Background: Although it is generally considered that Single incision laparoscopic appendectomy (SILA) is cosmetic and useful for acute appendicitis, it is rarely conducted for complicated appendicitis involving gangrenous or perforated appendices or in the case of abscess formation. We evaluated the benefits and feasibility of SILA for complicated cases. Subjects and Methods: Between July 2011 and July 2015, 77 patients underwent emergency surgery for complicated appendicitis at our hospital. We compared patient characteristics and postoperative outcomes between the single incision laparoscopic appendectomy (SILA) group (30 cases) and the open appendectomy(OA) group (47 cases). Results: There were no significant intergroup differences in the patient characteristics. However the cases in which drain insertion was required were significant less in the SILA than in the OA group (P=0.02). Furthermore, there were no significant intergroup differences in the incidence of postoperative complications. Conclusion: These data suggested that SILA is a cosmetic, safe and feasible treatment for complicated appendicitis.

Introduction: We are currently performing laparoscopic appendectomy using needlescopic instruments (hereinafter referred to as “this procedure”). In the present study, we report on the treatment results of this procedure. Subjects and methods: From April 2012 to October 2014, we performed this procedure in 102 patients. We investigated the operation time, the rate of postoperative complications, and postoperative length of hospital stay of these 102 patients who underwent this procedure. Result: Median operation time, 64 minutes (range, 28 to 149); the rate of postoperative complications, 4.9％(5/102); median length of postoperative hospital stay, 4 days (range, 2 to 15). Conclusions: We can perform safe and minimally invasive surgery using needlescopic instruments, and this method could become standard surgery for acute appendicitis.

Purpose: To evaluate the validity of initial nonoperative management for acute appendicitis, followed by interval single-incision laparoscopic appendectomy (SILA). Patients and Methods: Between 2009 and 2013, we performed 74 SILAs, of which 46 were emergency (EM) and 28 underwent initial conservative treatment, followed by interval appendectomy (IN) after three months. Operative outcomes were compared retrospectively. Results: There were no differences in demographic characteristics. The mean operative time was less in the IN group (58 vs 73 min, IN vs EM, P<0.05) . The time of starting oral intake was shorter in the IN group (1.4 vs 2.2 days, IN vs EM, P<0.01), which resulted in a shorter hospital stay (3.5 vs 4.9 days, IN vs EM, P<0.05). There were no differences in blood loss, total doses of analgesics, and postoperative complications. Conclusions: Although interval appendectomy requires two separated hospitalizations, a 3-month interval could abolish inflammation. Given the surgical difficulty of the SILA approach, the superiority of interval appendectomy might outweigh the problem of prolonged hospitalization.

Purpose and Methods：We retrospectively identified cases of spontaneous esophageal rupture reported from January 2007 to December 2013. Results：All eight identified cases were male, with a median age of 49.5 (35-80) years. Thoracic back pain and abdominal pain were the chief complaints in two and six cases, respectively. Three cases were transferred to a tertiary care center, four to a secondary emergency center, and two presented by themselves. Chest radiography revealed pleural effusion in five cases. Furthermore, pneumomediastinum was detected by computed tomography (CT) in all cases. Detection of the leaked stomach contents enabled a definitive diagnosis to be made. In all cases, surgery was performed successfully within 24h of the onset. Conclusions: Esophageal rupture has a good prognosis if diagnosed early and treated promptly. The diagnosis rate of esophageal rupture is low at initial presentation because of the lack of characteristic physical findings. However, chest CT imaging allows a definitive diagnosis to be made. Therefore, chest CT imaging should be promptly performed in cases of suspected esophageal rupture.

Background：The timing of conversion from surgical treatment for adhesional ileus is still controversial. Method：We registered 111 cases of adhesional ileus during 13 years. For the earlier 7 years, the timing to change from an indwelling tube to surgical treatment was not set (E-group). For the later 6 years, we set 3 or 4 days as the observation period to change to surgical treatment (L-group). We additionally classified patients into cases cured with only a conservative indwelling approach (C-group), and the cases treated surgically (S-group). Results：In the E-group, the mean days from indwelling to diet, and to hospital discharge, were 10.9, and 24.7 days. The days were 7.5, and 19.2 days in the EC-group, whereas they were 15.7, and 33.1 days in the ES-group. In the L-group, the mean days were 5.7, and 13.2 days. The days were 3.9, and 9.9 days in LC-group, whereas they were 9.1, and 19.0 days in the LS-group. The total mean days of the L, LC, and LS-groups were shorter than for the E, EC, and ES-groups respectively (P<0.01). Conclusions：Setting of a short observation period (3 or 4 days) to change from indwelling to surgical treatment would appear to contribute to shorten the afflicted period with adhesional ileus.

