Search

Introduction: Delayed splenic rupture is an often unpredictable event with high mortality. In this report, we discuss the successful management of delayed splenic rupture, presenting days after index injury, with no commonly associated injuries or blunt abdominal trauma., Case Presentation: A 50 year old male, not on anticoagulants, presented with blunt trauma after driving his motorcycle into a tree. The patient sustained right 3-5 rib fractures, displaced right midclavicular fracture, 25 % right pneumothorax, T5-9 posterior spinous process fractures, left 2nd-5th metatarsal fractures, and scattered abrasions to the left foot, knee and hand. Focused abdominal sonography for trauma (FAST) and admission abdominal multi-detector CT were negative for any intra-abdominal injuries. On hospital day 5, the patient acutely decompensated. FAST was grossly positive and emergent laparotomy revealed a splenic rupture. After a splenectomy, he recovered., Discussion: The spleen is the most commonly injured organ in blunt abdominal trauma. Although acute injury often presents with imaging findings or sequelae of hemorrhagic shock, complications of splenic trauma have the potential to result in delayed catastrophe. Bedside ultrasonography is a useful tool to assess acute decompensation in trauma patients along with CT imaging. Prompt identification and hemorrhage control are crucial to survival after trauma., Conclusion: Repeat CT scans are also important for the identification of delayed splenic rupture and timely intervention. Delayed hemorrhage after blunt trauma should never be ruled out regardless of the injury complexity or length of hospital admission., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously., Case Presentation: A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well., Discussion: High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team., Conclusion: The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury., Competing Interests: Declaration of competing interest None., (Copyright © 2022. Published by Elsevier Ltd.)

HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a rare but serious complication of pregnancy characterized by hemolytic anemia, elevated liver enzymes, and thrombocytopenia. It occurs in <1% of all pregnancies with 70% of cases developing before delivery, the majority occurring between the 27 th and 37 th weeks of gestation. Respiratory failure seen in HELLP syndrome clinically and radiographically appears similar to acute respiratory distress syndrome (ARDS), with presence of bilateral pulmonary opacities on imaging as well as persistent hypoxemia requiring elevated ventilator requirements. It is seen to complicate 3-10% of cases of HELLP syndrome. Pulmonary complications are theorized to occur as sequelae of the proinflammatory state induced by HELLP syndrome with endothelial dysfunction and subsequent microangiopathic hemolysis and thrombocytopenia. A robust cytokine inflammatory response similar to ARDS is seen, resulting in noncardiogenic pulmonary edema due to vasoplegia and capillary leak syndrome. We present a case of a 27-year-old uniparous female with a term pregnancy complicated by HELLP syndrome who developed respiratory failure requiring mechanical ventilation. Early CRRT and nitric oxide therapy were initiated, with the patient experiencing clinical and radiological improvement of respiratory function within 48 hours. We document the novel treatment of our patient's acute respiratory failure with CRRT and nitric oxide and delve into the literature regarding its use in acute respiratory failure and ARDS in association with HELLP syndrome., Competing Interests: The authors of this case report have no conflicts of interests or disclosures to report., (Copyright © 2021 Obteene Azimi-Ghomi et al.)

BACKGROUND Blunt renal injuries constitute a small proportion of solid organ trauma cases. Many American Association for the Surgery of Trauma grade IV and V lacerations are manageable with volume resuscitation and angioembolization. In select cases, emergent nephrectomy can be beneficial to patients, with little associated morbidity. CASE REPORT In 2 separate cases, an 18-year-old man and a 21-year-old woman were brought to our center after sustaining blunt trauma to the left flank. They were both found to have isolated grade V renal lacerations with vascular compromise. Both initially had normal vital signs but became unstable. Active extravasation was visible on contrast-enhanced computed tomography scans, and the patients ultimately underwent exploratory laparotomy and nephrectomy on hospital day 1. Both of them recovered quickly, had no acute complications, and were discharged in <1 week. Follow-up over the course of 1 year showed no untoward sequelae. CONCLUSIONS These cases highlight the role of nephrectomy to mitigate life-threatening hemorrhage in unstable patients. While observation or angioembolization is the preferred approach for many renal injuries, emergent nephrectomy remains important for patients who do not respond to blood products and have rapidly deteriorating shock. In these patients, results of an initial trauma evaluation can be unclear because of concomitant splenic injury, as well as renal injuries with hemoperitoneum that are visible on focused abdominal ultrasonography for trauma. When forgoing immediate laparotomy, surgeons can use continuous noninvasive hemoglobin monitoring along with serial hemoglobin measurements and abdominal examinations. Laparotomy with nephrectomy results in limited morbidity when it is done expeditiously with ongoing volume resuscitation.

Introduction: Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy., Presentation of Case: A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent., Discussion: BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks., Conclusion: Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Physician scientists who are also Editorial Board members or Associate Editors may prefer publishing in their own journal and therefore create an environment for conflicts of interest to arise., Objectives: To assess the relationship between the number of peer-reviewed publications in surgical journals in which authors serve as Editorial Board Members and Associate Editors and their total number of annual publications., Materials and Methods: A cross-sectional study utilizing PubMed was performed regarding the total annual number of peer-reviewed publications by Editorial Board Members/Associate Editors and the number published in their respective affiliated journals from 2016 to 2019. Significance defined as p < 0.05., Results: 80 Associate Editors and 721 Editorial Board Members (n = 801 total) were analyzed from 10 surgical journals. The mean number of total annual peer-reviewed publications varied from 5.19 to 17.18. The mean number of annual peer-reviewed publications in affiliated journals varied from 0.06 to 2.53. Multiple significant associations were discovered between the total number of annual peer-reviewed publications and number of peer-reviewed publications in affiliated journals for all authors/surgical journals evaluated, except for the International Journal of Surgery (p > 0.05)., Conclusions: We found significant associations between the total number of annual peer-reviewed publications by Editorial Board Members/Associate Editors and number of annual peer-reviewed publications by their affiliated surgical journals. The implementation and enforcement of a standardized double-blind review process and mandatory reporting of any potential conflicts of interest can reduce possible bias and promote a fair and high-quality peer-review process., Competing Interests: Authors declare no competing interests., (© 2020 The Author(s).)

