Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. Discussion: The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby’s head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely ‘Compressed Baby Head’. Conclusions: To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case’s uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.Background:  Indeed, child abuse encompasses abusive injuries of various types and entities, including acts of violence, sexual or non-sexual, as well as cases of neglect in the care, affection, and attention of a minor [The issue of l fields . The ter a minor .child abuse came with John Caffey when the author, in 1946, studied the fractures of the long bones of a group of children and their clinical aspects in the presence of chronic subdural haematoma, thus excluding systemic pathologies capable of causing them autonomously [In 2018, in the USA, data reported that 1770 children died due to neglect or abuse . The firShaken Baby Syndrome (SBS), identifying a cohort of lesions and symptoms that followed the violent shaking of an infant [Shaken Baby Syndrome strictly refers to a group of lesions and symptoms secondary to the violent shaking of the infant by parents or caregivers within the first year of life. According to the literature, SBS has a major incidence in the lower and middle social classes, and males are more affected than females in a ratio of 3:1. Several factors seem to be involved in the phenomenon of maltreatment, such as the low level of schooling of the parents or caregivers, in association with their inability to care for and provide for the child’s needs. In fact, ‘violent shaking’ mainly occurs when the child manifests difficult behaviours, such as uninterrupted crying and/or behaviour typical of childhood, that induce the parent/caregiver to make gestures of extreme violence [Around 40 years ago, Ludwig and Warman first introduced the term n infant . In partviolence .From a pathophysiological point of view, the peculiar clinical triad is represented by subdural haematomas, cerebral oedema, and retinal haemorrhages. Despite being inherently difficult to assess, the symptoms manifested by the infant take the form of changes in sleep/wake rhythm, vomiting, convulsions, inconsolable crying, anorexia, and generalised irritability. These manifestations are usually reported to the doctor by one of the parents or the caregiver. As a result, it is very often difficult to diagnose the injuries in time and thus bring the abuse to an end.The long-term sequelae observed are a consequence of the neurological damage caused by trauma or repeated trauma over time and are partial or total blindness, hearing loss, motor dysfunction, and intellectual disability, and in some cases, the complications are so severe that they lead to the child’s death.Early diagnosis is based on the semiotics of the signs and symptoms shown by the infant, as well as on the indispensable assistance of imaging diagnostics; in particular, computed tomography (CT) and magnetic resonance imaging (MRI) can aid in delineating subdural haematomas and cerebral oedema, which, according to the literature, are located in the parietal and occipital areas. A further diagnostic tool is represented by the examination of the ocular fundus, which represents the gold standard for detecting retinal haemorrhage, responsible for the long-term sequelae affecting the infant’s vision. Late diagnosis can also be made by studying the neurological complications and encephalic lesions observable by MRI detecting hypoxic–ischemic encephalic areas ,10,11,12Abusive Head Trauma; shaking is often reported in the literature to be associated with impact. Thus, a variant of SBS is defined as Shaken Impact Syndrome, in which the child is not simply shaken furiously but thrown violently against a surface, even if not necessarily a hard and rigid one. The impact produces a fracture or a group of focal, unilateral fractures [However, it should be pointed out that shaking is not the only mechanism of injury described in the spectrum of ractures .Shaken Impact Syndrome. As reported by Cory M. Pfeifer, vitamin D deficiency and/or genetic defects of ossification can be involved more or less significantly in the determinism of the fracture lesions, thus mystifying what has been objectified by the instrumental investigations [In this case, the clinical and pathological profile presented by the infant who comes to the doctor’s attention is almost superimposable to what is observed in SBS. However, the picture is burdened by cranial, vertebral, and/or long bone fractures as a result of the infant being projected against a surface. Diagnosis by MRI and CT turns out to be the fundamental diagnostic means for detecting the lesions produced as well as their timing through the observation of reparative phenomena or relict outcomes. However, it is necessary to specify that the staging of the lesions and their correlation to a traumatic event rather than an accidental one remain one of the most critical problems in igations ,15.However, in addition to shaking the child, violent impact against a blunt surface or the combination of the two traumatic mechanisms can generate clinical manifestations similar to SBS. For this reason, first the American Academy of Pediatrics and later the Centers for Disease Control and Prevention (CDC) defined the term abusive head trauma (AHT) to identify the set of clinical manifestations and injury mechanisms associated with abusive head injuries, judging the term to be more appropriate and precise ,17.The effects of AHT are catastrophic, as it is the leading cause of mortality and morbidity in children under the age of two years; AHT produces situations of marked long-term physical and intellectual disability, such as convulsions, cerebral palsy, and intellectual and learning deficits due to the severe encephalic lesions produced by the trauma, leading to death in about a third of cases ,19,20.The diagnosis of AHT is very complex due to the heterogeneity of the clinical and radiological signs, as well as the absence of external injuries in about 40% of cases and a generally unreliable clinical history . For theShaken Baby Syndrome or Shaken Impact Syndrome. In particular, within the various nosological realities that fall within the spectrum of abusive head trauma, this study aims to emphasize the injury dynamics that mainly involve the cranial district.Within the spectrum of clinical, radiological, and forensic manifestations related to abusive head trauma, the authors will present the case of an abused child, in which the injury modality appears to be different from those described so far in the literature and therefore cannot be categorised either as The aim of our study is, therefore, to identify a different injury mechanism from those described in the literature, i.e., to propose a new nosological entity in the field of abusive head trauma.Nicola (fictitious name) was born in May 2013 to a healthy young woman with an excellent socio-economic background. The course of the pregnancy was regular and free of complications, and the intrauterine development of the foetus was normal and consistent with the gestational age. Delivery was eutopic and spontaneous, with no reported difficulties in the expulsive phase, facilitated by episiotomy, with the foetus in occipito-iliac-left-anterior presentation. At birth, Nicola presented an APGAR of 9 in the first minute and an ND of 10 in the fifth minute, with a negative neuromotor examination and nothing significant on objective examination.Twenty-one days after his birth, the baby was taken by his parents to the paediatric emergency room in his hometown due to uncontrolled crying and impotence of the left upper limb. The doctors performed an X-ray of the left upper limb, which showed irregularities of the cortical profile in the proximal clavicular area, with thickening of the soft parts. The picture was compatible with a traumatic injury with active reparative phenomena.This finding was associated with childbirth.Ninety days after his birth, at 5 a.m., Nicola was again taken by his parents to the emergency room. During the clinical examination, the doctors observed a distressed appearance, plaintive crying, rigidity of all four limbs, pulsating bregmatic fontanelle, pale skin, and a body temperature of 38.3°.The initial clinical suspicion was of an ongoing infection, so Nicola was transferred to the infectious diseases ward. During the transfer to the ward, the baby was seized by repeated tonic–clonic convulsions.Diagnostic–instrumental and laboratory tests were prescribed.Unfortunately, no information is in our possession regarding medical–legal management at the time of the event, but we acquired all the clinical records 10 years after the event.Nicola underwent a thorough, objective examination, which revealed the presence of multiple small ecchymotic lesions in different body regions: frontal, nasal, right and left cheek, chin region, right nipple, left gluteal region, and fifth finger of the right hand. The lesions mentioned above were described and documented with different colour stages, probably occurring at different times.The infant underwent a specialist ophthalmic examination, which objectified the presence of diffuse oedema of the retina on the right, extending to the posterior pole, with congestion of the venous vessels. On the left, there was modest oedema of the upper eyelid and bulbar conjunctiva, as well as the presence of intraretinal and preretinal haemorrhages, some loculated, with no visualisation of the optic papilla, macula, and ipsilateral fovea.The cranial CT scan performed immediately after hospital admission showed the presence of diffuse cerebral oedema, as well as two lesion complexes:First lesion complex  at the l-Inferior “branch” (A), with a linear course, extending cranio-caudally and involving the internal cranial plateau and the full-thickness diploe;-Upper “branch” (B), linear course, extending caudo-cranially, to the left, terminating at the posterior third of the sagittal suture;-Posterior “branch” (C), linear course, extending antero-posteriorly, ending at the lambdoid suture.Second lesion complex  at the lTaken together, the three fracture “branches” described above, together with the sagittal suture and the right branch of the lambdoid suture, identified the structure of a quadrangular ‘baseball diamond’-like dowel.A right parietal subgaleal haematoma and a subdural and subarachnoid haemorrhage in the homolateral fronto-parietal-temporal area were also revealed .The appearance and extent of the haematomas were highlighted bilaterally, and the characteristics of the radiological images suggested that they may have appeared at the same time.The newborn underwent a control brainstem and encephalic MRI on the same day. This investigation, in addition to confirming the presence of the right and left subgaleal haematomas already shown by the cranial CT scan, highlighted the presence of diffuse cerebral oedema, a right parietal subdural haematoma, subdural haematic effusion localised between the sickle and tentorium of the cerebellum, epidural haemorrhage at the posterior cerebellar site, intraparenchymal cortical haemorrhage at the left temporal site, frontobasal subarachnoid haemorrhage bilaterally, and hygromatous stratum at the left frontotemporal site.The infant also underwent a chest X-ray, which showed the presence of multiple rib fractures and a left clavicular fracture. The lower limb X-ray documented the presence of a tibial diaphyseal spiral fracture bilaterally undergoing ossification, with the