【Introduction】In palliative stoma creation, it is important to reduce surgical invasiveness and maintain the patientʼs quality of life (QOL). We evaluated the feasibility of single-incision laparoscopic stoma construction for locally advanced colorectal cancer.

【Materials and methods】Between 2007 and 2014, we performed 49 palliative colostomies or ileostomies for locally advanced colorectal cancer with primary tumor-related symptoms. These were divided into two groups: the single-incisional laparoscopic surgery group (S group, n=22) and the open surgery group (O group, n=27). We retrospectively evaluated clinical data from these two groups.

【Results】The median operating time was significantly different between the two groups (S: 92min, O: 142min, p<0.01). The median incisional length, except at the stoma site, differed between the two groups (S: 0mm, O: 150mm, p<0.01). The levels of CRP on 1POD and 7POD were significantly lower in the S group (1POD: p<0.01, 7POD: p=0.05, respectively). The rate of stoma-related complications was significantly lower in the S group (S: 0％, O: 18.5％).

【Conclusion】In palliative stoma construction, single-incisional laparoscopic surgery may contribute toward maintaining the QOL of patients with cancer.

Introduction: We report our experience with transumbilical single-incision laparoscopic intragastric resection for gastric submucosal tumor located at the upper third of the stomach.

Patients and Methods: During recent 2 years, we performed above procedure in 4 patients. The mean age was 66 years. There were 3 males and one female. Initially, single-incision with gastrotomy was made at the umbilicus. Partial resection including the tumor was performed using a linear stapler. The resected specimen was directly retrieved from the umbilical incision.

Results: Laparoscopic intragastric resection was successful completed in all patients. The mean operation time and blood loss were 101.7min and 8ml. One patient was seen a postoperative intragastric bleeding form the stapled line with a successful endoscopic hemostasis. The mean postoperative hospital stay was 8 days. The mean maximum tumor diameter of resected specimen was 32mm. The pathological findings were gastrointestinal stromal tumor in 3 patients and leiomyoma in one, respectively. There were no recurrences or metastases during a mean follow-up period of 17.5 months.

Conclusion: Transumbilical single-incision laparoscopic intragastric resection is feasible and safe with careful procedures for bleedings from gastric mucosa or staple line.

Introduction: Since April 2016, laparoscopic anatomical liver resection has been designated as treatment in the Japanese insurance system. Laparoscopic right anterior sectionectomy (Lap-RAS) is one of the most technically difficult procedures among the laparoscopic anatomical liver resections. In our hospital, we standardized the Lap-RAS procedure making use of the benefit of the laparoscopic view. In this study, we evaluated our techniques for Lap-RAS and compared the perioperative outcomes between Lap-RAS and the open right anterior sectionectomy (Open-RAS).

Patients and methods: From April 2016 to May 2017, Lap-RAS was performed in 6 patients (Lap-group). Open-RAS was performed in 10 patients from April 2014 to May 2017 (Open-group). This study retrospectively compared the short-term outcomes of the Lap-group with those of the Open-group.

Results: There were no conversions from Lap-RAS to open surgery. No significant differences were found in the patient characteristics. The Lap-group had significantly less blood loss (70.5ml vs 753ml; p=0.011). There were no significant differences in the other perioperative outcomes including operation time, morbidity, and mortality between the Lap-group and the Open-group. We experienced no severe complications and mortality after Lap-RAS.

Conclusions: Our procedure for Lap-RAS is safe and useful in well-selected patients.

The patient was a 55-year female, who visited our hospital with the chief complaints of abdominal pain and nausea. Abdominal CT scan revealed localized thickening of the small intestinal wall with intestinal obstruction, and she was hospitalized. Although double-balloon enteroscopy revealed stenotic lesions in the small intestine, biopsy of the lesions showed no findings suggestive of malignancy. Therefore, for the purposes of diagnosis and treatment, laparoscopic partial resection of the small intestine was performed. Histopathological examination was suspected metastatic lesion, since the patient had a history of breast cancer 14 years ago. Immunostaining was performed, which revealed CK7 (+), CK20 (-), ER (+) and E-cadherin (-), suggesting the possibility of small intestinal metastasis from the primary breast cancer. The findings in the resected small intestinal segment and resected breast cancer specimen were similar; therefore, a final diagnosis of small intestinal metastasis from the breast cancer (invasive lobular carcinoma) was made. Since gastrointestinal metastasis has been reported as one of the rare metastatic patterns in cases of invasive lobular carcinoma, our case underscores the necessity of bearing in mind the possibility of metastasis in patients with a history of breast cancer presenting with cancerous lesions of the gastrointestinal tract.

