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A newborn (5 h old) quarter horse colt was presented because of lethargy and severe abdominal distention. Uroperitoneum was suspected during initial workup, based on sonographic imaging and peritoneal fluid analysis. Definitive diagnosis was confirmed during exploratory celiotomy. Surgery revealed a congenitally abnormal allantoic stalk/urachal remnant and a failure of embryological fusion of the dorsal bladder wall. Recovery was successful and the animal is now a healthy, 4-year-old western performance gelding. These specific congenital abnormalities have not been previously documented in the peer-reviewed literature. Key clinical message: Congenital abnormalities of the urachus and the urinary bladder should be suspected in foals with uroperitoneum at birth. Cases involving congenital abnormalities of the urachus and urinary bladder might have favorable prognoses if animals retain adequate function of the urogenital tract and do not have secondary complications before and following surgery., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Uroperitoneum is a rarely documented finding in heifers. More frequently uroperitoneum is described in male youngstock suffering from obstructive urolithiasis, or abscesses of the urachus. This report describes a case of uroperitoneum most likely as a result of a traumatic rupture of the urinary bladder in an 8.5 months old heifer. The animal was presented with a severely dilated abdomen and an undulating wave was evident upon palpation. The heifer exhibited physiologic urination. Additionally, left displacement of the abomasum was evident. In consequence to findings of the ultrasonographic examination and abdominocentesis, diagnostic laparotomy was performed. Urine was evacuated from the abdominal cavity in fractions and the damaged cranial pole of the urinary bladder was excised followed by the suture of the urinary bladder. The abomasum was replaced in its physiologic position and an omentopexy was performed. The heifer was discharged from hospital and was still in the herd 5 years after discharge., Competing Interests: Die Autorinnen erklären, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: Patients with superficial peritoneal endometriosis (SPE) present with symptoms suggestive of endometriosis but clinical and imaging exams are inconclusive. Consequently, laparoscopy is usually necessary to confirm diagnosis. The present study aimed to evaluate the accuracy of microRNAs (miRNAs) to diagnose patients with SPE from the ENDOmiARN cohort STUDY DESIGN: This prospective study (NCT04728152) included 200 saliva samples obtained between January and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy and/or MRI to confirm the presence of endometriosis. Among the patients with endometriosis, two groups were defined: an SPE phenotype group of patients with peritoneal lesions only, and a non-SPE control group of patients with other endometriosis phenotypes (endometrioma and/or deep endometriosis). Data analysis consisted of two parts: (i) identification of a set of miRNA biomarkers using next-generation sequencing (NGS), and (ii) development of a saliva-based miRNA signature for the SPE phenotype in patients with endometriosis based on a Random Forest (RF) model., Results: Among the 153 patients with confirmed endometriosis, 10.5 % (n = 16) had an SPE phenotype. Of the 2633 known miRNAs, the feature selection method generated a signature of 89 miRNAs of the SPE phenotype. After validation, the best model, representing the most accurate signature had a 100 % sensitivity, specificity, and AUC., Conclusion: This signature could constitute a new diagnostic strategy to detect the SPE phenotype based on a simple biological test and render diagnostic laparoscopy obsolete. PRéCIS: We generated a saliva-based signature to identify patients with superficial peritoneal endometriosis which is the most challenging form of endometriosis to diagnose and which is often either misdiagnosed or requires invasive laparoscopy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background/aim: Primary omental torsion is uncommon, mimicking appendicitis and other acute abdominal pathologies. It often escapes diagnosis on imaging investigation or conventional open laparotomy. This study aimed to evaluate the effect of laparoscopy on the various parameters of this entity, including incidence, diagnosis, and treatment., Materials and Methods: A systematic review was performed, including PubMed and Scopus databases, without a time limit, following the PRISMA principles. A total of 16 articles from January 2000 to December 2023, corresponding to 56 children with primary omental torsion, complied with the research criteria., Results: Primary omental torsion was associated with obesity. Symptoms were right abdomen oriented, often compared to those of acute appendicitis. Preoperative ultrasound displayed low diagnostic accuracy, whereas computerized tomography diagnosed only two thirds of cases. In all patients, the vermiform appendix was normal., Conclusion: Laparoscopy affected both diagnosis and treatment of primary omental torsion in children. Easy peritoneal cavity access rendered possible the diagnosis of cases previously discharged as abdominal pain of unknown etiology. Combined with the increased pediatric obesity, it also affected primary omental torsion incidence. The recent pathogenetic theories may be better supported today, as laparoscopy provides a detailed view in situ, and facilitates harvesting of fat tissue from the omentum for molecular investigation. The diagnostic efficiency of laparoscopy is superior to ultrasonography and computerized tomography. Finally, the removal of the ischemic omentum is technically easier compared to the open laparotomy alternative with all the technical difficulties of traction of a vulnerable hemorrhagic tissue through a small incision., (Copyright © 2024, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction: Non-pancreatic pseudocysts are rare lesions that typically form from the omentum and mesentery. These cysts have a thick fibrotic wall made up of fibrous tissue and may show signs of calcifications and inflammatory changes. The fluid inside them can vary, ranging from hemorrhage and pus to serous or sometimes chylous content. In most cases, these cysts appear as a result of trauma, surgery, or infection., Case Presentation: A 35-year-old male patient from Ethiopia presented with swelling in his lower abdomen that had been present for 2 years. Initially, the swelling was small but gradually increased in size. The patient experienced frequent urination but no pain or difficulty during urination, urgency, intermittent urination, or blood in the urine. The swelling was initially painless but became painful 2 months prior to his presentation. Abdominal computed tomography scans revealed a well-defined, lobulated peritoneal lesion measuring 16 × 12 × 10 cm, consisting primarily of fluid-filled cysts with a thick, enhancing wall and septa. Additionally, there was a large, heterogeneous enhancing soft tissue component measuring 8 × 6 cm. As a result, the cystic mass was surgically removed in its entirety with partial removal of the bladder wall, and the patient was discharged in an improved condition., Conclusion: Primary non-pancreatic pseudocysts are extremely rare lesions that must be differentiated from other possible causes of cystic lesions within the peritoneal or retroperitoneal regions. Surgeons should be aware of the potential occurrence of these lesions, which may have an unknown origin., (© 2024. The Author(s).)