presence of bony callus more significant on the left tibia .Subsequent radiological investigations carried out during the infant’s stay in the ICU did not reveal any presence of vertebral and/or spinal cord lesions. On the contrary, they confirmed the evolution of the cranio-encephalic lesion complex, attesting to the appearance of diffuse ischaemic phenomena at the encephalic level, as discussed below.Subsequent instrumental investigations were performed on the baby to assess cranio-encephalic outcomes. In particular, the MRI  performeFollowing the preliminary clinical investigation, the medical personnel on duty suspected infant maltreatment and therefore informed the judicial authority. The court ordered the immediate removal of the newborn from the family and relocated him into foster care.In the months and years that followed, the newborn was subjected to numerous wide-ranging genetic investigations to exclude any possible malformations and/or bone changes related to systemic diseases or genetic syndromes, which could have been the cause of the numerous bone fractures found.In particular, a molecular analysis of the COL1A1 and COL1A2 genes, responsible for the pathogenesis of osteogenesis imperfecta, was immediately carried out, which yielded negative results.Nicola was then subjected to CGH array analysis ,24, whicThe study of the genetic data acquired excluded a correlation between the microduplication found in Nicola’s DNA and his clinical picture, characterised by multiple-region fractures.The baby was also subjected to exome analysis by next-generation sequencing (NGS) ,26. ThisIn conclusion, the genetic investigations on baby Nicola allowed the authors to exclude the possibility that the immediate and subsequent severe cranial and neuropsychic injury and multidistrict fracture could be related to a genetic origin.Overall, the injury pattern observed in the newborn involved different body districts, with a more significant predominance of trauma in the cranium .child abuse. Referring to the definition given by the World Health Organization in 2002, ‘Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power’ [The analysis of this case study allowed us to better investigate the topic of r power’ .Within this context, multiple terms have been used over the years to define child maltreatment, such as ‘battered child syndrome’, ‘parent infant traumatic stress syndrome’, and ‘shaken baby syndrome’, but the most preferred term since 2009 is ‘abusive head trauma’. To diagnose one of these syndromes, it is necessary to subject the child to a thorough, objective examination and a targeted instrumental investigation. Of great importance is the role played by instrumental investigations such as CT and MRI as well as fundus oculi and retinal examination ,29.child abuse in general or the diagnosis of Shaken Baby Syndrome or Shaken Impact Syndrome [Although diagnostic criteria and helpful advice for the diagnosis and the treatment of such syndromes are widely described in the literature, in clinical and forensic practice, there may be more complex cases of difficult approaches. This is determined by the presence of heterogeneous and non-specific clinical and radiological data and, above all, the absence in 40% of cases of external injuries on the child’s body, which could better guide the diagnosis of Syndrome ,22,30.Abusive Head Trauma: vitamin D deficiency, metabolic disorders, skeletal pathologies , infections, glutaric aciduria type I, bleeding diathesis, connective tissue diseases and vasculopathies, Wormian bones, and congenital skull depression [Furthermore, excluding alternative causes that may have led to a compromised systemic picture in the child, with the presence of injuries that may mimic ecchymoses and/or traumatic fractures, is of considerable importance. It is worth remembering that there are specific systemic pathologies, including metabolic ones, that can mimic the lesions typical of pression .Abusive Head Trauma, including routine laboratory tests useful for studying coagulation as well as neonatal screening tests. The same guidelines also recommend cranial CT and MRI imaging of the brain and of the vertebral column [The American Academy of Pediatrics (AAP) has established guidelines in cases of suspected l column . Anotherl column .For all these reasons, and because of the heterogeneity of clinical presentations, the Royal College of Radiologists (RCR) of the United Kingdom recommends the performance of instrumental cranial CT examination in every case of suspected child abuse under one year of age. In particular, if there is any evidence of intracranial haemorrhage, parenchymal injury, or skull fracture on the CT scan, the recommendation is to perform an MRI scan within 2–5 days. In case of a negative CT scan but in the presence of ongoing neurological symptoms, an MRI scan is still recommended .Moreover, it is essential to combine clinical and instrumental studies with genetic investigations in order to search for or exclude any genetic pathologies that may induce spontaneous fractures or lead to lesions following minor trauma, such as the genetic study involved in osteogenesis imperfecta .Shaken Baby Syndrome, i.e., the classic triad of subdural haematoma, cerebral oedema, and retinal haemorrhage, associated with more non-specific clinical manifestations such as subgaleal haematomas, multiple rib fractures, and long bone fractures [In the case study presented here, the child victim presented the characteristic symptoms and clinical signs of ractures .Shaken Baby Syndrome (SBS), also known as Abusive Head Trauma (AHT) [ma (AHT) , represema (AHT) ,37.Shaken Baby Syndrome, given the presence of fracture lesions, nor can it be classified as Shaken Impact Syndrome due to the two symmetrical fracture complexes observed.However, in the case presented by the authors, the presence of a typical cranial lesion characterised by two symmetrical fracture complexes on the parietal bones was highlighted. This picture neither fulfils the diagnostic criteria for The instrumental investigations performed on the child (a CT scan and an MRI scan) showed the presence of three radiating fractures on the right parietal bone, one inferior, one superior, and one posterior, which depart from the same point, defined as the ‘point of impact’. Finally, the shape and direction of the three branches, together with the sagittal suture and the lambdoid suture, made it possible to identify a quadrangular dowel resembling the shape of a ‘baseball diamond’.At the left parietal bone level, however, instrumental investigations revealed the presence of a single linear fracture rhyme, independent from the previous fracture pattern.Firstly, the timing of the aforementioned lesions was studied, which was possible thanks to the analysis and comparison of the CT and MRI images taken at the time of the newborn’s admission to the hospital when he was under the care of the first doctors who visited him. Based on these data, it was possible to assume that the cranio-encephalic traumatism detected on the newborn child dated back to the hours immediately prior to admission to the hospital.In this sense, according to the objective characteristics of the ophthalmological instrumental investigations, it was possible to confirm that the retinal pathological complex, characterised by the presence of retinal oedema and haemorrhages, sometimes loculated, was also to be understood as occurring at the same time as the cranio-brain lesions, which means in the hours immediately preceding the baby’s admission to the hospital.Shaken Baby Syndrome, leading the authors to hypothesise that the injury mechanism responsible for the trauma observed was not just ‘simple’ shaking of the child.These findings were considered as ‘abnormal’ for the diagnosis of Shaken Impact Syndrome. In the Abusive Head Trauma context, it is possible to speak of Shaken Baby Syndrome by referring to a shaking mechanism of the child or an impact of the latter or a combination of the two traumatic actions, which will result in neurological injuries.  and one of which was smaller (on the left), led the authors to assume that this injury was produced by a double coeval impact, from both cranial surfaces, right and left, caused by a compressive action at the cranial level applied laterally.In particular, it was hypothesised, considering the site and the different entities of the fractures present, the associated subgaleal haematomas, more present on the right, as well as the absence of ecchymotic skin lesions at the cranial level, patterned or not, that the compression was determined by the action of a hand positioned on the left parietal bone, thus coherent with the linear fracture highlighted by the instrumental investigations. The compression, according to the authors, would therefore have been exerted from the left parietal bone towards the right parietal bone, which was resting on a rigid surface, hence where the lesion complex was most evident and where a point of departure of the three radiating fractures, called the ‘point of impact’, could be clearly observed. This is also confirmed by the radiological appearance and extent of the subgaleal haematomas found bilaterally at the cranial level, which allows us to affirm the contemporaneity of the lesions, which were therefore determined by a single traumatic mechanism.Furthermore, the predominance of fracture injuries over the shaking-related ones observed on the infant justifies the absence of vertebral injuries due to the discharge of kinetic energy acquired by the infant’s head impact on the right parietal bone.child abuse [‘Compressed Baby Head’ . The medical and forensic literature is of great help in identifying and recognizing even the most complex cases of child abuse, and the guidelines offer important help and recommendations to properly handle the case and the abused child.Abusive Head Trauma characterised by a double lesion complex at the cranial level, with symmetrical and bilateral localisation at the parietal bones. Through the study and analysis of the injuries found, the authors explained the cranial injury mechanism that may have determined the traumatic lesions observed in the child. The proposed mechanism is of compressive nature, thus identifying a new possible clinical entity included in Abusive Head Trauma: the ‘Compressed Baby Head’.However, some clinical cases can be complex and atypical. In this paper, the authors presented a case of Abusive Head Trauma.By presenting this case, the authors wish to propose to the scientific community that this new type of traumatic event should be included in the context of