We describe a case of squamous cell carcinoma of the lung with invasion of the esophagus treated by radical en bloc resection as salvage surgery. Chest computed tomography showed a 46-mm tumor and a 25-mm subcarinal lymph node invading the esophagus. After three cycles of chemotherapy with cisplatin plus vinorelbine, the bronchoscopic findings revealed that the hemorrhagic tumor had progressed, and hemoptysis, cough and dysphagia were getting worse and proving very bothersome to the patient. To resolve his symptoms, we performed left pneumonectomy with esophageal resection and reconstruction. The esophagus was reconstructed via a posterior mediastinal route to use the greater omentum for coverage of the stump of the left main bronchus and the anastomosis of the reconstructed esophagus. Although he died of metastatic lung and brain tumors 18 months after the surgery, he was doing well more than one year after the operation. In addition, improvement of the respiratory and digestive symptoms was also achieved with complete resection.

The patient was a 9-year-old boy who admitted the hospital for persistent vomiting, growing abdominal pain and distention. An upper gastrointestinal study showed mesenteroaxial gastric volvulus and complete obstruction. We underwent emergency laparotomy for diagnosis of acute gastric volvulus. Operative findings showed mesenteroaxial volvulus and the lower part of gastric corps wall damage, and we performed releasing the volvulus and resection of damaged part of the gastric wall. The surgical specimen showed mucosal injury in its end. On the 4^th day after the operation, he felt the perforation of upper part of the gastric corps and necessary to resection of the necrotic part. Acute gastric volvulus is an acute abdomen with complete obstruction of the stomach. Prompt diagnosis is necessary to sudden onset of persistent emesis, nonbilious vomiting, and abdominal pain keeping acute gastric volvulus in mind. If obtain the diagnosis of that, we should take the surgical treatment into consideration. When necessary to resection of the damaged part of the stomach, we have to take fully surgical margin to avoid delayed-onset gastric perforation.

A 66-years-old woman with cerebral palsy was admitted to our hospital as an emergency, with complaints of abdominal pain and vomiting after waking up. She was treated by laparoscopic gastropexy 3 years ago for a diagnosis of gastric dilation and mesenteroaxial volvulus. Nevertheless, the condition recurred twice postoperatively, and the endoscopic reduction was undertaken each time. Abdominal CT on arrival and emergency endoscopy suggested acute gastric dilation and duodenal volvulus, and she underwent endoscopic reduction. Her symptoms were relieved temporarily, but complained of abdominal pain and vomiting recurred after starting oral intake. She underwent laparoscopy-assisted gastrojejunal bypass and gastrostomy as quasi-emergency, with a diagnosis of mesenteroaxial gastric volvulus. Her postoperative course was uneventful, and she was discharged on 21st postoperative day. Although reports as gastric volvulus treated by gastrostomy have been found, those treated by gastrojejunal bypass has not been reported to our knowledge. Because of gastric motor disorder, gastrojejunal bypass may be effective for gastric volvulus in patients with intractable neurological disease such as cerebral palsy.

The patient was a 75 year-old man. Laparoscopy-assisted proximal gastrectomy and D1+ lymph node dissection were performed for gastric cancer. The histopathological examination results were U, post,Type0-Ⅱc, 20×15mm, tub2-tub1> por2, pT4a, int, INFb, ly2, v3, pN0(0/7), pPM0, pDM0, pT4aN0M0, and pStage ⅡB. S-1 was orally administered for one year as postoperative adjuvant chemotherapy. A CT examination performed 2 years after the operation revealed a mass at the superior margin of the pancreas. Gastric cancer recurrence was suspected and the decision was made to perform surgery. Since the mass was suspected to have invaded the gastric remnant and the pancreas, complete removal of the gastric remnant, pancreatic tail resection, and splenectomy were performed. The patient was diagnosed as having a desmoid tumor based on histopathological examination. Desmoid tumor is relatively rare and is difficult to distinguish from postoperative recurrence of gastric cancer due to poor characteristic imaging findings. We report a case with a desmoid tumor, developing as an intraperitoneal mass after laparoscopy-assisted proximal gastrectomy, which could be removed by combined resection of adjacent organs.