Background: The use of Twitter hashtags at medical conferences has revolutionized the way healthcare professionals interact and advance their education. We aim to investigate the scope of the Academic Surgical Congress's online reach and engagement through the use of Twitter hashtags #ASC from 2015 to 2019, by analyzing the number of impressions and tweets and retweets., Methods: A cross sectional study of Twitter data through Symplur with the following conference hashtags for the Academic Surgical Congress annual meetings for years 2015-2019: #ASC2015, #ASC2016, #ASC2017, #ASC2018, and #ASC2019. Data on tweets, retweets, users, and impressions was reviewed along with information on the top 10 influencers and the most frequently tweeted links. Symplur Signals software was utilized to extract and assimilate data. Statistical Significance was defined as p < 0.05., Results: Twitter engagement metrics significantly increased from 11,400 to 32,100 from 2015 to 2017 (p < 0.05). However, from 2017 to 2019, there was a significant decline in engagement metrics from 32,100 to 26,100 (p < 0.05). Impressions increased significantly from 13,100 in 2015 to 71,800 impressions in 2019 (p < 0.05). Users grew significantly from 1500 in 2015 to peak at 4600 in 2017 before dropping back to 3300 in 2019 (p < 0.05). The most influential organizations during these years were the organizers of the conference: Association for Academic Surgery and the Society of University Surgeons. Conference attendance progressively increased from approximately 1700 in 2016 to about 2100 in 2019 (p < 0.05)., Conclusions: Twitter engagement metrics at the Academic Surgical Congress 2015-2019 has fluctuated, while impressions significantly increased through the years indicating the consistent dissemination of conference content., Competing Interests: Authors declare no competing interests., (© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd.)

Background: Social media amplifies the accessibility, reach and impact of medical education and conferences alike. The use of hashtags at medical conferences allows material to be discussed and improved on by the experts via online conversation on Twitter. We aim to investigate the utilization of hashtags at the American Association for the Surgery of Trauma (AAST) meetings from 2016 to 2019 and its potential role in knowledge dissemination and meeting participations., Methods: Symplur Signals software was used to analyze hashtags for the AAST meetings by year: #AAST2016, #AAST2017, #AAST2018, #AAST2019., Results: Number of tweets decreased significantly from 2016 to 2019 (4500 to 4400 to 3600 to 2600, respectively, p<0.05). Retweets also decreased significantly from 2016 to 2019 (3600 to 3300 to 2600 to 1900, respectively, p<0.05). Users decreased from 2016 to 2019 (1600 to 1400 to 937 to 743, respectively, p<0.05). Despite this decrease, impressions were 5.8 million in 2016, increasing to 8.6 million in 2017, then 9.6 million in 2018 and finally peaking in 2019 where impressions reached 10 million (p<0.05). The top influencer for 2016-2019 was the AAST Twitter account., Conclusion: Twitter #AAST 2016-2019 online engagement and interactions have declined during the last 4 years while impressions have grown steadily indicating potential widespread dissemination of trauma-related knowledge and evidence-based practices, and increased online utilization of conference material to trauma surgeons, residents and fellows, trauma scientists, other physicians and the lay public. #AAST online engagement and impressions did not have influence on meeting attendance rates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND Empyema of the gallbladder is a complication of cholecystitis that can develop into sepsis if not treated promptly. Signs and symptoms of gallstone disease are nausea/vomiting, right upper quadrant tenderness, and a history of gallstone disease. With persistence of the obstruction, inflammation and bacterial overgrowth within the gallbladder lumen and tissue may lead to eventual venous congestion, pressure necrosis and even empyema of the gallbladder. CASE REPORT A 60-year old male presented with complaints of mild mid-epigastric pain radiating to the back. He denied previous similar history. CT and ultrasound of the abdomen revealed acute cholecystitis. During surgery, it was clear that the imaging did not accurately represent the severity of the infection and he was diagnosed with gallbladder empyema. Surgery was difficult but was successfully finished. The patient's symptoms and laboratory results normalized by post-operative day 3 and he was discharged. He had no further complications during 2-week follow up. CONCLUSIONS Physicians should keep the abnormal presentations of gallbladder empyema in mind and prepare themselves for a presentation different from imaging during surgery. Several prognostic factors including gallbladder wall thickness, gender, white cell count and diabetes mellitus have been associated with severe complicated cholecystitis and empyema of the gallbladder.

Introduction: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that occur along the alimentary tract, and are most commonly found in the stomach. Rarely, these tumors can occur in the small bowel, and when located in the duodenum or proximal jejunum, they may require challenging reconstruction of the alimentary tract. Patients with GISTs often present with non-specific abdominal pain or symptoms of obstruction, hemorrhage, and less commonly perforation., Presentation of Case: A 46-year-old male presented to the hospital with a one-day history of left upper quadrant pain with fevers and chills. Physical examination was significant for signs of peritonitis, and laboratory results revealed leukocytosis and lactic acidosis. CT abdomen showed a large soft tissue mass in the proximal jejunum. In the operating theater he was found to have a perforated jejunal tumor. Pathology report revealed a 13cm GIST, pT4N0M0, Stage IIIa. He had an uneventful recovery and was discharged nine days after surgery., Discussion: Proximal jejunal GISTs are a rare entity and when present, perforation is unlikely. Pathological diagnosis of GISTs are relies on immunohistochemistry demonstrating c-KIT or CD34 positivity. The prognosis of GISTs are dependent on the size and the mitotic index. Definitive treatment of non-metastatic GISTs is R0 resection. When located in the duodenum or proximal jejunum, resection can be very challenging and may require clinical expertise in order to safely perform complex alimentary tract reconstruction., Conclusion: Further investigation is required in order to determine best practice management for patients who present with proximal GISTs., Competing Interests: No conflicts of interest., (© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd.)