Primary pericardial tumors are very rare with an overall incidence of 0.001–0.007 % and account for approximately 10 % of heart neoplasms. We present two clinical cases of massive mature intrapericardial lipomas (maximum size 270 × 230 mm) that were successfully treated in our department.The first case is that of a 67-year-old male patient who underwent diagnostic investigations after the onset of dyspnea, which confirmed an intrapericardial mass of 270 × 230 mm in size that extended into the left lung field and was treated surgically by a clamshell incision. The second case is that of a 48-year-old patient who was completely asymptomatic and occasionally confirmed to have a 170 × 110 mm intrapericardial mass around the heart, which was surgically removed via sternotomy, also resulting in a mature lipoma.In asymptomatic patients with small lesions, close monitoring is generally indicated. In asymptomatic patients with large lesions the decision should be made after multidisciplinary (MDT) evaluation. In symptomatic patients, surgical treatment is indicated. Lipomas are usually mature lesions with a capsule connected to the origin structure by one or more pedicles. Once reached the cardiac level and opened the pericardium, attention must be paid in resecting these pedicles given the area of origin and the possibility that they may be associated with vital structures.Both cases were characterized by slow recovery of normal cardiac function in the postoperative course. The average length of patient stay was 12 days, and one case was noted for readmission because a slight increase in pericardial effusion was detected at the scheduled ultrasound check after discharge. After further expert evaluation and steriodine therapy, the patient was discharged to a healthy home after 5 days. This report aims to describe the decision-making process, successful surgical treatment and outcomes of two rare massive intrapericardial tumors. •Primary pericardial tumors are rare with an overall incidence of 0.001-0.007% and account for ≈10% of cardiac neoplasms.•We present two clinical cases of massive mature intrapericardial lipoma (maximum size 270x230 mm) treated surgically.•Once reached the cardiac level and opened the pericardium, attention must be paid in resecting the pedicles.•Both cases were characterized by slow recovery of normal cardiac function in the postoperative course. When they cause clinical symptoms, it may depend on both the location of the lesion and its mass in relation to adjacent structures . Imaging22, pulse rate 76 bpm, blood pressure of 143/76 mmHg. ECG showed no significant changes. Chest X-ray in anteroposterior view showed significant enlargement of the cardiac silhouette [A 67-year-old man was referred to our department  because of progressive dyspnea, reaching level 3 on the mMRC dyspnea scale, and persistent fatigue. On examination, the patient had the following characteristics: BMI 31,1 kg/mlhouette .A. Subselhouette .B/C. Thelhouette .B/C and lhouette .D/E, whilhouette .F. Histo2, pulse rate 59 bpm, blood pressure of 110/65 mmHg. ECG showed no significant changes. After the CT scan, the mass showed homogeneous fat content at the intrapericardial level, completely surrounding the heart to the origin of the epiaortic vessels (maximum diameter 170 × 110 mm) [The second case was a 48-year-old female patient who was completely asymptomatic and was found to have an occasional mass on a Chest radiography prior to screening colonoscopy. The patient's characteristics were: BMI 19,6 kg/m 110 mm) .A. No di 110 mm) .B/C. His3Intrapericardial lipomas may occasionally occur in otherwise healthy individuals and therefore do not have a hemodynamic or compressive effect due to the impact of the mass on adjacent structures . When prIn symptomatic patients or those with bulky lesions, it is indicated to perform examinations that may include chest CT, Magnetic Resonance Imaging (MRI), and transthoracic echocardiography (TTE). During the assessment phase, attention should be paid to the location of the tumor and the relationships between it and adjacent structures. The effects of compression on the cardiac chambers and the relationships with the coronary arteries must be carefully studied.MRI also allows assessment of the density and homogeneity of the tissues composing the lesion and confirm the suspicion of tumors containing fat (lipomas or liposarcomas). Lipomas are characterized by the presence of mature adipose tissue, resulting in a homogeneous density of the structures that make up the lesion. Liposarcomas, on the other hand, are malignant tumors with a lower degree of differentiation that results in a nonuniform density ,8.Lipomas should be distinguished from liposarcomas not only by cardiac MRI features or imaging but also histologically.In asymptomatic patients with small lesions, close monitoring is generally indicated. In asymptomatic patients with large lesions, the decision should be made after multidisciplinary (MDT) evaluation. Key factors in decision making should include: tumor size, location and relationship to intrapericardial structures, growth rate, and ability to differentiate between lipoma and liposarcoma on imaging. The patient's wishes should also be considered. In symptomatic patients, surgical treatment is indicated .In the first case described, we opted for the Clamshell incision, which allowed us to surgically control the mediastinum at any site and to safely work on the entire cardiovascular system because the intrapericardial lipoma completely encircled the heart. However because the intrapericardial lipoma was predominantly anterior, we opted for a median sternotomy in the second case, which provided adequate control of the vascular and cardiac structures.Lipomas are usually mature lesions with a capsule connected to the originating structure by one or more pedicles. Once we reach the cardiac level and open the pericardium, we must be particularly careful when resecting these pedicles given the area of origin and the possibility that they may form relationships with vital structures .D. In caBoth cases were characterized by a slow recovery of normal cardiac function in the postoperative course, with an episode of atrial fibrillation that returned after pharmacological cardioversion and the occurrence of a pericardial effusion that did not affect the patients' hemodynamics and did not require drainage or pericardiocentesis. The average length of stay of patients was 12 days, and one case was recorded as a readmission because a slight increase in pericardial effusion was detected at the scheduled ultrasound check after discharge. After further expert evaluation and steriodine therapy, the patient was discharged to a healthy home after 5 days. Cardiac follow-up, performed in the second patient about one month after surgery, showed a gradual decrease in pleural effusion and normal cardiac function. The follow-up examination, performed about four months after surgery, showed vital signs in the normal range and normal cardiac function without pericardial effusion in both patients. The next cardiac and radiological follow-up is expected approximately 6 months after the last visit if there is no change in clinic.4MDT evaluation of each case is essential because massive intrapericardial lipomas are extremely rare lesions and there are many factors that must be evaluated to make the correct treatment decision. After appropriate preoperative evaluation, including CT and an MRI scan when possible, surgery may be indicated in asymptomatic patients if they have massive lesions that are growing rapidly or if imaging is insufficient to differentiate between lipoma and liposarcoma. Surgical procedures should be performed in high-volume centres. Once the surgical indication is made and the lesion removed, coordination with other medical players such as the anesthesiologist and cardiologist is equally important for optimal management of postoperative cardiovascular function.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The work has been reported in line with SCARE criteria .This article does not contain any study with human participants or animals performed by any of the authors. Our institutional review board granted approval and waived the requirement for specific informed consent for this case report.The authors declare that the research was conducted in the absence of any commercial or financial relationships.Simone Tombelli and Domenico Viggiano contributed to the study concept, acquisition and interpretation of data. Simone Tombelli and Alberto Salvicchi wrote the paper. Alessandro Gonfiotti and Luca Voltolini revising it critically for important content. All authors contributed to manuscript revision, read, and approved the submitted version.Simone Tombelli.Not applicable.The author declares that he has no relevant or material financial interests that relate to the research described in this paper. No conflicts of interest were shown.


The case presented is of a male patient in his 20s who initially underwent an appendectomy for suspected acute appendicitis. However, histopathological examination revealed the unexpected diagnosis of a neuroendocrine carcinoid tumor of the appendix. A subsequent right hemicolectomy was performed for complete tumor removal. Neuroendocrine tumors (NETs) of the appendix are rare neoplasms, accounting for approximately 0.3-0.9% of all appendix tumors ,2. TheseThe appendix, traditionally considered a vestigial organ without significant physiological function, has recently been recognized for its potential role in the immune system, acting as a reservoir for beneficial gut bacteria . DespiteNETs arise from neuroendocrine cells located throughout multiple organ systems, including the gastrointestinal tract, respiratory system, pancreas, and adrenal glands . These tAppendiceal NETs can be classified into three subtypes, namely, classic carcinoid tumors, goblet cell carcinoids (GCCs), and mixed adenocarcinoma-neuroendocrine tumors (MANETs) . ClassicDiagnosing appendiceal NETs can be challenging, as they often lack specific symptoms or may present with nonspecific complaints such as abdominal pain, bloating, or changes in bowel habits . Due to Imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can aid in the detection and characterization of appendiceal tumors. Notably, MRI with diffusion-weighted imaging (DWI) has shown promising results in identifying and distinguishing appendiceal tumors, including NETs . This noManagement of NETs of the appendix generally involves surgical removal of the appendix, with the extent of surgery guided by tumor characteristics and the presence of metastasis . LocalizIn some cases, adjuvant treatments such as chemotherapy or somatostatin analogs may be recommended, particularly for advanced disease or tumors with high-risk features such as lymphovascular invasion or positive lymph nodes . DecisioIn this case report, we present the incidental detection and management of a neuroendocrine carcinoid tumor of the appendix in a young male patient. Our report aims to underscore the significance of early diagnosis and appropriate management of such tumors, particularly in young patients who may have a longer life expectancy and an increased risk of metastatic spread. By sharing this case, we hope to raise awareness among clinicians and encourage timely recognition and intervention for similar cases in the future.A young male patient, in his late 20s, presented to the emergency department with a history of worsening abdominal pain localized to the right lower quadrant for the past 24 hours. He also experienced episodes of nausea and vomiting but did not report any other symptoms such as changes in bowel habits, unexplained weight loss, or similar episodes in the past. On physical examination, tenderness at McBurney’s point with guarding was observed, consistent with acute appendicitis. Laboratory investigations revealed an elevated white blood cell count and C-reactive protein level, while other parameters were within normal limits. An abdominal ultrasound showed an enlarged appendix that was non-compressible, along with the presence of free fluid, supporting the diagnosis of acute appendicitis.The patient was informed about the diagnosis and the need for surgical intervention, specifically a laparoscopic appendectomy. Informed consent was obtained, and the procedure was successfully performed without any intraoperative complications. The excised appendix, upon histopathological examination, revealed an unexpected finding of a neuroendocrine carcinoid tumor situated