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Type IV paraesophageal hernia (PEH) is very rare and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a case of a 90-year-old male patient who presented at our emergency department complaining of epigastric pain that he had experienced over the past few hours and getting progressively worse. On the day after admission, his pain became severe. Chest radiography revealed an intrathoracic intestinal gas bubble; emergency exploratory laparotomy identified a type IV PEH with herniation of only the jejunum with perforated diverticula on mesenteric side through a hiatal defect into mediastinum. There are a few published cases of small bowel herniation into the thoracic cavity in the literature. Our patient represents a rare case of an individual diagnosed with type IV PEH with herniation of jejunum with perforated diverticula.

The duodenum is the initial C-shaped segment of the small intestine and is a continuation of the pylorus. Distally, it is in continuation with the jejunum and ileum, with the proximal segment being the shortest and widest. Positioned inferiorly to the stomach, the duodenum is approximately 25 to 30 cm long. Interestingly enough, this portion of the small intestine got its name due to its length. In Latin, the term "duodenum" means 12 fingers, which is roughly the length of the duodenum. The 4 segments of the duodenum include the following:  The duodenal bulb, which connects to the undersurface of the liver via the hepatoduodenal ligament, which contains the portal vein, the hepatic artery, and common bile duct.  The second or descending segment is just above the inferior vena cava and right kidney, with the head of the pancreas lying in a C-shaped concavity.  The third segment runs from right to left in front of the aorta and inferior vena cava, with the superior mesenteric vessels in front of it. The fourth segment continues as the jejunum. The walls of the duodenum are made up of 4 layers of tissue that are identical to the other layers of the gastrointestinal (GI) tract. From innermost to the outermost layer, these are the mucosa, submucosa, muscularis, and serosa layers. The mucosal layer lines the inner surface of the duodenum and is made of simple columnar cells with microvilli and numerous mucous glands. The submucosal layer is mostly a layer of connective tissue where blood vessels and nerves travel through. The muscularis layer contains the smooth muscle of the duodenum and allow mixing and forward peristaltic movement of chyme. The serosal layer is characterized by squamous epithelium that acts as a barrier for the duodenum from other organs within the human body., (Copyright © 2022, StatPearls Publishing LLC.)

Laparotomy is one of the most common surgical procedures performed for abdominal trauma. The essence of a successful trauma laparotomy outcome relies on a methodical sequence of steps, surgical knowledge of maneuvers, and sound surgical decisions based on evidence and experience. Surgical maneuvers have been developed over years of experience to enable the surgeon to gain access to injuries of deep abdominal structures, identify these injuries and address them appropriately. Complete left medial visceral rotation or Mattox maneuver is one such intraoperative surgical innovation which has revolutionized the trauma surgery since the 1970s. Definition Mattox Maneuver, also known as a left medial visceral rotation, is a surgical step to explore and handle Zone 1 and 2 retroperitoneal injuries (aorta, left iliac and pelvic vessels). It starts with incising the parietal peritoneum at the white line of Toldt from the sigmoid colon to the splenic flexure. The spleen, tail of the pancreas, left kidney, and stomach are mobilized and reflected medially during this maneuver to explore the deeper structures. Historical Perspective Dr. Kenneth L Mattox was a chief resident in surgery at Baylor College of Medicine, and he was operating on patient early in the morning. The patient underwent multiple previous abdominal surgeries and was bleeding into the retroperitoneal space. Dr. Mattox was assisted by a second-year urology resident. They needed to mobilize the viscera and obtain access and control deep retroperitoneal bleeding which was suspected to be coming from aorta or IVC. They developed this maneuver on the table. They could save the patient together. Encouraged by this “new approach” they performed a few more similar cases and presented their data at a national meeting, and hence it has been called the “Mattox maneuver” since then., (Copyright © 2022, StatPearls Publishing LLC.)

Head and neck cancer is the sixth most common cancer worldwide.[1] The single most important factor affecting prognosis for squamous cell carcinoma is the status of the cervical lymph nodes. Metastasis to the regional lymph nodes reduces the 5-year survival rate by 50% compared with that of patients with early-stage disease. The American Cancer Society reports that 40% of patients with squamous carcinoma of the oral cavity and pharynx present with regional metastases to the cervical lymph nodes.[2] Therefore, the management of cervical lymph nodes is a vital component in the overall treatment plan for patients with squamous cell carcinoma of the head and neck. Head and neck surgery for cancer is a major undertaking with potentially enormous morbidity. Not every patient is a candidate for surgery and to avoid poor outcomes, it is important to select patients appropriately via a preoperative cardiac and pulmonary workup, in addition to their cancer staging. While surgery has demonstrated superior local control rates, overall survival remains similar with surgical versus non-surgical therapy for many head and neck cancers; the astute clinician must therefore tailor treatment to the individual patient to maximize the quality of life and post-treatment functionality. Removal of the cervical lymph nodes for oncologic reasons is termed a "neck dissection," and the surgery is tailored to address the lymph node basins at risk for metastatic spread depending on the site of the primary tumor., (Copyright © 2022, StatPearls Publishing LLC.)