Background: The preoperative prediction of intraperitoneal adhesion (IPA) before repeated cesarean deliveries (CD), which are becoming more prevalent, is crucial for maternal health., Aim: The aim of the study was to preoperatively predict IPA in repeated CD with the stria gravidarum (SG) scoring system., Methods: A total of 167 patients with at least one previous CD at or beyond 37 weeks of gestation were analyzed. Preoperative SG was calculated according to the Davey scoring system: 0-2 score were defined as mild SG (Group 1; n: 94, 56.2%), and 3-8 score were defined as severe SG (Group 2; n = 73, 43.8%). Preoperative previous cesarean incision features were evaluated according to the Vancouver scar scale. IPA was evaluated according to the Nair's and modified Nair's scoring systems., Results: Parity, younger age at first pregnancy, higher body mass index, number of previous CDs, rate of scar symptoms, Nair's and the modified Nair's scores were statistically significant in Group 2 (P = 0.01; P = 0.04; P = 0.007; P = 0.004; P < 0.001; P = 0.007; P = 0.02, respectively). Davey score ≥3 and Vancouver score ≥4.5 were determined as the cut-off value to predict IPA (P = 0.1 and 0.07, respectively). According to multivariate analysis, both Davey and Vancouver scores are independent factors in predicting IPA (P = 0.02 and 0.04, respectively)., Conclusion: Evaluating the SG score through the Davey score in women with a history of previous CD may assist in predicting IPA status before the planning of a subsequent surgery., (Copyright © 2024 Copyright: © 2024 Nigerian Journal of Clinical Practice.)

Peritoneal loose body (PLB) is a kind of lesions located in the abdominal cavity or pelvic cavity, which is rare and difficult to diagnose. The diameter of PLB is mostly 0.5-2.5 cm. Most PLBS are asymptomatic. Here we reported a case of giant PLB in the pelvis and analyzed its structure and protein composition. Surgical exploration revealed a white oval mass (4.5*4*3 cm) in the pelvic cavity. After the mass was removed, the symptoms of hematuria disappeared and the patient was discharged on the second postoperative day. Histochemical staining showed that PLB was mainly composed of collagen and scattered calcification. The protein components of PLB were detected by proteome analysis, and a variety of proteins related to collagen deposition and calcification were identified in PLB., (© 2024. The Author(s).)