A 60-year-old woman visited our hospital because of acute onset abdominal pain and vomiting. Computed tomography showed obstruction and dilation of the small intestine, which had filled with fluid. She was diagnosed with strangulation ileus and an emergency operation was performed. A small intestinal intussusception, which was due to a tumor of the small intestine, was found 150cm distal to the Bauhin valve (BV). Additionally, two palpable masses were found at 250cm and 280cm distal to the BV. Partial resections for two segments of the intestine (150cm and 280cm lesion) were performed. The histopathological diagnoses of the two tumors were follicular lymphoma, Grade 1, Ann Arbor ⅡE, Lugano ⅡE, and FILIPI2 score 1. After the operation, she has been undergoing chemotherapy. The intussusception of a low-grade tumor, such as had occurred in this case of follicular lymphoma, is rare. Nevertheless, it is necessary to consider malignant lymphoma as an inducible factor for intussusception and to use combined modality therapy, including an immediate operation for intussusception of follicular lymphoma.

A spontaneous, intramural, small-bowel hematoma requiring a surgery is a rare complication of anticoagulant therapy. We present a case of an 82-year-old man who developed abdominal pain in the setting of abnormal coagulation function related to warfarin therapy used as chronic prophylaxis against recurrent pulmonary embolism. Computed tomography (CT) showed wall thickening and luminal narrowing of the jejunum. Dilation of the small bowel proximal to the thickening was also present, indicative of small bowel obstruction. Initially, the patient was treated conservatively, but he later required laparotomy due to worsening of his general condition. A 50cm jejunal segment was resected in order to relieve the intestinal obstruction and to arrest the bleeding. For intramural, small-bowel hematoma, conservative medical management should be the first treatment of choice, but surgical intervention may be indicated if conservative treatment is not successful.

Primary small bowel volvulus in adults is rare and might compromise small bowel form and function and can be potentially fatal. Furthermore, strangulated small bowel obstruction with chylous and non-bloody ascites is also rare. The patient was a 55-year-old male with no history of abdominal surgery, who presented with sudden severe abdominal pain. Abdominal CT showed a distended small intestine with ascites and a whirl sign. The patient was diagnosed with strangulated small bowel obstruction and emergency exploratory laparotomy was performed. The small intestine was observed to be torted and strangulated around the superior mesenteric artery, distended with chylous ascites and whitish thickened mesentery, but well-perfused. The condition was immediately improved by detorsion without small bowel resection. The patient tolerated the procedure well and was discharged after 10 days of hospitalization. Strangulated small bowel obstruction with chylous ascites might suggest possible bowel preservation by emergency surgical intervention. Chylous ascites and mesentery could also be diagnosed preoperatively by current diagnostic modalities such as computed tomography.

A 55-year-old man with a past medical history of gastric ulcer and diabetes mellitus was brought to our hospital by ambulance for acute abdomen. Enhanced abdominal computed tomography showed thickened small intestinal wall with free air and ascites. Under the diagnosis of perforative peritonitis, an emergency operation was performed. Upon laparotomy, a intestinal tumor with a perforation in the jejunum was identified, for which a part of the jejunum encompaning the perforated tumor. Immunohistochemically examination demonstrated that the tumor cells were positive for CD3, CD4, CD8 and CD56 and negative for CD5 and CD20. Therefore, the jejunum tumor was diagnosed as type Ⅱ Enteropathy-Associated T-cell lymphoma. Herein, we report our case, together with a review of the literature.

We herein report two cases of adult intussusception due to intestinal lipoma. Case 1: A 49-year-old woman was admitted to the hospital complaining of abdominal pain. Computed tomography revealed intestinal intussusception. After she had recovered from intussuception with conservative therapy, a small-bowel contrast series was performed to reveal the intestinal-protruding lesions. Laparoscopy-assisted resection (LA resection) of the ileum was performed. The pathological diagnosis was intestinal lipoma. Case 2: A 30-year-old woman was admitted to the hospital complaining of abdominal pain. Computed tomography suggested intestinal intussusception due to intestinal lipoma. LA resection of the ileum was performed. The definitive diagnosis was also intestinal lipoma. Adult intussusception is relatively rare. LA operations are suitable for patients with intussusception of the small intestine.

A 60-year-old male with hypertension and chronic kidney disease was diagnosed with splenic artery aneurysm of 35mm diameter at the splenic hilum using computed tomography upon extensive examination prior to cecal cancer surgery. Using contrast was impossible because of the chronic kidney disease and few thick arteries outflowing from the aneurysm. Hence, intravascular treatment was considered difficult. We decided to perform laparoscopic-assisted simultaneous ileocecal resection and splenectomy. First, we performed it in the dorsosacral position using two 12 and two 5mm trocars. Second, we performed functional end-to-end anastomosis at the outer abdominal cavity from the upper abdominal 4cm small incision. Finally, we performed laparoscopic-assisted splenectomy in the right hemi-decubitus position after moving the trocars. The splenic hilum was simultaneously resected using an auto suture device. Surgery time was 6 h and 27 min, and blood loss was 35ml. We performed simultaneous laparoscopic-assisted ileocecal resection and splenectomy using minimum trocars and a small incision by considering the trocar position. The case was reported with little bibliographic consideration.

