. Hormonal therapy must be continued after gonadectomy that is best to be postpubertal.

Highlights • There’s no consensus on definitions & types of intrabiliary hydatid rupture. • Original classification included either frank or occult rupture. • Hydatid cyst rupture should always be ruled out as a cause of biliary obstruction. • MRI may miss the diagnosis, and ERCP is valuable in diagnosis and treatment. • Surgical removal of the mother cyst is essential for treatment., Introduction A 64-year-old lady was diagnosed with having a klatskin type 3A tumor based on imaging, however, an alternative diagnosis was achieved during surgery. Presentation of case We present a case of a 64-year-old lady who presented for new-onset jaundice and was diagnosed with type 3A klatskin tumor based on MRCP findings. During surgery, it was revealed that the obstruction was caused by a frank intrabiliary hydatid cyst perforation. Choledocoscopy with irrigation, cholangiography, and removal of the mother cyst were performed, and an end-to-end biliary anastomosis over a t-tube was then done. The patient tolerated the intervention and recovered well. Discussion Hydatid cyst disease of the liver usually follows a benign course, however, intrabiliary rupture is one of the common complications associated with this disease. Intrabiliary rupture is classified into either frank or occult. Frank perforation, which is more common, is when hydatid material passes into the biliary ducts, and it may cause biliary obstruction and cholangitis with a high mortality rate. Occult perforation is when the hydatid cyst becomes infected itself, which usually leads to a silent presentation, and may only cause signs of suppuration. Diagnosis is usually achieved by imaging and relevant history. Treatment consists of medical and surgical intervention. Intraoperative cholangiography, choledocoscopy, and t-tube drainage are recommended during surgery for frank rupture. Conclusion Intrabiliary hydatid cyst perforation can mimic cholangiocarcinoma and must be considered as an alternative diagnosis in these patients prior to surgery.

Introduction Vascular access is essential in the management of patients, and sometimes poses a problem, especially in patients requiring chronic treatment. Surgical insertion of the port-a-cath solved this problem by providing easy access, but unfortunately, it's associated with some complications. Case presentation We present a case of 32 year-old woman, diagnosed with advanced breast cancer, admitted for insertion of a port-a-cath for neoadjuvant chemotherapy. A few hours after the operation, the patient developed hoarseness and a cough. A flexible laryngoscope showed the left vocal cord which was fixed in the middle position and did not move, while the other maintained normal motility. The patient was treated conservatively. Conclusion This case demonstrated a rare and unexpected complication of the insertion of a port-a-cath, which is the result of an injury to the recurrent laryngeal nerve. We are reporting this case to encourage physicians to take note of this complication and know how to manage it., Highlights • Vascular access is primary in the management of patients • Insertion of an implantable chamber catheter is used mainly for chemotherapy • It is considered a safe surgical intervention • Damage to the recurrent laryngeal nerve can cause vocal cord paralysis • In most cases they recover by themselves

Introduction Duodenal teratoma is a rare condition with only four cases reported in the English literature. Radiological imaging and tissue sample are necessary for diagnosis in addition to tumor markers. The most effective treatment is still complete excision with safety margins. Case presentation We report a case of 26 years-old-man, in whom epigastric pain, decreased appetite, and postprandial bilious vomiting had been prevalent for 5–6 months and had exacerbated prior to the emergency room. Enhanced abdominal computed tomography revealed a 10 × 15cm heterogeneous solid mass with cystic component in the third duodenum segment. The inferior veina cava and aorta were both compressed, although there was no sign of lymphadenopathy or ascites. An ulcerating non-bleeding lesion at the D2-D3 junction of the duodenum was discovered during a gastroduodenoscopy. Biopsies and immunohistochemical investigations revealed findings that were consistent with a mixed non-seminomatous germ cell tumor. A PET-CT scan was performed, which revealed FDG uptake by the duodenal lesion but no evidence of metastatic lesions. A distal duodenal segmentectomy is performed, and then a duodeno-jejunal anastomosis is used to restore continuity. The final diagnosis was teratomatous tumor of the duodenum without malignant changes. Conclusion This is the second adult case of main duodenal teratoma that has been reported. We publish it to encourage surgeons to think about this differential diagnosis and carefully plan surgery using a multidisciplinary approach., Highlights • Duodenal teratoma is an extreme rare disorder. • Tumor markers, radiological imaging, and tissue biopsy are required for diagnosis. • Complete excision with safety margins is gold standard. • We report the fifth case in literature.

