It is not necessary to fix a ProGripTM mesh (PG) with staples during transabdominal preperitoneal hernia repair, to prevent mesh migration, reduce pain, and reduce the costs. However, to insert the PG into the abdominal cavity, a port size greater than 10 mm in diameter is usually required. To overcome this disadvantage, we devised a method to insert the PG into the abdominal cavity via a 5-mm port. Once the 5-mm port was removed, the PG placed in the Penrose drain could be inserted into the abdominal cavity from the 5-mm port site. Herein, we introduce the novel method for TAPP using a PG that required only three 5-mm ports (TAPP-555).

The patient was a 60-year-old female. She had undergone nipple areolae-sparing subcutaneous mastectomy 20 years earlier, followed by postoperative adjuvant hormone treatment for 5 years. Local recurrence in the preserved areola was diagnosed 9 years after the first surgery. Wide-area resection was performed, followed by anticancer drug treatment, radiation treatment and 1st line hormone treatment at the request of the patient. Early after the resection, the patient presented with a metastasis in the ipsilateral axilla. Extensive resection was performed at the site of recurrence, followed by radiotherapy to the axillary and supraclavicular regions and the internal thoracic lymph node area, and 2nd line hormone therapy. The patient presented with disease recurrence again and was initiated on 3rd line hormone therapy. One year after the start of 3rd line hormone therapy, supraclavicular lymph node enlargement was noted. Thereafter, 1 year after the 4th line hormone treatment, recurrent metastatic lesions were found in the axilla. Treatment with an mTOR inhibitor/EXE was started as the 5th line hormone treatment. Clinical partial response (cPR) could be maintained for 1 year and 6 months after the start of mTOR inhibitor/EXE therapy. However, the patient developed breathlessness and tachycardia about 10 months after the start of mTOR inhibitor/EXE therapy. A chest radiograph showed enlargement of the heart shadow. Echocardiography revealed marked pericardial effusion. Administration of the mTOR inhibitor was discontinued and the symptoms alleviated.

We report the case of a 90-year-old female patient in whom left mastectomy was performed for a rapidly progressive hemorrhagic intracystic breast cancer. The patient presented with a rapidly growing mass in the left breast, which she had first noticed 6 months earlier, but had not sought medical attention for. Physical examination revealed a huge magenta-colored mass in the left breast, measuring about 28 × 23 cm in size. Breast ultrasonography, computed tomography, and magnetic resonance imaging revealed a cystic mass with a 1-cm elevated nodular lesion on the cyst wall. Fine needle aspiration of the cyst revealed bloody effusion, and the result of cytology was inconclusive. Left mastectomy was performed for the diagnosis and treatment of the cystic lesion. Histopathological examination and immunohistochemistry of the 1-cm nodular lesion on the cyst wall revealed a DCIS that was positive for ER and PgR, and negative for HER2. The Ki-67 index was 2.8%. Due to her advanced age, the patient was not administered any adjuvant therapies. Her postoperative course was uneventful and she has been under follow-up at our outpatient clinic, without any evidence of recurrent disease until date.

A 56-year-old man underwent combined surgery for synchronous esophageal carcinoma and lung carcinoma: thoracoscopy-assisted right middle lobectomy for the right lung cancer (invasive adenocarcinoma, pT1aN0, Stage ⅠA1) and thoracoscopic esophagectomy with lymph node dissection for the esophageal cancer (well-differentiated squamous cell carcinoma, pT2N1, pStage Ⅲ). Twelve months after the operation, he presented with a painful subcutaneous elastic-hard tumor on the posterior surface of the left lower leg. Ultrasound examination revealed a hypoechoic tumor, 2.5 × 1.5 cm in diameter, in the left gastrocnemius muscle. Serum carcinoembryonic antigen and squamous cell carcinoma antigen levels were elevated. Based on these findings, we suspected the lesion as a skeletal muscle metastasis from the lung cancer or esophageal cancer, and extirpated the tumor under local anesthesia. We confirmed the smooth surface of the tumor, without invasion of the adjacent muscle fibers during the operation. The histopathological diagnosis of the resected specimen was adenocarcinoma with TTF-1 (-) and PE-10 (±). The patient received combined chemotherapy with CDDP/PEM. However, he presented with local recurrence of the tumor about 1 month after the tumor extirpation. While the tumor proved resistant to combined chemotherapy with CDDP/PEM plus radiotherapy, nivolumab administration (10 courses) proved effective against the skeletal muscle metastasis from the lung adenocarcinoma, inducing tumor regression and improvement of the symptoms. Unfortunately, however, the patient died of respiratory failure associated with acute pulmonary embolism 27 months after the initial surgery. This patient is considered as a very rare case of skeletal muscle metastasis from a lung adenocarcinoma after combined surgery for synchronous esophageal/lung cancers.