Intestinal malrotation is a congenital anomaly which results from an abnormal rotation and fixation of the gut during embryogenesis. We herein report a case of acute appendicitis with intestinal malrotation in an adult. A 92-year-old man was admitted for a left lower abdominal pain and a high fever. Abdominal contrast-enhanced CT revealed swelling of the vermiform appendix in the left lower abdomen. Moreover, the superior mesenteric vein was located to the left of the superior mesenteric artery. Based on the image findings, we diagnosed the patient as acute appendicitis with intestinal malrotation, and successfully performed single-incision laparoscopic appendectomy. He was discharged on postoperative day 7 without complications. Thus, laparoscopic appendectomy was useful for acute appendicitis with intestinal malrotation. In addition, single-incision laparoscopic surgery might be one of the operation methods for appendicitis to achieve better cosmesis and less invasiveness.

Background: Low-grade appendiceal mucinous neoplasm (LAMN) is rare. Since it can progress to peritoneal pseudomyxoma or mucinous carcinoma, appropriate diagnosis and therapy are needed. Three LAMN cases in various stages that presented within only one year to our hospital are presented.

Case presentation: Case 1 was a 75-year-old woman with right lower quadrant abdominal pain. She was diagnosed with a mucinous mucocele of the appendix and underwent ileocecal resection. Case 2 was a 67-year-old man diagnosed with chronic appendicitis who underwent appendectomy. Case 3 was a 75-year-old man who was found to have a tumor of the appendix on a periodic examination after gastric cancer surgery and underwent ileocecal resection. These three cases were diagnosed with LAMN, and their surgical margins were negative on pathology. None of them have had recurrence.

Conclusion: There are no therapeutic guidelines for LAMN. However, since it has malignant potential, correct diagnosis and optimal surgical therapy are needed. Since LAMN can be seen even in small hospitals, these cases are reported along with a review of the relevant literature.

A man in his 70s with a known history of hypertension presented to a previous hospital with an acute epidural hematoma. He appeared to demonstrate a clinical picture of acute abdomen and subsequently presented to our hospital. He was diagnosed with ischemic colitis and was admitted to our hospital. Laboratory investigations showed a high lactic acid level with metabolic acidosis leading to a suspicion of necrosis of the intestinal tract for which he underwent an exploratory laparotomy. Intraoperatively, we noted necrosis throughout the colon and performed a subtotal colectomy and colostomy of the small intestine. Following an unremarkable postoperative course, he was discharged from the hospital postoperatively after 29 days. Histopathological findings revealed ischemic colitis throughout his colon. We report a rare case of gangrenous ischemic colitis of the entire colon.

We report a case of intussuscepted sigmoid colon cancer prolapsing through the anus and resected by laparoscopic surgery after reduction. A 65-year-old woman was admitted to our hospital because of colorectal prolapsing and anal bleeding. At the end of the prolapsed colon, type1 tumor, 3cm in diameter, was noted. In the emergency room, the prolapsed colon was reducted into the anus. After the reduction, Enhanced CT after the reduction revealed that sigmoid colon was invaginated into rectum. Endoscopic reduction was held and the tumor was diagnosed as well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy and lymph node dissection was performed. Postoperative course was uneventful. This is the first report in Japan resected by laparoscopic surgery for intussuscepted sigmoid colon cancer prolapsed through the anus.

A 77-year-old man underwent carotid artery stenting for stenosis of the right internal jugular artery at the Department of Neurosurgery in our hospital in July 2016. His postoperative course was uneventful, but he experienced abdominal pain and fever after taking a purgative drug on postoperative day 3 and underwent abdominal plain computed tomography (CT) on the same day. The CT scan indicated the possibility of a perforated appendix, and conservative medical treatments, including fasting and antibiotic administration, were initiated. The blood test results on postoperative day 4 indicated the progression of inflammation. The patient was diagnosed with idiopathic superior mesenteric arterial decortication, colon perforation, and localized peritonitis by contrast-enhanced CT and was referred to our department. The patient was taking two anticoagulants, which we replaced with heparinization and performed surgery on postoperative day 10. We further diagnosed the patient with colon necrosis and perforation due to idiopathic superior mesenteric arterial decortication and performed a resection of the right half of the colon. The patient underwent postoperative antithrombotic treatment, and dietary intake was recommenced on postoperative day 4. The patient was transferred to the Department of Neurosurgery and finally discharged following an uneventful postoperative course. There are rare cases with idiopathic superior mesenteric arterial decortication.