Despite its numerous benefits, peritoneal dialysis (PD) can rarely result in dangerous and even life-threatening complications, including peritonitis, hernias, encapsulating peritoneal sclerosis (EPS), and rarely peritoneal pseudocysts. Herein, we present a rare case of a giant intra-peritoneal pseudocyst that presented four months following the discontinuation of a 5-year course of complicated PD. Despite the initially successful drainages, the patient's symptoms continued to recur, and the imaging findings were concerning for underlying neoplastic processes. As such, a staged surgical approach was performed, starting with a diagnostic laparoscopy and was subsequently followed with cyst excision and marsupialization to the peritoneal cavity. While previous reports of such rare pseudocyst have been documented in the literature as a complication of PD, to our knowledge, this is the second case of pseudocyst formation to occur months after the discontinuation of PD therapy. This case emphasizes the importance of close follow-up in PD patients and showcases how a staged surgical approach can be utilized to accurately diagnose and manage such complicated cases., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim of the Study: This study aimed to investigate the incidence and degree of postoperative intra-abdominal adhesions(POAs) in secondary laparoscopic procedures and assess the power of the preoperative levels of tumor necrosis factor-alpha(TNF-α) and interleukin-1 beta(IL-1β) and selected peripheral inflammatory biomarkers(PIBs) in the prediction of the development and extent of POA., Patients and Methods: This prospective study enrolled 103 patients who had previously undergone at least one or more laparoscopic abdominal or gynecological operations. We examined TNF-α, IL-1β, and PIBs, namely C-reactive protein, white blood cell count, neutrophil-to-lymphocyte ratio(NLR), platelet-to-lymphocyte ratio, and systemic immune-inflammation index(SII) according to the presence, location, and score of adhesions determined during secondary laparoscopic procedures., Results: Only age, postoperative adhesion index(PAI) score, NLR, SII, TNF-α, and IL-1β resulted in a significant difference in the existence of adhesion(P<0.05). The correlation analysis of TNF-α with variables showed that the PAI score and IL 1β levels had a significantly positive correlation., Conclusion: The presence and extent of POA could be predicted by examining the preoperative TNF-α level in patients who had laparoscopic abdominal surgery previously. We could overcome adverse events during secondary laparoscopic procedures by assessing high-risk patients and integrating a personalized surgical approach to managing selected patients., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background: Omental infarction (OI) is a rare cause of acute abdominal pain, which is benign and self-limited. It is diagnosed by imaging. The etiology of OI is either idiopathic or secondary and due to torsion, trauma, hypercoagulability, vasculitis, or pancreatitis., Case Report: Here, we present a case of OI in a child with acute severe right upper quadrant pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Correct diagnosis of OI via imaging can prevent unnecessary surgery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Primary/secondary omental torsion (POT/SOT), isolated segmental omental necrosis (ISON), and primary epiploic appendagitis (PEA) are rare causes of acute abdominal pain that often lead to misdiagnosis. Although the differential diagnosis may vary according to the localization and severity of the pain, and associated symptoms such as nausea-vomiting and fever, depending on the disease and site of involvement, the character of the pain is generally similar and in a continuous form. Depending on pain localization, it can mimic different clinical pictures such as acute appendicitis, acute diverticulitis, ovarian pathologies, urinary tract stones and acute cholecystitis, and patients are often diagnosed after surgical exploration. With the increased availability of computed tomography and awareness of these diseases, more patients can be diagnosed in the preoperative process and unnecessary operations can be avoided. In particular, PEA is a self-limiting local inflammatory disease and can often be managed conservatively. For all diagnoses, the surgical treatment option is local excision of the relevant epiploic appendix or omental segment, preferably laparoscopically. The most common surgical indication is diagnostic confusion and the second is persistent pain., Methods: The data of patients followed up and treated for a diagnosis of POT, SOT, ISON or PEA between 2006 and 2021 were recorded in a specially prepared database. The demographic characteristics of the patients, and the data regarding the diagnosis and treatment process were evaluated retrospectively and discussed in the light of the relevant literature., Results: The reason for hospitalization and treatment in 12 of the 42 patients included in the study was necrosis of a part of the omentum. Of these patients, 4 were followed up and treated with a diagnosis of POT, 3 with SOT, 5 with ISON and 30 with a diagnosis of PEA. Thirty-three of the patients were diagnosed preoperatively, and 9 intraoperatively, 22 patients were operated on, and 20 patients with PEA were treated conservatively. After surgical or medical treatment, all the patients were discharged without complications. In the comparisons between the patients, no significant difference was observed in terms of clinical and laboratory findings., Conclusion: POT, SOT, ISON and PEA should be considered in the differential diagnosis of patients with acute abdominal findings. In patients with PEA diagnosed in the preoperative period, a conservative approach should be considered first. In patients with a diagnosis of POT, SOT, and ISON, a surgical or conservative approach should be evaluated according to the patient's clinical condition.

Pleuroperitoneal communication is a severe complication in peritoneal dialysis, and about half of the patients forced to discontinue peritoneal dialysis. The method of coloring dialysis solution by indocyanine green or CT peritoneography have been reported to make diagnosis of pleuroperitoneal communication, however sensitivity of these tests is not a satisfactory level. By repairing the pleural hole with thoracoscopic surgery, it is possible to resume peritoneal dialysis. However, the recurrence rate is very high unless precisely detecting the location of the pleural hole during surgery. We report three cases of pleuroperitoneal communication in peritoneal dialysis patients, in which we found the combination of contrast-enhanced ultrasonography and the indocyanine green fluorescence system are reliable method to make diagnosis and identify the location of leakage of pleuroperitoneal communication. By making definite diagnosis and precisely identifying the localization, we were able to close diaphragm holes by video-assisted thoracoscopic surgery., (© 2022. The Author(s) under exclusive licence to The Japan Society of Nephrology.)

Aim: Polypoid endometriosis is a rare variant of endometriosis and may mimic malignancy. The purpose of this study is to evaluate magnetic resonance (MR) imaging characteristics of polypoid endometriosis for the differential diagnosis with malignancy., Methods: MR imaging findings of four histologically proven polypoid endometriosis were retrospectively evaluated with the review of the literature., Results: All polypoid endometriosis exhibited high signal intensity on T2-weighted images reflecting abundant dilated endometrial glands. Peritoneal lesions were surrounded by low signal intensity rim represented the "black rim sign" reflecting endometriotic fibrous adhesion. Two cases arising from endometriotic cysts showed transmural extension (peritoneal extension and myometrial infiltration). Endometriotic hemorrhagic foci were demonstrated in four lesions as high signal intensity on T1-weighted images and/or susceptibility-induced signal voids on susceptibility-weighted MR sequence. Diffusion-weighted images showed high signal intensity with relatively high apparent diffusion coefficient (ADC) due to T2 shine-through effect but no diffusion restriction, and dynamic contrast-enhanced (DCE) MR imaging showed gradually increasing contrast-enhancement pattern like benign pathologies., Conclusions: Polypoid endometriosis may mimic malignancy; however, black rim sign may be a characteristic MR imaging finding for the peritoneal lesions, and no diffusion restriction and gradually increasing contrast-enhancement pattern may reflect its benign nature., (© 2022 Japan Society of Obstetrics and Gynecology.)