Background: Although prosthetic mesh repair has become the gold standard for elective management of hernia, its use in the setting of acute incarceration is still limited. We present our 15-year experience of conducting prosthetic mesh repair in the management of acutely incarcerated groin hernias and evaluated the outcomes. Method: We conducted a retrospective study of 123 patients who underwent emergency hernia repair for incarcerated groin hernias between 2001 and 2015. We evaluated the difference in the outcomes between patients who underwent prosthetic mesh repair and conventional repair Results: Prosthetic mesh repair was performed without bowel resection in 88 patients (93%) and with bowel resection in 28 patients (43％). There were no mesh infections or recurrences in either group. Conclusion: Prosthetic mesh repair can be safely performed in cases of incarcerated inguinal hernia, taking sufficient care to minimize the risk of infection.

Tension-free repair using a mesh is mainly performed for inguinal hernia Inguinal hernias are mainly treated by tension-free repair using a mesh?, however there is no consensus as to the best operative method or use of a mesh in cases of incarcerated inguinal? hernia. We conducted the present study to evaluate the outcomes of repair using a mesh for cases of incarcerated? inguinal hernia. Data of a total of 39 cases of [or‘patients diagnosed as having’] incarcerated inguinal hernia were retrospectively analyzed. Our findings suggested that tension-free repair using a mesh is safe and useful for patients with incarcerated inguinal hernia.

In our department, we have actively introduced the mesh repair technique, including the transabdominal preperitoneal approach (TAPP), for incarcerated inguinal hernias. We reviewed 82 patients who underwent emergency surgery for an incarcerated inguinal hernia during the eight-year period from April 2006 to March 2014. In the review, we looked at three aspects of the surgeries. First, we made a comparison between TAPP (13 cases) and inguinal hernia mesh repair (36 cases) in patients who had not undergone intestinal resection; second, we compared mesh repair techniques, including laparoscopy, (12 cases) and inguinal incision suture procedure (8 cases) in patients who had undergone intestinal resection without perforation; and third, we put together a case report on our experience with TAPP secondary to intestinal resection in cases involving perforation and colonic necrosis. In the first part of the review, TAPP was considered as a useful surgical technique, because it significantly reduced the bleeding volume (P<0.01). In the second part, no significant difference was found between the two groups, and the mesh repair techniques were found to be a safe procedure for patients on infection control measures after intestinal resection. In the third part, the uneventful clinical courses of the patients covered in the case report suggested the usefulness of TAPP as a secondary procedure. Further accumulation of such cases is needed. These findings suggest that the mesh repair technique, including TAPP, can be a useful surgical technique for properly selected cases of incarcerated inguinal hernia.

[Background] To investigate the clinical outcomes of incarcerated groin hernias. [Methods] A retrospective, single center study performed in the period of 2008 to 2014. Seventy-nine patients who underwent an emergency operation for incarcerated groin hernia were analyzed by the presence (41 cases) or absence (38 cases) of intestinal resection. [Results] Intestinal resection was more likely to be performed in women, who had a femoral hernia, comorbidity, and poor performance status. In the intestinal resection group, all hernia repair was performed by conventional methods. In the non-resection group, mesh repair was performed in 28 patients and a conventional method was performed in 10 patients. Longer operation time (110min vs. 68min) and more blood loss (45g vs. 15g) were noted in the resection group. Postoperative complications were observed in 13 patients in the resection group and 3 patients in the non-resection group. Three surgical site infections were recorded in the intestinal resection group. Recurrence was noted in 1 out of 51 hernias in the conventional repair group. [Conclusion] Given the relatively low recurrence rate of conventional hernia repair and concern for mesh-related infection, conventional repair is rational for those who have undergone intestinal resection.

