We evaluated preoperative predictors of intestinal ischemia in patients with an incarcerated groin hernia (IGH). Data of a total of 39 patients who underwent an emergency operation for IGH at our hospital from January 2008 through March 2018 were analyzed. The patients were divided into two groups: one group that had undergone resection of the small intestine (n＝22), and another that had not (n＝17). Local pain and skin redness at the first visit were found more frequently in the resected group (resected group: non–resected group＝12：3). The pre–contrast CT value of the incarcerated hernia contents was higher in the resected group than in the non–resected group. We performed a ROC curve analysis and found that the optimum cut–off value was 15 HU. These results indicate that the pre–contrast CT values of incarcerated hernia contents are higher (＞15 HU) and that necrosis of the intestine is associated with remarkable local findings.

Although the prognosis of cases of foreign body ingestion in children is generally favorable, complications may occur if the condition is not properly addressed. We reviewed the management of 94 cases of foreign body ingestion among patients under the age of 15 years at our hospital, excluding cigarettes, liquids, drugs, or others. The foreign bodies were mostly metals, button batteries, and plastics. The location of the foreign bodies could be confirmed by radiographic examination in 54 patients, and treatment was required in 25 cases (9 cases of foreign body in the esophagus, 14 cases of foreign body in the stomach, two cases of foreign body in the small intestine). Except for the 9 cases with button batteries identified in the stomach, the foreign bodies were mainly extracted with an endoscope; open surgery was needed in 3 cases. Complications occurred in three cases, including one case each of gastric mucosal injury caused by a lithium battery, esophageal diverticulum caused by a plastic seal, and small intestinal perforation caused by magnets. Because the nature of ingested foreign bodies also changes with time, the management methods need to be updated regularly. In this context, it is necessary to fully recognize the dangers associated with the rampant use of plastics.

A 50–year–old woman with lower abdominal pain was transferred to our facility and developed cardiopulmonary arrest just after vomiting during computed tomographic (CT) imaging. Spontaneous circulation returned after 8 minutes. Abdominal CT showed ascites, parenteral gas on the dorsal side of the descending colon, and upper rectal wall thickening, with an irregular border. Rectal perforation caused by cancer was suspected. We diagnosed the cardiopulmonary arrest in this case as having been due to suffocation and dehydration, and not due to septic shock. We prioritized the stabilization of hemodynamics and infection control, and treated the patients with intravenous fluids, catecholamines, red cells concentrates (RCC), fresh frozen plasma (FFP), and meropenem (MEPM), along with polymyxin B–immobilized fiber column–direct hemoperfusion (PMX–DHP) and intraperitoneal drainage. The hemodynamics improved after 20h. Hartmann’s operation was performed 60h after hospitalization. After the surgery, the patient was diagnosed as having liver and ovarian metastases from the rectal cancer, and abdominoperineal resection, hepatectomy and bilateral oophorectomy were performed 56 days after the initial surgery. The short–term recovery from CPA and localized peritonitis were both considered as good prognostic factors. When encountering a patient with rectal perforation associated with CPA not due to septic shock, it is effective to provide intensive supportive care while waiting to determine whether or not surgery is required.

The patient was a 71–year–old man who sustained injuries in a traffic accident in which the vehicle he was riding in collided with an oncoming car while turning right, and presented with a decrease in peripheral arterial oxygen saturation. He was brought to our hospital by ambulance approximately 1 hour after he sustained the injury. At arrival, the patient’s SpO₂ was 97％ (oxygen 10 L), but the patient was conscious and there were no other remarkable hemodynamic findings. Blood tests revealed an elevated white blood cell count (13,600/μL) and mild anemia (Hb 11.8 g/dL). Contrast–enhanced abdominal computed tomography revealed a left diaphragmatic perforation, prolapse of the stomach and descending colon into the thoracic cavity, and left lung exclusion, but no other apparent fractures or organ damage. Based on the above findings, the patient was diagnosed as having left traumatic diaphragmatic injury and underwent emergency surgery on the same day. A laceration, measuring approximately 10 cm, was found in the left diaphragm, and the stomach and descending colon had prolapsed into the thoracic cavity from the same site. There was no apparent organ damage, and the organs were manually repositioned into the abdominal cavity. The diaphragm was sutured with 2–0 Prolene, and a left chest drain was put in place. The patient’s postoperative course was good, and the drain was removed on day 4; the patient was discharged on day 15. Lone traumatic diaphragmatic injury is rare, therefore, we report this case with a review of the relevant literature.

