When simple hernia is not that simple: Treatment of concomitant pathology in acute care surgery, a case report.

Abstract Introduction Obstructed colon cancer is not an uncommon surgical emergency. But its presenting symptoms may be overlapped by many other surgical diseases. This paper aims to report a cancer colon case with delayed diagnosis due to a long-standing para-umbilical hernia (PUH). Case report 60 -year-old female presented to our emergency department (ED) with an obstructed PUH. The patient underwent many times for conservative management until the full optimization of the patient's comorbidities. This history of recurrent intestinal obstruction and incomplete regain of regular bowel habits after every hospital admission raises the possibility for concealed pathology. Further investigations, including computed tomography (CT), revealed a suspicion of an obstructed malignant mass at the colon's splenic flexure and associated with complete bowel obstruction. The patient and their family consulted for exploratory laparotomy and the possibility of stoma formation. The intra-operative was constant with a small ventral defect, and a dilated bowel loops up to a left colon transition zone. We achieved left hemicolectomy with a primary anastomosis after intra-operative bowel lavage. The postoperative period was uneventfully, and the patient was discharged home after seven days of admission. Follow up in the clinic after that for three months without recordable complications. The patient had transferred to the oncology center for the completion of adjuvant therapy. Discussion This case had a small PUH with recurrent obstruction. The delay in its management was due to the patient's comorbidities. However, the incomplete resolution of patient symptoms during watchful oversight increases the like hood of another hidden pathology that required further investigation. We expanded CT indication in such patients to find the exact cause of patient symptoms, especially chronic constipation and incomplete recovery after every admission. While concurrent pathology is the norm in elective surgery and can be dealt with safely, in non-elective surgery, a thorough search about the patient's exact complaints is mandatory to decrease morbidity and mortality rates for such patients. Conclusion In the same patient, both colon cancer and abdominal wall hernias can produce conflicting symptoms and delay diagnosis. However, with a high index of suspicion and correlation of patient symptoms, can be safely managed without morbidity.