Prosthetic mesh repair has become a standard operative procedure in normal surgery for groin, obturator hernias. However, in the case of surgery for incarcerated and/or strangulated cases where mesh infection is a potential problem, consensus has not been obtained on the indication of the mesh to be used. We report herein on results of emergency operations involving prosthetic mesh repair for incarcerated and/or strangulated groin and obturator hernias. Seventy-three of the patients received emergency repair of groin hernias in 10 years. No resection of viable intestine was performed in 61 patients, and we used mesh in 58 patients. There was no infection perioperative period in any patient. Resection of non-viable intestine was performed in 12 patients. We used mesh in 4 patients, 3 patients of them in whom resection of small intestine took place had a good clinical course, and in 1 patient from this group who required an ileostomy septic shock and wound infection occurred, without mesh infection. Eighteen of the patients received emergency repair for obturator hernias in 10 years. No resection of viable intestine was performed in 12 patients, and we used mesh in 10 patients. There was no infection perioperative period in any patient. Resection of non-viable intestine was performed in 6 patients. We used mesh in 1 patient in whom was no infection perioperative period. No resection of viable intestine in prosthetic mesh repair of incarcerated and/or strangulated groin and obturator hernias is safe. The resection cases of non-viable intestine prosthetic mesh repair do not necessarily lead to mesh infections in these cases.

Abdominal hernia with blood flow disorder, compared to inguinal hernia impeded blood flow, are not frequently seen in the emergency abdominal area. Currently, the simple suture closure and the mesh repair method are used for abdominal hernias. The usage of artificial mesh for abdominal hernias with blood flow disorder is controversial. To accurately diagnose any blood flow disorder and surgical site infection adjacent to the hernia, it is necessary to select the safer approach and repair method. We should strive not to cause any recurrence and postoperative complications.

Twenty-three patients with an obturator hernia who were undergoing surgery at the Okitama General Hospital between 2009 and 2013 were assessed to identity the clinical features of obturator hernias. Patients with obturator hernias tended to be elderly, thin women. A bowel resection was done in 12 cases; in three-fourths of the patients, we used a mesh sheet (6 patients) and mesh plug (3 patients). Closing the hernia orifice by placing meshes in the preperitoneal space using the midline extra-peritoneal approach could be beneficial in many cases.

An 83-year-old woman who had undergone cholecystectomy for cholecystolithiasis was admitted to our hospital with abdominal distension and vomiting. The patient was conservatively treated with parenteral nutrition and antibiotics, but the symptoms failed to resolve in response to decompression of the bowel. Because she had previously undergone cholecystectomy, an adhesive intestinal obstruction was the most likely diagnosis and surgery was performed. The intraoperative findings revealed four palpated tumors of the small intestine. A partial resection of the small intestine was performed. The tumor was diagnosed as a diffuse large B-cell lymphoma based on the histopathological findings. Chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) was therefore started. Although cases of intestinal malignant lymphoma with multiple lesions are rare, we should consider them for the patients with unidentified and repeated ileus.

Impalement rectal injuries with intraperitoneal organ injuries are rare. We report herein on the successful treatment of an anorectal impalement injury with injury of the rectum and the urinary bladder. An 82-year-old female was accidentally stabbed in the anus with a plastic bar, which was used for mixing hot water in the bathtub. She removed the bar by herself. After the accident she developed lower abdominal pain and the intestine emerged from her anus. When she visited our hospital, she was fully conscious. Abdominal CT showed protrusion of the intestine through the urinary bladder and the rectum. She underwent emergency surgery under general anesthesia. After the laparotomy, part of ileum was observed to be prolapsed into the urinary bladder and the rectum. We repaired these damages and performed a sigmoid colostomy. After surgery, the patient showed satisfactory recovery and was discharged from the hospital on day 21 post-surgery.

A 79-year-old man developed sigmoid volvulus a total of seven times during a two-year period since his first visit to our hospital. Though the patient had undergone endoscopic reduction after each onset, for the present visit he was to undergo a radical sigmoid colectomy. Because of marked elevation of the left diaphragm, we suspected a complication with diaphragmatic relaxation or a diaphragmatic hernia. The operative findings showed expansion of the sigmoid colon, and relaxation of the left diaphragm had occurred. We performed a laparoscopy-assisted sigmoid colectomy. Presently, one year after surgery, no relapse has been confirmed. In diaphragmatic relaxation, abdominal organs are easily raised to the area just below the diaphragm, possibly causing onset of volvulus of the sigmoid colon. To our knowledge, sigmoid volvulus with diaphragmatic relaxation has so far been reported in only one case in Japan.

