Introduction: Since April 2016, almost all of laparoscopic anatomical liver resection (LALR) has been designated as treatment in addition to left lateral sectionectomy in Japanese insurance system. In our hospital, we treated 35 cases with pure LALR from April 2016 to March 2017. We evaluated our techniques for LALR and compared the perioperative outcomes between LALR and the open anatomical liver resection (OAOR).

Patients and methods: This study consisted of all the 35 cases who underwent LALR and 64 cases who underwent OAOR against the similar indication as LALR from April 2014 to March 2017.

Results: There were no conversions from LALR to open surgery. The proportion of diseases was significantly different between LALR group and Open group (p=0.042). No other significant differences were found in the patient characteristics. LALR group had longer operation time (352 vs 296 minutes; p=0.029), less blood loss (150 vs 853 ml; p<0.001), and shorter postoperative hospital stay (8 vs 10 days; p<0.001). We experienced no severe complications and mortality after LALR.

Conclusions: LALR is safe, less invasive, and a useful option in well-selected patients, and it can become even standard.

The patient, a 62-year-old woman, had been diagnosed as having human epidermal growth factor receptor 2 (HER2) type breast cancer and treated by mastectomy at 49 years of age. For treatment of a metastatic skin tumor detected 10 months after the surgery, the patient was started on trastuzumab-based chemotherapy with sequential regimen changes, and lapatinib＋capecitabine therapy. After the 5th postoperative year, the patient developed disease progression, with metastases in the contralateral, formerly unaffected breast and lung. The response to treatment with pertuzumab＋trastuzumab＋paclitaxel was rather transient, and rapid exacerbation occurred following trastuzumab emtansine (T-DM1) treatment. However, reinstitution of lapatinib＋capecitabine therapy resulted in effective disease control, and subsequent resumption of pertuzumab＋trastuzumab-based chemotherapy led to near-complete resolution of the cutaneous and breast metastases, while the lung tumor enlarged slightly. Expression of the HER2 extracellular domain (ECD), which had been elevated, normalized after resection of the lung tumor. Thereafter, the patient has shown sustained complete response (CR). The expression status of HER2 ECD and HER2 in the metastatic lesions was examined in an attempt to determine the mechanism of resistance to T-DM1. The results revealed that the metastatic lesions were actively HER2 shedding tumors, possibly explaining the greater efficacy of the tyrosine kinase-inhibitor lapatinib than of the anti-HER2 antibody drugs in this case.

The present case involved a 44-year-old female who presented with a chief complaint of swelling in the left breast. A mass of >10 cm in diameter and skin erythema were confirmed in the left breast, which showed had partial ulceration with exudate. We performed a core needle biopsy and diagnosed an invasive triple-negative carcinoma accordingly. Chemotherapy for a locally advanced left breast cancer, T4bN3M0 Stage Ⅲc, was initiated. After three courses of EC, erythema had faded and the mass had slightly decreased in size; however, the mass rapidly regrew over the next week; therefore, the scheduled fourth course of chemotherapy was not implemented in that week. Despite a switch to DTX-based chemotherapy, the case progressed to PD. On CT scan, the mass was observed to decrease in size during EC and then to regrow and invade the thoracic wall without lymphadenopathy or metastasis to other organ including the lung or the liver. Therefore, in an attempt at curative resection, we performed radical left mastectomy, partial thoracic wall resection, and latissimus dorsi myocutaneous flap reconstruction. The postoperative course was good, and the left thoracic wall was treated with radiation. When chemotherapy is ineffective for locally advanced breast cancer, localized disease control is particularly important. Patient condition must be monitored closely to ensure that the timing window for resection is not missed and the patient is adequately prepared for surgery.

A 67-year-old woman had experienced intermittent vomiting. She was admitted to our hospital because the symptom did not improve. An upper gastrointestinal barium study, computed tomography and gastrointestinal endoscopy showed esophageal hiatal hernia through which a large part of the gastric body herniated into the mediastinum. Therefore, we diagnosed upside down stomach with gastric volvulus in a mesenteroaxial form. Attempts at endoscopic repair failed to reduce the stomach, and laparoscopic surgery was performed.

The enlarged esophageal hiatus was sutured with a mesh reinforcement, and Toupet fundoplication was performed as an antireflux procedure. The postoperative course was uneventful, and the patient was discharged on the postoperative day 14. Recently we sometimes encounter cases of upside down stomach in the literature, but this disease is rare and only 41 cases have been reported in Japan. We herein report such a case successfully treated by laparoscopic surgery.