Pleuroperitoneal communication is one of the complications for continuous ambulatory peritoneal dialysis. Communication sites, such as defects or bleb-like lesions, are found in the diaphragm, but it is sometimes difficult to detect these sites. We combined the infrared thoracoscopy and negative pressure technique to detect communication sites. We think our new technique will become an alternative option for difficult and complex cases., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Introduction: Omental infarction describes ischemic torsion of the distal portion of the omentum and constitutes an infrequent cause of acute abdominal pain in childhood of which few cases are known. Objec tive: To analyze through a clinical case the characteristics and management of this pathology, to consider this entity in the differential diagnosis of acute abdominal pain., Clinical Case: An 11-year- old child consulted the emergency department due to a 48-hour history of continuous abdominal pain, which had progressively increased. On the physical examination, the patient presented pain in the right side of the abdomen and the epigastric area, with no signs of peritoneal irritation, and was overweight (BMI 91st percentile). Biochemical analysis showed a slight increase in c-reactive protein (CRP) 41.31 mg/L (reference value < 3.0 mg/L) without leukocytosis and normal ultrasound study, without visualization of the appendix. Due to persistent pain, increased CRP, and absence of appen dix visualization in the ultrasound, the study was completed with an abdomen and pelvis CT scan which showed trabeculation of the fat of the anterior right subhepatic space, thus diagnosing omental infarction. The patient was hospitalized for conservative management with analgesia, anti-inflamma tory drugs, and fluid therapy, presenting good evolution in the first 48 hours., Conclusion: Omental infarction is an infrequent cause of acute abdominal pain in childhood. Imaging studies play a funda mental role in the differential diagnosis of this entity with other clinical conditions of similar course, thus avoiding unnecessary surgical interventions.

Rationale: Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations., Patient Concerns: A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis., Diagnosis: The patient was diagnosed with omental torsion based on imaging and laparoscopy., Interventions: Laparoscopic exploration was performed., Outcomes: The patient was discharged seven days after satisfactory postoperative recovery., Lessons: Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Aim: In middle-aged men, omental torsion (OT) can be a cause of acute abdomen.The right side of the omentum is longer, heavier and more mobile than the left one and, as a consequence, it can twist more easily on its vascular axis. Consequently, OT localization in the lower right quadrant is more frequent, and therefore it can mimic acute appendicitis clinical onset.In most cases, OT is defined as "primary" in the absence of any other underlying pathologies, or,  rarely, "secondary", when caused by other intra-abdominal diseases such as inguinal hernia, tumors, cysts or post-surgical scarring. To date, clinical diagnosis of OT still remains a challenging one in a preoperative setting and most cases are diagnosed intraoperatively. If diagnosis is correctly achieved preoperatively by adequate imaging examinations, most patients presenting with OT do not undergo surgery anymore. Such considerations gain importance at the time of COVID 19 pandemic, where a conservative management and an early discharge may be preferred owing to in-hospital morbidity after abdominal surgery whenever surgery may be avoided., Methods and Results: We present a case of an OT successfully treated in a non-operative manner during COVID-19 outbreak in Norhern Italy and offer a review of the literature that supports such a clinical attitude.  Conclusions:  OT preoperative diagnosis is challenging and is usually achieved by abdominal CT-scan. The suggested OT initial management is conservative, leaving a surgical approach, preferably by laparoscopy, for the 15% of cases not improving with a non-surgical approach.

Keratin granulomas in the peritoneum are a rare finding with multiple etiologies and can be especially challenging for both the pathologist and the surgeon when these lesions are grossly visible. We report a case of a unique frozen section diagnostic scenario of evaluation of keratin granulomas in the peritoneum of a 47-year-old woman in the setting of multiple potential culprits: endometrial endometrioid adenocarcinoma following fertility sparing treatment, and a concurrent dermoid cyst. We discuss the various etiologies of keratin granulomas in the peritoneum, mechanism of their formation, diagnostic significance, as well as implications of fertility sparing treatments. To the best of our knowledge, this is the only case of keratin granulomas in the peritoneum with multiple distinct potential pathologic culprits as well the only case following fertility sparing treatment.

