Eleven obturator hernia cases treated at our hospital between 1998 and 2010 were retrospectively analyzed. All 11 patients were female, with a median age of 82 years and a median body mass index of 14.8 kg/m². Overall, 91% of the patients were multiparas, and 55% had not had previous abdominal surgery. Symptoms resembling ileus were observed in 82% of patients, and the Howship-Romberg sign was present in 64% of patients. In addition, 3 patients had femoral pain, and these patients could be diagnosed early. While 73% of patients were diagnosed preoperatively by computed tomography findings, 2 patients (18%) were diagnosed based on operative findings. One patient could not be diagnosed and died of septic shock caused by intestinal perforation. Surgery was performed in 10 patients (91%), with bowel resection in 6 patients. Despite its high mortality, obturator hernia tends to be diagnosed late because of its minimal symptoms. In cases of thin, elderly women without a history of previous abdominal surgery who complain of symptoms such as ileus or femoral pain, obturator hernia should be considered in the differential diagnosis, and these patients should be diagnosed and treated early.

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The aim of this retrospective study was to evaluate the usefulness of the transanal decompression tube as a bridge to surgery in left-sided obstructive colorectal carcinoma. The subjects comprised 30 patients who had undergone transanal decompression in the period from January 2004 through December 2009. We analyzed the success rates of intubation and bowel decompression, the surgical procedure, complications, and so on. The intubation rate was 80% (24/30), and the bowel decompression rate was 79.2% (19/24). We experienced two cases of septic shock immediately after intubation. As an elective operation, resection of the carcinoma with bowel anastomosis could be performed in 78.9% (15/19). There were no cases of anastomotic leakage, and no severe complications were experienced. The transanal decompression tube is useful in acute, malignant left-sided colorectal obstruction. Moreover, improvement of the technique is required to increase the intubation rate and the decompression rate, and to diminish the time from admission to elective surgery.

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Objectives: We examined the usefulness and limitations of laparoscopic surgery for acute abdominal conditions. Method: A retrospective study of 236 patients having acute abdominal conditions treated with laparoscopic surgery (Lap) was performed in comparison with 254 similar acute abdominal patients treated with laparotomy. Upon preoperative diagnosis, after classifying these cases into intestinal obstruction, gastrointestinal perforation, acute appendicitis, and acute abdominal conditions with unknown causes upon preoperative diagnosis, we examined the accuracy rate of laparoscopic diagnosis, the method of surgery, operating time, and postoperative complications. Results: The accuracy rate of laparoscopic diagnosis was 91.1%, in 71.6% of which laparoscopic surgery could be performed completely following diagnosis. The main reason for converting to laparotomy was bowel adhesion or intestinal necrosis. The mean operating time was 104.0±46.3 minutes in Lap and 65.3±34.6 min in laparotomy. Morbidity of Lap was similar to laparotomy (21.4% vs. 19.3%). Conclusion: Due to its diagnostic and therapeutic advantages, laparoscopic surgery is useful for acute abdominal conditions, but there is a limit to continue with a laparoscopic procedure in cases of strong bowel adhesion or intestinal necrosis.

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The purpose of this study was to evaluate operative procedures that young acute care surgeons (ACSs) should learn and perform. The operative procedures that the three ACSs in the critical care center of our hospital performed during two years were evaluated with an electrical operative database. One ACS performed 164 operative cases per year, which included 116 emergency operations. Appendectomies accounted for half of these operations, and the remaining operations included colon perforation, small bowel obstruction and so on. Sixty percent of patients with acute cholecystitis and 54% with gastroduodenal perforation underwent laparoscopic procedures. Trauma procedures were rare, and the ACS should perform trauma operations with an attending trauma surgeon.

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This study examined training methods for acute care surgeons by comparing such methods between an urban emergency critical care center and the surgical department of a regional core hospital, both of which were assumed to be involved in acute care surgery at the time of the study. The conditions of surgical practice were retrospectively investigated at the Department of Critical Care Medicine and Traumatology of the National Hospital Organization National Disaster Medical Center, where first author was then affiliated, and the Department of Surgery of Iwaki Municipal Iwaki Kyoritsu Hospital, where first author was previously affiliated. Regarding surgery, the annual number of surgical cases performed by each young surgeon was 85 at the National Disaster Medical Center and 155 at the Department of Surgery of Iwaki Kyoritsu Hospital. The modalities of surgery also varied more widely at the latter. Regarding surgical critical care, the numbers of experiences with mechanical ventilation support, hemodiafiltration, and open abdominal management were all larger at the National Disaster Medical Center. The annual number of trauma surgeries performed by each young surgeon was small at both the National Disaster Medical Center and Iwaki Kyoritsu Hospital, being 16.0 and 3.2, respectively. As a training site for acute care surgeons, surgical departments of regional core hospitals provide fewer opportunities to experience surgical critical care while the variation of surgical modalities experienced by young surgeons is limited at urban emergency critical care centers. Thus, exchange and other programs for young surgeons between institutions should be considered. Because experiences with trauma surgery are limited at both types of institution, training for trauma surgical procedures is an issue.

