A 68–year–old woman was admitted to our hospital with a swelling of the right inguinal area. Abdominal computed tomography showed a herniated appendix through the right femoral ring. The patient was diagnosed as having a de Garengeot hernia. Elective surgery was performed because she had no pain or symptoms of bowel obstruction. Intraoperatively, the tip of the appendix was incarcerated into the right femoral canal. The incarcerated appendix was released by incision of the lacunar ligament. There were no evidence of appendiceal necrosis or abscess formation. After laparoscopic resection of the appendix via the same operative field, the femoral ring was patched with a mesh by the standard transabdominal preperitoneal approach. The postoperative course was favorable, and she has shown no signs of recurrence or mesh infection.

An 85–year–old man was admitted to our hospital with persistent fever for 4 days. Abdominal CT revealed an abscess in the abdominal wall. The patient had undergone appendectomy 15 years earlier. He had a pararectal incision scar in the right lower abdomen. Moreover, we also found another scar. We speculated that he had undergone several abdominal surgeries more than one year earlier. We performed an operation laparotomy after conservative treatment with antibiotics for 13 days, and found pus around a folded mesh in the abdominal wall. We report this case of late mesh infection occurring more than one year after mesh repair for an incisional hernia.

Appendiceal diverticulitis is rare, and preoperative diagnosis is difficult. Here, we report a case of appendiceal diverticulitis that was preoperatively diagnosed as a tumor or abscess of the appendix. A 93–year–old woman complaining of abdominal pain was referred to our hospital. Findings of abdominal computed tomography suggested a mass lesion of the appendix. Because laboratory data and imaging findings suggested the presence of inflammation, immediate laparoscopic exploration was performed. On laparoscopic view, a mass lesion of the appendix measuring approximately 3 cm in diameter was detected. Considering possible malignancy of the appendix, partial excision of the cecum, including the appendiceal root, was performed. Histopathological examination of the resected specimen revealed appendiceal diverticulitis. Thus, the laparoscopic procedure was useful for both diagnosis and treatment in this case. Because the appendix atrophies with aging, appendiceal inflammatory diseases in super–old patients are rare. We have reported a case of appendiceal diverticulitis in a patient aged over 90 years old. In addition, we review the data of 7 patients with appendiceal diverticulitis or diverticula who underwent surgical resection at our institute between 2000 and 2018, and discuss the diagnosis and treatment of this condition.

The patient was a 72–year–old male who had undergone laparoscopic omental filling and drainage for gastric perforation. Postoperative upper gastrointestinal endoscopy revealed evidence of adenocarcinoma in the antral ulcer region. Distal gastrectomy was performed for the gastric cancer one month after the first surgery. The patient developed fever on the 5th postoperative day. Contrast–enhanced CT revealed a residual abscess, and the patient was followed up with percutaneous drainage treatment. Thereafter, it was confirmed by fluoroscopy of stomach that there was no anastomotic leakage and oral intake was resumed on the 15th postoperative day. Food residue leaked from the drain insertion site, and we diagnosed severe anastomotic leakage. We started decompression of the anastomosis and enteral nutrition with a W–ED tube using a fiberoptic endoscope. The drainage treatment reduced the abscess cavity size, and upper gastrointestinal endoscopy revealed the formation of granulation tissue and mucosal regeneration in the open area, so that oral intake was resumed. The patient was discharged on the 94th postoperative day. Although reoperation is often necessary for severe anastomotic leakage, we report a case of successful decompression and enteral nutrition using a W–ED tube in a patient with severe anastomotic leakage.

Small intestinal bleeding has been reported to account for approximately 2％–5％ of all cases of gastrointestinal bleeding, which that can be diagnosed using contrast–enhanced CT. However, it is difficult to detect the precise location of the lesion preoperatively or intraoperatively, which could result in excessive resection or a residual lesion. Herein, we present the case of a patient with a Dieulafoy’s ulcer in whom the oral margin of resection of the intestine was restricted by laparoscopic surgery, resulting in minimization of the intestinal resection. An 82–year–old woman was transported to our hospital by ambulance because of massive anal bleeding. She was in a shock state and was also found to be severely anemic (Hb 5.7 g/dL). CT findings suggested arterial bleeding from the ileum and emergency surgery was performed. Laparoscopically, we could easily confirm the end of the retrograde spread of blood in the intestinal lumen as the oral margin of resection of the intestine in which the lesion was suspected to be included. We then resected the distended 70 cm section of the intestine via a small–sized laparotomy. However, we found a small nodule by palpation 10 cm anal side from the resected part, and resected the additional segment. We completed the operation after confirming that the patient was hemodynamically stable. The histopathological diagnosis was Dieulafoy’s ulcer.