A 66-year-old woman suffering from hepatitis C virus related chronic hepatitis, rheumatoid arthritis, and diabetes mellitus was admitted to our hospital. She had been on oral glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs) for four years. Serum AFP levels were elevated and a complete checkup was conducted. She was diagnosed with hepatocellular carcinoma in segment 2 of the liver (T2N0M0 Stage Ⅱ) and gastric cancer at the antrum of the stomach (T1bN0M0 Stage ⅠA). She underwent laparoscopic lateral segmentectomy of the liver and distal gastrectomy with Roux-en-Y anastomosis. She developed an ulcer perforation at the anterior wall of the remnant stomach on postoperative day (POD) 19 and underwent emergency closure of ulcer under laparoscopy. Nine days after the repeat surgery, she developed bleeding from a staple line of the Y-limb, and endoscopic hemostasis using clips was performed. Next day, she developed bleeding from the closure point of the end of jejunum, and endoscopic hemostasis by clips was performed again. A combination of glucocorticoids and NSAIDs may cause gastric ulcer and anastomotic bleeding after gastrectomy due to the delay of mucosal healing.

We report herein a case of laparoscopic ileocecal resection for an ileocecal abscess due to Crohnʼs disease complicated with severe motor and intellectual disabilities. A 23-year-old woman was admitted to a nursing home because of cerebral palsy and mental retardation. Because of lack of activity from 1 month ago, she visited a nearby doctor. She was diagnosed with suspected intussusception and introduced to our hospital. At the time of admission, abdominal contrasted CT examination showed thickening of the wall from the terminal ileum to the ascending colon, and findings suspected of abscess formation in the ileal mesentery. Laparoscopic ileocecal resection was performed after infection control by conservative treatment for intraperitoneal abscess. Macroscopic findings of the excised specimen showed a longitudinal ulcer and fistulization, while histological findings revealed full thickness inflammation and epithelioid granuloma, resulting in a diagnosis of Crohnʼs disease. Early diagnosis of the intraperitoneal abscess was difficult because she was a patient with severe motor and intellectual disabilities who had difficulty communicating, and diagnosis findings were unclear. Laparoscopic surgery superior in minimally invasive and well-tolerable was possible by preceding infection control by conservative treatment.

We encountered 2 patients with diarrheal irritable bowel syndrome (IBS) refractory to general treatment, who experienced improvement of diarrheal IBS symptoms following appendectomy for appendicitis. Case 1 was a 47-year-old male patient with primarily diarrheal IBS who complained of approximately 10 watery bowel movements per day, on average. The chief complaint was epigastric pain. Under a diagnosis of acute appendicitis, laparoscopic appendectomy was performed. Following the surgery, the patient showed marked improvement of the IBS-related symptoms, with 1 to 2 ordinary bowel movement(s) per day. Case 2 was a 42-year-old female patient with diarrheal IBS complaining approximately 3 loose or watery bowel movements per day, on average, along with epigastric pain. The chief complaint was lower right quadrant abdominal pain. With a diagnosis of acute appendicitis, laparoscopic appendectomy was performed. Following the surgery, the patient showed marked improvement of the IBS-related symptoms, with one ordinary bowel movement every other day. We report these cases with some bibliographic considerations, as a thorough search conducted by us of the literature published in the website of the Japan Medical Abstracts Society failed to reveal any case reports of improvement of diarrheal IBS symptoms following appendectomy.

We report 2 patients with intramesenteric penetration of colon diverticulitis. Patient 1 was a 52-year old male. He visited our hospital with chief complaints of hypogastrium pain and fever. His physical finding revealed rebound tenderness of lower abdomen. Judged from abdominal CT showing intramesenteric air of sigmoid colon, he was diagnosed as intramesenteric penetration of sigmoid colon diverticulitis. First, we performed conservative therapy, considering peritonitis was localized and the hemodynamics was stable. On 17^th day after admission, his clinical symptom got worse and abdominal CT showed enlarged abscess including air in mesentery of sigmoid colon. We conducted Hartmann’s operation. Intramesenteric penetration of sigmoid colon was recognized from the removed specimens. Patient 2 was a 55-year old female. She visited our hospital with a chief complaint of hypogastrium pain. Her physical finding showed rebound tenderness of lower abdomen, and abdominal CT revealed a low density area including air bubble in mesenterium of sigmoid colon and rectosigmoid colon. We emergently performed Hartmann’s operation on diagnosis of intramesenteric penetration of sigmoid colon diverticulitis. We identified intramesenteric penetration of rectosigmoid colon and extensive abscess extending from subserosa to muscularis propria on the resected specimens.