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Despite the high demand for medical services, the number of surgeons is decreasing, and in particular the number of abdominal emergency medicine physicians (EMPs) is dwindling. Patients' needs have become diverse, resulting in discrepancies in views and thoughts between patients and healthcare professionals and the potential for litigation has become a major risk. The specialty of surgery tends to be disliked by new physicians. To secure a sufficient number of EMPs, the promotion of high professional satisfaction and reduction of mental stress among physicians involved is essential. The current training system, in which physicians are forced to provide training during busy clinical practices, but without having their efforts reflected through salary/performance assessment, is problematic. A critical care system making use of IT may promote rapid treatment of critical patients at appropriate facilities tailored to their severity level. E-learning will play an even greater role in the teaching process, probably changing the education system drastically.

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Medical practice in the emergency department is performed under conditions of limited time, facilities and personnel, so it can lead to high-risk situations. The degree of professionalism is believed to be mostly reflected under such settings. We therefore analyzed how junior residents in our hospital think about the professionalism and perspectives of emergency medicine through a questionnaire to those residents who trained under daily practice in our department. As a result, many residents answered that they considered professionalism comprised knowledge, technique, and ethics and humanity. Although the number of emergency physicians is said to be declining, nearly half of our residents were willing to become emergency physicians. To educate an emergency physician with steadfast professionalism, the anxiety faced by staff in the emergency setting must be ameliorated or removed. The need of the general public for medical service is getting higher and higher, and emergency physicians are required who are conscious of professionalism and able to deliver best practice. The development of a system which supports those residents who are trying to be positively concerned with emergency medicine is important for the training of emergency physicians of the future.

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The decline in trauma surgery and decrease in young surgeons have become problems in Japan, as in the USA. In our emergency center, acute care surgeons undertake emergency room practice, emergency surgery, and intensive care for critically ill abdominal emergency surgical patients. In the past ten years in our center, there were 570 abdominal trauma patients (blunt injury 476, penetrating injury 94) and 673 non trauma disease patients (perforating peritonitis, intestinal ischemia, ileus, rupture of abdominal aortic aneurysm, etc.), not including cardiopulmonary arrest and acute appendicitis patients. The hospital mortality rate of the 58 patients with failure of more than four organs was 48%, which is superior to the outcomes in Europe and the USA. For the past five years, 30 complicated emergency surgical patients were transferred to our center, of whom 7 died. Most patients have been seen by a surgeon, and problems included an inadequate primary survey and treatment plan, delayed diagnosis, and a lack of intensive care. An acute care surgeon acting as an emergency physician improves the survival rate of critically ill emergency surgical patients and plays an important role in the education of surgeons and emergency physicians. Therefore, the nurturing of acute care surgeons is very important.

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An attractive training system is essential for training young trauma surgeons. We have developed an off-the-job training course-named, the “Surgical Strategy and Treatment for Trauma” (SSTT) -to train individual trauma surgeons as well as teams including nurses. In this paper, we present this new training course. This course aims to impart an understanding of the principles of trauma surgery as well as 4 factors, including “Speed and suitability,” “Strategy,” “Tactics,” and “Teamwork.” The students can learn from both the generalities and particulars related to trauma surgery, and can learn about strategy and teamwork building for trauma surgery, by using “Decision making,” an operative simulation. They can also learn about operative tactics, strategies, and team building for trauma surgery by operating on pigs in animal laboratories. Thus, we have established an effective and fascinating training system for young doctors and nurses using both on-the-job and off-the-job training-the SSTT course.

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Emergency radiologist are responsible for making a correct diagnosis immediately, and can save lives through interventional radiology (IVR). The resident training is carried out with rotation among the nine surgical subspecialities of neurosurgery, head & neck, respiratory, cardiovascular, gastrointestinal, skeletal, pediatric, urology & IVR. Residents in our department are educated and trained in how to chose the appropriate modality for emergency cases, how to read the images, and regarding the indication and performance of IVR.

