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BACKGROUND: The principles of perineal reconstructive surgery comprise adequate filling of the defect along with stable and durable skin coverage, with a low morbidity rate. Two-flap perineal reconstruction is a simple, fast and reliable technique that uses a single donor site. This improves scar position with low morbidity. It is based in the use of 2flaps; one flap fills the defect with a «turn over¼ technique and the other is a rotation - advancement flap for skin coverage. CLINICAL CASE: A 52-year-old male diagnosed with Lynch syndrome who underwent laparoscopic abdominoperineal amputation for adenocarcinoma of the lower rectum and developed recurrence 2years later over the perineal scar that required radical resection and perineal reconstruction. CONCLUSION: The use of this approach facilitates perineal reconstruction and enables treatment of patients with large and complex defects in frequently irradiated tissues where wound dehiscence and infection are common.

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BACKGROUND: Combined hepatocellular-cholangiocarcinoma is a rare primary hepatic tumour, showing both hepatocellular as well as biliary epithelium differentiation. Its diagnosis is often delayed, as it occurs in young patients without comorbidities and with non-specific symptoms. Most cases are confused with other types of cancer, especially fibrolamellar liver cancer, which is more frequent and has similar clinical and radiological features. CLINICAL CASE: The case is presented of a 26 year old woman with a giant combined hepatocellular-cholangiocarcinoma with difficulties in its diagnosis and a complicated surgical approach. DISCUSSION: The definitive diagnosis of this disease is defined by the histological demonstration of cholangiolar and hepatocellular differentiation, with surgical treatment always being the best choice, but with lower survival than classic hepatocellular carcinoma and cholangiocarcinoma. In some patients with unfavourable prognostic factors, adjuvant chemotherapy mainly directed cholangiolar component can be given. CONCLUSION: The current incidence of combined hepatocellular-cholangiocarcinoma varies from 2 to 5% of cases, and is one of the rarest histological types in the world. The large size and hypervascularisation of the tumour makes a surgical approach difficult in these patients, while the rare histological features require a more detailed study of the piece and the application of immunohistochemical techniques to confirm the diagnosis.

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La incidencia de masas anexiales diagnosticadas durante el embarazo varía según las diferentes series consultadas; sin embargo, masas de tamaño superior a 6 cm suponen casos excepcionales en la literatura. El manejo de este tipo de pacientes supone un reto para el equipo multidisciplinario, ya que se debe tener en cuenta el riesgo de cáncer de ovario en este tipo de pacientes. Se trata de una gestante de 34 años a la que se le diagnostica una masa anexial gigante durante el control ecográfico del primer trimestre. Ante la ausencia de sufrimiento fetal y teniendo en cuenta las características radiológicas de la lesión, se decide mantener una actitud expectante a la espera de un parto vía vaginal y poder realizar una cirugía electiva para la exéresis de la lesión. Tras el parto, la paciente sufre una anemización progresiva, por lo que se decide priorizar la intervención quirúrgica. Se llevó a cabo una exéresis de la masa mediante un abordaje mínimamente invasivo. Tanto la paciente como el recién nacido, tuvieron una evolución favorable. La paciente fue dada de alta tres días después de la cirugía(AU)

The incidence of adnexal masses diagnosed in pregnancy varies by the different consulted series; however, over 6cm long masses represent exceptional cases in literature. The management of this type of patients is a challenge for the multidisciplinary team since the risk of ovarian cancer should be taken into consideration in this type of patients. This is a 34 years-old pregnant patient who was diagnosed with giant adnexal mass during the echographic control of the first trimester. Due to the lack of fetal distress and the radiological characteristics of the lesion, it was decided to keep surveillance to wait for the vaginal delivery and to perform an elective surgery to remove the lesion. After the childbirth, the patient suffered a process of anemia, so it was decided to prioritize surgery. The mass was excised through a minimally invasive approach. Both the mother and the newborn had favorable recovery and the patient was discharged from hospital three days after surgery(AU)

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Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

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Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

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Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

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