Small bowel Volvulus due to a large intestinal lipoma: a rar
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A 63-year-old man was admitted to the emergency department with a typical clinical picture of the occlusive syndrome: severe and diffuse abdominal pain, nausea and vomiting, and no evacuation of feces for 3 days. Abdominal examination revealed diffuse distension with increased tympanic bowel sounds. BMI was 26 kg/m2 and he had no clinical history of previous abdominal surgery or other diseases. On arrivals WBC count was normal but C-reactive protein levels were hight. They performed a contrast-enhanced CT abdominal scan that showed a dilated intestine with multiple air-fluid levels and a volvulus due to a lipoma of the distal middle third of the ileum. Considering the presence of limited working space for the distension of the small bowel we preferred a laparotomic rather than laparoscopic approach and we performed an exploratory 10-cm lenght minilaparotomy through a supra-sub umbilical incision in urgent setting.

On the contrary in this case laparoscopic exploration was contraindicated for abnormal small bowel dilation with a higher risk of visceral lesions. After initial surgical exploration, we found a volvulated small bowel loop over a large exophytic lipomatous mass (12 cm in diameter) located in the antimesenteric border of the middle ileum with initial sign of vascular distress. The volvulus was easily de-rotated and the mass was resected en-block with involved bowel. They did an antiperistaltic side-to-side mechanical anastomosis using linear cutter with blue reload (Proximate™ linear cutter 75 mm, Ethicon). At the end of procedure they placed an abdominal drain in the Douglas space. No other macroscopically evident lesions were observed in the explored peritoneal organs. Our patient had no postoperative complications and was discharged on POD 6. Histopathological examination of surgical specimen showed a tumor composed of mature white adipose tissue with no evidence of nuclear atypia or mitosis, confirming that it was a benign lipoma .

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