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A-65-year-old female was brought to the emergency room (ER) with abdominal pain, and was diagnosed with contrast - enhanced CT scan as having a ruptured anterior superior pancreaticoduodenal aneurysm including multiple abdominal visceral aneurysms. Successful emergency transcatheter arterial embolization (TAE) stabilized the patient's hemodynamic state. However, follow-up CT scans showed new dilatation of the posterior superior pancreaticoduodenal artery (PSPDA) soon after TAE, and she underwent a second angiography on the 11th hospital day to treat the progressive dilatation of the aneurysm. The second interventional radiology (IVR) resolved the two pseudoaneurysms of the PSPDA that were not recognized in the first angiography. There were no new aneurysms or any indication of dilatation of the preceding aneurysms, and therefore she was transferred to another hospital on the 22th day. She was clinically diagnosed as having segmental arterial mediolysis (SAM) because of the multiple abdominal visceral aneurysms; there are no clinical reports of aneurysmal formation over several days associated with SAM as in this case. Although the definitive diagnose of SAM is based on a histopathological examination, it is necessary to establish the clinical diagnostic criteria because nonoperative management of such cases is increasing and appropriate intervention is necessary in patients with rapidly progressive arteriopathy.

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A 66-year-old man was admitted to our hospital with mild dyspnea, abdominal distension and hematemesis. Chronic pulmonary emphysema and right emphysematous bullae has been diagnosed 3 years previously. Chest CT scan revealed mediastinal shift by the exclusion of a huge right lung cyst. Gastrointestinal perforation was diagnosed to find the free air on chest X-ray and abdominal CT scan. Upper gastrointestinal endoscopy revealed active peptic ulcers at the gastric angle and anterior wall of the duodenal bulb. An emergency operation for pan-peritonitis and the lung cyst was performed on the same day. The patient underwent an omental patch for the perforation on the anterior wall of the duodenal bulb and wash and drainage for pan-peritonitis. Thoracoscopic resection of the right lung emphysematous bullae was performed at the same time. The patient had postoperative lung edema and lobar pneumonia which were managed with a respirator. After our multidisciplinary treatment, these diseases were improved and the patient recovered.

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Internal hernias through a defect of the broad ligament of the uterus are rare. A 42-year-old female without any history of previous surgery was admitted to hospital because of upper abdominal pain and nausea. Abdominal CT showed dilated small bowel loops and the displacement of the uterus toward the left side. Symptomatic remission was not attained by the placement of a long tube, and surgery was therefore performed 3 days after admission. Surgery revealed a fissure in the right broad ligament of the uterus measuring about 2 cm in diameter and a part of the distal ileum measuring about 30 cm in length and located 100 cm proximal to the ileocecal valve was incarcerated through this defect. The ileum was carefully reduced and the defect of the broad ligament was sutured. An approximately 10 cm long segment of the ileum had lapsed into ischemic necrosis and was thus resected. The patient's postoperative course was uneventful and she was discharged on the 14th postoperative day.

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The patient was a 60-year-old male who had suffered from spinal canal stenosis for 30 years and was using NSAIDs (diclofenac sodium) daily. He was admitted to another hospital for abdominal pain and was examined for anemia. He was then transferred to our clinic for ileus treatment. The patient was diagnosed as having small intestinal expansion on the basis of plain abdominal X-ray and CT findings, and a small intestinal obstruction was detected with contrast radiography of the ileus tube. Extreme malnutrition was observed in the patient at the time of transfer to our hospital, and progressive neurological manifestations such as poor articulation and numbness in the extremities appeared later, the causes of which could not be determined. After surgical treatment of the small intestinal obstruction, the patient's general condition, including his neurological manifestations and malnutrition, improved significantly. We made the final diagnosis of NSAID enteropathy on the basis of the pathological finding of a deep ulcer lesion, the absence of other abnormalities such as noncaseating granulomas, and the daily use of NSAIDs by the patient. Thereafter, NSAID administration was discontinued, and no relapse has been noted since then.

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Diverticular disease accounts for 40% of lower gastrointestinal bleeding. Multiple diverticular disease in the total colon is extremely rare and is an indication for an operative procedure if bleeding is repeated. Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. We report herein on a case of multiple diverticular disease with repeated bleeding treated with laparoscopic-assisted subtotal colectomy. A 64-year-old man had repeated hemorrhagic shocks due to massive bleeding from the colon diverticula for five years. The patient was admitted to our hospital complaining of melena, was managed conservatively and improved. Several examinations showed multiple diverticula in the total colon. Because of repeating bleeding, we performed laparoscopic-assisted subtotal colectomy. Operative time was 488 minutes and the blood loss volume was 765 mL. Laparoscopic-assisted subtotal colectomy is a safe and effective surgical procedure for diverticula of the colon.