Competing Interests: There are no conflicts of interest.

Background: Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications., Study Design and Methods: This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined as P < 0.05., Results: Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763], P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290], P < 0.0001)., Conclusion: Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Emergencies, Trauma, and Shock.)

Introduction: A true brachial artery aneurysm is a rare pathology with an incidence of 0.17% of all peripheral artery aneurysms. This pathology can manifest devastating complications if overlooked, however, a high index of suspicion coupled with a thorough history and physical allows easy diagnosis. We present a rare case of the oldest documented patient with a true brachial artery aneurysm with idiopathic etiology., Presentation of Case: An 83-year-old gentleman presented with left upper extremity pain, erythema, and swelling for 1 week. He denied trauma to the area. Examination revealed a pulsatile mass of the antecubital fossa and decreased distal pulses. Imaging illustrated a 9mm aneurysm of the brachial artery with stenosis of the radial artery and non-enhancement of the origin of the ulnar artery. The patient underwent a brachial aneurysm excision, radial and ulnar embolectomy, and brachial to ulnar and radial artery bypass. Postoperatively, palpable pulses were appreciated in the radial and ulnar arteries. Pathology demonstrated a true aneurysm. The patient's postoperative course was uneventful and follow-up 6 months later revealed normal perfusion., Discussion: This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering neurovascular complaints of the upper extremities. Operative intervention even in asymptomatic patients is warranted due to a high complication rate of 33%., Conclusion: More research into the pathophysiology of this rare pathology is needed to further understand, prevent, or mitigate its complications., Competing Interests: No conflicts of interest., (© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd.)

Introduction: Vascular injuries account for approximately 2-4% of trauma admissions with only 2.5% of these being traumatic arteriovenous fistulas (AVFs). We offer a case report of a traumatic AVF and review of the literature., Presentation of Case: A 40-year-old male presented following 4 gunshot wounds, 2 in the forearm and 2 in the left upper thigh. The patient had decreased range of motion and paresthesia of the left lower extremity with palpable pulses and adequate capillary refill in all extremities. A CT angiogram demonstrated a left traumatic AVF involving the left deep femoral artery and left common femoral vein with an adjacent bullet fragment. The patient was taken to the operating room and underwent an exploration of the left groin, repair of the traumatic AVF, and removal of bullet fragment. The venous aspect had a grade IV injury and was ligated. The arterial defect was debrided to healthy tissue and repaired primarily. The patient recovered from his injuries with adequate ambulation and resolution of lower extremity edema. He was discharged home on postoperative day 4 on aspirin and a compression stocking., Discussion: Traumatic AVFs are rare, with up to 70% diagnosed in a delayed fashion. Clinicians must maintain a high index of suspicion to correctly diagnose and manage this injury to avoid potential morbidity and mortality., Conclusion: Despite literature accounts of surgeons' experience, this pathology is lacking level one evidence-based standardized surgical management algorithms. Controversy exists regarding venous repair methods., Competing Interests: None., (© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd.)

Introduction: Subclavian artery injury secondary to blunt trauma is rare and only a few cases have been documented in the literature. Subclavian arteries are protected by the clavicles, ribs, and chest wall. Clinical management and surgical approach vary depending on the specific injury. We present the case of a 50 year old male with blunt right subclavian transection., Case Presentation: A 50-year-old male presented after being struck by a train. On exam, the patient had open injuries to the right upper chest/extremity. CTA showed a transection of the mid right subclavian artery along with a long traumatic occlusion distal to the defect. The patient was taken to the operating room where median sternotomy with supraclavicular extension was used to expose the transected ends of the subclavian artery and successfully perform a bypass graft. After a long hospital stay, he had a near-full functional recovery., Discussion: Blunt subclavian injury is rare and carries a high mortality. Adequate intervention requires prompt identification and proper surgical approach for repair. Median sternotomy offers the best approach to visualize the proximal right subclavian artery. Extension with a supraclavicular incision can be necessary for distal control. This approach offered timely intervention, which ultimately saved his life and allowed for return of pre-trauma functional status., Conclusion: Prompt identification of subclavian artery injury is paramount as such injuries carry a high mortality. Median sternotomy with supraclavicular extension is an appropriate open surgical approach to successfully manage proximal right subclavian artery injuries., Competing Interests: No conflicts of interests., (© 2020 The Author(s).)

BACKGROUND Thyrocervical trunk pseudoaneurysms are rare complications that have been documented after internal jugular or subclavian venous cannulation. Even less common, these pseudoaneurysms can arise after blunt or penetrating trauma. Clinical hallmarks include an expanding supraclavicular mass with local compressive symptoms such as paresthesias, arterial steal syndrome, and Horner's syndrome. Patients may be asymptomatic, however, or present with overlying ecchymosis or the presence of a new bruit or thrill. With the risk of rupture, thyrocervical trunk pseudoaneurysm is associated with significant morbidity and mortality. CASE REPORT We report the case of a 27-year-old man who presented after sustaining a self-inflicted stab wound to zone I of his neck. Initial examination revealed only a superficial small laceration, but a chest x-ray revealed a pneumothorax, and tube thoracostomy returned 300 mL of bloody output. After resolution of the hemothorax and removal of the thoracostomy tube, the patient reaccumulated blood, requiring a repeat tube thoracostomy. Angiography at that time revealed a pseudoaneurysm of the thyrocervical trunk, and coil embolization was performed to obliterate the pseudoaneurysm. CONCLUSIONS Thyrocervical trunk pseudoaneurysms can be asymptomatic, often have a delayed presentation, and can be life-threatening due to the risk of rupture and subsequent hemodynamic decline or airway compromise. While these pseudoaneurysms are well-known complications of deep penetrating injuries, they can also present following superficial penetrating injury to zone I of the neck. Selective angiography is the imaging modality of choice. Open surgical repair was traditionally the criterion standard for treatment; however, endovascular approaches are minimally invasive, feasible, and safer alternatives with reduced complications and are becoming more common.