We encountered a patient with a perforated duodenal diverticulum, who was successfully treated by conservative therapy using a double elementary diet tube (W–ED tube). A 57–year–old female patient presented to us with right back pain and epigastric pain of sudden onset. Abdominopelvic CT revealed pneumoretroperitoneum and a fluid collection inside the descending part of the duodenum, and we diagnosed the patient as having a perforated duodenal diverticulum. Considering her good general condition, we initiated conservative treatment using a W–ED tube, which was useful not only for decompression of the duodenum, but also for tube feeding. She was successfully treated without serious complications and was discharged after 23 days at the hospital. Surgical treatment for a perforated duodenal diverticulum is highly invasive. Conservative treatment using a W–ED tube could be a useful minimally invasive treatment.

A 51–year–old woman presented to our department with a history of recurrent episodes of small bowel obstruction since the age of 43 years. She had undergone intestinal bypass for congenital small bowel stenosis 2 days after her birth. Abdominal CT revealed 4 high–concentration density calcifications in the dilated and sac–like segment of the intestine on the oral aspect of the anastomotic site. We suspected intra–intestinal fistula due to Meckel’s diverticulum or multiple intestinal tracts. Intraoperative exploration revealed a dilated segment of the intestine 50 cm oral to Bauhin valve. A saccular type of dilatation was observed at the site of the previous intestinal anastomosis performed for congenital small bowel stenosis, and this dilated part of the intestine contained four enteroliths measuring a few centimeters in diameter. We suggest that the usually incarcerated enterolith dropped every now and then into the intestine on the anal side of the bypass anastomosis, causing recurrent episodes of small bowel obstruction. The postoperative course was uneventful, and the patient was discharged on the 6th postoperative day. In this case, we believe that the enteroliths that gradually formed at the site of anastomosis were responsible for the recurrent episodes of small bowel obstruction. To the best of our knowledge, there are few reports of similar situations.

An 89–year–old woman with a history of epigastralgia and repeated vomiting was admitted to our facility. Computed tomography revealed that the transverse colon had prolapsed into the mediastinum from the abdominal cavity. We diagnosed the patient as having a hernia of Morgagni. The obstruction of the transverse colon was successfully treated by reduction of the herniated colon, followed by laparoscopic repair. After the hernia contents were repositioned into the abdominal cavity, we repaired the defect of the diaphragm with a mesh to achieve tension–free repair. The postoperative course was uneventful, and there has been no recurrence. Hernia of Morgagni is a rare type of diaphragmatic hernia. We consider that endoscopic reduction helps in avoiding emergency surgery, and a period of fasting before surgery and elective laparoscopic mesh repair is a simple and safe procedure for elderly patients.

The patient was an 81–year–old male in whom CT performed during a medical check–up revealed free air in the abdomen. Physical examination revealed no abnormalities, including signs of peritoneal irritation. Abdominal contrast–enhanced CT showed marked intraperitoneal free gas and intestinal emphysema, but no ascites. The patient was taking an α–glucosidase inhibitor and suffered from constipation. The α–glucosidase inhibitor was withdrawn and the patient was followed up for 1 month, however, the intestinal emphysema and intraperitoneal free gas persisted. We performed diagnostic laparoscopy and left inguinal hernia repair. The diagnostic laparoscopy showed intestinal emphysema, but there was no evidence of intestinal perforation. The intraperitoneal free gas and intestinal emphysema were no longer noted in a repeat CT performed 1 month after the surgery. We report a case of pneumatosis cystoides intestinalis (PCI) with intra–abdominal free air that underwent diagnostic laparoscopy and inguinal hernia repair.

A 40–year–old woman with severe aplastic anemia who was receiving immunosuppressive therapy presented with hematochezia. Small bowel endoscopy showed a hemangioma in the jejunum, which was considered as the source of bleeding. Conservative management was initially chosen. However, rebleeding occurred and we performed operation. Laparoscopic observation of the entire small intestine revealed a large Meckel’s diverticulum. Intraoperative endoscopy showed a blood pool around Meckel’s diverticulum, which led us to consider it as the source of bleeding, and we performed partial resection of the small intestine. There were no major postoperative complications. Patients with aplastic anemia are considered as being high–risk for surgery, because of their immunosuppressed state. However, minimally invasive surgery with strict perioperative management under life–threatening conditions could prove life–saving.