A 61–year–old woman was admitted to our hospital with a abdominal pain. She was diagnosed as having bowel obstruction caused by adhesions, based on the previous history of abdominal surgery and findings on abdominal computed tomography. She was treated with an ileus tube. However, her condition worsened, and emergency surgery was performed. Intraoperatively, laparoscopic examination revealed that the small intestine was occluded by an adhesion band. At mini–laparotomy, however, the ileum was found to be occupied by a mass, which was identified as a potato; therefore, the final diagnosis was dietary bowel obstruction. We encountered a case of dietary bowel obstruction that was diagnosed preoperatively as bowel obstruction caused by adhesions. We suggest examination of the intestine by mini–laparotomy is useful during laparoscopic bowel obstruction surgery.

A 35–year–old pregnant woman visited a hospital emergency department at 38 weeks of gestation because of epigastric pain. However, her symptom improved soon, and she was sent home. The following day, she visited the obstetrics and gynecology department at an institution in her neighborhood, but was urgently referred to the obstetrics and gynecology department of our institution. Examination at presentation led to the suspicion of small bowel obstruction, but abdominal computed tomography (CT) revealed no evidence of strangulation. Accordingly, a nasogastric tube was inserted, and the patient was hospitalized for conservative treatment. She then experienced labor pain and delivered a baby by normal vaginal delivery on the same day, but her abdominal symptom persisted. A repeat abdominal CT was performed the following day, which revealed strangulated bowel obstruction. An emergency surgery was therefore performed. The small intestine was found to be incarcerated and strangulated in the intersigmoid fossa. Small bowel resection was not performed, because the strangulated small bowel showed no evidence of ischemia. Subsequently, the hernial orifice was sutured and closed. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Intersigmoid hernia is a relatively rare disease, with only three cases, including the present case, reported during pregnancy to date. Herein, we report our experience with this case, along with a review of the literature on this topic.

Adhesion is the most common cause of small bowel obstruction, accounting for about 60％ of all cases. However, among patients with strangulated small bowel obstruction and a history of laparotomy, there are cases in which small bowel obstruction is not caused by adhesion, but by paracecal hernia. Here, we describe a case of strangulated small bowel obstruction caused by a paracecal hernia. A 73–year–old woman who underwent total hysterectomy presented with abdominal pain and vomiting and was diagnosed as having strangulated small bowel obstruction based on the findings of abdominal CT. Initially, adhesion was suspected as the cause of the intestinal obstruction. However, intraoperative findings revealed a lateral type of paracecal hernia with small bowel obstruction. Postoperative review of CT revealed displacement of the cecum and ascending colon into the ventral and medial sides because of a closed small intestinal loop that was present behind the colon. Furthermore, our case report suggests that in cases that exhibit the abovementioned CT findings, despite a history of laparotomy, paracecal hernia rather than adhesion should be considered as the likely cause of strangulated small bowel obstruction.

A 37–year–old woman was admitted to our hospital because of abdominal distention and epigastralgia. Blood tests revealed severe anemia (Hb 4.6g/dL). Abdominal computed tomography showed a dilated stomach stuffed with an air–containing mass. Upper gastrointestinal endoscopy revealed a large trichobezoar in the stomach which could not be removed with the endoscope. Thus, laparotomy was performed using a smart retractor inserted into the stomach through the abdominal wall. We could remove the trichobezoar without dividing it. Only 12 adult cases of trichobezoar have been reported in Japan, and this is the first case in which a wound protector was used for removal. A smart retractor hooked into the stomach is useful for minimizing the incision and preventing spillage of gastric contents.