We report herein a life-saving procedure of the enforcement of renal replacement therapy (RRT) in a case of acute renal failure (ARF) caused by traumatic rhabdomyolysis other than crush syndrome, hemorrhagic shock and respiratory failure. A 35-year-old man came to our hospital having been struck by a heavy-duty track, while driving a 125-cc bike. In the image inspection, we found out diaphragmatic hernia, hemopneumothorax, spleen injury, and pelvic fracture. Respiratory failure and hemorrhagic shock were exacerbated, so that we undertook emergency surgery comprising diaphragmatic plication and splenectomy. The patient had a good postoperative course, but muscle injury and renal function were found to be worse from the blood examination. In spite of fluid resuscitation, his urine output decreased. On the 4th day, we diagnosed ARF caused by traumatic rhabdomyolysis and introduced RRT. He was able to leave hospital on the 31st day. He was moved to the rehabilitation department on the 52nd day. Undertaking RRT from an early stage seems to be effective for ARF with rhabdomyolysis.

A 68-year-old man was brought to our hospital for sudden and progressing severe abdominal pain. He had a history of conservative therapy for frequent diarrhea and abdominal pain 2 months previously. He underwent an emergency operation with suspected colon perforation, because the CT scan showed free air in the abdominal cavity and a dilated colon replete with feces. Laparotomy showed a large sigmoid colon perforation with substantial feces and turbid ascites in the abdominal cavity. No definite tumorous lesion was palpable in the abdominal cavity. A loop sigmoid colostomy was constructed using a perforation site. He was discharged from the hospital after ICU treatment. Postoperative colonoscopy revealed a progressing stenosing lesion in his rectum, and he was diagnosed as having ischemic proctitis with a rectal stricture based on the imaging and histological features. Seven months after the first operation, he underwent a low anterior resection of the rectum with an end-to-end sigmoid-proctostomy. When we encounter colon perforation, the cause of perforation and subsequent therapy should be determined carefully even if ischemic proctitis with a rectal stricture rarely occurs.

A 56-year-old male was seen at our hospital because of right flank pain. An abdominal CT revealed an abdominal wall abscess and a fishbone in the abscess. A laparoscopic operation was performed. Intraoperatively, an abscess and a fishbone were found in the right lateral abdominal wall. We performed removal of the fishbone and drainage from the abscess. Twenty days after the surgery, the patient started having symptoms of high fever and a sense of fatigue. An abdominal CT was performed, which revealed recurrence of the abdominal wall abscess and remnant fishbone. Following the diagnosis, a laparotomy was performed. During which an abdominal wall abscess was found, but the rest of the fishbone was not. Removal of the abscess wall and drainage were performed. After the surgery, abdominal CT showed disappearance of the remnant fishbone and abscess. In the treatment of an abscess caused by perforation, or penetration of a fishbone through the intestine, it is considered that complete removal of the fishbone is important.

A 75-year-old man was transferred to our hospital with massive melena. At the initial presentation, endoscopic examination was precluded by signs and symptoms of shock. Contrast-enhanced computed tomography of the abdomen was therefore performed. Because contrast medium leaked into the cecum, gastrointestinal bleeding was diagnosed. Extensive transcatheter arterial embolization (TAE) was performed to treat several episodes of extravasation of contrast medium from the ileocolic artery, resulting in hemostasis. On the following day, however, signs and symptoms of peritoneal irritation developed. Post-TAE peritonitis was diagnosed, and an emergency laparoscopic ileocecal resection was performed. The postoperative course was good, and the patient was discharged on the eighth hospital day. About 2 years have elapsed, and there has been no recurrence of bleeding. In recent years, TAE has been used to treat many patients with gastrointestinal bleeding. However, we should bear in mind the risk of not only recurrent bleeding, but also of short-term postoperative complications such as intestinal necrosis associated with ischemic colitis.

A 70-year-old male underwent endoscopic resection for an adenoma in the ascending colon in February 2013. At the end of December 2014, he was admitted to our hospital with a complaint of right lower abdominal pain and fever. CT showed swelling of the appendix-and a clip in the appendix lumen；the patient was hospitalized with a diagnosis of acute appendicitis. We began conservative treatment with antibiotic medication, but his symptoms did not improve. Five days after admission, we performed emergency surgery. The appendix was found to be swollen and surrounded by an abscess. The middle portion of the appendix had severe inflammation due to incarceration of the clip. We performed an appendectomy and drainage. Although adverse events due to a dropped clip are extremely rare, it may cause acute appendicitis due to incarceration in the appendix as in this case.

