Correct answer is: Bilateral Tessier Type 3

Click here to view after photos after birth >>

Explanation:

This is a bilateral Tessier type 3 because the cleft is from the nasal alar up to the medial orbit bilaterally. However, this is a rare case of Type 3 because the upper lip and the maxilla are intact.

Facial cleft – also called craniofacial cleft – is one of the most commonly arising non‐lethal congenital abnormalities. The worldwide incidence ranges between 1 and 2.2/1000, depending on the geographical region [1].

The classification proposed by Tessier uses the numbers from 0 to 14 depending on the location of a cleft in relation to the median facial line. Clefts number 0 to 6 are craniofacial defects, while clefts number 8 to 14 are cerebrocranial defects [2]. The classification is simple, logical and has been widely accepted due to the precise description of a defect and facilitation of comparison of various defects between centers.

References

[1] Moore, MH. Rare craniofacial clefts. The Journal of Craniofacial Surgery 1996; 7 (6): 408–11.

[2] Tessier P. Anatomical classification of facial, cranio-facial and latero-facial clefts. Journal of Maxillofacial Surgery 1976; 4 (2): 69–92.

Correct answer is:

Relapsed Grynfelt lumbar hernia.

Explanation:

Lumbar hernia is characterized by the presence of a failure in the transversal fascia or aponeurosis of the transverse muscle of the abdomen that results in the extrusion of intra-abdominal content through the defect in the posterolateral abdominal wall.

Lumbar hernias are quite rare, have a higher prevalence in males (about 2/3 of all reported cases) and the majority are unilateral, being twice as common on the left side than on the right side [1; 2]. Most diagnosed patients are in the sixth to seventh decade of life. [3, 4] There is a higher prevalence of lumbar hernias located in the upper lumbar triangle, probably because it is larger and located in a region with weaker musculature than the lower triangle [2].

The lumbar region can be anatomically defined as the area of the abdominal wall lateral to the midclavicular line, between the subcostal plane and the plane that connects the tubercles of the iliac crests.

Lumbar hernias are classified as superior or inferior according to their anatomical location. The upper lumbar or Grynfelt hernia is the one that appears through the anatomical triangle delineated superiorly by the 12th rib, laterally by the external oblique muscle, inferiorly by the internal oblique muscle and medially by the erector spinae muscle. [1, 5]

The lower lumbar or Petit’s hernia is located in the lower triangle, limited inferiorly by the iliac crest, medially by the latissimus dorsi muscle and laterally by the external oblique muscle [1, 5].

The diagnosis is suspected by clinical and physical examination, and may be confirmed by imaging methods such as ultrasound, computed tomography or magnetic resonance imaging. Like other types of hernias, lumbar hernias can evolve with complications such as incarceration and necrosis of intestinal loops [6]. In the present case, the patient presented recurrence after herniorrhaphy with mesh placement.

Take Home Message

Although lumbar hernias are very rare, it is an important differential diagnosis to remember. The suspected clinical diagnosis can be confirmed by ultrasound with high accuracy.

References

1.Heniford BT, Iannitti DA, Gagner M. Laparoscopic inferior and superior lumbar hernia repair. Arch Surg 1997;132: 1141-4.

2.Zhou X, Nve JO, Chen G (2004) Lumbar hernia: clinical analysis of 11 cases. Hernia 8:260–263.

3.Sharma, Lt Col P (2009) Lumbar hernia. MJAFI 65:178–179. 42.Baker ME, Weinerth JL, Andriani RT et al (1986) Lumbar hernia: diagnosis by CT. AJR Am J Roentgenol 148:565–567.

4.Baker ME, Weinerth JL, Andriani RT et al (1986) Lumbar hernia: diagnosis by CT. AJR Am J Roentgenol 148:565–567.

5. Stamatiou D, Skandalakis JE, Skandalakis LJ, Mirilas P. Lumbar hernia: surgical anatomy, embryology, and technique of repair. American Surgeon. 2009;75(3):202–207.

6. Christiano Marlo Paggi CLAUS1,2, Lucas Thá NASSIF1 , Yan Sacha AGUILERA. Reparo Laparoscópico de hérnia lombar (GRYNFELT): Descrição ténica. 2017;30(1):56-59.

Correct answer is:

Left portal vein -> umbilical vein/paraumbilical vein -> superior epigastric vein -> internal thoracic vein -> brachiocephalic vein -> superior vena cava

Explanation:

In the context of portal hypertension, the umbilical vein undergoes recanalization and, as well as the paraumbilical veins that run with it in the falciform and round ligaments, have their flow inverted, from the peripheral portal branches of the left hepatic lobe towards the epigastric veins. From there the blood goes in cranial direction (superior epigastric vein – internal thoracic vein – brachiocephalic vein – superior vena cava) or caudal (inferior epigastric vein – external iliac vein – common iliac vein – inferior vena cava) to achieve the ultimate goal which is the arrival of blood to the heart, deviating from the liver.

Discussion of the image interpretation leading to the diagnosis compared to the alternative answers

Doppler demonstration of hepatofugal flow in the umbilical veins is pathognomonic for portal hypertension. Paraumbilical vein dilation has been observed in about 34% of cirrhotic patients, while in groups with greater impairment of the liver function (Child C patients) this percentage may be even higher, with reported rates as high as 57%.

Portosystemic communication can lead to vascular dilation in these pathways, that may lead to a peculiar aspect in the periumbilical region often compared to Medusa’s head (origin of the latin term caput medusae).