We report a case of descending colon cancer (CRC) presented with multiple liver abscesses (MLA) in bilateral lobes. A 68-year old female had been transferred to our hospital on diagnosis of descending CRC with MLA. Enhanced-contrast abdominal CT showed multiple homogeneous low density areas (LDAs) in right hepatic lobe of liver and a heterogeneous LDA in lateral segment of liver. The treatment with antibiotics and percutaneous transhepatic abscess drainage was performed. Histological and cytological examinations in LDAs of liver revealed no malignancy. After the inflammatory reaction disappeared, she underwent laparoscopic partial colectomy to descending CRC on 57^th day after initial admission. The pathological diagnosis was D, Type 1, 25×20 mm, tub2, pT3, pN0, sH0, sM0, sPUL0, PN0, ly1, v1, pStage Ⅱ. On 6 months after operation, MLA disappeared, but a solitary metastatic lesion emerged in anterosuperior segment of right lobe of liver. She has been treated with chemotherapy. In a case of CRC with MLA, there is a possibility that MLA may disappear by radical surgery of CRC, which proposes radical surgery of CRC following improvement inflammatory reaction of MLA should be indicated with differentiation between MLA and hepatic metastasis strictly considered.

The patient was a 65-year-old man. Three years previously, he consulted his local physician for a chief complaint of bloody stools. On lower gastrointestinal endoscopy, an easily bleeding elevated lesion with an irregular surface was found approximately 25 cm from the anal verge, and on biopsy, the results revealed group 5 and tub 2. Sigmoidectomy (D3) was performed. Pathohistological examination results revealed pT2 (MP), pN0, pStage Ⅰ, tub 2, ly0, and v0. After discharge from the hospital, he was regularly followed up on an outpatient basis. On imaging performed 6 months thereafter, a metastatic liver tumor was noted and right lobectomy was performed. Furthermore, on diagnostic imaging performed 1 year after the hepatectomy, a metastatic tumor was found in the caudate lobe, and caudate lobectomy was performed. He experienced reduced vision of the left eye and complained of blurred vision during regular examinations performed approximately 6 months after the second hepatectomy. Therefore, he was referred to the ophthalmology department of our hospital for further examination. The visual acuity of his left eye was found to have decreased from 1.0 to 0.05. On close examination, left choroidal metastasis of the sigmoid colon cancer was diagnosed as part of the clinical course.

We herein report the case of a 59-year-old male in whom hepatocellular carcinoma (HCC) and hepatic angiomyolipoma (AML) were simultaneously found in liver without B or C hepatitis. Six years after resection of thyroid cancer, abdominal enhanced CT showed highly enhanced lesions in liver S1, S7, S4 and S3 subsegment during arterial phase. S1 tumor remained the enhancement at the equilibrium phase. On the other hand, the other tumors diminished the enhancement at the equilibrium phase. HCC was pathologically diagnosed by the needle biopsy of S7 tumor. HBV and HCV marker were negative. Under the suspect of multiple HCCs in fatty liver, we planned extended right hepatectomy plus S3 partial hepatectomy. Since the future remnant liver was small, interventional radiologic chemotherapy followed by percutaneous transhepatic portal embolization were performed. After confirming growth of the future remnant liver and tumor control, the above-mentioned hepatectomies were performed. S1 tumor was pathologically proved to be AML on the basis of the typical histological characteristics and immunohistochemical staining, while S7 tumor was moderately differentiated HCC. In lesions of S3 and S4, HCC cells were not found. When hypervascular mass is found in hepatitic liver, AML as well as HCC must be taken into consideration.