Enterocutaneous fistula is a rare complication that could develop immediately after incisional hernia repair, however, delayed fistula formation may also occur. A 69–year–old woman was admitted to our hospital with abdominal pain. She gave a history of having undergone abdominal incisional hernia repair using a mesh plug 19 years prior to her current presentation. Abdominal computed tomography revealed a soft tissue mass contiguous with the colon in the right lower abdominal wall, and abscess drainage was performed. On contrast radiography performed through the drainage tube, we identified the right–sided colon, the findings suggestive of an enterocutaneous fistula. We performed laparoscopically assisted mesh removal, partial colectomy, and repair of the abdominal defect using simple sutures. She was discharged without postoperative wound infection, and showed no evidence of recurrence until at least 20 months after the surgery.

Segmental absence of the intestinal musculature (SAIM) is a rare condition, characterized by partial absence of the intestinal muscularis propria layer. A 60–year–old female patient presented to us with diarrhea two days after undergoing barium gastrography. Abdominal CT showed barium inside the sigmoid colon and free air in the adjacent region. An emergency operation was performed under the tentative diagnosis of intestinal perforation. At laparotomy, intraoperative examination revealed a fragile part of the bowel wall in the sigmoid colon and retention of stool containing barium in the mesentery; therefore, Hartmann’s operation was performed. Macroscopic and histological examination revealed the absence of the intestinal muscularis propria and intestinal perforation, which led us to the diagnosis of SAIM. It was inferred that the increase in intestinal pressure due to barium excretion might have caused perforation in the fragile part of the bowel that lacked the muscularis propria layer.

We report a case of appendiceal torsion treated by laparoscopic surgery. A 71–year–old man presented to a previous doctor with abdominal pain, and was prescribed antibiotics for suspected acute colitis. However, his symptoms did not improve, and he was referred to us for further examination and treatment. He had right lower quadrant pain and persistent tenderness. Abdominal computed tomography was performed, which revealed findings suggestive of acute appendicitis. We decided to perform emergency laparoscopic surgery. Intraoperatively, the appendix appeared black owing to necrosis, and torsion of the appendiceal root was noted. We reduced the torsion and performed appendectomy. This report describes a case of appendiceal torsion that was successfully treated by laparoscopic appendectomy. The symptoms of appendiceal torsion are similar to those of acute appendicitis, but since appendiceal torsion can cause perforation, it should be treated surgically.

An 87–year–old male who visited a local clinic complaining of vomiting and anorexia was referred to our hospital for further evaluation and treatment. Physical examination on arrival revealed a swelling extending from the right groin to the scrotum. Abdominal CT showed a lumen structure existing in the inguinal canal toward the abdominal cavity. Surgery was performed under the suspected diagnosis of right incarcerated inguinal hernia. Intraoperative examination revealed incarceration of the ileocecum and findings suggestive of appendicitis. Therefore, appendectomy and inguinal hernioplasty were performed. The patient did not develop postoperative surgical site infection. In this patient, the appendicitis appeared to have been caused by strangulation of the appendix at the hernia orifice. Inguinal herniation of the ileocecum is relatively rare. There have been some reported cases of Amyand’s hernia, in which the appendix constitutes the contents of the inguinal hernia. We present this case of appendicitis which was caused by incarceration of the ileocecum in an inguinal hernia.