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A 48-year-old man was admitted to our hospital complaining of epigastric pain after falling up some stairs. Abdominal CT revealed a type IIIb hepatic injury. Because the patient was hemodynamically stable, we chose conservative treatment. Follow-up CT at 2 weeks after the accident demonstrated a hepatic pseudoaneurysm with an arterioportal shunt. Transarterial embolization (TAE) was attempted initially but was switched to laparotomy because the shunt flow was very fast and there was a danger of causing wide embolization of the portal vein through the shunt. We performed ligation of S5b+c Glisson under ultrasound (US) monitoring of blood flow in the pseudoaneurysm (US-guided) because the patient was a heavy drinker and we were hesitant to perform extensive hepatectomy. At 16 days after the operation, the pseudoaneurysm had reformed through the collateral arteries and we performed TAE of the middle hepatic and A8 arteries. TAE could be performed safely because S5b+c Glisson was already ligated. US-guided selective ligation of Glisson's capsule is considered a relatively simple and minimally invasive method that offers effective management of hepatic aneurysms following blunt liver injury.

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A 71-year-old woman was referred to our hospital following a traumatic right upper abdominal injury caused by a blow from a gate ball stick. She complained of right upper abdominal pain. An abdominal CT scan showed free air in the retroperitoneal space. An emergency laparotomy revealed a perforation about 2cm in diameter in the second portion of the duodenum, and simple closure and tube duodenostomy, were performed with abdominal drainage. The postoperative course was uneventful without serious complications and the patient was discharged on the 24th day after the operation. Traumatic duodenal perforation as a result of a right upper abdominal sports injury is uncommon.

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[Objective] We report herein on a case of Salmonella splenic abscess that has been rare in Japan, successfully treated with percutaneous drainage. [Case] A 60-year-old male developed a fever and antibiotics were administered at a nearby clinic. However, the treatment was not effective and one week later he was transferred to our hospital with disturbed consciousness and in shock. Blood culture detected Salmonella. CT on admission showed a low density area in the spleen, while ultrasonography suggested a splenic cyst. Antibiotics treatment was administrated, then since the lesion suspected of being a splenic cyst turned out to be a heterogeneous space-occupying lesion, it was diagnosed as splenic abscess on day 16. On day 17, percutaneous drainage was carried out under CT guidance. Although placement of a pleural drainage tube was required due to left pleural effusion, body temperature declined quickly and the inflammatory reaction subsided. A reduction in the size of the abscess was confirmed by periodical CT examinations and the abscess drainage tube was removed on day 53. He was eventually discharged on day 62. [Conclusions] Diagnosis of a Salmonella splenic abscess may sometimes be difficult. Percutaneous drainage was effective in this case.

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A 62-year-old man who had been diagnosed with alcoholic liver cirrhosis (Child-Pugh Grade C) was admitted to our hospital with emesis followed by dyspnea 4 h after the onset. A chest radiograph revealed a right pneumothorax, and an esophagogram revealed leakage of contrast medium from the lower esophagus to the right thoracic cavity. Following the diagnosis of spontaneous esophageal rupture (extramediastinal type), percutaneous right thoracic drainage was performed, and his general condition improved. Owing to his severe underlying disease, we chose a conservative treatment with total parenteral nutrition and administration of omeprazole and antibiotics. On day 2 of hospitalization, he suffered from acute respiratory distress syndrome (ARDS), and therefore, endotracheal intubation, mechanical ventilation, and sivelestat sodium administration were started. Although tracheostomy was required for the treatment of pneumonia, he recovered from ARDS. However, his consciousness level progressively deteriorated despite administration of branched-chain amino acids, and Pseudomonas aeruginosa was persistently isolated from the thoracic drain fluid culture. An esophagogram performed on day 28 of hospitalization revealed persistent leakage of contrast medium from the lower esophagus. His liver and renal function progressively deteriorated, and he died of liver failure on day 34.