To evaluate disparities in the National Institute of Health (NIH) trauma research funding.Traumatic injury has increased in both prevalence and cost over the last decade. In the event of a traumatic injury, patients in the United States (US) rely on the trauma system to provide high-quality care. The current trauma research funding is not commensurate with the extent of the burden of trauma on the US population.In this qualitative study, the National Institutes of Health's Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC) data were reviewed. The burden of traumatic injury on the US and the NIH trauma research funding was examined and compared with other diseases.In 2018, the NIH funded an estimated $639 million to traumatic injury research projects, <2% of the NIH budget. Comparatively, the NIH funded an estimated $6.3 billion towards cancer research in 2018. Cancer research receives extensively more funding than trauma research despite that trauma accounts for 24.1% of all years of potential life lost (YPLL) before age 75 compared with 21.3% for cancer.In the event of traumatic injury, trauma systems in the US should be able to provide high-quality care to patients yet cannot do so without adequate research funding. The federal funding contributed towards trauma research deserves a re-evaluation.

BACKGROUND Diaphragmatic rupture is a rare pathology that reported in less than 0.5% of all trauma cases, with signs and symptoms that can easily be misdiagnosed. Clinicians must maintain a high index of suspicion to correctly diagnose and manage this pathology. We present a rare case of a large diaphragmatic rupture with transthoracic gastric and colon herniation that was successfully repaired, along with a literature review. CASE REPORT A 59-year-old woman presented to our Trauma Center after being involved in a motor vehicle collision. She complained of chest and abdominal pain, with decreased breath sounds on the left side. CT imaging revealed discontinuity of the left hemidiaphragm, with intrathoracic herniation of stomach and colon with multiple other injuries. The patient was taken for an emergent laparotomy. The diaphragmatic rupture measured 20 cm in length, with a stellate component. After ensuring complete reduction of the herniated organs, the diaphragmatic defect was primarily repaired. The patient recovered from her injuries and was doing well at last follow-up in the clinic. CONCLUSIONS This case highlights the importance of diaphragmatic rupture and its associated intra-abdominal injuries when treating trauma patients. With missed diaphragmatic injuries leading to a potential morbidity rate of 30% and mortality rate as high as 10%, the clinician must have a high index of suspicion to correctly diagnose and manage this pathology in a timely fashion. More research is needed to provide surgeons with evidence-based standardized therapies for dealing with these rare pathologies to ensure optimal patient outcomes.