Background

Synchronous neoplasms of the colorectum and kidney rarely occur. This paper is the second report on synchronous sigmoid colon and renal cancers treated laparoscopically. In this report, we describe synchronous cT4b sigmoid colon and left renal cancers treated laparoscopically simultaneously, along with the summary and review of reported cases.Case presentation

A 45-year-old male presented with high fever and left lower abdominal pain. Computed tomography showed a solid sigmoid colon tumor that was 7cm in diameter and perforated its mesentery. Colon cancer was suspected to infiltrate the adjacent organs including the abdominal wall. In addition, a 5-cm tumor on the left kidney was accidentally discovered, which was suspected to be renal cancer. Colonoscopy showed a circumferential tumor at the sigmoid colon that was 25cm from the anal verge. There was no evidence of distant metastasis. After intravenous antibiotics therapy, we planned laparoscopic left hemicolectomy and nephrectomy. The sigmoid colon cancer adhered to the abdominal wall, small bowel, and appendix; therefore, we performed en bloc resection of the tumor and the adjacent organs. After colectomy, we performed left nephrectomy. Postoperative course was good. The patient was discharged 12 days after the operation.Conclusion

Laparoscopic synchronous resection is a feasible and curable procedure providing several benefits for the patient. Furthermore, left hemicolectomy and radical left nephrectomy can be a good indication of synchronous resection because both include the same procedure such as mobilization of the splenic flexure. For cT4b colon cancer like in our case, en bloc resection without touching the adhesion can be a curable procedure.

A 64-years-old man underwent colonoscopy for bloody stool, while demonstrated a type 2 rectal tumor 7cm from anal verge. The ascending colon was located on the left side of abdomen, and horizontal portion of the duodenum ran ventral to the superior mesenteric artery in abdominal CT. We diagnosed his illness as rectal cancer with non-rotation type intestinal malrotation. We performed laparoscopic low anterior resection and covering ileostomy. His postoperative course was uneventful. Herein， we report a case of rectal cancer with non-rotation type intestinal malrotation who underwent laparoscopic surgery, and reviewed the literature.

This is a case of a 65-year-old female who had undergone low anterior resection and right hemicolectomy for transverse colorectal cancer. She complained of loss of appetite and diarrhea after the right hemicolectomy and was readmitted in the previous hospital; she was then moved to our hospital. Enhanced computed tomography (CT) revealed enterocolitis in the residual colon. It was difficult to identify the left branch of the middle colic artery, but there was a small amount of blood flow from the residual colon to the inferior mesenteric vein. A contrast enema showed focal narrowing of the residual colon, which was more serious on the distal side of the lesion. She was diagnosed with ischemic colitis of the residual colon. Her symptoms and nutritional condition did not improve with conservative management; therefore, we performed total colectomy and ileostomy. Her postoperative course was uneventful. The albumin value which was 1.7g/dl at the first visit increased to 2.7g/dl on the 11th day after the operation, and she was discharged with improved nutritional status and reduced edema. After 2 months, her albumin value improved to 3.9g/dl. There have been few reports on ischemic colitis after a surgery for colorectal cancer. We report a case of ischemic colitis of the residual colon after rectal and transverse colon cancer surgery along with a review of literature.

The case reported here concerns a 78-years-old man who was referred for additional screening of the left side wall of the rectum during an examination for prostate cancer. Magnetic resonance imaging (MRI) revealed a low rectal tumor measuring 77mm in diameter, and a biopsy specimen was positive for CD34 and c-kit. Based on these findings, the tumor was diagnosed as a rectal GIST. The boundaries between the prostate gland or left muscle obturatorius internus and the tumor were unclear. It was considered an invasion. We decided to treat the case with neoajuvant therapy using imatinib mesylate (IM) to reduce the tumorʼs size. He took IM at a daily dose of 400mg. After 11 months, MRI revealed a decrease of the maximal diameter of the tumor to 37mm (a 52％ reduction) and it had not invaded further. Fourteen months after the initial diagnosis, laparoscopic abdominoperineal resection was performed. Although 4 years and 5 months have passed since the surgery, obvious signs of recurrence have yet to be observed.