A 56-year-old man, previously diagnosed as having rectal cancer, experienced pelvic recurrence of rectal cancer five years after undergoing a Miles' operation. After receiving cetuximab chemotherapy, he was admitted to our hospital with abdominal distention. Computed tomography(CT) revealed pneumatosis coli from the cecum to the descending colon and emphysema from the retroperitoneum to the mediastinum. Based on these findings, pneumatosis cystoides intestinalis(PCI) was the most probable diagnosis. There were no signs of peritonitis and the patient's general condition was stable；therefore, we initiated conservative treatment. According to subsequent CT findings, the pneumatosis coli and emphysema decreased in severity, and the patient was discharged 23 days after his admission. PCI resulting from cetuximab administration has recently been reported, and cetuximab may have also induced PCI in this case. Although PCI rarely presents with extraluminal air, the decision to operate on such a patient is difficult because of the possibility of an intestinal perforation. Therefore, careful evaluation of the diagnostic data, considering all available physical, laboratory, and imaging findings, is essential.

A 13-year-old girl visited our hospital with persistent abdominal pain and vomiting. Abdominal CT scans revealed a cluster of small bowel loops on the left side of the ligament of Treitz. The patient was diagnosed as having a left paraduodenal hernia, and an emergency laparoscopic operation was performed. Herniation of the jejunum was observed into the dorsal side of the inferior mesenteric vein through a hernia orifice located at the left side of the ligament of Treitz. Furthermore the jejunum-comprising the content of the hernia had penetrated the hernia sac and prolapsed into the abdominal cavity. The jejunum which was incarcerated was reducted possibly by traction. The hernia orifice was laparoscopically sutured. A paraduodenal hernia is categorized into a retroperitoneal hernia. Cases in which the hernia sac has collapsed and the small bowel has penetrated the hernia sac are rare. Laparoscopic surgery for the paraduodenal hernia made diagnosis and treatment possible with its good field of view．We have gained an extremely favourable impression of this procedure.

We experienced a case of enteric intussusception led by a heterotopic pancreas. A 24-year-old female was admitted with vomiting and epigastric pain. Abdominal Computed tomography demonstrated an enteric intussusception. We therefore performed emergency surgery, which revealed an intussusception of 3cm, palpable at 300cm to the anal side from Treitz' ligament. Subsequently a partial resection of the small intestine and bowel reconstruction were performed with functional end-to-end anastomosis. Pathological examination revealed a heterotopic pancreas (Heinrich Type Ⅲ) of the ileum. Enteric intussusceptions in children is often encountered, however it is uncommon in adults. This case emphasizes the point that in the case of enteric intussusceptions in adults, organic diseases must be immediately investigated and a rapid decision regarding an emergency operation must be made.

Intussusception is the most common abdominal emergency in early childhood, but it is a rare entity in adults. Jejunum-duodenum intussusception is an exceedingly rare retrograde small-bowel intussusception. We report herein on a 16-year-old woman with muscular dystrophy who had undergone a tracheotomy and was taking nutrients through a percutaneous endoscopic gastrostomy jejunum tube. She was admitted to hospital because of vomiting, and showed retrograde intussusception on the jejunum-duodenum. An emergency laparotomy was performed. We reduced the jejunum manually, and the absence of organic disorders in the invaginated jejunum was confirmed, the surgery was completed without performing intestinal ablation. Though we were unable to elucidate the cause of this retrograde intussusception, we consider PEG-J and muscular dystrophy induced this rare phenomenon.