Introduction: Traumatic diaphragmatic ruptures are rare injuries in the pediatric population that can present with dyspnea, abdominal pain, or even be asymptomatic., Case Presentation: A 4-year-old boy presents to our Level 1 Pediatric Trauma Center after being hit by a car. He presented awake and alert but with low oxygen saturations and chief complaint of left sided abdominal and chest pain. The initial chest radiograph showed an elevated left diaphragm and bilateral opacities. A laparoscopic approach confirmed the diagnosis of a diaphragm rupture and an open approach allowed for the diaphragm repair, after returning the stomach, colon and spleen back to the abdominal cavity. He had an uneventful recovery and was discharged home on postoperative day seven., Discussion: Traumatic diaphragmatic hernia continues to be a difficult diagnosis to make without a high index of suspicion with variable time to diagnosis. This has been attributed to nonspecific clinical presentation and low incidence of the condition. Chest radiograph has been suggested to be an appropriate initial imaging modality with computed tomography as an accurate adjunct. Right sided diaphragm hernias, although less common, still occur and are often misdiagnosed. Recovery without significant morbidity after definitive surgical treatment with laparotomy is common., Conclusion: Consider a traumatic diaphragmatic hernia in a blunt pediatric trauma patient with abdominal pain and dyspnea once other life-threatening injuries have been ruled out. This is an easily missed injury that can lead to significant morbidity and mortality if not identified early in the patient's hospital course., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Axillo-subclavian arterial injuries are generally associated with penetrating trauma. On rare occasion, blunt mechanisms can cause these injuries in the setting of high-energy trauma, humeral head or neck fractures, and severe glenohumeral dislocations. Glenohumeral dislocations sustained from ground-level falls are generally reduced in the emergency department without associated morbidity., Presentation of Case: An 80-year-old woman presented with an inferior glenohumeral dislocation after a ground-level fall that was found to be complicated by axillary dissection, pseudoaneurysm, and acute hemorrhage. Endovascular intervention with a balloon-inflatable stent successfully controlled extravasation and restored perfusion to the affected upper extremity. After a short hospitalization, the patient was discharged with intact neurovascular status., Discussion: Blunt axillary artery injury and inferior glenohumeral dislocations are both uncommon entities. A correlation exists between inferior dislocations and neurovascular complications. Accordingly, there may be a role for diagnostic vascular imaging for patients with inferior glenohumeral dislocations. Endovascular stenting was successful in our case and backed by case series and cohort studies in the literature. Some controversy exists regarding stent patency and follow-up planning in trauma patients., Conclusion: This case represents a critical vascular injury from an unexpected mechanism. Inferior glenohumeral dislocations, regardless of injury mechanism, should raise the index of suspicion for vascular involvement. Endovascular repair in our patient was life-saving given her advanced age, acute blood loss anemia, rarity and severity of her injuries and multiple medical comorbidities., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Ocular trauma is a common occurrence in trauma settings but often occurs with little to no effect on the vision of the patient. Traumatic enucleation is a rare but devastating injury., Case Presentation: A 40-year-old male presented to our trauma center after an assault resulting in right globe enucleation. CT confirmed absence of the globe with disruption of the ipsilateral orbital contents and distal optic nerve disruption. The patient was started on intravenous antibiotics and the right orbit was packed. He was taken to the operating room for exploration of the right orbit and placement of an implant. His remaining hospital course was unremarkable., Discussion: Documented mechanisms of injury for traumatic enucleation are diverse, but often involve significant retro-ocular force to completely dislodge the globe from the orbit. Optic nerve avulsion may cause associated optic nerve chiasm damage leading to temporal hemianopia in the uninjured contralateral eye. Treatment involves stabilization and preparation for future implant placement., Conclusion: Traumatic enucleation is extremely rare. Development of a grading system applicable to traumatic enucleation may be helpful in guiding management in this complex patient population., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance., Case Presentation: A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition., Discussion: Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible., Conclusion: Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Malignant spermatic cord tumors have an annual incidence of 0.3 cases/million. The vast majority of tumors in this region are benign. We present a rare case of a dedifferentiated liposarcoma of the spermatic cord successfully treated., Presentation of Case: A 59-year-old gentleman presented complaining of an enlarging painful right groin mass. On exam there was an obvious 10 cm inguinal mass. Imaging illustrated a right inguinal soft tissue mass that was not present on imaging 22 months prior. The patient underwent a right inguinal exploration, en bloc resection of the mass, and radical orchiectomy to ensure negative margins. Histopathological analysis revealed a grade 2 dedifferentiated liposarcoma that measured 9 × 6 × 5 cm, with 5 cm negative margins. The patient did well and was discharged on postoperative day one. On 6-month follow-up there was no evidence of recurrence., Discussion: We present a rare dedifferentiated liposarcoma of the spermatic cord that was successfully treated with surgical resection. This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering an enlarging inguinal mass. This rare pathology is lacking level one evidence-based standardized treatment algorithms. The mainstay of treatment is surgical resection., Conclusion: For spermatic cord liposarcomas, the surgical approach is en bloc resection with radical orchiectomy aiming for R0 margins. Prognosis depends on tumor grade, anatomic site, and the ability to achieve a microscopically tumor negative resection. Despite our patient's disease free status, prolonged surveillance with physical examination and cross sectional imaging is still warranted., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: The Roux-en-y gastric bypass (RYGB) surgery is one of the most common and successful weight loss procedures. Procedure mortality is low, but intestinal complications account for a high percentage of associated morbidity. Internal hernias remain one of the most common complications while volvulus and intussusception are rare., Presentation of Case: A 22-year-old woman with a past surgical history of laparoscopic RYGB six years prior presented with a 12 -h history of abdominal pain. Exploratory laparotomy revealed concomitant volvulus, internal hernia and intussusception at the J-J anastomosis which was reduced without need for bowel resection. Her post-operative course was unremarkable and she was discharged home five days later., Discussion: Many previous cases of intussusception related to RYGB surgery have required treatment with bowel resection secondary to delayed surgical intervention. Due to high variability in clinical presentation of post-RYGB obstruction, a high index of suspicion is necessary for prompt recognition. Early surgical intervention may prevent the need for bowel resection and improve patient outcomes., Conclusion: This case represents an unusual complication of RYGB involving intussusception, internal hernia and volvulus that was successfully managed without need for bowel resection due to early identification and surgical intervention., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Gallbladder disease is a common surgical pathology. Gallstones can remain asymptomatic or develop into an acute cholecystitis and need for surgical intervention. Significant enlargement of the gallbladder well beyond the normal volume is rare. Such "giant" gallbladders can affect feasibility of subsequent management options., Presentation of Case: An 80-year-old female presented to the emergency department with a two-day history of acute on chronic gastric reflux with nausea and vomiting. On examination, she had right upper quadrant abdominal pain. CT imaging identified an enormous gallbladder creating mass effect and compression on the distal stomach. She underwent successful laparoscopic cholecystectomy and was discharged from the hospital the next day, doing well. On two-week follow up, her reflux symptoms had completely resolved and she had no complaints., Discussion: Giant gallbladders are a rare entity. Our patient's case is unique in both its occurrence as well as presentation with predominant reflux symptoms secondary to mass effect by the enlarged gallbladder. Current cholecystitis grading systems do not utilize size as a means of predicting severity and risk of operative complications or difficulty of procedure. Laparoscopic cholecystectomy was a successful approach in managing this extreme pathology., Conclusion: Updated classifications systems that include size and mass effect as a predictive measure are needed to better assess surgical outcomes, especially in "giant" gallbladder disease. Despite the large size and potential mass effect on surrounding structures, laparoscopic cholecystectomy can still be attempted if no other contraindications exist., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

BACKGROUND Axillo-subclavian vessel injuries were traditionally the result of combat-related trauma encountered by military surgeons. An increase in gun-related violence in our backyards, however, have brought these injuries to our doorsteps. The majority of the available data explores the management of arterial injuries. There is a deficiency in the literature discussing the management of isolated axillo-subclavian venous injuries. CASE REPORT We report the case of a 25-year-old male who presented after sustaining a gunshot wound to his right lateral chest and axillary area. Computed tomography angiography revealed axillary vein transection. Upon emergent operative intervention, vascular control of the hemorrhage was achieved with ligation of the axillary vein. The patient had an uncomplicated postoperative course and follow up in the office was unremarkable. CONCLUSIONS Axillo-subclavian vessel injuries can result in exsanguination and are associated with a significant mortality risk. Early detection and expeditious management are essential for preserving the patient's limb and preventing the loss of life. Isolated axillary vein injuries can be managed in an unstable patient with ligation and is well-tolerated by patients with an evanescent upper extremity edema.