Take Home Message

As important as detecting collateral circulation in cases of portal hypertension, as important it is to know its possible paths.

References

1. Melo-Leite AF, Mota Jr. A, Chagas-Neto FA, Teixeira SR, Elias Junior J, Muglia VF. Acquired portosystemic collaterals: anatomy and imaging. Radiol Bras.2016 Jul/Ago;49(4):251–256.
2. MARTINELLI ALC. Hipertensão portal. Medicina, Ribeirão Preto, jul./dez. 2004; 37: 253-261.
3. Machado MM, CRF Ana, Barros N, Azeredo LM, Rosa JBF, Cerro LMO, Chammas MC, Daher MT, Daher RT, Saad WA, Cerri GG. Estudo Dopper na hipertensão portal. Radiol Bras 2004; 37 (1):35-39.

Correct answer is:

Spontaneous complete detorsion of previously twisted ovary/adnexa

Explanation:

We have shown a case of spontaneous detorsion of a previously twisted ovary. Ovarian or adnexal (ovary and fallopian tube) torsion is a surgical emergency that requires prompt diagnosis and treatment. It is defined as complete or partial rotation of the adnexa around the pedicle, causing lymphatic and venous ovarian congestion, followed by ischemia and necrosis due to arterial occlusion when untreated. It can rapidly progress to a stage of hemorrhagic necrosis in a few hours or remain at the stage of edema for several days, rarely resulting in complete spontaneous detorsion.

Adnexal torsion accounts for approximately 3% of all gynecological emergencies [1]. The torsion may involve normal adnexa, however ovarian enlargement predisposes to torsion, commonly by corpus luteal cyst, benign ovarian tumour or ovulation induction [2, 3]. Prompt diagnosis is important to prevent irreversible damage of the ovary. However, the diagnosis can be challenging because clinical presentation of ovarian torsion is variable and often misleading. Definitive diagnosis is often achieved by surgery [4, 5]. Sonography is usually the first imaging tool used for evaluation, but the diagnostic accuracy is rather poor (46-74%) [6-9]. The sonographic findings vary from the enlarged ovary simulating a mass with peripherally displaced follicles in the early phase and a “solid” avascular appearance of the ovary in the late phase. However, Doppler is not a very sensitive for diagnosing ovarian torsion, and normal flow does not rule out torsion [10, 11]. An important sonographic sign of adnexal torsion is the “whirlpool sign”. A coiling pattern of ovarian vessels in the ovarian ligament refers to the sonographic appearance of the twisted ovarian vascular pedicle and has been shown to have up to 87% diagnostic accuracy for ovarian torsion [12-14]. In the rare cases of spontaneous complete detorsion the ultrasound findings can persist for a while after the untwisting because the edema does not disappear immediately [15].

In conclusion, the diagnosis of ovarian torsion remains challenging. In a patient who presents with acute pain and an ovary that demonstrates sonographic findings consistent with ovarian torsion, the diagnosis should be suggested even in the presence of documented arterial blood flow.

References

1. Rochelle F. Andreotti, Sara M. Harvey. Sonographic Evaluation of Acute Pelvic Pain. J Ultrasound Med 2012; 31:1713–1718.
2. Mashiach S, Bider D, Moran O, Goldenberg M, Ben-Rafael Z. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Arch Gynecol Obstet 2002;267(1):4 –6.
3. Purcell K, Wheeler JE. Benign disorders of the ovaries and oviducts. In: De Cerney A, Nathan L, editors. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill; 2003.
4. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000; 180: 462–465.
5. Gordon JD, Hopkins KL, Brooke JR, Giudice LC. Adnexal torsion: color Doppler diagnosis and laparoscopic treatment. Fertil Steril 1994; 61: 383–385.
6. Mazouni C, Bretelle F, Ménard JP, Blanc B, Gamerre M. Diagnosis of adnexal torsion and predictive factors of adnexal necrosis. Gynecol Obstet Fertil 2005; 33:102–106.
7. Bar-On S, Mashiach R, Stockheim D, et al. Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate? Fertil Steril 2010; 93:2012–2015.
8. Reuven Mashiach, Nir Melamed, Noa Gilad, Gadi Ben-Shitrit, Israel Meizner. Sonographic Diagnosis of Ovarian Torsion. Accuracy and Predictive Factors. J Ultrasound Med 2011; 30: 1205–1210.
9. Cohen SB, Weisz B, Seidman DS, Mashiach S, Lidor AL, Goldenberg M. Accuracy of the preoperative diagnosis in 100 emergency laparoscopies performed due to acute abdomen in nonpregnant women. J Am Assoc Gynecol Laparosc 2001; 8: 92–94.
10. Hurh PJ, Meyer JS, Shaaban A. Ultrasound of a torsed ovary: characteristic gray-scale appearance despite normal arterial and venous flow on Doppler. Pediatr Radiol 2002; 32(8): 586- 8.
11. Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med 2008; 27:7–13.
12. Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med 1998; 17:83–89.
13. Vijayaraghavan SB. Sonographic whirlpool sign in ovarian torsion. J Ultrasound Med 2004; 23: 1643–1649.
14. V. Valsky, E. Esh-Broder, S.M. Cohen, M. Lipschuetz and S. Yagel. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol 2010; 36: 630–634.
15. Ghossain MA, Hachem K, Aoun NJ, Haddad-Zebouni S, Mansour F, Suidan JS, Abboud J (2006) Spontaneous detorsion of the ovary: can it be diagnosed by MRI? J Magn Reson Imaging 24(4):880–885.