An 81-year old woman was transferred to our hospital with low blood pressure and continuous abdominal pain. She was receiving with Warfarin potassium regularly following a cerebral infarction. Laboratory data revealed a prothrombin time-international normalized ratio of 10.0, and abdominal computed tomography demonstrated segmental thickening of the jejunal wall and mesentery, and fluid collection which appeared to be bloody ascites. Although an anticoagulant drug induced intramural and mesenteric hematoma was suspected, the symptoms worsened, and the possibility of intestinal necrosis could not be ruled out. After vitamin K administration, emergency surgery was performed. The peritoneal cavity was found to contain bloody ascites, segmental thickening of the jejunal wall and mesentery was seen due to the hematoma and part of the jejunum was found to be necrosed. Partial resection of the jejunum was performed. The postoperative course was uneventful. Conservative treatment is the first-choice treatment for intramural hematoma. However, some cases exist which may be complicated by hemorrhagic necrosis or perforation, hence careful observation is needed and surgery should be considered before the condition of the patient deteriorates.

An over 50-year-old man presented to our emergency department with a 3-day history of persistent nausea and abdominal pain. Enhanced abdominal computed tomography(CT) revealed the target sign in the left lower abdomen and the patient was admitted with a diagnosis of intussusception. Conservative treatment with an ileus tube proved unsuccessful. A chest CT revealed a 7-cm tumor in the right lung apex. Two days after admission, emergency exploratory surgery was performed. In perioperative findings Intraoperatively, a jejunojejunal intussusception was noted 90cm distal from the Treitz ligament. Following manual reduction of the intussusception, a 4-cm tumor was found; thus, partial resection of the small bowel was performed. Histopathological examination of the resected tumor showed proliferating atypical cells containing enlarged nuclei, mainly in the submucosa. Immunohistochemical staining showed positive staining of the tumor cells for CK7 and negative staining results for CK20, TTF-1 and PE10, leading to the diagnosis of small-intestinal metastatic tumor from primary lung cancer. The patient began experiencing weakness of the right upper extremity, dysarthria, and convulsions. Brain CT and MRI revealed metastases in the right frontal and left occipital lobes, and Gamma Knife surgery was performed. The brain metastases worsened and the symptoms progressed progressed and the symptoms worsened?, and the patient died 85 days after the operation.

An 81-year-old woman presented with a severe right lower abdominal pain with sudden onset after exercise. She had a previous history of undergoing a total hip arthroplasty 21years before admission. Computed tomography (CT) showed that prominent acetabular screw tips into the pelvis had impinged against the rectum. A follow-up CT on the next day showed worsening of edematous changes of the sigmoid colon and the rectum, therefore an emergency operation was indicated. Intra-operative findings revealed that the inflammatory changes were associated with the impingement of a 2-cm screw prominence. Removing or shortening of the screw was avoided because the tip had pierced the right external iliac vein. We applied a type of hernia mesh, ULTRAPROTM Hernia System (UHS), to cover the tip and to intervene between the tip and the rectum. The patient's postoperative course was uneventful. We conclude that an application of UHS is useful when removing or shortening of prominent acetabular screws cannot be executed.

A 65-year-old man visited a local doctor with a 5-month history of fever and abdominal pain. Abdominal computed tomography and ultrasonography revealed enlarged intra-abdominal lymph nodes, and elevated serum soluble interleukin-2 receptor levels. A diagnosis of suspected malignant lymphoma was made, and he was transferred to our hospital for further examinations. Five days later, the patient experienced massive melena with hemorrhagic shock, and subsequently underwent emergency surgery. The operative findings revealed numerous small yellowish-white nodules covering a discontinuous belt-shaped area on the reddened serosal surface in the intestinal tract at approximately 200 cm from the ileocecal valve. Therefore, ileocecal resection, including the ileum of 200 cm where the lesions were present, was performed, and an ileostomy was constructed at the stump of the ileum. The resected specimen included all of the small nodules, and multiple ulcers of various sizes were irregularly distributed in the ileum. Histopathology revealed epithelioid granuloma and Ziehl-Neelsen staining identified the presence of Mycobacterium tuberculosis. Thus, the patient was diagnosed as having intestinal tuberculosis, and transferred to another hospital for treatment of tuberculosis at two weeks after surgery. Although intestinal tuberculosis is uncommon, it is clinically important to consider this disease in the differential diagnosis of melena and multiple-ulcer-lesions in the ileocecal region.