Introduction: Abdominal tuberculosis (TB) is a common epitome of extrapulmonary TB (EPTB), wherein peritoneal and intestinal TB are the most prevalent forms. Diagnosis of abdominal TB is a daunting challenge owing to variable anatomical locations, paucibacillary nature of specimens and atypical clinical presentations that mimic other abdominal diseases, such as Crohn's disease and malignancies. In this review, we made a comprehensive study on the diagnosis of abdominal TB., Area Covered: Various modalities employed for abdominal TB diagnosis include clinical features, imaging, bacteriological tests (smear/culture), histopathological/cytological observations, interferon-gamma release assays and nucleic acid amplification tests (NAATs). Among NAATs, loop-mediated isothermal amplification assay, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® MTB/RIF were discussed. Identification of circulating Mycobacterium tuberculosis cell-free DNA by real-time PCR within ascitic fluids is another useful approach., Expert Opinion: Several novel molecular/immunological methods, such as GeneXpert Ultra, aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR) and nanoparticle-based I-PCR have recently been developed for detecting pulmonary TB and several EPTB types, which may also be explored for abdominal TB diagnosis. Precise and prompt diagnosis of abdominal TB may initiate an early therapy so as to reduce the complications, i.e . abdominal pain, ascites, abdominal distension, intestinal obstruction/perforation, etc., and avoid surgical involvement. Plain Language Summary Abdominal tuberculosis (TB) is a manifestation of extrapulmonary TB (EPTB), where peritoneal and intestinal TB are two major forms. Diagnosis of abdominal TB is difficult owing to low bacterial load present in clinical samples and non-specific clinical presentations as it mimics other diseases such as inflammatory bowel diseases, abdominal malignancies, etc. Bacteriological tests (smear/culture) almost fail owing to poor sensitivities and it is not always possible to get representative tissue samples for histopathological and cytological observations. In recent years, molecular tests i.e . nucleic acid amplification tests (NAATs), such as PCR/multiplex-PCR (M-PCR), nested PCR and GeneXpert are widely employed. Markedly, PCR/M-PCR and nested PCR exhibited reasonable good sensitivities/specificities, while GeneXpert revealed low sensitivity in most of the studies but high specificity, thus it could assist in differential diagnosis of intestinal TB and Crohn's disease. Further, novel molecular/immunological tests employed for pulmonary TB and other EPTB types were described and those tests can also be utilized to diagnose abdominal TB. Reliable and rapid diagnosis of abdominal TB would initiate an early start of anti-tubercular therapy and reduce the severe complications.

Acute abdomen is a common emergency condition affecting young adults, and the first consideration is usually aimed to rule out acute appendicitis in this age group. Omental fat torsion has emerged as one of the rare etiologies of acute abdomen in the younger population. It warrants serious consideration as it closely mimics acute appendicitis in its clinical presentation. Herein we report a case of omental fat torsion in a 22-year-old male patient who presented with an acute right-sided lower abdominal pain which was highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum with an infarcted omental segment on the right side of the greater omentum. A laparoscopic omentectomy and an appendectomy were performed with an uneventful postoperative recovery. The pathology report confirmed omental fat infarction and a normal appendix. This case highlights omental fat infarction as a rare etiology of acute abdomen in a young male patient.

Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery., Competing Interests: 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., (Copyright © 2021 Koninckx, Fernandes, Ussia, Schindler, Wattiez, Al-Suwaidi, Amro, Al-Maamari, Hakim and Tahlak.)

Abstract: Hydatid cyst is a parasitic infection caused mainly by Echinococcus granulosus, which is generally considered benign. However, the hepatic hydatid cyst rupture in the abdominal cavity is a life-threatening incident that requires urgent and multidisciplinary management (emergency physicians, radiologists, anesthetists, and surgeons). This study describes clinical and paraclinical liver hydatid cyst rupture in the peritoneal cavity and details the appropriate treatment.A retrospective review of clinical records of patients hospitalized in Jendouba Hospital for liver hydatid cyst was performed over 8 years, from January 1, 2012 to December 31, 2019. Fifteen cases of liver hydatid cyst complicated with acute rupture into the abdominal cavity were collected out of 625 hydatid liver cysts. All patients underwent emergency laparotomy allowing conservative unroofing procedure associated with peritoneal lavage and external drainage combined with necessary intensive care measures. Clinical features, therapeutic procedures' details as well as postoperative outcomes are reported. Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 20.There were 9 men and 6 women. Patients' age ranged from 14 to 59 years, with an average of 38 years. Two patients were admitted with abdominal trauma. Acute abdominal pain was the most common complaint. Only 1 patient had an anaphylactic shock. Abdominal ultrasonography and computed tomography scan showed discontinuous cyst wall associated to intraperitoneal fluid in all cases. Intraoperatively, the intraperitoneal effusion was clear in 13 cases and purulent in 2. All patients underwent unroofing procedures associated with intra-operative peritoneal lavage and external drainage. The mean hospital stay was 6.11 days, and the mean follow-up was 19 months. No case of recurrence was reported among the patients.In endemic areas, rupture of a hepatic hydatid cyst in the abdominal cavity should be considered in every case of acute abdominal pain, especially if associated with anaphylaxis signs. Early management starting in the emergency room is needed to ensure good outcome., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Endometriosis is generally histopathologically defined as the presence of at least 2 of the following: endometrial stroma, Müllerian epithelium, and/or hemosiderin-laden macrophages (HLM). Despite clinically evident endometriotic lesions, biopsies are frequently nondiagnostic. In this study, we conducted a large-scale review of biopsies of lesions clinically thought to represent endometriosis and correlate the histologic findings with clinical appearance to expand sensitivity of the pathologic definition of endometriosis, particularly in patients on hormonal therapy. In all, 112 biopsies from 78 patients (mean age=25, range 18-39 yr) were reviewed for histopathologic features suggestive of or diagnostic for endometriosis including the presence of endometrial stroma, Müllerian epithelium, dystrophic calcifications, HLM, chronic inflammation, adhesions, and vascular proliferation. Endometriosis was confirmed by pathologic criteria in 37 of 78 patients (47%). Biopsies from patients on hormonal therapy (n=62, 80%) were significantly less likely to meet pathologic criteria for endometriosis (P=0.01). Nondiagnostic biopsies (70/112; 63%) frequently displayed HLM (20%), chronic inflammation (29%), dystrophic calcifications (26%), vascular proliferation (20%), or adhesions (20%) and were significantly more likely to have a vascular clinical appearance (P=0.01). Diagnostic biopsies (42/112; 38%) were more likely to have a blue/black clinical appearance (P=0.03), demonstrate HLM (P=0.004), and display pseudodecidualization (P=0.05). Patients with a high clinical suspicion of endometriosis have a range of histologic findings, with less than half meeting the current histopathologic criteria for diagnosing endometriosis. Given the heterogeneous histopathologic appearance, revision of the histologic criteria may be warranted with further exploration, particularly for lesions with predominantly vascular features., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 by the International Society of Gynecological Pathologists.)