Although the number of studies of conservative therapy for gastrointestinal tract perforation by ingested fish bone is increasing, there are very few reports of long–term follow–up of these patients after conservative therapy. We report three cases of fish bone perforation of the gastrointestinal tract that were initially treated conservatively and followed up for 1 to 4 years. Case 1: An 83–year–old man with upper abdominal pain was diagnosed as having duodenal perforation caused by an ingested fish bone. His symptoms improved with conservative therapy, and he had no recurrence over the subsequent 2 years. Case 2: A 55–year–old man with continuous left–sided abdominal pain was diagnosed as having intestinal perforation caused by a fish bone. His symptoms improved with conservative therapy. However, he returned with abdominal pain 3 years later and underwent surgery for a recurrent intra–abdominal abscess. Subsequently, he remained without evidence of recurrence for 1 year after the surgery. Case 3: A 48–year–old man, in whom a fish bone was identified incidentally in the abdominal cavity on computed tomography. He opted for follow–up without any treatment, and remained asymptomatic for 1 year. Conservative therapy is a treatment option for some patients with perforation or penetration of the digestive tract caused by an ingested fish bone. However, there is the risk of development of abscess formation after a period of several years due to the fish bone remaining within the abdominal cavity. We should explain this risk to the patient and obtain his/her informed consent prior to providing conservative therapy.

An 18–year–old woman was admitted to our hospital with right lower abdominal pain of increasing severity and signs of peritoneal irritation. Abdominal computed tomography revealed ileocecal intussusception, necessitating emergency surgery. Laparoscopic exploration revealed the ileum, cecum and appendix intussuscepted into the ascending colon, and reduction (Hutchinson procedure) was performed. No obvious tumorous lesions were observed in the intestinal tract, and we diagnosed the case as a case of intussusception caused by a mobile cecum. We performed cecopexy without intestinal resection, because the intussusception was not secondary to a neoplasm, and no intestinal ischemia was observed. She did not report any of her symptoms, and colonoscopy and abdominal computed tomography showed no abnormalities. She has had no recurrence until now, 10 months after the surgery. Intussusception in adults is often caused by organic conditions such as tumor, and resection of the affected segment of the bowel is often required. We report a case of intussusception in an adult caused by a mobile cecum. This condition was successfully treated by a minimally invasive procedure, namely, laparoscopic reduction and cecopexy.

The patient was a 68–year–old woman who underwent stent placement in the bile duct because of bile duct stenosis caused by hilar lymph node metastasis from breast cancer. Chronic inflammation and fistula formation between the common bile duct and duodenum were also noted. While the patient was hospitalized for cholangitis caused by metastasis, she developed sudden cardiopulmonary arrest. Upper gastrointestinal bleeding was suspected from abdominal CT performed after resuscitation, and upper gastrointestinal endoscopic examination performed subsequently showed active bleeding from the fistula. Resuscitative endovascular balloon occlusion of the aorta (REBOA) enabled avoidance of the development of shock during endoscopic hemostasis and interventional radiology (IVR) controlled the hemorrhage. We report a patient with severe upper gastrointestinal bleeding whose life was saved by IVR in conjunction with REBOA, along with a review of the relevant literature.

A 75–year–old man underwent subtotal stomach–preserving pancreatoduodenectomy for lower bile duct carcinoma, and subsequently, pancreatojejunostomy was performed by the modified Blumgart method using a 7.5–Fr pancreatic duct tube as a internal stent. Since blood was drawn on the 5th, 7th, and 9th days after the surgery, endoscopy was performed each time. However, in consideration of the burden on the pancreatojejunostomy, observations of the anastomotic part were avoided. No lesion that could cause massive hemorrhage was detected, but a hematoma was found in the region of the Braun anastomosis, which was suspected as the bleeding site; therefore, the Braun anastomosis was clipped under the endoscope on the 7th day after surgery and the same site was opened and re–anastomosis was performed on the 9th day after surgery. On the 11th day after surgery, bleeding occurred again, and contrast–enhanced CT revealed a large hematoma extending from the pancreatojejunostomy to the Braun anastomosis, and bleeding near the pancreatojejunostomy was suspected. Because arterial hemorrhage from the jejunal mucosa opposite the pancreatojejunostomy was confirmed by endoscopic observation, hemostasis was accomplished with clips. The bleeding was considered as having been due to physical stimulation by the internal stent. The patient was discharged on the 35th day after the first operation without any further bleeding episodes.