in the mid-appendix, measuring 1.5 cm in its largest dimension. The resection margins were clear, indicating complete removal of the tumor. However, due to the presence of the neuroendocrine carcinoid tumor, further imaging investigations were conducted to evaluate for possible metastasis. A CT scan of the abdomen and pelvis, along with an octreotide scan, showed no evidence of distant metastasis or lymphadenopathy.Considering the size of the tumor and after extensive discussions with the patient regarding the potential risks and benefits, it was decided to proceed with a right hemicolectomy to ensure complete excision of any residual tumor tissue. The right hemicolectomy procedure was performed without any complications, and the patient’s recovery in the postoperative period was uneventful. A picture of the specimen is shown in Figure Following the right hemicolectomy, the resected specimen was sent for further histopathological examination. The examination confirmed the presence of a neuroendocrine carcinoid tumor within the appendix, with clear resection margins, indicating successful removal of the tumor. The tumor was found to be located in the mid-appendix and measured 1.5 cm in its largest dimension. Microscopic analysis revealed the characteristic features of a well-differentiated neuroendocrine carcinoid tumor, including nests and trabeculae of uniform tumor cells with round-to-oval nuclei and finely granular chromatin. Mitotic activity within the tumor was low, and there was no evidence of lymphovascular invasion. Figure Given the unexpected finding of a neuroendocrine carcinoid tumor in a young patient, further discussions were held with the patient to understand his medical history, family history, and any potential risk factors for the development of this tumor. The patient denied any significant past medical history, including any previous gastrointestinal symptoms. Family history was negative for any known genetic syndromes associated with NETs. Genetic counseling was recommended to the patient to assess the potential underlying genetic predisposition; however, the patient declined genetic testing at this time.To assess the overall extent of the disease and evaluate for any residual tumor or possible metastasis, close postoperative follow-up was planned. This included regular physical examinations, measurement of tumor markers such as chromogranin A and serotonin levels, and periodic imaging studies such as CT scans. The patient was also advised to report any new symptoms or changes in his health status promptly.At the time of the report, the patient had completed his surgical treatment successfully and was recovering well. The multidisciplinary team, consisting of surgeons, oncologists, and pathologists, continued to monitor his progress and formulate a personalized follow-up plan based on his individual characteristics and tumor pathology. The aim was to ensure early detection of any potential recurrence or metastasis and to provide appropriate interventions to optimize the patient’s long-term outcomes.Neuroendocrine carcinoid tumors of the appendix represent a relatively rare pathology, often discovered incidentally during appendectomies performed for suspected appendicitis, as was the case in our patient. These tumors are generally small and found in the distal third of the appendix, contrasting with our case where the tumor was located in the mid-appendix and measured 1.5 cm [The management strategy for appendiceal neuroendocrine tumors is primarily dictated by the size of the tumor. Tumors measuring less than 1 cm can usually be managed with a simple appendectomy, given their low potential for metastasis. However, for tumors measuring between 1 and 2 cm, as in our case, the decision for additional surgery is guided by factors such as age, general health of the patient, and tumor characteristics .Our patient underwent a right hemicolectomy given the tumor size and location. This decision aligns with the European Neuroendocrine Tumor Society guidelines that suggest right hemicolectomy for tumors greater than 2 cm or for those with involvement of the base of the appendix, lymphovascular invasion, or high-grade tumors .Comparison to the existing literature reveals that our case mirrors the typical presentation and management strategies for appendiceal carcinoid tumors, with the exception of tumor location. This case underscores the importance of histopathological examination of the appendix, even in clinically straightforward cases of acute appendicitis. It also emphasizes the need for a multidisciplinary approach in managing such incidental findings to ensure optimal patient outcomes.Despite the relative rarity of appendiceal NETs, the incidence appears to be rising, which might be due to the increased use of imaging and endoscopy as well as more frequent histopathological examination of appendectomy specimens .Once diagnosed, these tumors carry a generally favorable prognosis, particularly when identified at an early stage and managed appropriately. The five-year survival rate for localized appendiceal carcinoid tumors is reported to be more than 90% . In our This case report highlights the importance of a high index of suspicion for this rare condition when dealing with patients presenting with signs and symptoms of acute appendicitis. It also underscores the value of routine histopathological examination of the appendix following appendectomy to rule out such incidental findings.Learning pointsNeuroendocrine carcinoid tumors of the appendix, though rare, can present as acute appendicitis. Unexpected histopathological findings post-appendectomy require further evaluation and potentially additional surgical intervention. Despite their potential for metastasis, the prognosis of localized carcinoid tumors is generally favorable with appropriate surgical management.Patient’s perspectiveThe diagnosis of a neuroendocrine carcinoid tumor was a complete surprise to me. I had initially come to the hospital with what I thought was a typical case of appendicitis. However, the news that I had a tumor was quite shocking, as I am generally a healthy person with no significant medical history.Once the initial shock wore off, my doctors were very thorough in explaining the diagnosis, the nature of the tumor, and the potential risks and benefits of further surgery. They provided me with all the necessary information in a clear and understandable way, allowing me to make an informed decision about my treatment.I chose to proceed with the right hemicolectomy. The postoperative period was challenging, but the constant support and reassurance from the healthcare team helped me through it.In the following months, I felt relieved to learn that the tumor had been completely removed and there were no signs of disease recurrence. This experience has made me more aware of my health. I am now regularly attending follow-up appointments and maintaining a healthy lifestyle.Looking back, I feel grateful for the quality of care I received. I hope my story can help others who might find themselves in a similar situation. It is important to remember that even in the face of unexpected diagnoses, there are teams of medical professionals ready to provide the best possible care.We presented a case of incidental detection and management of a neuroendocrine carcinoid tumor of the appendix in a young male patient. The unexpected finding of the tumor prompted further investigations, ultimately leading to the decision for a right hemicolectomy to ensure complete removal. Although neuroendocrine carcinoid tumors of the appendix are rare, this case highlights the importance of thorough examination and consideration of differential diagnoses in patients with atypical presentations of appendicitis. With appropriate management and regular follow-up, the patient has a favorable prognosis. Awareness of such cases is crucial to promote early diagnosis, optimize treatment strategies, and improve outcomes for patients with NETs of the appendix.


Typically, an intracranial tuberculoma occurs within the brain parenchyma. Intraventricular tuberculomas are rare in the absence of systemic tuberculosis (TB), and the differential diagnosis between tuberculoma and other lesions, such as primary brain tumors, can be difficult. We report an extremely unusual case of solitary fourth-ventricular tuberculoma, which occurred in a 3-year-old female patient, with no indication of TB. This lesion appeared as a primary intraventricular tumor in the fourth ventricle in both clinical and radiological examinations. In this scenario, a surgical treatment option was pursued. Histopathological testing supported the diagnosis of tuberculoma. The patient was subsequently treated with 18 months’ therapy for tuberculous, without adverse events. Mycobacterium tuberculosis that endures as a public health concern in developing countries [M. tuberculosis, and might present as a tuberculous abscess, tubercular meningitis, or a tuberculoma [Tuberculosis (TB) is a widespread infectious disease caused by ountries . TB mostountries . Extrapuountries . Centralerculoma .A tuberculoma is a tumor-like presentation, often positioned in the cerebellar and cerebral parenchyma , 5. The This article reports a very unusual case of tuberculoma, without pulmonary TB, which mimicked a primary predominant tumor in the fourth ventricle and describes the difficulties encountered during diagnosis and treatment.Figure 1). The right-to-left (RL), anterior-to-posterior (AP), and feet-to-head (FH) diameters of the mass were 42 mm, 34 mm, and 31 mm, respectively. No ossification or hemorrhage was detected within the mass on susceptibility-weighted imaging . The mass was typically ring-enhancing, with central necrosis, on T1-weighted image using contrast enhancement . The mean apparent diffusion coefficients for the solid component of the mass and the normal-appearing parenchyma were 0.76 × 10−3 mm2/s and 0.63 × 10−3 mm2/s, respectively . On the T1-perfusion map, the relative enhancement (%), maximum enhancement, maximum relative enhancement (%), time to peak (s), wash-in rate (s−1), wash-out rate (s−1), and area under the curve values for the mass compared with the normal-appearing parenchyma were as 46.11 vs 1.80, 220.76 vs 73.42, 11.33 vs 4.36, 149.14 vs 22.10, 22.93 vs 24.49, 1.69 vs 12.17, and 3375.17 vs 842.17, respectively . The clinical and radiological information suggested the initial diagnosis, in this case, of a suspiciously anaplastic ependymoma or a high-grade glioma. Neuroradiologists and neurosurgeons fully agreed to recommend surgery as the optimal treatment option. Her preoperative human immunodeficiency virus (HIV) test was negative. The patient underwent radical tumor eradication surgery, and the histopathological findings revealed granulomatous inflammation, coupled with caseous necrosis inside the lesion, consistent with a tuberculoma. Hematoxylin and eosin staining showed epithelioid histocytes and Langhans giant cells surrounding the necrotic areas. Acid-fast bacilli (AFB) were noted in the tissue sample. Additionally, polymerase chain reaction (PCR) for M. tuberculosis was performed and its result was positive. The postoperative period was uneventful. Antituberculous therapy including isoniazid, rifampicin, pyrazinamide, and ethambutol was administered for 18 months after surgery. This report has been approved by the hospital ethics committee (Ref: 352/NĐ2-CĐT) and the patient's anonymity has been preserved as far as possible. The mother of the patient has provided explicit documented consent for publication of this report and accompanying