Intra-abdominal Hernia with Bowel Obstruction Triggering Multi-organ Failure: The Role of Preoperative Enteritis This report details the clinical course of a 41-year-old male who developed fulminant multiple organ dysfunction syndrome following emergency surgery for a strangulated intra-abdominal hernia. Preoperative manifestations, including diarrhea and marked leukocytosis, pointed towards an underlying infectious enteritis. We posited that surgical release of the obstructed, ischemic bowel segment precipitated a massive systemic influx of endotoxins and inflammatory mediators, triggering septic shock and rapid sequential organ failure. This case underscored the critical need to suspect concomitant gastrointestinal infection in patients presenting with mechanical bowel obstruction accompanied by infectious signs. Aggressive perioperative sepsis management encompassing early empiric antimicrobial therapy, vigilant hemodynamic monitoring, and preparedness for advanced organ support is essential to mitigate this severe complication.

Primary Hepatic Diffuse Large B-Cell Lymphoma: A Diagnostic Challenge Mimicking Cholangiocarcinoma: Diagnostic Pitfalls and Role of Timely Biopsy Primary hepatic diffuse large B-cell lymphoma (DLBCL) is a rare malignancy that is often misdiagnosed as hepatocellular carcinoma or cholangiocarcinoma due to nonspecific radiological findings, highlighting diagnostic challenges and underscoring the critical role of systematic biopsy. A 67-year-old Malay woman presented with progressive jaundice, abdominal distension and weight loss. Cross-sectional imaging revealed an infiltrative hepatic mass with vascular involvement, initially suggestive of cholangiocarcinoma. Two percutaneous core biopsies were nondiagnostic, with definitive DLBCL diagnosis (germinal center B-cell subtype) achieved through subsequent laparoscopic wedge biopsy. The patient commenced rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP) chemotherapy with good tolerance. Primary hepatic lymphoma should be considered in atypical liver masses, particularly with inconclusive initial biopsies. A structured approach beginning with image-guided coaxial biopsy and escalating to surgical biopsy when necessary is essential to avoid diagnostic delays. Modern coaxial techniques minimise tumour seeding risk and should not deter adequate tissue sampling

Clinical Presentation and Management of Severe Bilateral Duct Ectasia: A Case Report Mammary duct ectasia is frequently asymptomatic and found incidentally during routine screening but its presentation is varied. In this case report, we highlight a case of bilateral duct ectasia with extensive inflammatory changes in a parous, obese and diabetic middle aged woman. Her condition had been recurrent over several years, despite multiple courses of antibiotics and was increasing in severity. It was successfully treated with bilateral total ductal excision.

Spontaneous Ileal Perforation in a Case of Neutropenic Enterocolitis Managed Laparoscopically Neutropenic enterocolitis (NE) or ‘typhlitis’ is a serious condition. It is commonly associated with malignancy, intensive chemotherapy and severe neutropenia. The decision for surgery remains a clinical dilemma. We present a case of NE with ileal perforation that underwent laparoscopic small bowel resection and ileostomy. An 11 years old boy diagnosed with acute lymphoblastic leukemia, was receiving induction chemotherapy. He developed neutropenic fever which was treated with antibiotics. He subsequently experienced lower abdominal pain predominately at the right iliac fossa radiating to the suprapubic region. Abdomen examination revealed tenderness over the right iliac fossa with localised guarding. Chest X-ray erect showed no air under diaphragm. Ultrasound abdomen showed presence of minimal free fluid in the abdomen. A computed tomography abdomen was performed, which revealed evidence of pneumoperitoneum predominantly at the dependent areas of the abdomen. There was a focal defect seen at the anterior wall of distal ileum with connection with a fluid locule, suspicious of ileal perforation. The patient subsequently underwent an urgent laparoscopic small bowel resection and double barrel ileostomy. Intraoperatively, there was a 1 x 1 cm perforation at the distal ileum about 3 cm from ileocaecal junction with localised contamination. Postoperatively, the patient gradually recovered and was discharged. NE is a potentially life-threatening condition associated with high mortality. Contrary to belief, surgery in neutropenic patients is not deleterious, especially in complicated NE. Prompt and accurate decision-making holds an important role in improving patient outcomes.

The Rotated Bipedicled Tram Flap: Maximising Breast Projection but Minimising Donor Morbidity - A Case Report Autologous breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap remains a cornerstone of breast reconstructive surgery. However, with the classical TRAM flap, it is challenging to close a large post mastectomy defect in nulliparous and/or slim women. The resultant reconstructed breast also lacks projection. This case reported a novel modified TRAM flap technique performed in a nullipara. She had previously undergone a hysterectomy and oophorectomy for endometrial carcinoma via a pfannenstiel incision. She presented with a large left breast invasive micropapillary carcinoma (ER/PR negative HER2 3+) with only marginal response to neoadjuvant chemotherapy. She underwent a left mastectomy with axillary dissection and immediate breast reconstruction. The rotated bipedicled TRAM Flap was used to close the large defect, maximising breast projection while minimising donor site morbidity.