A 73–year–old woman was brought to our hospital with sudden onset of melena. Upper gastrointestinal endoscopy revealed no obvious bleeding point. Plain abdominal computed tomography revealed blood pooling within the ascending colon; however, the cause of the bleeding remained unclear. As the melena persisted even after admission, we performed enhanced CT. Coronal–section images revealed active bleeding from a point in the small intestine approximately 8cm oral to the Bauhin’s valve. As the patient was in hypovolemic shock, emergency laparotomy was performed. We resected the ileocecal region, including the area of blood pooling 20cm oral to the Bauhin’s valve. The blood pressure recovered rapidly following the resection. The postoperative clinical course was satisfactory and the patient was discharged on the 16th hospital day. We diagnosed the patient as a case of hemorrhage from a diverticulum, based on histopathological identification of a solitary diverticulum in the ileum 8cm oral to the Bauhin’s valve. It is sometimes difficult to confirm the bleeding point and determine the segment to be resected in cases of small intestine hemorrhage. In the present case, we successfully saved the patient’s life because we could confidently resect the affected region based on the distance between the Bauhin’s valve and the bleeding point, based on information obtained from enhanced CT images subjected to multiplanar reconstruction.

A 69–year–old male patient was transferred to the emergency department due to blunt abdominal trauma and fracture of the right ankle sustained in a car accident. Abdominal contrast–enhanced CT revealed bleeding from the mesentery of the small intestine with peritoneal fluid, and emergency surgery was performed under the diagnosis of intraperitoneal bleeding and mesenteric injury. A mesenteric laceration was detected as the source of the bleeding 100cm from the Treitz ligament, and because of the severe mesenteric laceration, resection of the affected small bowel segment was performed. In addition, intestinal hematomas with oozing were detected in the mesentery at 50cm and 110cm from the Treitz ligament, and small intestinal ischemia was suspected. We assessed the viability of this segment by indocyanine green fluorescence angiography, and perfusion of ICG was visualized in the intestinal wall, so that the small intestine was preserved. The postoperative course was uneventful. Oral intake was started on the 6th day after surgery, and the patient was transferred for treatment of the bone fracture on the 13th day after surgery.

A 48–year–old man was admitted to the emergency department of a local hospital because of acute abdominal pain and loss of consciousness. Abdominal enhanced computed tomography revealed a ruptured aneurysm of the middle colic artery (MCA) and he was referred to our hospital. An abdominal angiogram also revealed an aneurysm in the main trunk of the MCA. During angiography, we confirmed blood flow between the right branch of the MCA and the right colic artery and between the left branch of the MCA and the marginal artery of the descending colon. Therefore, we performed coil embolization for the aneurysm. The postoperative course was uneventful. Angiography is useful for the diagnosis of ruptured aneurysm, if the vital signs are stable. Post embolization resection of the colon can be avoided depending upon the location of the middle colic aneurysm.

A 64–year–old woman with a previous history of a reducible hernia presented to the emergency department with a right groin mass. She was found to have a painless elastic–soft mass in her right groin. Abdominal ultrasound and CT showed a part of the small intestine and ascites in the right groin area. She was taken to the operating room for emergency exploration of the right groin hernia. We chose the inguinal approach, and made an incision in the right groin. A right femoral hernia was confirmed intra–operatively. When an incision was made on what was thought to be the hernia sac, her bladder catheter became visible. We made the diagnosis of femoral urinary bladder herniation, repaired the bladder wall and performed a McVay repair. We removed the bladder catheter after a bladder leakage test on the 7th postoperative day. The patient was discharged on the 10th postoperative day. No recurrence has occurred until now, three and a half years after the operation.