The present case suggests that neoajuvant therapy using IM is useful for advanced rectal GIST.

Superior mesenteric artery syndrome (SMAS) in elderly patients often requires surgical treatment, because of the abdominal surgery. Nowadays, laparotomy can often successfully be replaced by laparoscopic surgery. Herein, we report a case of SMAS that was successfully treated by laparoscopic duodenojejunostomy. A man in his eighties was admitted to our hospital with severe vomiting. He was diagnosed as having SMAS based on the findings of abdominal enhanced computed tomography, gastroduodenal endoscopy and gastroduodenography. Conservative therapies such as nasogastric decompression, nil by mouth and hyperalimentation proved to be ineffective, therefore, we performed laparoscopic duodenojejunostomy. The post operative course was uneventful, and the patient was discharged on the postoperative day 16. Duodenojejunostomy is widely performed for SMAS and is considered as an appropriate procedure for obtaining a good outcome. We believe that the laparoscopic surgery adopted in this case is more effective and less invasive than laparotomy for SMAS.

A 53-year-old man presented with acute abdominal pain and was admitted for further examination. Abdominal CT revealed a multilocular structure, resembling an expanded small intestine, in the upper abdomen with poor contrast effect. The possibility of a strangulated bowel obstruction could not be excluded; hence, we performed an emergency surgery. No intestinal dilation or necrosis was observed. However, a soft multicellular cystic tumor was noticed in the small intestine. The jejunum, which was 30cm long, and the mesentery, including the tumor, were resected and anastomosed. Immunohistochemical staining revealed that the tumor was positive for D2-40. The histopathological diagnosis was jejunal mesenteric lymphangioma.

Mesenteric cyst is rare in adults; in Japan, only 29 cases have been reported to date. Here, we present our case along with an overview of the existing literature and a summary of reported cases in Japan.

A 31-year-old woman was admitted to our hospital for the treatment of multiple hepatic tumors, which were detected using computed tomography (CT) at a local hospital when she was undergoing treatment for gastroenteritis. Her physical examination and laboratory data did not reveal any abnormal findings. CT showed multiple delay-enhanced and slightly ring-enhanced tumors in the liver, with diameters of 5-50mm. Magnetic resonance imaging (MRI) showed similar findings as those obtained using CT. Gastrointestinal endoscopy revealed negative results; however, we considered the presence of multiple metastatic liver tumors. We performed a liver biopsy, but this did not provide sufficient evidence for a diagnosis. Therefore, we performed partial hepatectomy to confirm the diagnosis. The resected specimen revealed multiple, white-colored, solid masses. With hematoxylin and eosin (HE) staining, mostly hepatic cells were not detected, which revealed hyaline and fibrotic degeneration. The tumor cells had invaded the sinusoid irregularly, as detected with positive CD34 and CD31 stains. The patient was finally diagnosed with hepatic epithelioid hemangioendothelioma. After surgery, she was not administered any medication, but remained alive for 1 year and 4 months with no changes observed in the liver tumors.

A 44-year old woman was admitted to our hospital with a complaint of right flank pain. She was diagnosed with chronic cholecystitis and underwent a laparoscopic cholecystectomy. Intraoperatively, we observed a node on the surface of the gallbladder, which resembled the liver in its color. The node was not continuous with the liver, although histopathological examination revealed the node to be ectopic liver tissue.

Reportedly, presence of liver tissue at extrahepatic sites, as was observed in our patient, is known to be associated with carcinogenesis, rupture, and/or dissemination. Therefore, prompt removal of such liver tissue from extrahepatic sites is important following its detection.

We report a case of liver metastasis from thyroid cancer treated with laparoscopic hepatectomy. A 67-year-old man treated with total thyroidectomy with lymph node dissection of both sides neck and mediastinum for poorly differentiated carcinoma with multiple lung metastasis. Although he had passed without local recurrence or increase in pulmonary lesions, he was suspected liver metastasis of thyroid cancer or hepatocellular carcinoma because hepatic S3/2 tumor 2cm in diameter appeared in the 8 months after surgery of the enhanced CT scan, enhanced MRI, and PET-CT examination. We considered non-hepatic metastatic lesions is regulated in the sorafenib, and underwent resection of laparoscopic lateral segment of liver for diagnosis and treatment. Tumor was diagnosed liver metastasis from thyroid cancer by histopathological and immunohistochemical examination results. He discharged from the hospital 12 days after surgery without any complications. But lenvatinib was introduced in outpatients because lung metastatic lesions increased. He has been disease-free for 11 months after laparoscopic hepatectomy.