Adenotonsillectomy for Paediatric Sleep Disordered Breathing – Post Surgery Placement and Outcome Adenotonsillectomy (AT) is the treatment of choice for children with sleep disordered breathing (SDB) caused by adenotonsillar hypertrophy. However, there is an increased risk of post operative complications among those with identified risk factors. Therefore, they are electively admitted to critical care wards after surgery. Unfortunately, due to limited resources and availability of beds in critical care wards, the cancellation rate for AT can be significant at some hospitals. It is becoming more difficult to satisfy the heightened demand for close monitoring post AT due to the increasing number of obese children and surge of SDB cases. Delaying surgery may indirectly worsen the child’s co-morbidities. Thus, it is vital to have a flowchart for post AT placement, which can be practical to many centres facing similar logistics concerns. This retrospective chart review done over 6 months included all paediatric patients who had AT for SDB at our centre. The objectives of this review were to identify factors contributing to elective admission to the paediatric intensive care unit (PICU)/paediatric high dependency unit (PHDU) following AT among patients with paediatric SDB, recognize association between obesity and PICU/PHDU admission as well as find the association between severity of allergic rhinitis with outcome post AT. We aim to have a flow chart for preoperative planning of post-surgery nursing placement among patients with SDB who are managed with AT at this centre. Obese patients without significant co-morbidities can be nursed in the general ward, the real admission rate to PHDU/PICU is lesser compared to that was planned pre-operatively and children with moderate- severe AR tend to have residual snoring post AT. A flow chart for preoperative planning of post-surgery nursing placement among patients with SDB can help to reduce unnecessary booking and admission to critical care wards, decreasing the waiting time for AT and backlog of cases at public hospitals.

The Submammary-Evert (Sub-E) Technique for Excision of Benign Breast Lumps in Underdeveloped and Developing Countries - A Case Series The Submammary-Evert (Sub-E) technique is a novel technique for the excision of one or multiple benign breast lumps. It may be performed by surgical trainees and general surgeons. It is best suited for deep seated, medium to large breast lumps. It enables the lump or lumps to be excised through one hidden inframammary scar. As the approach is through the avascular submammary plane, blood loss is minimised. Unlike the endoscopic or percutaneous vacuum assisted biopsy, this procedure is easy to learn with no additional instruments required; thus minimising cost. This makes it feasible to be performed in underdeveloped and developing countries. We describe a series of ten women (age 18-35 years old) with one or multiple breast lumps (1-5 breast lumps) who underwent this procedure. The size of the lumps measured 1-13 cm. All lumps measuring a minimum of 3 cm were located at the upper half or retroareolar region. The duration of surgery for excision of a lump was 50-100 minutes. The surgery to remove 5 lumps took the longest time of 125 minutes. There were no intra or post-operative complications.

Enhancing Visual Outcomes and Patients’ Satisfaction: A Case Series of Mix-and-Match Approach for Unhappy Presbyopic Patients Post-Cataract Surgery This case series explored the mix-and-match approach of implanting an extended depth of focus (EDOF) intraocular lens (IOL) in the fellow eye to improve visual outcomes, reduce spectacle dependence, and enhance satisfaction in presbyopic patients dissatisfied with monofocal IOL outcomes, highlighting personalised refractive solutions for suboptimal results post-cataract surgery. Seven patients dissatisfied with post-operative presbyopia following monofocal IOL in first eye received EDOF IOL in the second eye (mix-and-match approach). Visual outcomes were assessed using a logMAR chart for near (40 cm), intermediate (60 cm and 80 cm) and distance (6 m) visual acuity (VA). Contrast sensitivity was measured using the Pelli-Robson chart, and halos and glare were evaluated with the Zeiss Halo and Glare Stimulator. Patient satisfaction was measured using the CATQUEST-9SF 2011 questionnaire before and after EDOF IOL implantation in the second eyes. Results showed statistically significant improvement in uncorrected near VA at 40cm and intermediate VA at 60cm in eyes with EDOF IOL (0.26 ± 0.18 and 0.11 ± 0.15 respectively) compared to eyes with monofocal IOL (0.64 ± 0.28 and 0.39 ± 0.26 respectively), while maintaining good uncorrected distance VA. Only one patient reported halos with the EDOF IOL, not affecting night driving. Contrast sensitivity showed no significant difference between monofocal IOL (1.60 ± 0.14) and EDOF IOL (1.60 ± 0.17) eyes. All patients were satisfied, experiencing improvements in recognised faces, walking on uneven surfaces, reading newspapers and TV subtitles, engaging in hobbies and seeing price tags. This mix-and-match approach demonstrated efficacy in enhancing near and intermediate vision while maintaining good distance vision, offering a personalised solution to reduce spectacle dependence without compromising contrast sensitivity or causing significant halos and glare.

When Rarity Strikes: Documenting Spontaneous Cutaneous Endometriosis In The Mons Pubis Region This case report highlighted a rare instance of spontaneous cutaneous endometriosis in the mons pubis region, presenting significant diagnostic challenges. Endometriosis, characterised by the presence of endometrial-like tissue outside the uterus, can manifest in various atypical locations, complicating diagnosis and treatment. We detailed the case of a 37-year-old woman with a history of involuntary subfertility who experienced cyclic pain and a palpable mass in the right mons pubis correlated with her menstrual cycle. Unfortunately, there was a substantial delay in diagnosis, with an average interval of one year from symptom onset to surgical intervention. Surgical excision was ultimately performed, confirming the diagnosis of endometriosis through histopathological examination. This case underscores the necessity for clinicians to consider cutaneous endometriosis in differential diagnoses for women presenting with cyclical pain and masses. Prompt recognition and surgical intervention are crucial, as they can lead to effective treatment and resolution of symptoms, emphasising the importance of heightened awareness among healthcare providers regarding this condition.

Giant Condyloma Acuminata or Buchke Lowenstein tumors: A Rare Manifestation of Human Papillomavirus (HPV) Infection Giant condylomata acuminata (GCA) or Buchke Lowenstein tumors are rare manifestation of Human Papillomavirus (HPV) infection. They are usually considered the intermediate state between benign condyloma and malignant squamous cell carcinoma. Usually these manifestations are related to HPV 6 & 11 infections and if left untreated can grow larger and is locally aggressive. The most important treatment method is surgical excision which differs from benign condyloma acuminatum cases due to its high degree of malignancy. This report presented a case of immunodeficient patient post renal transplant, with a presentation of large penile wart with histopathological findings of condyloma acuminata.