images and has been provided the opportunity to see and read the material submitted for publication.A 3-year-old girl was admitted to Children's Hospital 2, Ho Chi Minh city, Vietnam, with a 3-month history of severe headache, nausea, and vomiting. The patient's medical profile was unremarkable, without TB risks or immunocompromising diseases. The patient received a Bacillus Calmette–Guérin (BCG) vaccination after birth and she had no history of lymphadenopathy. Immunodeficiency disorders were not detected. Her neurological examination was unremarkable, without focal neurological deficits. No signs of infection and no abnormalities were detected on a chest radiograph. The patient underwent 1.5 tesla magnetic resonance imaging (MRI) of the brain, with a gadolinium-based contrast agent  at a dose of 0.1 mmol per kilogram body weight. The axial T2-weighted image showed a large intra-fourth-ventricular, central hyperintensity with a peripheral thick irregular T2 hypointensity mass, which was clearly defined by surrounding vasogenic edema  or MRI. Tuberculomas might present as a round or lobulated nodule with moderate-to-severe edema on CT. Both solid and ring appearances are typical of postcontrast enhancement results. A central calcification core with a ring of peripheral enhancement has been documented, but is not specific to TB. The lesions are generally >20 mm in diameter. In India, the most frequent radiological finding in a young adult with a new onset seizure is a solitary ring-enhancing lesion on a CT scan of the brain, with the most frequent cause being neurocysticercosis (NCC), followed by tuberculoma. MRI is the method of choice for evaluating suspected tuberculomas with a pretty strong caseous necrosis centrally on the background of a granulomatous reaction. On MRI imaging, appearance varies depending on the stage of maturation of the tuberculoma, whether noncaseating, caseating with a solid center, or caseating with a liquid center. Tuberculomas with solid caseating center appear hypo-to-isointense on both T1W and T2W images along with an iso-to-hyperintense rim on T2W images accompanied by a peripheral rim of enhancement, while tuberculomas with central liquid are hypointense on T1W images and hyperintense on T2W images along with a peripheral hypointense rim, and the rim gets enhanced on contrast study. On MRI, ring-chancing lesions such as NCC, abscess, primary brain neoplasms, and metastases can mimic the radiological features of tuberculous. MRI spectroscopy can help distinguish tuberculoma from other lesions such as NCC, lymphoma, and glioblastoma multiforme. MRI spectroscopy revealed an increased lipid peak, cholesterol ester, plasmalogen, and phenolic glycolipids, which can be used to differentiate tuberculomas from malignant tumors and other diseases. Furthermore, the presence of a lipid signal in MRI spectroscopy in the setting of a ring-enhancing lesion is highly specific for tuberculoma and has never been detected in instances of NCC 14,18,19,20Unfortunately, the diagnosis of CNS tuberculoma in patients without an established bacillary history can be extremely complicated ,12,13,14M. tuberculosis [14The criterion standard for a tuberculoma diagnosis is a brain lesion biopsy, for histopathological assessment 14,16,17. Hulosis 14,16,17.If a patient presents with the signs of increased intracranial pressure, the radical eradication of the lesion so as to decompress it is essential. Upon surgery, the patient may also require 18 months’ of antituberculous chemotherapy to completely eradicate the TB infection .Pediatric, intraventricular tuberculoma in the fourth ventricle, without systemic TB, is uncommon and extremely difficult to diagnose effectively. However, tuberculoma should be deemed as a crucially differential diagnosis for an intraventricular, ring-enhancing mass, particularly in immunocompromised individuals and patients from developing countries, to determine an appropriate treatment strategy and achieve an improved prognosis.


Mirizzi syndrome (MS) is a complicated form of longstanding, symptomatic cholelithiasis. According to Beltran Classification MS Type V has been introduced to describe the cholecystoenteric fistula, with or without gallstone ileus. Mirizzi syndrome Type V with double fistula has been reported in the past; however, the triple fistula is an even rarer case, first described in the international literature so far.A 77-year-old male was admitted to our surgical department with recurrent episodes of abdominal pain, which initially presented in the last 6 months and was accompanied with jaundice. Computed tomography showed findings of cholelithiasis, pneumobilia and choledocholithiasis. We performed an ERCP, which showed two fistulas of the gallbladder with the pyloric antrum and the duodenum, respectively. Surgical treatment was immediately undergone and during laparotomy, we confirmed these findings. We ligated and dissected these communications. In addition, a third fistula between the gallbladder and the common bile duct was identified. An insertion of a Kehr T-tube into the common bile duct was performed via the gallbladder. After 3 months, the Kehr T-tube was removed and in the subsequent 2 years of follow-up the patient was presented without complications.Mirizzi syndrome complicated with triple fistula, first described in the international literature, to the best of our knowledge, confirms the long natural history of inflammation. Mirizzi syndrome (MS) is a rare condition caused by the obstruction of the common bile duct (CBD) or common hepatic duct (CHD) by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch . This syA 77-year-old male was admitted to our surgical department with recurrent episodes of abdominal pain, accompanied with jaundice. The symptoms were initially presented in the last 6 months before he visited our hospital. The patient denied any clinical symptoms before the last 6 months. These findings led us to perform an abdominal computed tomography (CT) to diagnose the cause of this clinical presentation. The examination showed findings of cholelithiasis, pneumobilia and choledocholithiasis.The CT findings led us to perform an endoscopic intervention and an endoscopic retrograde cholangiopancreatography (ERCP) was carried out. It showed two fistulas of the gallbladder with the pyloric antrum and the duodenum, respectively Fig. .Fig. 1ERSurgical treatment was immediately undergone and we decided to perform a laparotomy rather than a laparoscopic approach, because of the complications of MS and the presence of these two intricate fistulae , 6. DuriAfter 3 months, the Kehr T-tube was removed and in the subsequent 2 years of follow-up the patient was presented without complications.The MS bears its name in honor of Pablo Louis Mirizzi, a professor of Surgery, who described it first in 1948 as “Functional Hepatic Syndrome” , 11. LatAt this moment, MRCP is the preferred method for the preoperative diagnosis of MS, as it is a non-invasive imaging technique , 15. It Instead of the MRCP, ERCP is an invasive diagnostic approach, but it is considered as the gold standard method for the diagnosis of MS, as it offers a superior visualization of extra-hepatic ducts . FurtherSurgical management is the mainstay treatment for MS, and the surgical approach varies according to each case . The safMirizzi syndrome Type V with double fistula has been described in the past. However, in all these cases, one or two fistulas are presented. MS complicated with triple fistula is an extreme rare case, first described in the international literature, to the best of our knowledge, and confirms its long natural history of inflammation.


Intussusception is a common cause of acute and subacute small bowel obstruction in children, young, and older patients; however, despite increasing awareness of the condition and the number of patients diagnosed with it across all ages, its clinical and diagnostic approach remains challenging. A 17-year-old girl attended our gastroenterology outpatient department complaining of a 6-month history of recurrent right iliac fossa pain associated with nausea and vomiting at times with no past medical history of note. Initial blood tests revealed a slightly raised CRP (9.1 mg/L) and a significantly elevated fecal calprotectin (>1000 µg/g). Computed axial tomography scan of the abdomen and pelvis revealed ileocecal intussusception with no evidence of small or large bowel obstruction. On subsequent colonoscopy a 5-cm mass protruding through the ileocecal valve was identified and multiple biopsies were taken for histological analysis, which confirmed a diagnosis of Burkitt’s lymphoma. The lesion was surgically resected and plans for adjuvant chemotherapy were discussed. The learning lessons to take from this case are to widen the list of differential diagnoses of unexplained recurrent abdominal pain to include intussusception and to actively rule it out with an appropriate diagnostic approach that addresses its potential malignant etiology across all ages. Intussusception is a common cause of acute and subacute small bowel obstruction in children, young, and older patients attending emergency departments with obstructive symptoms like abdominal pain, nausea with or without vomiting. Despite increasing awareness of the condition and number of patients diagnosed with it across all ages, its clinical and diagnostic approach remains challenging. Intussusception is largely considered a condition of childhood with the highest incidence in the United Kingdom occurring in the fifth month of life . In chil9/L. C-reactive protein (CRP) showed only a mild elevation of 9.1 mg/L and there was a significantly raised fecal calprotectin level of >1000 µg/g.A 17-year-old female attended our gastroenterology outpatient clinic with a 6-month history of recurrent lower abdominal/right iliac fossa pain associated with nausea and vomiting at times. She was rushed to the local emergency departments on multiple occasions for assessment and analgesia. Medical assessments in visited emergency departments included physical examination, blood and urine testing, and abdominal imaging with plain radiograph and ultrasounds, which revealed no specific diagnosis. She was a healthy and active student with no personal or family history of note. Further enquiries about bowel habit, bleeding per rectum and weight loss were unremarkable. Initial tests including full blood count showed normal hemoglobin and white blood cells and a platelet count of 439 × 10Given pain as her main presenting problem, she underwent a compound computed axial tomography (CAT) scan of the abdomen and pelvis with contrast which showed ileocecal intussusception with no radiological evidence of small or large bowel obstruction Figure .A colonoscopy Figure  was thenThe results of the endoscopic findings and options for further management were discussed with family and a plan of urgent surgical resection of the lesion, which should inform further plan of treatment according to histopathological examination of the surgical specimen was agreed upon. The lesion was surgically resected and sent for histopathological analysis.The histopathological analysis of the endoscopic biopsy and subsequent surgical specimen reported features of a lymphoproliferative state, suggesting a diagnosis of Burkitt’s lymphoma. Further immunohistochemistry testing demonstrated features of a B-cell immunophenotype, high-grade non-Hodgkin’s lymphoma favoring a diagnosis of Burkitt’s lymphoma Figure . The patAs we can see from Table The patient has given consent for the publication of this case report.