A 45-year-old female with a 5-year history of continuous ambulatory peritoneal dialysis (CAPD) complained of epigastralgia. She also had a history of intestinal obstruction, appendectomy, and total hysterectomy. She had persistent abdominal pain due to cholelithiasis, but received only antibiotic therapy because of her medical history. She was diagnosed with acute exacerbation of chronic cholecystitis and was treated with antibiotics. Her symptoms were relieved, but laparoscopic cholecystectomy was performed because of repeated cholecystitis even though intraabdominal adhesion was expected. Abdominal cavity examination indicated specific CAPD-induced changes such as fibrosis and thickening of the peritoneum, but no intraabdominal adhesion that prevented laparoscopic surgery. Therefore, we could perform laparoscopic cholecystectomy with an irregular port arrangement. Even in cases of a history of CAPD, laparoscopic cholecystectomy can be performed and minimally invasive surgery provided.

An 89-year-old man, with a history of diabetes mellitus, chronic atrial fibrillation, and an indwelled stent graft for an abdominal aortic aneurysm, visited a neighboring hospital with the chief complaints of upper abdominal pain and vomiting. He was transferred to our hospital with suspected calculous cholecystitis according to the abdominal plain CT findings. Enhanced CT showed the presence of gallstones and a hemorrhage in the gallbladder, swelling of the gallbladder, and the aneurysm at the bottom of the gallbladder, and so we diagnosed him with intra-gallbladder hemorrhage due to rupture of a cystic artery aneurysm. Because he was of an advanced age, had multiple comorbidities, and took an anticoagulant, we did not perform an emergency operation but conducted transcatheter arterial embolization (TAE). He achieved hemostasis by TAE and was discharged. Five months later, he safely underwent elective cholecystectomy. His postoperative course was uneventful. A cystic artery aneurysm is rare as a cause of hemobilia, but it is necessary to conduct an emergent procedure when it occurs. We report a rare case of ruptured cystic artery aneurysm treated by elective cholecystectomy after hemostasis involving emergent TAE.

A 75-year-old woman with epigastrium and back pain visited our hospital. Magnetic resonance and endoscopic retrograde cholangiopancreatography were used to determine the microstructure in the lower bile duct. Since these findings indicated choledocholithiasis, endoscopic sphincterotomy (EST) was performed. Due to the patientʼs previous history of a papillary tumor in her Vaterʼs papilla, we performed an endoscopic biopsy. Subsequent immunostaining only revealed an intraductal papillary neoplasm of the bile duct (IPNB). Endoscopic ultrasonography revealed a low echoic lesion that was approximately 10mm in size in the lower bile duct. Cholangioscopy revealed irregularities in the duodenal side of the lower bile duct. Subtotal stomach-preserving pancreastoduodenectomy was performed. Pathological findings indicated an increase in the papillosity with adenocarcinoma of the columnar epithelium, which was only localized to the mucous membrane. Immunostaining indicated positive expression of MAC5AC and weak expression of MAC6. Differences between papillary type cholangiocarcinoma and IPNB have yet to be elucidated; however, in this case, IPNB invasive carcinoma in the lower bile duct was diagnosed via biopsy after EST.

A 76-year-old Japanese woman underwent endoscopic retrograde cholangiopancreatography to investigate high serum levels of CA19-9, and common bile duct cancer (BDC) was diagnosed. We performed choledochectomy, and well-differentiated tubular adenocarcinoma limited to the mucous membrane (well-tub) with no lymph node metastasis or vessel infiltration was pathologically diagnosed. Surveillance 22 months after choledochectomy revealed well-tub of the papilla of Vater limited to the mucous membrane, and pancreatoduodenectomy was performed. Both well-tub were morphologically similar, and showed positive staining for CDX2, CK7, and CK19, and negative immunohistochemical staining for CK20. A skin tumor 2cm in diameter on the surgical scar developed 5 months after pancreaticoduodenectomy, and biopsy revealed well-tub. We diagnosed metachronous double cancer of the bile duct and papilla of Vater, and skin metastasis. This suggests that intraoperative sprays of bile juice can cause intraoperative and fistulous dissemination. The patient died due to intraabdominal dissemination 29 months after the first operation. Both double early-stage cancers involving the bile duct and papilla of Vater, and early dissemination of BDC are rare. This, however, suggests that BDC in the early stage could disseminate to other sites. Clinicians should bear this potential for dissemination in mind, and plan imaging studies for bile duct tumors carefully.