Brunner’s gland hyperplasia is a submucosal tumor-like lesion of the duodenum that is often diagnosed by upper gastrointestinal endoscopy. In general, benign tumors are followed up, but tumors that occupy the lumen, tend to grow, and/or bleed are candidates for resection. Endoscopic resection is performed, because the tumor is mainly localized in the deep mucosa to the submucosal layer; however, complications are more frequent in cases with a tumor diameter of more than 30 mm, and duodenal resection by open surgery or laparoscopic surgery is needed. Endoscopic operation for a pedunculated Brunner’s gland hyperplasia measuring 40 mm in diameter and occupying the bulb of the duodenum was expected to be difficult to perform. Therefore, we excluded the duodenal wall using laparoscopic assistance, and moved the tumor to the stomach through the pylorus and performed EMR.

We report a case of Brunner’s gland hyperplasia that was successfully operated by the described procedure.

A 77-year-old man visited our hospital complaining of abdominal pain. There was no history of trauma. The whole abdomen was stiff, with signs of severe peritoneal irritation. Abdominal CT showed free air and ascites. He was diagnosed as having gastrointestinal perforation and emergency surgery was performed. At the time of laparotomy, contaminated ascites was found, along with a 15 mm-sized perforation in the ileum, 40 cm from the terminal ileum, on the wall contralateral to the mesentery. There were no other abnormal findings, and partial intestinal resection and intraperitoneal drainage were performed. Histopathological examination showed no abnormalities of the mucosa around the perforated site, and a diagnosis of idiopathic perforation of the small intestine was made. In addition, a muscular defect was recognized at the periphery of the perforated area. The patient was discharged on the 16th operative day without any complications. Idiopathic small bowel perforation is a relatively rare condition. A partial defect of the intestinal muscularis has been reported as the cause of idiopathic gastrointestinal perforation. In this case also, the findings suggested the possibility of intestinal perforation due to a defect of the intestinal muscle layer.

We report a case of mesenteric phlebosclerosis (MP), which is a rare ischemic colon disease that was described recently. A 70-year-old woman was referred to our hospital with abdominal pain and fever. She had a past medical history of SLE and hypertension, and was receiving oral herbal medicines (kamishoyosan). Blood tests showed evidence of an inflammatory reaction. Abdominal computed tomography (CT) showed thickening of the colonic wall of the right-sided colon and a high-density lesion around the hepatic flexure of the colon, with linear calcification of the marginal vessels. She was diagnosed as having ischemic colitis and received conservative therapy; the herbal medicines were discontinued. Colonoscopy and X-ray fluoroscopy revealed stenosis at the hepatic flexure, therefore, we performed right hemicolectomy. Histopathological examination revealed denudation of the mucosa, submucosal fibrosis, and fibrous thickening of the venous walls with calcification, consistent with the diagnosis of MP. The postoperative course was uneventful, and the patient has shown no evidence of relapse after the surgery. Early diagnosis of MP may allow avoidance of surgery, although MP should be kept in mind as a cause of acute abdomen.

A 45-year-old male who had been diagnosed as having Crohn’s disease 10 years earlier presented with an anal lesion. Infliximab was initially administered for treatment of the fistula, although with gradual decline of the drug efficacy, the therapy was switched to anti-drug antibodies (ADA). Following ADA treatment, the patient experienced episodes of ileus that sometimes necessitated hospitalization. Our examinations revealed stenosis as well as a fistula in the ileum, and surgery was scheduled. During the operation, the lesions in the terminal ileum were observed to have conglomerated into a single mass, with fistula formation and organic dilatation of the oral intestinal tract. An ileocecal resection was performed, after which we confirmed, by visual inspection and palpation, the absence of any residual lesion from the ligament of Treitz to the ileal end. The ileus tube was then removed and the operation completed. Following surgery, the patient failed to defecate and vomited for 4 days, for which he was given conservative treatment with decompression and placement of an ileus tube. However, as the condition did not improve, additional examinations were performed. Abdominal computed tomography revealed intussusception and a reoperation was performed, although removal of the intussusception was difficult and an ileal resection of 60 cm was required. Following that procedure, the condition of the patient improved and he was discharged. Although rare, prompt and appropriate treatment are very important in Crohn’s disease patients with intussusception.

The patient, a 66-year-old woman, had been receiving conservative treatment for mucosal prolapse syndrome (MPS) for over 10 years. However, as the stenosis of the rectum was becoming worse, we decided to perform operation. Although repeated biopsies showed no evidence of malignancy, we could still not fully exclude the possibility of rectal cancer. Therefore, we performed low anterior resection (LAR). We also performed ileostomy, because of the high-risk of suture failure in view of a past history of ischemic colitis. After confirmation of the absence of recurrence of the MPS recurrence by colonoscopy, ileostomy closure was performed after 6 months.

The patient developed recurrence of MPS despite receiving conservative therapy. LAR may contribute to provisional improvement and provide a histopathological diagnosis, but it does not represent radical treatment for MPS. Conservative treatment for MPS is required even after LAR.