We report a case of laparoscopic surgery performed for a patient with an esophageal hiatal hernia associated with an upside–down stomach, caused by gastric volvulus, which is a rare disorder. The patient was an 86–year–old woman who presented with a history of epigastralgia developing frequently after a meal, which had worsened gradually over time. Computed tomography (CT) showed that the stomach had rotated and invaginated into the mediastinum. We diagnosed the patient as having esophageal hernia with an upside–down stomach, and urgently hospitalized. She vomited black blood, and fiberoptic upper gastrointestinal endoscopy revealed impairment of the blood supply to the gastric corpus mucosa. As endoscopic repositioning proved difficult, we performed laparoscopic surgery. The esophageal hiatus was repaired, and gastropexy and Toupet fundoplication were performed. This patient became symptom–free after the operation.

We report a case of invasive pneumococcal infection, presumably associated with immune dysfunction, in a case of splenic hypoplasia. The patient, a 46–year–old man, was brought to our hospital by ambulance with a history of dull abdominal pain, diarrhea and vomiting. His abdomen was soft, with only mild tenderness in the epigastric area. His body temperature was 40.5℃. Blood tests showed evidence of only mild inflammation. Abdominal computed tomography showed mild fluid collection in the stomach and intestinal tract. The patient was diagnosed as having acute gastroenteritis and was started on fluid replacement therapy after admission. However, about 12 hours after arrival, he suddenly went into septic shock and disseminated intravascular coagulation (DIC), and died. An autopsy determined the cause of death to be multiple organ failure due to DIC. Subsequently, a positive result of a blood culture for Streptococcus pneumoniae was reported, and the patient was diagnosed as having had invasive pneumococcal infection. Review of a CT examination performed at admission revealed a reduced spleen volume of 38.6 mL, indicating splenic hypoplasia.

A 73–year–old woman was admitted to our hospital complaining of acute abdominal pain. We diagnosed her as having extensive mesenteric ischemia and extreme coagulopathy induced by the oral dabigatran she was taking. Enterectomy and Hartmann procedure were performed as emergency operations. Serious coagulopathy and active bleeding persisted for two days after the surgery. Finally, the bleeding stopped, and the patient was discharged from our hospital on hospital day 45. Blood concentrations of dabigatran may increase significantly in some patients, for a variety of reasons, and these patients are at a high risk for developing hemorrhagic complications. Such patients may be treated with antagonists or by blood purification therapy. Doctors dealing with abdominal emergencies need to be aware of the adverse effects of dabigatran.

A 68–year–old man with a few days’ history of abdominal discomfort and impaired consciousness was transported to our emergency department. At the first examination, his consciousness was rated as GCS E1V1M1; his blood pressure was 77/58 mmHg, and pulse rate was 118 bpm. Abdominal CT showed enlargement of the pancreas and pneumoretroperitoneum. Emergency laparotomy was performed under the tentative diagnosis of severe acute pancreatitis or perforation of the alimentary tract. Intraoperatively, there was no evidence of perforation of the alimentary tract. The pancreas appeared enlarged. Fat necrosis of the pancreas and wine–red ascites around the pancreas were detected. Drainage of the fluid around the pancreas was performed, followed by drain tube management. The patient was discharged from the hospital on day 73. It is extremely rare for acute pancreatitis to cause extensive pneumoretroperitoneum.

A 77–year–old man presented to our emergency department with acute abdominal pain. Abdominal computed tomography (CT) showed volvulus of the mesentery and a closed loop sign of the sigmoid colon. Emergency surgery was performed to release the small intestine and sigmoid colon. We found a 180–degree torsion of the small intestine with sigmoid colon strangulation and impaction near Treitz ligament. There was no necrosis of the intestine, so that the surgery involved only repositioning. Because of the absence of adhesions, bands, and malformations, we made the final diagnosis of primary volvulus of the small intestine with strangulated obstruction of the sigmoid colon. Primary volvulus of the small intestine is relatively rare in adults in Japan. In particular, such a condition complicated by strangulated obstruction of the sigmoid colon is even rarer, and we report this case with a review of some relevant literature.