A 68-year-old woman with a positive fecal occult blood test and Type Ⅱ lesion observed on colonoscopy, underwent a biopsy revealing adenocarcinoma (tub1). She was diagnosed as having cecal cancer and underwent laparoscopic ileocecal resection. Her postoperative course was uneventful, and she was dischargeed on the sixth postoperative day. Two months after surgery, she visited the emergency department with fever. An abdominal computed tomography (CT) scan revealed a mosaic low density area in liver segments 6, 7 and 8, and she was diagnosed as having a liver abscess. She was urgently admitted to the hospital on the same day and antibiotic treatment initiated. Because she did not improve, percutaneous transhepatic abscess drainage (PTAD) was performed twice. A culture of the abscess fluid grew Klebsiella pneumoniae. After PTAD, her pyrexia resolved and inflammatory reaction subsided. On the 11th day after draining the abscess, the drain was removed, and she was discharged on the 16th day post-PTAD. Liver abscess secondary to colorectal cancer occurs due to celozoic bacterial infection transmitted to the liver via the portal vein, due to destruction of the intestinal wall by the tumor. In addition to decreased immunity due to the malignancy, systemic factors, viz., old age, and diabetes are likely causes. In this case, the patient had no prior medical history, a stable preoperative systemic condition, and no postoperative complications. We report a rare case of a patient, who developed a liver abscess after laparoscopic ileocecal resection.

We experienced a case of bilobular spontaneous biloma associated with acalculous cholecystitis. Pt: A 84-year-old woman with Right hypochondralgia. We diagnosed her as acalculous cholecystitis and S6 liver cyst by blood examination and CT. Cholecystitis was relieved and S6 cyst reduced by antibiotics medication, however, a new cystic lesion appeared at the other side of the liver (left lobe). As cystic lesions were suspected bilomas, chelecystectomy and drainage of the bilom was done. We tabulated 46 reports of the spontaneous biloma and described its characteristics.

A 31-year-old woman suspected the presence of a left upper abdominal tumor after the delivery of her second child. The tumor was identified to be a mucinous cystic neoplasm (MCN) after abdominal ultrasonography, computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. She underwent distal pancreatectomy with splenectomy. Pathological examination of the resected specimen revealed that the tumor was a mucinous cystic adenoma. There is no evidence of tumor recurrence two years after the surgery. Examination of her past reports revealed that MCN associated with pregnancy and childbirth has a larger diameter, is more metastatic, and has a higher risk of rupture than the usual MCN. Laparotomy was considered to be appropriate because of the risk of mucus leakage into the peritoneal cavity. When malignancy is suspected in early pregnancy, surgical resection of the tumor is considered to be suitable at mid-term or after abortion. When the tumor is benign, surgical resection is considered to be suitable at mid-term or after childbirth.

Renal cell carcinoma (RCC) is well known for its propensity to metastasize to various organs，but gallbladder (GB) metastasis from RCC is extremely rare.

A 58-year-old woman underwent radical left nephrectomy for RCC. Three years later, she developed cholecystitis. Abdominal CT showed hyperdense enhanced 24mm tumor at the fundus of the GB. GB carcinoma accompanied by acute cholecystitis was suspected by enhanced CT. We perfomed cholecystectomy and intraoperative pathological examination showed GB cancer within mucosal layer. By final histopathological examination, the tumor indicated clear cell carcinoma and was diagnosed as metastasis to the GB from RCC.

There are 25 cases of solitary asynchronous metastasis from RCC to the GB. 4 cases of those was diagnosed GB metastasis from RCC accompanied by acute cholecystitis.

We report a case of malignant lymphoma discovered during treatment of superior mesenteric vein thrombosis (SMVT). A 56-year-old man was admitted to our hospital because of upper abdominal pain. No signs of peritoneal irritation were found. Computed tomography (CT) revealed a SMVT but no findings of intestinal ischemia. The symptoms improved with anticoagulation therapy. Without thrombus extension on the follow-up CT, the patient was discharged on the 11th hospital day. Warfarin therapy was continued because the antithrombin Ⅲ level was decreased on admission.

However, pain in the right side of the abdomen developed 1 month after discharge. CT revealed systemic lymphadenopathy, and the patient was readmitted to the hospital. The patient was diagnosed as having a malignant lymphoma by using inguinal lymph node biopsy. Although chemotherapy was performed, the patient died 45 days after readmission. In this case, malignant lymphoma was thought to have an influence on the development of SMVT.

Identifying the causative disease is mandatory in parallel with the treatment of SMVT. Though rare, malignant lymphoma should be considered as a possible cause of SMVT.