Highlights • Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. • Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. • Histopathology and immunohistochemistry are the gold standard in diagnosis. • Resection/surgery is the mainstay treatment., Introduction Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. Gastric type is usually asymptomatic or may show nonspecific symptoms. Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. Presentation of case A 42 years old healthy female presenting with chronic symptoms for epigastric discomfort and mild nausea. Labs showed mild anemia. A gastric lesion was detected by Endoscopy and being studied by echo-endoscopy and needle aspirate. Gastric Inflammatory fibroid polyp was diagnosed after distal gastrectomy by histopathology and immunohistochemistry. Conclusion Gastric inflammatory fibroid polyp is a preoperative diagnostic challenge of unclear pathogenesis. Histopathology and immunohistochemistry are the gold standard. Studies around this exact pathology are required for better management and prevention.

Highlights • Ectopic adrenocortical tissue is a rare finding that can be encountered in inguinal hernial sacs of adults. • Surgeons should be aware of this and are encouraged to resect Ectopic adrenocortical tissue when grossly identified. • Secondary hyperplasia after adrenalectomy, adrenal insufficiency, and neoplastic transformation should all be considered., Introduction A 37-year-old male patient operated for inguinal hernia repair was found to have ectopic adrenocortical tissue in the hernial sac. Case presentation A 37-year-old man was admitted for bilateral inguinal hernia. An uneventful open repair was done, and the resected hernial sacs were sent to pathology. Histopathology reported the presence of adrenocortical tissue in the right inguinal hernial sac. Discussion Ectopic adrenocortical tissue (EACT) in the groin region is not an unusual finding in children, however, it’s rarely reported in adult patients. Only 9 cases have been reported in English describing EACT in an adult’s inguinal hernia. The finding can be attributed to the close proximity of the developing gonads and adrenal cortex during embryogenesis, and subsequent mechanical translocation of adrenocortical tissue during testicular descent. Some theoretical clinical implications exist for this condition, including secondary hyperplasia after adrenalectomy, adrenal insufficiency in certain situations, and possible neoplastic transformation. Generally, it is recommended that surgeons resect ectopic adrenal glands when identified intra-operatively. However, actively searching for these glands has no known benefit and carries some surgical risks, and is hence not recommended. It is reasonable as well, that clinicians keep the clinical implications of this finding in mind during future follow-ups with such patients. Conclusion The presence of ectopic adrenocortical tissue in inguinal hernia sacs is a rare encounter in adults. The condition can have several theoretical clinical implications that need to be considered by surgeons while assessing patients in whom this phenomenon is observed.

Highlights • Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases. • Pseudo-aneurysm is an overlooked complication. • Angiography followed by embolization is best for diagnosing and treating. • Common risk factors for pseudo-aneurysm include, infection, trauma, neoplasm, inflammation and surgery. • Treatment was surgical, this case was treated by interventional radiology., Introduction Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases however pseudo-aneurysm is an overlooked complication. Case For instance, we present case of a 25 year-old Lebanese woman that undergone sleeve gastrectomy and presented 3 weeks later with a bleeding left gastric artery pseudo-aneurysm. Conclusion Angiography followed by embolization is best for diagnosing and treating the pseudo-aneurysm by coiling. Serious outcomes could arise from such a complication. Hence, accurate diagnosis and treatment using the appropriate methods is essential to avoid life-threatening events.

Highlights • RI is a mysterious pathophysiology that is still uncommonly present post Roux en Y gastric bypass. • Exploratory laparoscopy is a more confirmative diagnostic option. • The state of the intussuscepted intestine determines the plan of treatment. • The most adequate surgical treatment technique is still debatable., Introduction Intestinal intussusception is an uncommon entity when preceded by Roux en Y gastric bypass. Retrograde intussusception is an enigmatic phenomenon characterized by reversely intussuscepted intestinal loop that may involve any piece of the Roux en Y limbs. Computed Tomography is gold standard for diagnosis. Surgical management is highly debatable. Case presentation A 35 years old female known for morbid obesity, post roux en Y gastric bypass since 5 years with 100 % excess weight loss presenting for on-off episodes of small bowel obstruction symptoms. She was diagnosed laparoscopically for retrograde intussusception that was reduced easily with closure of Peterson’s pouch due to high suspicion of an internal hernia. She did well postoperatively and followed up adequately with no recurrence of her symptoms. Conclusion Retrograde intussusception remains an interesting uncommon phenomenon in the horizon of the roux en Y gastric bypass surgeries. Several surgical options were discussed in the last 12 years and they are still debatable.