A 78-year-old woman with jaundice initially seen at a local hospital was referred to us for further study. An abdominal contrast enhanced computed tomography revealed a mass in the pancreatic head with dilatation of the intrahepatic bile duct and main pancreatic duct. Moreover, a ring-enhanced splenic tumor 15 mm in diameter was detected. MRI revealed that the splenic mass was low-intensity on T2-weighted images. The tumor markers including CA19-9 and Dupan-2 were elevated. Preoperative diagnosis was pancreatic head carcinoma with hemangioma or metastatic splenic tumor. Since the possibility of a metastatic tumor could not be excluded, the patient underwent pancreaticoduodenectomy and splenectomy. He was discharged from the hospital on the 13th postoperative day without complications. Histopathologically, the splenic mass was diagnosed as inflammatory pseudotumor, which was suggestive of IgG4-related inflammatory pseudotumor.

We experienced an obturator hernia case treated by laparoscopic surgery after ultrasound-guided reduction. A 54-year-old woman with a chief complaint of right groin pain underwent abdominal computed tomography (CT) at another hospital, which showed a round mass between the right pectineus and external obturator muscles. A right obturator hernia was thus diagnosed. She was referred to our hospital for surgery and immediately underwent reduction of the incarcerated bowel using an ultrasonic probe. Subsequently, laparoscopic repair of the obturator hernia was performed on the same day. Obturator hernia was previously regarded as a rare preoperative diagnosis, being detected at laparotomy for unexplained ileus. However, it is now being diagnosed preoperatively in more cases thanks to advancements in imaging diagnosis, and pelvic CT is reported to be especially useful in many cases. Standard surgical procedures have not yet been established, with a variety of procedures being used according to bowel damage and abdominal cavity contamination. When reduction of the incarcerated bowel was achieved soon after the onset, however, immediate laparoscopic surgery is expected as a less invasive repair procedure.

A woman in her 80s underwent laparoscopic-assisted high anterior resection for sigmoid colon cancer. She developed abdominal distension and vomiting on the fifth post-operative day. Abdominal CT-scan revealed incarcerated small bowel loop at the drain site in the right lower abdomen and obstruction of the small intestine.

The drain was immediately removed and an attempt was made to restore incarcerated bowel segment back into the abdominal cavity. However, the bowel could not be restored and an emergency exploration was performed laparoscopically.

A part of ileum was found to be incarcerated into the drain site, and was pushed back into the abdominal cavity. There was no intestinal ischemia rendering a resection unnecessary.

Port-site hernia is a relatively rare complication, however, cases are increasingly being reported with the advent of laparoscopic surgery. The possibility of port site hernia should be considered in the presence of bowel obstruction following laparoscopic surgery.

Suturing peritoneum, and fascia during port closure is necessary for preventing the occurrence of port-site herniation.

A woman in 30s with past appendectomy, was admitted to our hospital because of nausea, vomiting and epigastralgia. An abdominal CT scan showed obvious dilation of the small intestine in Morrisonʼs pouch. A gastrointestinal contrast examination showed the obstruction of the small intestine at the right upper abdomen, and internal hernia was suspected．

An emergency operation was started under the laparoscopy.

The dilated small intestine was on the head side of the right transverse colon and running to the foramen of Winslow. However, we couldnʼt confirmed the hernia hiatus because of dilation of the small intestine. Therefore, we converted to open laparotomy, and diagnosed a foramen of Winslow hernia. Manual reduction was performed without intestinal resection.

In our case, the small intestine herniated into the foramen of Winslow through the cavity, which caused by postoperative adhesion of omentum, on the head side of right transverse colon.

We report and analyze a rare case of hernia of foramen of Winslow.

A 69-year-old man was admitted to our hospital with a chief complaint of epigastric discomfort. A preoperative diagnosis of gastric volvulus associated with Bochdalek hernia and the patient underwent laparoscopic surgery. With operative findings, a diaphragmatic hernia was found in the left vertebrocostal trigone, leading to a definitive diagnosis of Bochdalek hernia. We performed reduction of the herniated viscera into the abdominal cavity, covered the hernial orifice with Composix Mesh, and fixed it to the diaphragm without suturing the orifice. In addition, the stomach was returned to its original position, and fixed to the abdominal wall. His postoperative course was uneventful, with no signs of recurrence after surgery. Gastric volvulus is frequently secondary to diaphragmatic defects. This patient also developed gastric volvulus secondary to Bochdalek hernia. Laparoscopic surgery for gastric volvulus is useful in that it facilitates detailed examination of the diaphragm, thereby making it possible to exclude or definitively diagnose diaphragm diseases.