A 17-year-old male was admitted to our hospital with the chief complaint of pain in the right lower quadrant abdomen. Physical examination revealed hard tenderness in the right lower quadrant. His body temperature was 38.8°C. Laboratory test results showed a white blood cell count of 14,830 cells/µL and a C-reactive protein level of 0.23 mg/dL. Computed tomography (CT) revealed inflammatory changes and some swollen lymph nodes around the ileocecal region, but not the typical findings of acute appendicitis. We suspected mesenteric lymphadenitis and administered antibiotics to the patient. However, no improvement in clinical findings was observed the next day. With the suspicion of acute appendicitis, we decided to perform an emergency appendectomy. However, intraoperative findings did not show typical findings of acute appendicitis. Pathological findings indicated secondary appendicitis. 5 days after operation, physical findings worsened, and tenderness and rebound tenderness in the right lower quadrant were noted. CT revealed an intraperitoneal abscess. A diagnosis of mesenteric lymph node abscess was confirmed; percutaneous abscess drainage was performed and the antibiotic was changed. The patient was discharged 20 days after hospitalization. This case illustrated the difficulty in distinguishing between acute appendicitis and a rare mesenteric lymph node abscess. Here, we report our experience in treating a patient with a mesenteric lymph node abscess.

We present the case of a patient who underwent laparoscopic resection of a primary torsion of the greater omentum diagnosed via preoperative computed tomography (CT) scan. This 66-year-old male presented with complaints of epigastric abdominal pain, localized to the right lower region. His blood test showed a slightly increased white blood cell count, elevated human C reactive protein (CRP), and elevated indirect bilirubin. Abdominal CT scan showed a volute shape, which was a concentrically layered structure with mixed high and low densities in the upper right umbilical region. We diagnosed his illness as primary torsion of the greater omentum and performed partial laparoscopic omentectomy, including the necrotic portion. We discharged the patient on postoperative day 5. Laparoscopic surgery may be favorable for this disease because definitive diagnosis and treatment can be performed simultaneously, in a less invasive and safe manner.

70 years old male was followed up for chronic pancreatitis. However, on CT examination, dialation of the main pancreatic duct was observed. He was diagnosed as IPMN. After further examination, the pylorus-preserving pancreaticoduodenectomy was performed. On histopathology, IPMC was diagnosed. After the resection, he received gemcitabine and S-1 chemotherapy. At 24 months after the resection, lung nodule was observed on chest CT examination. The lung nodule gradually increased in size. On 38 months, lung resection was performed. Histological examination revealed that the lung nodule mostly resembled pancreatic IPMC. Therefore the diagnosis was lung metastasis of pancreatic IPMC. 16 months after lung resection, the patient was well, without any signs of recurrence.

A 33-year-old woman with a mass adjacent to the pancreas was referred to our hospital. Computed tomography demonstrated an oval shaped tumor dorsal to the pancreas, which was 4.7cm in diameter. The tumor had a small area of calcification, and faintly enhanced. We planned to perform laparoscopic distal pancreatectomy under the preoperative diagnosis of solid pseudopapillary neoplasm of the pancreas. Intraoperatively, the tumor was easily separated from the pancreas and existed in the retroperitoneum, so we resected the tumor under laparoscopy. Histological diagnosis was schwannoma. We safely performed laparoscopic resection of retroperitoneal schwannoma mimicking pancreatic tumor. This surgical procedure may be useful for resection of a benign or low-grade malignant retroperitoneal tumor.

The patient was a 63-year-old woman who consulted a local physician because of heartburn. Ultrasonography, contrast-enhanced computed tomography, and magnetic resonance imaging of the abdomen showed an intra-abdominal mass about 40 mm in diameter adjacent to the intestine. No distinct feeding vessels could be identified. Close examination of the upper and lower gastrointestinal tract showed no abnormalities. The mass was laparoscopically resected for the purpose of diagnosis and treatment. The mass was located in the omentum proximal to the transverse colon and was mobile, with no invasion of the gastrointestinal tract or other organs. An omental tumor was diagnosed. Immunohistochemically, the mass was negative for c-kit, CD34, and S-100 and positive for vimentin and desmin, with an MIB-1 index of ≤1%. A leiomyoma of the omentum was thus diagnosed. If an intra-abdominal mass is found incidentally, leiomyoma should be considered in the differential diagnosis. Because it is difficult to make a definitive diagnosis before surgery, laparoscopic surgery, which permits minimally invasive observation and resection, is useful.