We report herein on a rare case of an acute peritonitis due to perforation of a small intestine tumor metastasized from a lung small cell carcinoma. A 77-year-old man visited our emergency room complaining of lower abdominal pain. Mild signs of peritoneal irritation were recognized in the lower abdomen. An a Abdominal enhanced CT scan revealed enhanced wall thickening at the small intestine and a small amount of free gas around it in the abdominal cavity. The peritonitis was nonoperatively managed because the physical findings were not so remarkable. Chest CT scan showed a nodule in the right upper lobe measuring 1.3×1.1 cm. Under the suspicion of primary lung cancer, a transbronchial biopsy was performed, the results of which pathologically indicated the lesion was small cell lung cancer. We diagnosed this case as perforation of a small intestine tumor metastasized from a lung small cell carcinoma and performed elective surgery because we were worried about reperforation of the small intestine tumor. The patient’s postoperative course was generally uneventful. He responded to the chemotherapy for a certain term and died 426 days after the operation.

An 81-year-old woman was referred to our hospital with a fever and abdominal defence. Abdominal CT revealed free air around the sigmoid colon and fluid mainly in the Douglas pouch, and thickening of the enteric wall. We made a diagnosis of sigmoid colon perforation with generalized peritonitis, so an emergency operation was performed. Intraoperatively, an expanded intestine and a large quantity of purulent ascites were observed. There was no perforation of the small intestine or colon. Purulent fluid had pooled in the Douglas pouch, and a perforation was found at the dorsal side of the corpus uteri. We made a diagnosis of perforative pyometra, and enforced a subtotal hysterectomy with drainage. After surgery, acute cure for sepsis and DIC was performed. In this case, diagnosis was difficult because of a uterine myoma.

A 43-year-old man sustained a hard blow to his abdomen when playing volleyball and was rushed to the emergency outpatient clinic of our hospital. Computed tomography showed massive ascites and free intraperitoneal air, and the patient was diagnosed as having generalized peritonitis caused by traumatic perforation of the gastrointestinal tract. Emergency surgery was performed on the day of admission. A small perforation, about 1 cm in diameter, was found in the jejunum; the perforated site was resected and the anastomosis was performed. Sedation was provided by intravenous infusion of fentanyl and propofol after the operation. The patient became notably febrile (body temperature, >38℃) on the 2nd postoperative day and was treated for infection. However, his temperature increased to 41.1℃ on the 7th postoperative day, and therefore, fentanyl and propofol were discontinued. After the administration of cyproheptadine and extracorporeal cooling, his body temperature decreased to 37.5℃ in 6 hours. The patient was concomitantly given dantrolene. Rhabdomyolysis developed concurrently, requiring hemodialysis, but no high fever occurred. Thereafter, the patient's condition improved and he was discharged from the hospital. The clinical course was like the serotonin syn-drome.

A 63-year-old man who had been undergoing hemodialysis for 6 years because of diabetic renal disease was admitted to our hospital with fever and abdominal pain. Computed tomography revealed a gallbladder stone and ascites, and acute cholecystitis was diagnosed. After admission, he went into shock and we performed emergency surgery for septic shock due to gangrenous cholecystitis. Laparoscopy revealed massive intra-abdominal hemorrhage and pulsatile bleeding from the fundus of the gallbladder. We diagnosed hemorrhagic shock, converted to laparotomy, and performed a cholecystectomy. However, bleeding from the gallbladder bed continued, and hemostasis was difficult to achieve because of coagulopathy. We performed perihepatic towel packing, and the patient was moved to the intensive care unit. With improvement in the coagulopathy, we successfully removed the towels from the abdomen seven days after the initial operation. Hemorrhagic cholecystitis with massive intra-abdominal hemorrhage is rare and was successfully treated with a two-stage operation.

A 41-year-old man visited our hospital with right lower abdominal pain. He had tenderness in the right lower quadrant of the abdomen, slight bulging in the right groin region and swelling of the right scrotum. Blood studies revealed an elevated leukocyte count and C reactive protein level. Abdominal CT examination showed a whorl-like structure which was just below the umbilical region and distally toward a high-density area connecting to the right groin hernia. Under a diagnosis of secondary omental torsion caused by an incarcerated right groin hernia, emergency surgery was performed. During surgery, an indirect groin hernia was found. The greater omentum had not entered the hernia sac and was twisted one and a half times in the umbilical region. Because the distal side of the omentum was necrotic, the necrotic omentum was resected at its normal site. Repair of the right groin hernia by the modified Kugel procedure was performed. The postoperative course was good and the patient was discharged on postoperative day 6. In this paper, the 39 cases of secondary omental torsion caused by groin hernia in the Japanese literature were analyzed.