Intracranial germ cell tumors (GCTs) are a relatively rare malignancy in clinical practice. Natural regression of this tumor is also uncommon. We describe a rare case of an intracranial GCT in the thalamus of an adult that showed spontaneous regression and recurrence after steroid therapy.A 38-year-old male patient's MRI of the head suggested space-occupying masses in the left thalamus and midbrain. MRI examination revealed demyelination or granulomatous lesions. After high dose steroid treatment, the symptoms improved. The lesions were significantly reduced on repeat MRI, and oral steroid therapy was continued after discharge. The patient's symptoms deteriorated 1 month prior to a re-examination with head MRI, which revealed that the mass within the intracranial space was larger than on the previous image. He revisited the Department of Neurosurgery of our hospital and underwent left thalamic/pontine mass resection on October 16, 2019, and the pathological results showed that the tumor was a GCT.Intracranial GCTs are rare in the adult thalamus but should be considered in the differential diagnosis. The intracranial GCT regression seen in this case may be a short-lived phenomenon arising from complex immune responses caused by the intervention. Intracranial germ cell tumor (GCT) is a relatively rare malignancy in the clinic. These tumors are more common in the sellar area and pineal area of adolescents and children, relatively rare in elderly and young children and relatively rare in the thalamus and basal ganglia . GCTs caRegarding imaging features, intracranial GCTs usually show equal or long T1 or long T2 signals on MRI. Diffusion-weighted imaging (DWI) typically shows high signal, uniform enhancement, and clear borders, and only a few tumors have moderate or uneven enhancement. GCTs in the basal ganglia have the following unique imaging features: larger tumor, no obvious space-occupying effect, mild peritumoral oedema, and atrophied cerebral cortex of the ipsilateral sylvian fissure. The enhanced scan can show irregular rosette-like enhancement or spot-like enhancement . MR specThe incidence of spontaneous regression in tumors is 1/60,000–1/100,000. The central nervous system diseases that require differential diagnosis include primary central nervous system lymphoma, demyelinating pseudotumors, glioma , infectiA 38-year-old male patient was admitted to the hospital with weakness in his right limbs for 6 months and decreased vision in his left eye for 3 months.The patient developed numbness of the right upper limb without obvious inducement in April 2019 and then experienced continuous numbness without an intermittent period; this was accompanied by weakness of the upper limbs, and then the above symptoms were aggravated with right lower limb weakness, which caused walking instability. In June 2019, the abovementioned symptoms were gradually aggravated with blurred vision and decreased vision in the left eye. In August 2019, the neurosurgery department in our hospital considered the possibility of demyelinating pseudotumors. After high dose dexamethasone treatment, the patient's right limbs remained weak, his visual impairment significantly improved, and the lesion was significantly reduced in size. However, in October 2019, his symptoms worsened, and the lesions appeared larger than before see .The patient was healthy and had no history of surgery. His family history was negative, with no congenital diseases.Physical examination: The following findings were observed: drooping of the left eyelid, decreased visual acuity in the left eye, left pupil:right pupil ratio = 4:2, dull light reflection, level 4 right limb muscle strength, and significantly decreased sensation to both deep and shallow stimuli in the right limb.Laboratory examination: In August 2019, routine blood tests, electrolytes, liver and kidney function, coagulation function, tumor markers, and electrocardiography showed no obvious abnormalities. The cerebrospinal fluid analysis revealed significantly increased levels of trace total protein, but there were no obvious abnormalities. Ferritin was significantly increased, but the CA125, CA199, CA153, CEA, and AFP levels were not abnormal.In June 2019, a head MRI performed at an external hospital showed a lesion occupying the left thalamus and midbrain space. Considering the possibility of malignant tumors, PET-CT was performed and showed that tumor-like changes with demyelination were likely.The MRI in August 2019  can significantly shrink the tumor . In simiSecond, steroids are usually ineffective for GCTs. In our case, the mass was considered a demyelinating pseudotumor and lymphoma before operation. Because of the use of high dose steroid therapy, the patient's symptoms improved, and the phenomenon appeared resolved on MRI. For demyelinating pseudotumors , lymphomFinally, the complex immune response of the above factors with human immune responses and tumors may be the reason for natural regression . HoweverIntracranial GCTs occur in the adult hypothalamus, and regression is extremely rare. This case of GCT was misdiagnosed because of an atypical appearance on MRI and “regression” and recurrence after steroid therapy. We speculate that the regression observed may be an iatrogenic transient phenomenon arising from the complex immune response caused by the intervention. Therefore, it is necessary to be aware of the possible impact of iatrogenic intervention and that it may cause regression of intracranial GCTs, especially when patients show improved symptoms. Before providing further treatment, more imaging tests should be performed to reduce the incidence of misdiagnosis.Intracranial GCTs occur in the adult hypothalamus, and regression is extremely rare. This case of GCT was misdiagnosed because of an atypical appearance on MRI and “regression” and recurrence after steroid therapy.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Clinical Research Ethics Committee of Shenzhen Second People's Hospital. The patients/participants provided their written informed consent to participate in this case study and for the publication of this case report.S-pL contributed to the conception of the study. Y-nF, H-wZ, and YL contributed significantly to the analysis and manuscript preparation. FL performed the data analyses and wrote the manuscript. JY helped perform the analysis with constructive discussions. All authors contributed to the article and approved the submitted version.This study was supported by a grant from the Basic Plan Program of Shenzhen, China (No. JCYJ20180228163333734) and Clinical Research Project of Shenzhen Second People's Hospital, China (No. 20193357021).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Sialoblastoma is an extremely rare embryonal tumor derived from salivary gland primordial cells. Treatment usually consists of surgery alone; however, in some cases, chemotherapy is required and is administered with good response. We present a case of a 5-week-old girl diagnosed with a parotid gland tumor and co-existing nevus sebaceous on the face. Initial tumorectomy was microscopically non-radical and histopathology revealed sialoblastoma. The patient received adjuvant chemotherapy consisting of vincristine, actinomycin, and cyclophosphamide. Due to imaging studies being inconclusive regarding response and possible residual disease, a second surgery  was performed. The histopathology results showed fields of necrosis in the parotid gland but no neoplastic cells in the material. The patient remains under watchful observation and there is no evidence of relapse 12 months after the second surgery. The adjuvant chemotherapy regimen with vincristine, actinomycin, and cyclophosphamide is a viable option of treatment in children with sialoblastoma. Sialoblastoma is an embryonal tumor derived from salivary gland primordial cells. Salivary gland malignancies are uncommon in children . In geneSurgery is the most effective and often solely sufficient treatment for this tumor; however, some cases described to date required chemotherapy. Most of those cases responded well to systemic treatment, indicating sialoblastoma chemo-sensitivity. Local recurrences of the tumor and even metastatic disease were reported, but overall, based on available reports, prognosis tends to be favorable ,6.In this report, we present a case of a 5-week-old girl diagnosed with a parotid gland tumor and co-existing nevus sebaceous on the face, who underwent surgical treatment and received adjuvant chemotherapy.A 5-week-old girl was admitted to our Oncology Department for a palpable tumor in the chin, located near the left mandibular angle. According to her mother, the tumor seemed to grow rapidly. The girl also presented with a large, peculiar nevus on the left cheek of approximately 4 × 4 cm in size , and a sAn initial ultrasound examination revealed an irregular, solid mass 21 × 24 mm in size with small contact with the superficial lobe of the left parotid gland, with a high level of vascularization and small calcifications. Laboratory tests did not indicate any elevation or significant alterations in markers such as beta subunit of human chorionic gonadotropin (beta-HCG), alpha-fetoprotein (AFP), or neuron-specific enolase (NSE).Magnetic resonance imaging (MRI) of the head and neck revealed a well-defined tumor mass located between the anterior pole of the parotid gland and the posterior part of the musculus masseter, 23 × 21 × 23 mm in size . The lesAfter consultation with a maxillo-facial surgeon, the patient received indication for tumor resection. Intended macroscopic total resection of the parotid tumor with simultaneous nevus biopsy was performed. The tumor was accessed with a cut encircling the left mandibular angle. The facial nerve was located and dissected using neuromonitoring. The tumor was dissected and removed in one piece.Histopathology of the tumor revealed the presence of the primitive basal cells organized in lobular and ductal structures with the following immunohistochemical profile: PanCK+, p63+, S100−, EMA+, GFAP−, chromogranin−, synaptophysin−, beta-catenin−, and non-diagnostic WT1. Neoplastic cells were highly polymorphic, with a mitotic index of 23 mitosis/10 high power fields and a focal Ki67-positive fraction of up to 60% of the cells. Small fields of necrosis and angioinvasion were noted in the peripheral parts of the lesion. Neoplastic cells were found at the surgical margin. The diagnosis was sialoblastoma.The national reference pathologist confirmed this diagnosis.Histopathological examination of the nevus revealed typical nevus sebaceous histology.After surgery, the patient was reassessed via MRI, which revealed numerous irregular hypointense fields in the superficial lobe of the left parotid gland merging with the musculus masseter and partially encircling the mandibular ramus. In the posterior pole of the same parotid gland, a new lesion 10 × 4 mm in size was observed with restricted diffusion and contrast enhancement. Imaging results suggested non-specific residual disease and likely post-surgical lesions. A computed tomography scan of the chest, abdomen, and pelvis did not reveal any other suspicious focal lesions.Complete resection of the suspicious lesion without a significant risk of irreversible facial nerve damage or cosmetic mutilation was not possible. Therefore, after discussing therapeutic options with the parents, we decided to initiate systemic treatment, hoping for a reduction in tumor mass. After reviewing the existing literature on sialoblastoma, our team decided to administer chemotherapy using the VAC (vincristine/actinomycin/cyclophosphamide) regimen in accordance with CWS Guidance protocol. Our patient received a total of five courses, with a 4-week interval between day 1 of each cycle, consisting of vincristine, actinomycin D (actinomycin was omitted in the