A 27-year-old man with no surgical history visited a local clinic on 3 different occasions for intestinal obstruction. The cause was unclear, thus he was referred to our hospital. Double-ballon enteroscopy revealed a bidirectional lumen in the small bowel and Meckelʼs diverticulum was suspected to be the cause of obstruction, and he was sent to our department for surgery. During the operation, an adhesion of the apex of Meckelʼs diverticulum with the adjacent ileum was found, which formed a loop and caused an internal hernia. Diverticulum resection and stricture plasty were performed, and the obstruction was diagnosed as being caused by inflammatory adhesion of Meckelʼs diverticulum. Histopathological examination findings showed Meckelʼs diverticulum without ectopic composition, such as gastric or pancreas mucosa. The postoperative course was stable and intestinal obstruction has not recurred.

Amyandʼs hernia is a rare case of inguinal hernia which involves herniation of the appendix. We report an extremely rare condition of Amyandʼs hernia which protruded through the internal supravesical fossa. A female in her mid-twenties, who had a history of acute appendicitis treated with an antibiotics 6 months ago, had suffered from right lower quadrant pain and a groin mass for a month. The groin mass had already diminished spontaneously on the initial visit of our hospital, but computed tomography revealed an inflamed appendix with appendiceal abscess located in the internal supravesical fossa. Laparoscopy operation was performed for chronic appendicitis concomitant with abdominal wall abscess. We recognized that an inflamed appendix was incarcerated in the hernia orifice of supravesical fossa. Partial resection of the cecum was performed by using a stapling device and incarcerated appendix was removed. The tension-free prosthesis repair was not employed due to the risk of infection and the drainage tube was placed. Post-operative course was uneventful and recurrent inguinal hernia has not been encountered with 12 months after surgery. Laparoscopic surgery is thought to be useful for the diagnosis of Amyandʼs hernia and has an advantage in the surgical approach for incarcerated appendix.

A 70ʼs man visited our outpatient clinic for painless bulging in the left groin and right lateral abdomen. The patient was diagnosed with a left inguinal hernia with an orifice size of 1.5 finger widths and a Spigelian hernia with an orifice size of 1 finger width. As there was no sign of incarceration, the patient was scheduled for elective surgery. Transabdominal preperitoneal (TAPP) repair was selected to treat the two lesions in one stage. A camera port was inserted in the umbilical area. Intraperitoneal observation revealed a left direct inguinal hernia, a right Spigelian hernia, and another left Spigelian hernia that had not been identified preoperatively. The TAPP method was performed for the groin hernia on schedule. Direct closure of the hernia orifices was performed for both Spigelian hernias because the orifices were small. The postoperative course was favorable, and the patient was discharged on postoperative day 4. A Spigelian hernia is a relatively rare abdominal wall hernia. In this case, laparoscopic observation enabled us to identify and treat a hernia that had not been diagnosed preoperatively. This case highlights the significance of intraperitoneal observation during laparoscopic surgery, and we report the case with a literature review.

A 77-year-old man was urgently admitted to the hospital with complaints of abdominal pain and vomiting. Abdominal X-ray and CT revealed intestinal obstruction. At first, conservation therapy using an ileus tube was performed because of no ischemic change of the small intestine. The symptoms and intestinal expansion improved, but CT and upper gastrointestinal series showed persistent intussusception. Therefore, laparoscopic surgery was performed. Intraoperative findings showed a cord-like structure extending from the mesentery of the ileum, 50 cm proximal to the Bauhinʼs valve and adhering to the left medial umbilical fold. We considered the cord to be vitelline vascular remnants because of the running and macroscopic findings. We examined the small intestine, but there was no evidence of Meckelʼs diverticulum. We report this very rare case with some literature reviews.

The patient was a 90-year-old elderly woman with dementia but no known history of esophageal hiatal hernia. The patient suffered abdominal pain when she vomited after eating lunch one day, and an emergency request was received from a visiting nurse, who sent the the patient to our hospital for emergency care. An abdominal contrast CT revealed that the stomach was escaping into the mediastinum and showed a stomach wall defect as well as mediastinal emphysema. Because there was no obvious penetration into the thoracic cavity, an emergency laparotomy was performed. When the stomach –which had invaded the mediastinum –was returned to the abdominal cavity side, a perforation 2.5×1.5cm was found in the front wall of the upper part of the stomach. The esophageal hiatus had opened with three lateral fingers. After releasing the fundus section of the stomach and suturing and closing the perforation, the esophageal hiatus hernia was repaired using the Nissen method. The postoperative course was good.