Background: Clinicians must maintain an index of suspicion to diagnose an anorectal foreign body (FB). The patient may not be forthcoming with information secondary to embarrassment or possibly psychiatric issues. Providers must express empathy and compassion while maintaining nonjudgmental composure. Despite accounts of anal FB insertion, this pathology is lacking level one evidence-based surgical algorithms., Case Presentation: A 46-year-old male psychiatric patient presented in septic shock, complaining of lower abdominal/pelvic pain starting 1 week prior. His past medical history was significant for schizophrenia, bipolar disorder, and noncompliance with medications. CT of the abdomen/pelvis revealed a rectal perforation with free air and a FB which appeared to be a screwdriver. Fluid resuscitation and broad-spectrum antibiotics were administered. In the operating room, after unsuccessful transrectal removal, an exploratory laparotomy was performed. The metallic end of the screwdriver had perforated the rectosigmoid. Resection of the perforated rectum with removal of the screwdriver, incision and drainage of a large right buttock abscess and colostomy was performed. The patient recovered and was discharged to behavioral health. At 2 weeks follow-up the patient was doing well with a functioning colostomy and reversal was planned for later this year., Conclusion: This case highlights the importance of maintaining a high index of suspicion when encountering psychiatric patients with nonspecific lower abdominal or anorectal pain with inconsistent presentations. Controversy exists regarding the type of surgical treatment in case of anorectal perforation. More research is needed to provide surgeons with evidence-based standardized methods for dealing with these rare pathologies., Competing Interests: None., (© 2019 The Author(s).)

BACKGROUND First described in 1863 by French surgeon Victor-Auguste-François Morel-Lavallee, the Morel-Lavallee lesion (MLL) is a closed traumatic soft-tissue degloving injury. These lesions most commonly occur following motor vehicle collisions (MVCs). The pathophysiology stems from a shearing force that causes separation of the soft tissue from the fascia underneath, which disrupts the vasculature and lymphatic vessels that perforate between the tissue layers. Timely diagnosis and treatment are imperative, as a delayed diagnosis can lead to complications. However, at present there is no universally accepted treatment algorithm. CASE REPORT A 60-year-old morbidly obese woman presented after being involved in an MVC. She complained of abdominal tenderness in the right lower quadrant, with no evidence of peritonitis. Cross-sectional imaging revealed hemoperitoneum and a traumatic posterior abdominal wall/lumbar hernia on the right, with multiple contusions in the subcutaneous abdomen. The patient was taken to the operating room and underwent an exploratory laparotomy that revealed a large abdominal Morel-Lavallee lesion (MLL) along with a traumatic abdominal wall hernia (TAWH). There was also a mesenteric avulsion injury with an associated ileocecal injury. The patient underwent resection of the involved bowel, with primary anastomosis, debridement of the abdominal wall degloving injury, and expectant management for the hernia defect. She recovered from the injuries and was doing well when followed up in the clinic, with follow-up to repair the hernia in the near future. CONCLUSIONS More research is needed to provide surgeons with evidence-based standardized therapies for dealing with these rare pathologies to ensure optimal patient outcomes.

Teaching status/academic ranking may play a role in the variations in trauma center (TC) outcomes. Our study aimed to determine the relationship between TC teaching status and injury-adjusted, all-cause mortality in a national sampling.Retrospective review of the National Sample Program (NSP) from the National Trauma Data bank (NTDB). TCs were categorized based on teaching status. Adjusted mortality was determined by observed/expected (O/E) mortality ratios, derived using TRauma Injury Severity Score methodology from the Injury Severity Score and Revised Trauma Score. Chi-square and t test analyses were utilized with a statistical significance defined as P <.05.Of the 94 TCs in the NSP, 46 were university, 38 were community teaching, and 10 were community nonteaching. For the University TCs, 62.8% were American College of Surgeons (ACS) level 1 and 81.2% state level 1. Of the community teaching TCs, 39.0% was ACS level 1 and 35.1% was state level 1. Of the community nonteaching TCs, 0% was ACS level 1 and 11.1% was state level 1. University TCs had a significantly higher O/E mortality rate than community teaching (0.75 vs 0.71; P = .04). There were no differences in O/E between community teaching and nonteaching TCs (0.71 vs 0.70; P = .70).Community teaching and nonteaching TCs have lower injury-adjusted, all-cause mortality rates than University Centers. Future studies should further investigate key differences between University TCs and community teaching TC to evaluate possible quality and performance improvement measures.

Introduction: A compartment syndrome (CS) occurs when increased pressure within an anatomic compartment leads to inadequate perfusion. Although rare, gluteal CS can be encountered when an unconscious person has a prolonged period of immobilization., Presentation of Case: A 20-year-old male with history of polysubstance abuse leading to passing out, presented with right buttock and lower extremity pain, increased creatinine phosphokinase (CPK), and acute renal failure. Physical examination and MRI confirmation supported gluteal CS. Patient was taken to the OR for gluteal fasciotomy. Afterwards, the pain improved, the CPK and creatinine trended to normal. He was discharged home on day 7., Discussion: CS can occur in any part of the body with fascial compartments. Increased compartmental pressure causes compression of vessels and nerves in the area that can lead to ischemia and necrosis. CS can occur after trauma, excessive fluid resuscitation, or surgery. It is also reported due to the prolonged periods of immobilization and increasing pressure on dependent areas. Often, intra-compartmental pressure is measured to confirm the diagnosis. The mainstay of treatment is fasciotomy., Conclusion: Due to the rarity of gluteal compartment syndrome, the diagnosis is often delayed. If the affected area is ischemic for a significant amount of time, it can lead to sciatic nerve palsy, paresthesias, paralysis and muscle necrosis. Patients may experience irreversible damage after the syndrome and as such providers should be cognizant of this clinical entity to make an early diagnosis of gluteal compartment syndrome.