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An 86-year-old woman was admitted to our hospital with vomiting and abdominal pain. On physical examination, a bulge was found in the left inguinal region. Abdominal computed tomography (CT) showed the bulge was filled with herniated intestine and omentum, and a left incarcerated femoral hernia was diagnosed. We performed emergency surgery with the laparoscopic approach. Laparoscopy showed that the small intestine and omentum were herniated into the left femoral canal. We were able to release the small intestine and omentum using laparoscopic forceps. The ischemic color of the strangulated portion of the small intestine was not ameliorated, necessitating resection. The hernia space was repaired by laparoscopically reefing between the iliopubic tract and Cooper ligament, not using mesh because of the possibility infection. The patient's postoperative course was uneventful, and she was discharged on postoperative day 14. Laparoscopic repair is a minimally invasive and useful method for incarcerated hernia.

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A 65-year-old man who had been under hemodialysis reported a high fever and abdominal pain from the day before he came to our hospital, where he was diagnosed as having a gastrointestinal perforation. Emergency laparotomy revealed a perforation of the sigmoid colon diverticulum, and Hartmann's procedure was performed. Postoperative respiratory management was needed for eight days and absorption of endotoxin was performed for 24 hours. Continuous hemodialysis filtration was performed for ten days and periodic hemodialysis was restarted on the twelfth day after operation. On the 24th day, the patient vomited blood due to bleeding from a circumferential esophageal ulcer 20 cm long. The ulcer was cured with a 15-day fast. On the 20th, 35th, and 61st day, the recurrent intraabdominal abscess was punctured using ultrasonography, and the drain was kept inserted for ten days each time. He contracted bronchitis on the 92nd day but recovered following treatment with antibiotics. The patient moved into another hospital on the 107th day to remake his vascular access. It is important to perform an operation as soon as possible and to persevere in treatment against complications even if the patient is under hemodialysis.

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A 53-year-old woman complained of abdominal pain a week after her first treatment with leuprolide acetate for the bleeding caused by a uterine leiomyoma. CT showed portal and superior mesenteric vein (SMV) thrombosis. She was treated with thrombolytic therapy, but femoral vein thrombosis occurred around the central vein catheter. We undertook inferior vena cava filter placement and operated for bowel obstruction. Pathological examination revealed the obstruction had been caused by SMV thrombosis. It was considered that luprolide acetate might have been associated with the thrombosis because none of the other thrombotic factors was detected.

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We experienced three cases of perforated duodenal diverticulum between January 2008 and October 2011. All patients (mean age, 66.7 years) were female. The chief complaint at presentation was abdominal pain, and muscular defense was observed in only 1 case. In all cases, diverticulectomy was performed with a mean operation time of 174 minutes and mean blood loss of 180g. Duodenal diverticulum was found in the descending portion of the duodenal in all patients, and the postoperative course was uneventful. Perforation of the duodenal diverticulum is very rare. Although we have had difficulties in diagnosing and treating this condition, it is important to select a suitable treatment. We reviewed 52 cases of perforated duodenal diverticulum in the Japanese medical literature, and suggest diagnosis and treatment policies for perforation.

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A 75-year-old man was admitted to our hospital due to accidental ingestion of hydrogen peroxide. Although he suffered from repeated vomiting and abdominal fullness, signs of peritonitis were not detected. An abdominal CT examination showed obvious gas images in the gastroepiploic vessels and intrahepatic portal veins. Upper gastrointestinal endoscopy revealed mucosal redness, swelling, and erosion from the lower part of the esophagus to the middle body of the stomach, while there was no evidence of gastrointestinal tract perforation. We treated him non-operatively with a proton pump inhibitor and sodium alginate. On the next day, all of the hepatic portal venous gasses had disappeared on CT and his symptoms had improved. He was discharged on the fifth day after admission. When the hepatic portal gas associated with the ingestion of hydrogen peroxide is not combined with gastrointestinal perforation, conservative therapy can be performed, but it is necessary to observe the case carefully because it could be a preliminary symptom of gas embolism.

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A 68-year-old woman with a history of right obturator hernia for which she had received conservative treatment presented to our hospital with abdominal pain. A diagnosis of right obturator hernia was made on the basis of the results of contrast-enhanced abdominal computed tomography (CT). The patient's pain was alleviated, but abdominal CT showed that the hernia persisted. Moreover, the small bowel had extended further. Therefore, an emergency laparoscopic hernioplasty was performed. We confirmed that the hernia was reduced and that there was no intestinal necrosis. C-QUR Edge^TM mesh was used to close the hernial orifice. We were able to observe both sides of the obturator during the laparoscopic surgery, and it was a non-invasive approach; therefore, laparoscopic surgery was useful for treating the obturator hernioplasty. In addition, C-QUR Edge^TM is useful for hernioplasty because the percentage of shrinkage is lower than that of conventional meshes and it is hard to adhere adhesion formation is rare.

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