The patient was a 66-year-old man who had been diagnosed as having hepatocellular carcinoma (HCC) in the lateral segment of the liver at another hospital. He was involved in a traffic accident and was admitted to our hospital complaining of severe abdominal pain. The blood pressure and heart rate at admission were 109/61 mm Hg and 60/minute, respectively. Blood examination revealed no anemia, and abdominal enhanced CT revealed a hepatic mass in the lateral segment with fluid collection around the mass, and intratumoral extravasation of contrast medium. The patient was diagnosed as having traumatic rupture of HCC, and emergency hemostasis was successfully accomplished by transcatheter arterial embolization. Further evaluation of the tumor and hepatic reserve was performed after confirming stabilization of the patient’s general condition, and subsequently, elective lateral segmentectomy of the liver was performed, without any complications. Since traumatic rupture of HCC is rare, we report this case here, with a review of the literature.

The patient was a 75-year-old man, who presented with a history of recurrent fever and bacteremia three months after he underwent laparoscopic total gastrectomy for gastric cancer. Twelve months after the onset of symptoms, jaundice developed and close examination revealed that the hepatic peribiliary cysts (HPBCs) which had been detected at the time of gastric cancer surgery, had increased in size, one of the enlarged cysts causing narrowing of the origin of the left hepatic duct. A tube stent was placed in the bile duct, and puncture of the enlarged cyst that appeared to be the cause of the stenosis was performed; however, the cholangitis was difficult to control. Therefore, eventually, left hepatectomy was performed. There has been no evidence of recurrence of cholangitis after the operation.

HPBCs are usually followed up if asymptomatic, but treatment becomes necessary if they cause jaundice or cholangitis. Our present case was a rare case that required surgical treatment, because enlargement of the cysts after total gastrectomy caused hilar bile duct stenosis. Therefore, we report this case with a brief review of the literature.

A 16-year-old man was referred to Ageo Central General Hospital for resection by robotic surgery of a pancreatic NET (G1) after receiving treatment for acute pancreatitis. Abdominal CT revealed a tumor in the pancreatic head measuring 8 cm in diameter, without any evident dilatation of the bile duct or the pancreatic duct. Thus, robot-assisted pylorus-preserving pancreatoduodenectomy was performed. Histopathologically, the tumor was diagnosed as a pancreatic NET (G2). After surgery, the patient was discharged without any postoperative complications. We report a juvenile case of pancreatic NET which was successfully treated by robotic surgery.

The patient was an 80-year-old woman who had undergone left lower lobectomy with aortic adventitia for left lower lobe lung cancer. Two years after the surgery, a thoracic CT revealed a single tumor in the spleen, and a repeat CT obtained 6 months later revealed that the tumor had increased in size. FDG-PET/CT showed abnormal uptake by the splenic tumor, but no other sites of abnormal uptake. We diagnosed the tumor as a solitary splenic metastasis from lung cancer and performed laparoscopic splenectomy. The histopathological characteristics of the tumor were the same as those of the primary lung cancer. we see the patient 36 months after the operation. Although lung cancer often metastasizes to multiple organs, isolated splenic metastasis is very rare. We report a case with a single splenic metastasis that was diagnosed after surgery for primary lung cancer.

A 62-year-old man diagnosed as having an adrenal tumor was admitted to our department for operation. The patient had a medical history of having undergone left hepatic lobectomy for HCC. Abdominal CT and MRI revealed a tumor in the right adrenal gland that measured 2 cm in diameter, which was suspected as a metastasis from the HCC. Thus, we performed laparoscopic adrenalectomy under ICG fluorescence imaging guidance, because we expected strong adhesions around the tumor caused by the previous operation. The tumor was easily detected by ICG fluorescence imaging despite the presence of severe adhesions. Histopathological examination revealed the lesion as an adrenal metastasis from HCC. This case serves as an important reminder to consider ICG fluorescence imaging for easy detection of metastatic lesions from HCC.

The patient was an 88-year-old woman with dementia who presented with fever, malaise, and abdominal pain. Physical examination revealed a flat and hard abdomen. There was tenderness in the lower abdomen, but this was unclear due to the dementia. Blood tests showed evidence of an inflammatory reaction, and abdominal CT showed free air in the lower abdominal/pelvic cavity. We suspected peritonitis caused by a gastrointestinal perforation and decided to perform diagnostic laparotomy. Laparotomy revealed no stool or leaking stool in the abdominal cavity. Observation from the Treitz ligament up to the rectum revealed no perforation. However, snow-ball crepitation and edematous changes were noted in the bladder wall. Therefore, we diagnosed the patient as having emphysematous cystitis, completed the operation and closed the abdomen. After surgery, the patient was transferred to the urology department, and while urinary catheterization and antibiotic administration improved the signs of infection, the patient died of aspiration pneumonia during the clinical course. We report a case of emphysematous cystitis diagnosed by diagnostic laparotomy that was difficult to distinguish from gastrointestinal perforation.