two first courses due to the patient’s age), and cyclophosphamide given on day 1 of each course. Vincristine was also given on days 8 and 15. The treatment was tolerated well; there was no need for blood transfusion, no serious infections, and no apparent signs of neurotoxicity. After two courses, an imaging evaluation showed no significant changes in the lesion.Another evaluation after four cycles of VAC was comparable with previous imaging, with no signs of progression or regression of the suspicious lesion.After surgical consultation, concerned about the residual disease, we decided to perform a second, more radical surgery, followed by two additional courses of VAC. Total parotidectomy with facial nerve dissection under neuromonitoring was performed. The same surgical access as before was used. The surgery resulted in paresis of the marginal mandibular and buccal branches of the facial nerve. One course of postoperative chemotherapy was administered. The histopathology results showed fields of necrosis in the parotid gland but no neoplastic cells in the material. We decided to stop further chemotherapy.A control MRI revealed a heterogenous 17 × 22-mm (AP × RL) tissue with contrast enhancement and a focus of restricted diffusion measuring 6 × 9 mm in the place of the resected parotid gland, which was most likely a post-surgical scar, according to the radiologist; however, residual disease could not be excluded. A similar contrast-enhanced focus measuring 4 × 11 mm was observed at the same site in the subcutaneous tissue near the anterior wall of the external acoustic meatus, in addition to a focus 12 × 8 × 15 mm in size in the subcutaneous tissue of the submandibular area. A multi-disciplinary council including surgeons, radiologists, and the local CWS Guidance Study Group center concluded that the probability of the visible MRI changes being residual disease was low, and the patient was placed under cautious observation, without further interventions.During follow-up, control MRIs of the primary site, in addition to ultrasound imaging of the abdomen and chest X-rays, were performed every 3 months. In the subsequent imaging studies, the previously described post-surgical lesions were stable in size. One of the lesions, which was located in the area of the resected parotid gland, even decreased slightly in size. No signs of evident relapse were noted during 12 months of observation.Facial nerve function improved slightly over the course of rehabilitation; however, small facial asymmetry is still present.An initial genetic consultation has taken place, and the patient is awaiting further molecular testing at the time of the publication of this report.Sialoblastoma is a malignant neoplasm of embryonal origin that is mostly found in young children, especially in the first months of life; however, patients older than 2 years of age, including teenagers, have been described . DardickOur patient’s initial resection was non-radical, and histopathological examination revealed a very high mitotic index in the lesion. As the imaging assessment indicated that re-operation was not possible without significant mutilation , and with our knowledge regarding the chemosensitivity of sialoblastoma, our team decided to administer adjuvant chemotherapy. The initial goal was to reduce the tumor mass, perform less radical re-operation, and prevent metastasis, as the histopathology of our case seemed unfavorable and metastatic cases had been described in the literature. The effectiveness of the chosen VAC regimen had been confirmed in three previously described pediatric cases ,15.The imaging reassessments performed after the administration of the second and fourth courses of chemotherapy were difficult to interpret due to technical reasons (one of the MRI studies had to be performed at a different resolution than the rest), as well as the heterogeneous, diffuse, and non-specific characteristics of the lesions. However, there were no apparent signs of tumor regrowth during treatment. The lesion, which we suspected to be the remnant of the tumor, seemed stable in size and morphology. Therefore, we failed to perform less-mutilating re-operation. On histopathological examination of the resected parotid gland, no apparent neoplastic cells were found; however, atypical fields of necrosis suggested possible foci of the neoplasm, which responded to the chemotherapy. Similar, almost purely necrotic foci of sialoblastoma have previously been described in the literature after treatment with the IVAdo regimen . The VACThe uniqueness of our patient’s case results from the co-occurrence of the nevus sebaceous, which was located on the same side of the face and close to the tumor. This type of nevus is characterized as a congenital hamartoma of a pilosebaceous unit and usually presents as a solitary, oval or linear, and well-defined elevated plaque that is yellow or pink in color . Our patThere have been at least eight reported cases of synchronous sialoblastoma and hepatoblastoma. The analysis of one such case conducted by Yang et al.  revealedTotal surgical resection remains the most effective treatment for sialoblastoma. Chemotherapy should be considered in cases with subtotal resection, local recurrence, or metastases. We believe that chemotherapy might help in avoiding mutilating surgery in some patients; however, in those who have already undergone a surgical procedure, proper assessment of the residual disease and its response to treatment might be challenging. A chemotherapy regimen with vincristine, actinomycin, and cyclophosphamide is well tolerated, even by infants, and it appears to be effective against tumor cells in vivo. Some cases of sialoblastoma may co-exist with nevus sebaceus, which may suggest a common pathogenic factor.


Teratoma is a type of germ cell tumor consisting of one or multiple tissues derived from germinal layers. The location and size of the tumor can cause various presentations. Here we report one of the largest ever cases of immature cystic teratoma.In this report, we presented a 24-year-old patient with dyspnea, chest pain, nausea, and anorexia. A computed tomography scan revealed a giant, right-sided mass measuring about 190 × 150 × 140 mm. Chemotherapy was initiated for the patient, followed by thoracotomy. Histopathological evaluation revealed the nature of the mass to be an immature mediastinal teratoma.the incidence of immature mediastinal teratoma is uncommon, and due to its rarity, the diagnosis needs more profound evaluation studies such as radiological and pathological assessments. Immature teratomas are optimally treated by a combination of chemotherapy and complete resection. Teratoma is a type of germ cell tumor consisting of one or multiple tissues derived from cells of three germinal layers, which may contain variable amounts of mature and immature tissues. Teratomas are mostly benign and are predominantly found in gonads; however, they can be identified in different anatomical locations such as the neck, retroperitoneum, sacrococcygeal region, and the thorax , 2.Extragonadal germ cell tumors are most commonly located in the mediastinum and account for 15% of all mediastinal tumors in adults , 4. The A 24-year-old male was referred to our hospital complaining of a ten-month history of dyspnea, nausea, and anorexia, followed by a mild intermittent chest pain radiating to his back. He was a lifetime nonsmoker and denied any recent fever, chills, night sweats, or weight loss during this time. In physical examination, the patient was afebrile with normal vital signs, and oxygen saturation of 97%.In his past medical history, first, the patient was visited regarding his signs and symptoms by a local physician, and high-resolution computed tomography (HRCT) scan was requested. The HRCT showed a large soft tissue mass in the anterior mediastinum with areas of coarse calcification (130 × 139 × 176 mm), causing the shift of heart and trachea to the left side and several lung nodules in both lungs up to 9.5 × 11 mm in the upper part of the lower lobe of the left lung, which could be metastatic lung nodules. The possible diagnosis was reported malignant teratoma and less likely other germ cell tumors. Besides, mild to moderate pericardial effusion was seen. He was referred to another city for further evaluation.There, spiral computed tomography (CT) angiography of pulmonary vessels, chest x-ray, and biopsy of the mass were requested. Chest x-ray demonstrated a very large mass in the right mediastinum Fig. , and theIn the second center, another HRCT was done. Pericardial tap, pericardial biopsy, and tumor biopsy were also taken; HRCT report was similar to previous HRCT report, pericardial fluid cytology was negative for malignancy, pericardial biopsy showed congestion and mesothelial cell hyperplasia with no malignant cell, and tumor biopsy was reported teratomatous tissue containing foci of immature mesenchymal and cartilaginous tissues, in favor of immature teratoma (grade I-II). Besides, another CT angiography was done, which the report was similar to the previous CT angiography. Based on the diagnosis made by tumor biopsy, the patient was referred to an oncologist.The oncologist started chemotherapy, and the patient received four episodes of the VeIP regimen . Then, he was referred to our center with a high β- Human chorionic gonadotropin (β-hCG) and alpha-fetoprotein (α-FP) and diagnosis of immature teratoma for tumor excision. Laboratory features of the patient are demonstrated in Table The operation was performed under general anesthesia with a right posterolateral thoracostomy. In exploration, a huge mass with adhesion to the trachea, superior vena cava, innominate vein, esophagus, lung, pericardium, and diaphragm was observed. Also, the mass extended to the left pleura. Therefore, pneumolysis and then, partial pericardiectomy was done; and, the mass was released from its adhesive sites. Two chest tubes into the right side and one chest tube into the left side were inserted. Besides, the mass was sent for pathological evaluation.Grossly, the tumor size was 20 × 20 × 11 cm. In the pathological examination, serial cut sections revealed bone and cartilage formation, cystic space, some of them filled with yellow soft material and hair tuft. Also, diffuse myxoid degeneration and calcification with multiple finger-like projections covered by skin and hair were present. Finally, the definite diagnosis was reported to be an immature cystic teratoma with 10% necrosis. Microscopic sections showed mature cartilage, glial tissue, and gastrointestinal type epithelium as well as cutaneous tissue Fig. .The patient was discharged a week after the surgery in good condition Fig. . CurrentThe anterior mediastinum is the most frequent location for extra-gonadal germ cell tumors and that teratomas are the most common form of germ cell tumors seen in the mediastinum . MediastBecause of their insidious growth, most of the mediastinal cases remain asymptomatic until they become big enough to reveal the compression effects on the nearby structures. The common symptoms of mediastinal teratomas, including substernal chest pain, dyspnea, and cough  followedChest CT scan is the modality of choice for the diagnosis of mediastinal teratoma , 13. It Like in our case, an elevated α-FP is not uncommon in immature mediastinal teratoma at the time of diagnosis . AccordiOur patient underwent surgical resection, which has been demonstrated in previous reports to be efficient in managing benign intrapulmonary and mediastinal teratomas , 18. FacIn conclusion, the incidence of immature mediastinal teratoma is uncommon, and due to its rarity, the diagnosis needs more profound evaluation studies such as radiological and pathological assessments. Immature teratomas are optimally treated by a combination of chemotherapy and complete resection.