Primary torsion of large omentum is a rare cause of abdominal pain. The knowledge of this disease is essential for surgeons. It plays an important role in differential diagnosis of acute abdomen. The authors present two cases of primary omental torsion. They describe the diagnostic and therapeutic process. Diagnosis of omental torsion is difficult. Frequently, it presents with abdominal pain and imitates other acute abdominal diseases such as acute appendicitis in most cases. It is difficult to diagnose before surgical revision is approached. Laboratory and paraclinical examinations may not provide any clear findings. Laparoscopic revision is the method of choice, with confirmation of the diagnosis and laparoscopic resection of the ischemic part of omentum.

Objective: To demonstrate a unique presentation and surgical treatment of a posterior uteroperitoneal fistula with excision of the fistula tract and repair in multiple layers., Design: Illustrative video presentation. A case report is used to describe potential causes of an uteroperitoneal fistula found in a patient during evaluation of secondary infertility and to highlight surgical technique and management using the principles of fistula repair through a minimally invasive approach. The Institutional Review Board reviewed this video article and it was deemed "not human subject research.", Setting: Tertiary medical center., Patient(s): A 33-year-old G1P1001 woman with a history of a cesarean section presented with secondary infertility, pelvic pain, and dysmenorrhea and was found to have a posterior uteroperitoneal fistula at the time of hysterosalpingography., Intervention(s): The patient underwent an uncomplicated robot-assisted laparoscopic excision of a posterior uteroperitoneal fistula with the use of careful dissection of the fistula tract, continuous reassessment, and tension-free closure in layers., Main Outcome Measure(s): Preoperative diagnosis and surgical management displaying intraoperative techniques for robot-assisted excision of fistula tract and repair of defect., Result(s): The patient underwent robot-assisted operative laparoscopy that revealed a 4-cm mass on the right posterior aspect of the uterus independent from her adnexa. Concomitant hysteroscopy revealed normal endometrium without an evident fistula. During chromopertubation, extravasation was seen into the peritoneal cavity from this mass. The mass and fistula tract were excised without a connection found from her cesarean scar, and reconstruction was performed in multiple layers. Endometriotic lesions were noted intraperitoneally in locations distant from the mass. The patient had significant improvement in her symptoms after surgery., Conclusion(s): We present a unique case of a suspected spontaneous posterior uteroperitoneal fistula in the presence of endometriosis without evidence of a connection to her prior hysterotomy scar. Possible etiologies include an undiagnosed, unrepaired hysterotomy extension or a result of chronic inflammation from deep infiltrating endometriosis. Adverse effects on fertility from uteroperitoneal fistulas may be due to disruption of sperm function or endometrial quality secondary to presence of old blood products sequestered in the fistula or due to resultant inflammation from the same. As in this video case, successful treatment of symptoms resulting from an uteroperitoneal fistula requires removal of the fistula tract. The constellation of pelvic pain, dysmenorrhea, postmenstrual bleeding, and infertility should raise suspicion for an uteroperitoneal fistula., (Published by Elsevier Inc.)

The perihepatic space is frequently involved in a spectrum of diseases, including intrahepatic lesions extending to the liver capsule and disease conditions involving adjacent organs extending to the perihepatic space or spreading thanks to the communication from intraperitoneal or extraperitoneal sites through the hepatic ligaments. Lesions resulting from the dissemination of peritoneal processes may also affect the perihepatic space. Here we discuss how to assess the perihepatic origin of a lesion and describe the magnetic resonance imaging (MRI) features of normal structures and fluids that may be abnormally located in the perihepatic space. We then review and illustrate the MRI findings present in cases of perihepatic infectious, tumor-related, and miscellaneous conditions. Finally, we highlight the value of MRI over computed tomography., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 The Korean Society of Radiology.)