Introduction: Traumatic intracranial hemorrhages (ICHs) are high priority injuries. Traumatic brain bleeds can be categorized as traumatic subarachnoid hemorrhage (SAH) versus non-SAH-ICH. Non-SAH-ICH includes subdural, epidural, and intraventricular hematomas and brain contusions. We hypothesize that awake patients with SAH will have lower mortality and needless interventions than awake patients with non-SAH-ICHs., Study Design and Methods: A review of data collected from our Level I trauma center was conducted. Awake was defined as an initial Glasgow coma score (GCS) 13-15. Patients were divided into two cohorts: awake SAH and awake non-SAH-ICH. Chi-square and t -test analyses were used with statistical significance defined as P < 0.05., Results: A total of 12,482 trauma patients were admitted during the study period, of which 225 had a SAH and GCS of 13-15 while 826 had a non-SAH-ICH with a GCS of 13-15. There was no significant difference in demographics between the two groups. Predicted survival between the two groups was similar (97.3 vs. 95.7%, P > 0.05). Mortality rates were, however, significantly lower in SAH patients compared to the non-SAH-ICH (4/225 [1.78%] vs. 22/826 [2.66%], P < 0.05). The need for neurosurgical intervention was significantly different comparing the SAH group versus non-SAH-ICH (2/225 [0.89%] vs. 100/826 [12.1%], P < 0.05)., Conclusion: Despite similar predicted mortality rates, awake patients with a SAH are associated with a significantly lower risk of death and need for neurosurgical intervention when compared to other types of awake patients with a traumatic brain bleed., Competing Interests: There are no conflicts of interest.

The American College of Surgeons (ACS) Committee on Trauma (COT) verification and State designation of trauma centers (TCs) into Level 1 or 2 establishes a distinction based on resources, trauma volume, and educational commitment. The ACS COT and individual states each verify TCs to differentiate performance levels. We aim to determine the relationship between ACS and State Level 1 versus 2, and injury-adjusted, all-cause mortality in a national sampling.TCs were identified by review of the National Sample Program (NSP) from the National Trauma Data Bank (NTDB)-the largest validated trauma database in the nation-of the year 2013. TCs were categorized by ACS or State Level 1 or 2 status, all others were excluded. Adjusted mortality was determined using observed/expected mortality (O/E) ratios, derived by trauma and injury severity score (TRISS) methodology. Chi-squared and t test analyses were used for categorical variables, with a statistical significance defined as P-value <.05.Of the 94 TCs in the NSP, 67 had ACS and 80 had State designations. There were 38 ACS Level 1 TCs and 29 ACS Level 2. For State designations, there were 45 as State Level 1 and 35 State Level 2. ACS Level 1 TCs had a similar O/E compared with ACS Level 2 verified centers (0.73 vs 0.75, chi-square, P = .36). Level 1 TCs designated by their state, had a similar O/E compared with State Level 2 centers (0.70 vs 0.74, chi-square, P = .08).Both ACS and State Level 1 and 2 trauma centers performed similarly on injury adjusted, all-cause mortality.

Introduction: Neuroendocrine tumors (NETs) are neoplasms that arise from neuroendocrine cells that have properties of both neuronal and endocrine cells. NETs are most common in the small intestine, rectum, and the appendix and frequently termed carcinoid., Presentation of Case: A 30-year-old male presented with abdominal pain and tenderness in the RLQ. Computerized tomography revealed findings consistent with acute appendicitis. The patient underwent an uneventful laparoscopic appendectomy for an acutely inflamed appendicitis. Histopathological examination, showed a 0.5 cm well-differentiated neuroendocrine tumor of the distal appendix, with clear margins. The mitotic rate was <2 mitoses/10 high power field. Following guidelines, no further procedures were performed and follow-up one week later was uneventful., Discussion: Appendectomy for the treatment of appendiceal NETs smaller than 1 cm has been recommended as the treatment of these neoplasms by the guidelines set by The North American Neuroendocrine Society (NANETS). NANETS recommends right hemicolectomy for tumors originating at the base of the appendix, for tumors >2 cm in size, if there is evidence of lymphovascular or meso-appendiceal invasion, with mesenteric lymph node metastases, or for intermediate or high-grade tumors., Conclusion: We present the case of a 30-year old male that presented with an appendiceal, well-differentiated NET that manifested as appendicitis and laparoscopic appendectomy was performed. The appendix was resected with clear margins. Given appropriate markers appendectomy can be curative.