A Spigelian hernia is a very rare type of anterior abdominal wall hernia. The etiology revolves around the dehiscence of the transverse abdominis and internal oblique aponeurosis. The majority of Spigelian hernias develop in the lower abdomen where the posterior sheath is absent. This condition is also known as a spontaneous lateral ventral hernia or hernia of the semilunar line. It is mostly asymptomatic and is generally proven by radiological diagnosis. In the worst-case scenario, strangulation of the Spigelian hernia can occur. Here, we report a case series of contrasting presentations of Spigelian hernia in a single surgical unit of a tertiary healthcare center, considering the rarity and associated complications of Spigelian hernia. A Spigelian hernia can be defined as a herniation or protrusion of preperitoneal fat or the peritoneal sac, with or without organs, caused by a deficiency in Spigelian aponeurosis . The SpiTo diagnose this rare entity, a very high level of suspicion is required. Although abdominal ultrasonography (USG) may be informative in some cases, contrast-enhanced computed tomography (CT) is the mainstay for verifying the diagnosis, especially when it is uncertain . ObesityCase oneA 64-year-old male presented to the outpatient department with the chief complaint of swelling in the left lower abdomen associated with pain for the past six months. The swelling became more prominent on straining, while it reduced in size on lying down.On examination, an oval swelling measuring 6 × 4 cm was seen in the left lumbar and iliac regions with a positive cough impulse. On palpation, a swelling measuring 6 × 4 cm was palpable in the left iliac fossa, with a smooth surface and soft consistency that could be reduced manually, as shown in Figure The hematological parameters were within normal limits. The USG of the whole abdomen suggested a defect measuring approximately 2.8 cm in the left iliac fossa with the omentum extending through the defect during the Valsalva maneuver, suggesting a Spigelian hernia. Similar findings were confirmed on CT.We subjected the patient to a sublay mesh hernioplasty. Intraoperatively, a 2 × 2 cm defect was noted at the junction of linea semilunaris and semicircularis, with omentum as content, as shown in Figure The patient was commenced on oral intake on postoperative day one, which he tolerated well. The patient did well during the hospitalization period and was discharged on postoperative day two under satisfactory conditions.Case twoA 48-year-old male presented to the outpatient department with the chief complaint of swelling in the right lower abdomen associated with a dragging sensation for the past three months. The swelling increased in size on standing, coughing, or straining and reduced in size on lying down. Additionally, it was associated with pain following meals.On examination, a swelling measuring 8 × 5 cm was seen in the right lower abdomen, extending to the right iliac fossa. On palpation, a swelling measuring 8 × 5 cm with a 3 × 3 cm defect was present in the right lower abdomen, through which the contents could be reduced with a gurgling sound. A cough impulse was present. The margins were ill-defined, and the contents could be reduced manually. The CT of the whole abdomen, including the pelvis, suggested herniation of the descending colon and small bowel segments through the abdominal wall with a herniated sac lateral to the right rectus abdominis along the semilunar line (Spigelian line) through the transverse abdominis aponeurosis, strongly in favor of a Spigelian hernia.The patient was posted for a sublay mesh hernioplasty, and intraoperatively, a defect measuring 3 × 3 cm was noted with omentum and bowel as contents. Primary repair of the hernia was done, and the mesh was placed between the sheath and peritoneum. Oral intake was commenced on postoperative day two, which he tolerated well. The patient did well during the hospitalization period and was discharged on postoperative day three under satisfactory conditions.Case threeAn 85-year-old male presented to the surgery emergency with the chief complaints of swelling in the left flank region for the past 10 years associated with pain in the abdomen, multiple episodes of vomiting, and absolute constipation for the past two days. As stated by the patient, he was apparently asymptomatic two days back when he developed pain in the left lower abdomen, which was sudden in onset, rapidly progressive, severe in intensity, non-radiating, aggravated by exertion, and without any relieving factors. The swelling could not be reduced by lying down or manual manipulations.On examination, a swelling measuring 30 × 20 cm was noted extending from the left subcostal margin to the left iliac fossa and paraumbilical region of the abdomen, as shown in Figure A cough impulse was absent. On palpation, tenderness was present, and a soft-to-firm swelling occupied the left hemi-abdomen with distinct borders and margins. The contents of the swelling could not be reduced manually. On auscultation, bowel sounds were present over the swelling. The USG of the whole abdomen suggested dilatation of small bowel loops with to and fro peristalsis and a large defect measuring 10 × 3 cm with small bowel and omentum as content, features suggestive of an obstructed Spigelian hernia. The CT was also in favor of an obstructed Spigelian hernia with small bowel and omentum as contents.The patient was planned for mesh hernioplasty in the emergency operation theater, and during the procedure, a 10 cm defect was noted in the left side of the internal oblique, and a 10 × 15 cm sac was present with small bowel and omentum as contents, as shown in Figure The patient was started on oral intake on postoperative day five, which he tolerated well. He passed flatus on postoperative day two and stools on postoperative day five. The drain output was 40 mL serosanguinous on postoperative day one, which was reduced to minimal output on day seven, and, subsequently, the drain was removed on the same day. The patient did well during his hospital stay and was discharged on postoperative day eight under satisfactory conditions.Spigelian hernias are an uncommon variant of ventral abdominal wall hernias that develop as a result of a weakness in the rectus sheath aponeurosis and transversus abdominis muscle, allowing abdominal contents to herniate through the linea semilunaris. A well-defined gap in the Spigelian aponeurosis at the Spigelian hernia belt is frequently where it begins as preperitoneal fat protruding through the defect. Nearly, 85-90% of hernias occur in this area of the aponeurosis, which is the widest region of the muscle and is located between 0 and 6 cm cephalad to the interspinous plane [There are two types of Spigelian hernias, namely, acute and chronic incidental. A patient of the first type exhibits an acute abdomen and requires immediate evaluation and surgical care. In its second form, it is discovered by accident while looking into persistent and nebulous stomach pain, as in our situation.Patients with a suspected hernia are routinely examined in erect posture in the clinical context to aid in hernia identification. The hernial sac may spread in the intramuscular plane of the abdomen and may not be well palpable. Patients with possible anterior abdominal hernias should ideally be examined in the upright position. We should ideally perform CT scans in the left and right decubitus positions instead of the supine position while elevating intra-abdominal pressure by having patients perform the Valsalva maneuver. The semi-circular line  is where Spigelian hernias most frequently manifest. The Spigelian aponeurosis is a single layer and herniation-resistant below this line. According to reports, 21% of patients may exhibit small bowel obstruction as a sequela .It is possible to make a preoperative clinical diagnosis in patients who have a palpable mass along the Spigelian aponeurosis, but this may be challenging in patients who have non-specific abdominal pain but no visible or palpable mass because of reducible hernia or the presence of an intramural or interparietal hernia. It is suggested to make a gridiron incision over the mass while treating a Spigelian hernia surgically. The hernial sac is made visible by cutting the external oblique aponeurosis along the direction of its fibers. Once the hernial sac is detected, it is dissected, reduced, and then the defect is closed. Thereafter, the layers of the external oblique aponeurosis and internal oblique muscle are reapproximated.Spigelian hernias should be promptly repaired surgically to prevent further complications such as bowel obstruction and strangulation, in particular, when patients present with these symptoms. Depending on experience and the accessibility of facilities for laparoscopy, either an open or laparoscopic approach may be used. In the pre-laparoscopic era, this hernia was traditionally repaired with a transverse incision and primary repair, but nowadays, these repairs are performed laparoscopically whenever possible.