Giant melanomas of the peripheral limbs are a rare surgical entity, with fewer than six cases reported in published literature. Previous case reports primarily described attempts at surgical cures utilizing a multidisciplinary approach. We believe this is the first report addressing the complexities of tumor complications specifically from the perspective of acute care surgery. The surgical procedure in this case aimed exclusively at arresting bleeding rather than oncological cure. The role of surgery in addressing complications in palliative care of large tumors is significant. It enhances patient comfort and assists in establishing management guidelines for rare tumors, such as giant peripheral melanoma.

Small intestinal neuroendocrine tumors are rare gastrointestinal malignancies (< 0.5% of all cancers). Complications at presentation include bleeding, abdominal pain, and bowel obstruction; small bowel ischemia and bowel necrosis are rare. A 63-year-old patient was referred from a rural hospital to Acute Care Surgery with bowel obstruction, and arrived in septic shock. He was resuscitated, diagnosed with mesenteric ischemia, and underwent an exploratory laparotomy which identified an internal hernia (which was released), and small bowel ischemia and necrosis which were resected. The incidence of acute mesenteric ischemia < 0.2% of all acute surgical admissions. Nonocclusive mesenteric ischemia accounts for 20% of all etiologies and was evident in this case. The superior mesenteric artery pulse was clinically palpable and there were no signs intraoperatively of venous stasis at the root of the mesentery. Pathology confirmed multiple small bowel mesentery neuroendocrine tumor nodules. Surgical resection remains the mainstay of treatment.

Sigmoid volvulus is a rare form of large bowel obstruction and makes up < 5% of all colonic obstruction. The commonest aetiologies include a lead point involving an intra or extra luminal mass such as a malignancy or a benign stricture or colonic dysmotility especially in the geriatric population. Rare aetiologies include a mesenteric defect, or as in this case report, a congenital omental defect acting as the lead point. This makes for an increasingly unusual case report, and we believe that this is the first such report in English language literature. The management remains the same, irrespective of the aetiology. Endoscopic bowel decompression in the acute phase is followed by definite surgical management with or without a primary surgical anastomosis.

An appendiceal mucinous neoplasm is a rare condition with a clinical picture that can resemble appendicitis. Published reports have documented an incidence of 0.07-0.3% of all appendicectomies. The ubiquitous use of computerized tomography scans has helped plan surgical strategies as these patients may often require a right hemicolectomy in order to ascertain oncological clearance. This helps the clinician to avoid the complication of pseudomyxoma peritonei with its attendant increased mortality. In this case report the presence of a normal appendix base allowed for a laparoscopic intervention without having to resect the right hemi-colon. All published case reports to date have documented the involvement of the entire appendix. This case report is unique in the sparing of the proximal appendix.

Small intestinal diverticula is a rare occurrence, and their surgical management remains controversial due to the lack of a recognized classification system. Complications such as perforation and obstruction are treated surgically. Their etiology remains nebulous but theories such as damage to the Auerbach’s nerve plexus have been advanced as a possible cause. The concomitant presence of a sigmoid intussusception due to diverticular disease in the same patient is truly a rare occurrence. The vast majority of colonic intussusception is due to malignancy and a benign etiology remains elusive. The reported cases of benign causes include a lipoma and benign lymphadenopathy. We believe this to be the first such case report of a colonic diverticulum causing an intussusception. Despite an exploratory laparotomy of less than sixty minutes, the patient demised in the intensive care unit following an occipital lobe stroke. We believe this case of sigmoid intussusception with concomitant small intestinal diverticula to be the first such case report of its kind in English-language scientific publications.

A gastrointestinal stromal tumor (GIST) arising in the duodenum is a rare subtype of mesenchymal tumor. GISTs have a reported incidence of 11.9–19.6 per million population and duodenal GISTs make up just 5% of these tumors. Common presentation of duodenal GISTs is through an upper gastrointestinal bleed, of which, they are responsible for less than 1% of all gastrointestinal bleeding. In an elective setting, surgical management remains the mainstay of treatment. In this Case Report, the emergent management of a localized duodenal resection was performed by an acute care surgeon, in an unstable patient. The risk factors for malignancy include tumor size and a high mitotic cell index. Tumor recurrence is determined by tumor size, tumor rupture, high mitotic cell index, a non-gastric location and gastrointestinal bleeding.

The laparoscopic repair of traumatic diaphragmatic injuries in the acute phase has not been well established. The current consensus view is an elective repair by a surgeon with an advanced laparoscopic skill set. This case report illustrates the position that with judicious patient selection an acute repair is not only possible but well within the realm of an acute care surgeon. Anterior diaphragmatic injuries with penetrating trauma can even be repaired primarily without the need for prosthetic reinforcement. It is hoped that this case report will add to the surgical armamentarium of the acute care surgeon.

Spigelian hernias are a rare type of abdominal wall hernia. A weakness in the spigelian fascia causes abdominal contents to herniate between the abdominal muscle layers as an interparietal hernia. We present the case of a 72-year old woman with acute onset abdominal pain and distention. A computed tomography scan revealed an incarcerated spigelian hernia with small bowel obstruction. This necessitated an acute surgical intervention with a laparoscopic tissue repair. The case is unique as our patient had a large hernial neck measuring 4.8 centimeters, one of the largest in published literature. The laparoscopic tissue repair is outside the current norm for this type of hernial repair and remains a rare type of surgical herniorrhaphy. Laparoscopic ventral hernia repair in the acute setting should form part of the surgical skill set of acute care surgeons as borne out by the published literature and this case report.