Introduction: Intra-abdominal and pelvic abscesses can develop because of multiple etiologies. Typically, these abscesses are managed via a combination of medical (antibiotics) and surgical (drainage) interventions. This is a unique case report of a giant idiopathic pelvic abscess with necrotizing fasciitis that failed conservative management with antibiotics, requiring urgent surgical intervention and complex closure of the wound., Case Presentation: A 71-year-old female presented to the emergency department in sepsis, complaining of right hip and flank pain of one-month duration. Imaging revealed a giant right flank abscess with necrotizing fasciitis. The abscess extended from the pelvis to the right retroperitoneal space, traversing several soft tissue planes, to the skin. She was treated emergently with open surgical drainage, debridement, and delayed complex closure. The patient significantly improved post-operatively and was subsequently discharged., Discussion: Pelvic abscesses are commonly due to gastrointestinal, genitourinary, post-surgical, or rarely idiopathic causes. US, CT, or MRI are the imaging modalities effective in diagnosing and staging abscess severity. Currently percutaneous, image-guided abscess drainage is the primary management due to it being minimally invasive, having better outcomes and reduced hospital stay. In large, multi-loculated abscess as exhibited by our patient, open surgical drainage and debridement of the infected cavity was not only successful but imperative in effective resolution., Conclusion: Most pelvic abscesses can be treated with percutaneous drainage but those complicated by necrotizing fasciitis, or multi-loculated collections may be better treated with open drainage., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Pheochromocytoma are neuroendocrine tumors that arise from sympathetic chromaffin cells within the adrenal medulla. They principally secrete catecholamines, potentially causing life-threatening cardiovascular complications. A myriad of symptomatology and clinical findings are associated with pheochromocytoma, including a catecholamine-induced dilated cardiomyopathy., Presentation of Case: A 50-year-old woman presented with retrosternal chest pain and underwent diagnostic evaluation for acute coronary syndrome. Cardiac catheterization demonstrated patent coronary arteries and a pattern of ventricular hypokinesis consistent with takotsubo cardiomyopathy, also known as broken heart syndrome. Further imaging with abdominal CT revealed an adrenal mass. Laboratory markers supported the clinical picture of pheochromocytoma. Right adrenalectomy was performed and our patient was symptom-free at discharge on post-operative day three., Discussion: Alpha and beta adrenergic blockade are used in a critical care setting to prevent perioperative hemodynamic instability as well as catecholamine-induced heart failure in the setting of pheochromocytoma. Patients commonly require vasopressors in the postoperative period due to the rapid reduction in circulating catecholamines following resection. Discharge planning should include recommendations for genetic counseling to screen for syndromic causes of pheochromocytoma that increase the risk for other neoplasms., Conclusion: We present a case report of a rare adrenal tumor in a middle-aged woman that manifested as acute coronary syndrome. A presumptive diagnosis of takotsubo cardiomyopathy on cardiac catheterization led to further investigation. Abdominal imaging located an adrenal mass that correlated with laboratory studies positive for high levels of catecholamines and their metabolites. The tumor was excised and the patient recovered without complications., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Body packing is the use of intra-corporeal packages of illicit drugs for the purpose of smuggling, usually through customs. Clinical cases and experience with body packers has increased since the first report appeared in 1971. These cases remain an uncommon cause of acute drug toxicity and/or bowel obstruction., Presentation of Case: A 23 year-old man was brought to the emergency department with seizures. CT imaging revealed numerous intestinal foreign bodies, suspicious for body packing. The patient was stabilized and taken emergently to the operating room for exploratory laparotomy and removal of 34 cocaine packets. Ongoing treatment for cocaine overdose was also utilized. The patient recovered without complications., Discussion: This case provides insight and awareness for proper diagnosis and management of body packers by physicians and surgeons alike., Conclusion: We present a case report of acute cocaine intoxication in a young man who ingested 34 packets of cocaine for means of drug trafficking. Medical approaches are available for cases in which patients remain asymptomatic, but surgical intervention is necessary for those with signs and symptoms of bowel obstruction or drug overdose., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Urinary bladder ruptures are an uncommon injury, occurring in less than 1% of all blunt abdominal trauma. Extraperitoneal bladder ruptures are generally associated with pelvic fractures and usually managed nonoperatively. Conversely, intraperitoneal injuries are often caused by large compressive and shear forces produced during seatbelt injuries and almost invariably require surgical intervention., Presentation of Case: A 29-year-old woman presented as a trauma alert after a motor vehicle collision with abdominal/flank pain and gross hematuria. Free intraperitoneal fluid was found on ultrasound and CT imaging. Exploratory laparotomy located an intraperitoneal rupture across the bladder dome. The patient recovered without complications, was discharged on postoperative day three, and continued bladder catheter care at home for an additional week until outpatient follow up and catheter removal., Discussion: As evidence for surgical management of bladder trauma continues to grow, clinical practice guidelines have been developed for trauma surgeons. Recent recommendations from the Eastern Association for the Surgery of Trauma appraise the evidence for cystography in the perioperative setting. Postoperative care is focused on preventing catheter-associated urinary tract infections in patients recovering from urotrauma in the critical care setting., Conclusion: We present a case of intraperitoneal bladder rupture in the setting of a blunt traumatic seatbelt injury. Our patient recovered uneventfully after surgical repair, a three-day hospitalization, and ten days with an indwelling bladder catheter., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Cases of inguinal bladder hernia are rare, with bladder involvement seen in 1-4% of inguinal hernias. The majority of cases are diagnosed intraoperatively, with only 7% of bladder hernias identified prior to surgery. Diagnosis may be challenging as patients are often asymptomatic or have nonspecific symptoms. Surgical repair is currently the standard treatment, and careful surgical planning is necessary to avoid complications including bladder injury., Presentation of Case: A 58-year-old man presented to our Emergency Department with 2-day history of progressively worsening left lower quadrant pain, groin bulge, and dysuria. Physical exam revealed an irreducible left inguinal hernia associated with urinary urgency on attempted reduction. Plain CT was ordered and demonstrated inguinal hernia with bladder protrusion into the left scrotum. The patient underwent open surgical reduction and hernia repair and made a quick postoperative recovery without complications., Discussion: Inguinal bladder hernia most often presents in older, obese males and clinicians should have a high index of suspicion when assessing patients with inguinal hernia. Preoperative diagnosis based on history, physical, and radiologic imaging allow for careful surgical planning and prevention of severe complications including bladder injury and leakage., Conclusion: We present a case report of inguinal bladder hernia in a middle-aged man that presented as left lower quadrant pain, groin pain, and dysuria. Diagnosis was confirmed preoperatively with radiographic imaging. The hernia was surgically reduced and the defect repaired without complications., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)