A 57–year–old man with a history of atrial fibrillation under treatment with warfarin, had a habit of inserting a tubular rod about 30 cm long into his anus during masturbation; he called the emergency medical service after 2 days of progressively worsening lower abdominal pain that began a day after he masturbated using the rod, and was transported to our hospital. On arrival, he was in a shock state, with a systolic pressure of 40 mmHg measured by palpation. His hemodynamic status improved with rapid fluid infusion. Abdominal CT revealed a large amount of abdominal fluid within and adjacent to the mesentery near the rectal Rs portion, but there was no evidence of intraperitoneal free air. From the history, we diagnosed the patient as having developed rectal and mesenteric injury and intraabdominal hemorrhage caused by the tubular rod that he had inserted into his anus. We performed segmental resection of the rectum and colostomy, and succeeded in saving the patient. Transanal insertion of foreign bodies can cause hemorrhagic shock with intraabdominal hemorrhage, and timely diagnosis and treatment with proper history taking is essential.

A 65–year–old man who was admitted to our hospital with sudden severe pain in the lower right abdomen. Abdominal contrast–enhanced computed tomography revealed wall thickening and obstruction of the ileum near the ileocecal region. Conservative treatment was started, but without any improvement, and on the 9th day of hospitalization, we performed partial ileal resection. Wall thickening and severe stenosis were observed in the ileum 20 cm orally from the terminal ileum. Histopathology revealed no specific findings other than mucosal shredding and inflammatory cell infiltration with severe fibrosis. Therefore, the patient was diagnosed as having a simple ulcer of the small intestine. The postoperative course was uneventful and the patient was discharged on the 13th day of hospitalization. Thereafter, he had no relapse. A simple ulcer of the small intestine is relatively rare, and its preoperative diagnosis is frequently difficult. Thus, we report our experience of a patient with a simple ulcer presenting with intestinal obstruction, along with a review of the relevant literature.

Fournier gangrene commonly occurs as a complication of anal fistula, perianal abscess, and urological diseases, and there are few reports of patients developing Fournier gangrene as a complication of rectal cancer. Herein, we report a case of Fournier gangrene encountered by us that was caused by penetrating throughout rectal cancer. The patient was a 70s male who visited a nearby hospital with a history of fever and right lower abdominal pain. He was diagnosed by abdominal CT as having penetrating rectal cancer, and colostomy was performed. The patient was subsequently referred to our hospital due to insufficient improvement of the inflammation. He was diagnosed as having Fournier gangrene caused by penetrating rectal cancer, and urgent debridement was performed. After repeated cleaning and debridement, the inflammatory reaction improved. Due to severe leakage of albumin from the site of debridement, leg amputation was necessary to secure hemodynamic stability. Systemic chemotherapy was administered for pulmonary metastasis that had been diagnosed before the surgery, but the patient died 8 months after the surgery.

A 47–year–old woman with a history of lower right abdominal pain and fever was admitted to our hospital. Physical examination revealed slight tenderness of the right flank. In addition to slight increases of the inflammatory reactants detected on blood examination, abdominal contrast–enhanced computed tomography (CT) revealed an enlarged appendix and surrounding panniculitis, based on which we made the diagnosis of acute appendicitis. The patient was referred to our department and emergency laparoscopic appendectomy was performed. The histopathological diagnosis was low–grade appendiceal mucinous neoplasm (LAMN). LAMNs are clinically malignant tumors that can cause pseudomyxoma peritonei. There are no therapeutic guidelines for LAMNs. We report a case of LAMN in which no cystic lesions could be identified on CT and preoperative diagnosis was difficult; we present the case with a review of the relevant literature.

Incarcerated obturator hernias are most frequently seen in thin elderly women, and the main modality of treatment is surgery. Although various surgical procedures have been reported, no standard method has been established yet. We report a case of incarcerated obturator hernia in which we performed laparoscopic reduction by the water pressure method and high ligation of the hernia sac. An 86–year–old woman was referred to our hospital complaining of right femoral pain of a few hours’ duration. Abdominal and pelvic CT revealed a right incarcerated obturator hernia and an emergency operation was performed via a laparoscopic transabdominal approach. After the incarcerated small bowel was reduced by the water pressure method, the hernia sac was closed by high ligation. The patient had a good postoperative course and was discharged from the hospital on day 10 after the surgery. This method seems to be a simple and beneficial procedure and could be the treatment of first choice for emergency surgery.