Objective: to identify novel biomarkers for peritoneal endometriosis in eutopic endometrium thus giving an oportunity for non-invasive diagnosis., Design: A cross-sectional single-center study SETTING: tertiary care hospital PATIENTS: 49 patients subjected to laparoscopy because of suspected endometriosis, 33 patients out of the group qualified to the study had sufficient endometrial tissue taken and were in their follicular phase of menstrual cycle., Interventions: biopsy sampling of eutopic endometrial tissue during diagnostic or diagnostic and terapeutic laparoscopy, questionaires, MAIN OUTCOME MEASURE(S): qRT-PCR to evaluate the mRNA expression of selected candidate marker genes in endometrium: ARO1 (aromatase), CXCL8 (interleukin 8), NGF (nerve growth factor), VEGF-A (vascular endothelial growth factor A), PDGF-A (platelet-derived growth factor A)., Results: mRNA expression of ARO1, CXCL8, VEGF-A and PDGF-A did not differ significantly between women with and without endometriosis. NGF mRNA expression was decreased in women with endometriosis., Conclusions: Observed preliminary results suggest a possible role of NGF in early diagnosis of peritoneal endometriosis. The role of NGF changes in eutopic endometrium of patients with peritoneal endometriosis needs further evaluation., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Peritoneal melanosis is an uncommon benign condition, the pathophysiology of which is unclear. Macroscopically, it appears as diffuse dark brown or black pigmentation within the peritoneum, mimicking more sinister conditions such as metastatic melanoma. It has been described in a variety of contexts, but only exceedingly rarely in association with metastatic melanoma, with only two previous published case reports. We present a case of peritoneal melanosis associated with metastatic melanoma involving the spleen, previously treated with targeted and immune checkpoint inhibitor therapy. With increasing reports of melanoma regression manifesting as cutaneous tumorous melanosis in patients treated with immune checkpoint inhibitors, we postulate that, similarly, immunotherapy and tumour regression might have a role to play in the pathogenesis of the peritoneal pigmentation in this case., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Taenia martis is a tapeworm dwelling in the intestine of mustelids and a rare zoonotic cysticercosis pathogen in its larval stage. The metacestode is morphologically very similar to more prevalent cysticercosis parasites, such as the larvae of Taenia solium and Taenia crassiceps , and may be indistinguishable from other metacestodes on histological sections. However, the epidemiology of human T . martis infections is different, and for prognosis, prevention, and detection of natural parasite reservoirs, the species should be identified. We here report the molecular identification of a T. martis larva located in the pouch of Douglas in a female German patient who underwent surgery for endometriosis. This case represents the fifth human infection described worldwide; all previous cases were also in European women, involving the eye, brain, and the peritoneum.

Study Objective: Prior research has collectively shown that endometriosis is inversely related to women's adiposity. The aim of this study was to assess whether this inverse relationship holds true by disease severity and typology., Design: Cross-sectional study among women with no prior diagnosis of endometriosis., Setting: Fourteen clinical centers in Salt Lake City, UT, and San Francisco, CA., Patients: A total of 495 women (of which 473 were analyzed), aged 18-44 years, were enrolled in the operative cohort of the Endometriosis, Natural History, Diagnosis, and Outcomes (ENDO) Study., Interventions: Gynecologic laparoscopy/laparotomy regardless of clinical indication., Measurements and Main Results: Participants underwent anthropometric assessments, body composition measurements, and evaluations of body fat distribution ratios before surgery. Surgeons completed a standardized operative report immediately after surgery to capture revised American Society for Reproductive Medicine staging (I-IV) and typology of disease (superficial endometriosis [SE], ovarian endometrioma [OE], and deep infiltrating endometriosis [DIE]). Linear mixed models, taking into account within-clinical-center correlation, were used to generate least square means (95% confidence intervals) to assess differences in adiposity measures by endometriosis stage (no endometriosis, I-IV) and typology (no endometriosis, SE, DIE, OE, OE + DIE) adjusting for age, race/ethnicity, and parity. Although most confidence intervals were wide and overlapping, 3 general impressions emerged: (1) women with incident endometriosis had the lowest anthropometric/body composition indicators compared with those without incident endometriosis, (2) women with stage I or IV endometriosis had lower indicators compared with women with stage II or III, and (3) women with OE and/or DIE tended to have the lowest indicators, whereas women with SE had the highest indicators., Conclusion: Our research highlights that the relationship between women's adiposity and endometriosis severity and typology may be more complicated than prior research indicates., (Copyright © 2020 AAGL. All rights reserved.)

Study Objective: To evaluate the diagnostic accuracy of transvaginal ultrasound in predicting a laparoscopic, surgically assigned, revised American Society of Reproductive Medicine (ASRM) endometriosis stage., Design: A multicenter, retrospective, diagnostic accuracy study., Setting: The patients visited 1 of 2 academic gynecologic ultrasound units and underwent laparoscopy led by 1 of 6 surgeons in metropolitan Sydney, Australia, between 2016 and 2018., Patients: Patients with suspected endometriosis (n = 204)., Interventions: Ultrasound followed by laparoscopy., Measurements and Main Results: Surgical cases were identified. The preoperative ultrasound report and surgical operative notes were each used to retrospectively assign an ASRM score and stage. The breakdown of surgical findings was as follows: ASRM 0 (i.e., no endometriosis), 24/204 (11.8%); ASRM 1, 110/204 (53.9%); ASRM 2, 22/204 (10.8%); ASRM 3, 16/204 (7.8%); ASRM 4, 32 204 (15.7%). The overall accuracy of ultrasound in predicting the surgical ASRM stage was as follows: ASRM 1, 53.4%; ASRM 2, 93.8%; ASRM 3, 89.7%; ASRM 4, 93.1%; grouped ASRM 0, 1, and 2, 94.6%; and grouped ASRM 3 and 4 of 94.6%. Ultrasound had better test performance in higher disease stages. When the ASRM stages were dichotomized, ultrasound had sensitivity and specificity of 94.9% and 93.8%, respectively, for ASRM 0, 1, and 2 and of 93.8% and 94.9%, respectively, for ASRM 3 and 4., Conclusion: Ultrasound has high accuracy in predicting the mild, moderate, and severe ASRM stages of endometriosis and can accurately differentiate between stages when ASRM stages are dichotomized (nil/minimal/mild vs moderate/severe). This can have major positive implications on patient triaging at centers of excellence in minimally invasive gynecology for advanced-stage endometriosis., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

