Introduction We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. Presentation of case A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. Discussion Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. Conclusions Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.

Background The accessory spleen is a congenital defect characterized by a separated ectopic splenic parenchyma. The size is rarely more than 4 cm. The preoperative diagnosis is prohibitive preoperatively. The aims of the present manuscript were to present the case of a patient with a rare oversize accessory spleen and a review of the literature. Case presentation A 15-year-old boy was admitted to the emergency department following blunt abdominal trauma. The computed tomographic scan showed a traumatic rupture of the spleen and a 7-cm mass at the left side of the retroperitoneal space. Conservative treatment started and aborted after 4 h due to the onset of haemodynamic instability. Splenectomy was performed. An accessory spleen was discovered. A second large mass in the retroperitoneum was diagnosed as a second large accessory spleen that was also left in place. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Seven months later, the CT scan showed viability of both accessory spleens. Conclusion An accessory spleen can be variously located and the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still difficult, especially in emergency and as in our case, the literature shows the difficulty of reaching a diagnosis before surgery. The main misdiagnosis is neoplastic disease and for this reason accessory spleen can be wrongly removed. An undiagnosed pre or intra operative retroperitoneal mass, closely to the spleen, have to be managed carefully. The diagnosis of accessory spleen needs to be ever considered as if found, represents a great possibility to conduct a normal life after splenectomy (of main spleen) for trauma.

Background: Laparoscopic cholecystectomy is one of the most performed surgeries worldwide but its learning curve is still unclear. Methods: A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the learning curve of laparoscopic cholecystectomy were included. The Newcastle-Ottawa scale for cohort studies and the GRADE scale were used for the quality assessment of the selected articles. Results: Nine cohort studies published between 1991 and 2020 were included. All studies showed a great heterogeneity among the considered variables. Seven articles (77.7%) assessed intraoperative variables only, without considering patient's characteristics, operator's experience, and grade of gallbladder inflammation. Only five articles (55%) provided a precise cut-off value to see proficiency in the learning curve, ranging from 13 to 200 laparoscopic cholecystectomies. Conclusions: The lack of clear guidelines when evaluating the learning curve in surgery, probably contributed to the divergent data and heterogeneous results among the studies. The development of guidelines for the investigation and reporting of a surgical learning curve would be helpful to obtain more objective and reliable data especially for common operation such as laparoscopic cholecystectomy.