A 61-year-old male patient presented to our hospital's emergency department with a history of worsening abdominal pain. The symptoms began as epigastric pain and later localized to the right lower quadrant. On physical examination, there was rebound tenderness mainly in the right lower quadrant and in the right upper quadrant. The laboratory results showed leukocytosis. Abdominopelvic computed tomography scan revealed that a definite twisting on the long axis with three complete counter-clockwise turns was observed in the vascular structures of greater omentum. At operation, the greater omentum was found to be twisted and gangrenous. The infarcted omentum was ligated at the pedicle and excised. Primary torsion of the omentum is one of the uncommon causes of acute abdominal pain. Although rarely diagnosed, the entity is important to the surgeon because it mimics the common causes of the acute surgical abdomen. Omental torsion usually occurs on the right side. Abdominal pain starts suddenly after a heavy meal or hard exercise, and is not accompanied with nausea, vomiting and anorexia. Abdominal computed tomography may show peculiar features suggestive of omental torsion. Treatment consists of ligation and resection of the involved portion of the omentum and recovery is usually rapid, uneventful and complete. Primary omental torsion should be considered in the differential diagnosis of acute abdomen. The surgeon must remain aware of the disease and search for it if, at laparotomy, other adequate cause is not found to explain the symptoms, especially if free sero-sanguineous fluid is found in the peritoneal cavity. KEY WORDS: Acute abdomen, Greater omentum, Omental torsion, Omental infarction, Omental necrosis.

Research Question: This study aimed to evaluate the presence of superficial peritoneal endometriosis (SUP) in women referred to emergency surgery for right iliac fossa (RIF) pain and undergoing an appendectomy, considering which factors may be useful to suspect and identify endometriosis., Design: An observational case-control study was conducted on a group (n = 149) of fertile age women. After surgery, Group A was selected upon the diagnosis of endometriosis (n = 34); Group B (n = 115) represented the controls. Demographics, comorbidities and clinical findings were registered and analysed., Results: Appendicitis of various grades of severity was diagnosed in all patients, but SUP was also identified in 23%, of which 14.7% also presented with endometriosis of the appendix. Women in Group A reported chronic pelvic pain, dysmenorrhoea, dyspareunia and oral contraceptive use more frequently. At multivariate analysis, factors associated with endometriosis were: age <40 years, autoimmune disorders, multiple allergies, abdominal chronic pain, associated gynaecological pain symptoms, Alvarado score ≤6, and inconclusive ultrasound findings., Conclusions: The incidental finding of SUP in fertile age women presenting with an acute RIF pain and undergoing emergency surgery is a relevant observation. Clinical history and symptoms should guide surgeons in performing a correct diagnosis and in referring the patient to the gynaecology specialist., (Copyright © 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

A patient with a history of multiple jejunal diverticulosis (JD) presented with a non-peritonitic abdominal pain and leucocytosis. CT scan showed a thick-walled interloop collection within the left mid-abdomen with dilated bowels and mild diffuse air-fluid levels. Exploratory laparotomy revealed multiple diverticular outpouchings in the mid-jejunum, one of which was perforated, contained within the mesentery. Resection of the contained abscess and primary anastomosis were performed subsequently., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Endometriosis is a gynecological disease characterized by pain and infertility. The diagnosis is very often made during the infertility work-up, together with other reproductive diseases and uterine disorders. A retrospective cohort study was conducted on infertile women with clinical or ultrasound suspect of endometriosis, undergoing an ultrasound (US) evaluation by a team of expert sonographers ( n  = 419), with the aim to evaluate the prevalence of concomitant uterine disorders. The US coexistence of endometriosis with uterine fibroids and/or adenomyosis was investigated according to three age intervals (<35years; 35 ≥ years <45; ≥45 years) and to endometriosis phenotypes: ovarian endometriosis (OMA), deep infiltrating endometriosis (DIE), or both. The US diagnosis of fibroids was made in 3.1% of cases, adenomyosis was found in 21.2%, and the co-existence of both uterine disorders with endometriosis was reported in 14.6% of patients. When analyzed according to age, patients aged >35 years were more likely to be affected by uterine fibroids ( p  = .003), adenomyosis ( p  = .030) and both adenomyosis and fibroids ( p  < .0001). No statistically significant association was found between endometriosis phenotypes and myometrial pathologies. Uterine disorders coexistence should be considered in the assessment of women with endometriosis, in order to better define a treatment strategy for infertility, especially in women older than 35 years.

Mesenteric diseases are broadly separated into 2 groups: non-neoplastic and neoplastic. Common non-neoplastic mesenteric diseases include those involving the mesenteric vasculature and those of inflammatory processes. Mesenteric inflammatory processes can mimic a neoplastic process. Neoplastic diseases of the mesentery are rare. Generally, the morphology, behavior and diagnostic criteria for mesenteric tumors are similar to their soft tissue or organ-specific counterparts. Their recognition can be challenging because they sometimes are overlooked in differential diagnoses., Competing Interests: Disclosure None., (Copyright © 2020 Elsevier Inc. All rights reserved.)