To evaluate the current status of exercising of parental leave entitlement and issues related to progression of a surgical career while parenting in Japan, we performed a sub-analysis of a global survey conducted to explore the knowledge about and experience of legislation and entitlement of parental leave among surgeons, and their perspectives on work-life balance, childcare, and compatibility of parenthood with a surgical career. Completed questionnaires received from a total of 109 Japanese surgeons (27 trainees and 82 consultants) were analysed. In Japan, surgical trainees are relatively less likely to have children (Japan = 7.4% vs. Overall = 36.3%, p = 0.0013). Many felt that applying for paternity leave was not easy and none of the respondents had ever taken full parental leave. Of all the respondents, 97.2% were told a surgical career was not compatible with parenthood (Japan = 97.2% vs. Global = 82.8%, p < 0.0001). To facilitate an environment in which surgeons can exercise their entitlement to parental leave, use of internet technologies to allow continued education at home, promotion of a team work culture, and increased sharing of housework between men and women may be needed.

Patients and methods: A total of 19 patients diagnosed as having a urachal remnant underwent laparoscopic surgery between October 2012 and June 2020. The average age of the patients was 27.3 years, and there were 15 men and 4 women. The urachal remnant was classified as an umbilical-urachal sinus in all cases. The procedure was performed with the patients lying in the supine position and three trocars placed in the right or left abdomen.

The median umbilical ligament from the vicinity of the bladder to the umbilicus was released and excised through an umbilical incision on the body surface.

Results: The mean operative time was 79.8 minutes and the blood loss was trivial in all cases. The mean postoperative hospital stay was 4 days. Histopathologically, the lesions were benign in all cases. We encountered no complications and no recurrences, except for one case of umbilical wound infection, who was treated conservatively by drainage.

Conclusion: Laparoscopic surgery for a urachal remnant is a useful technique, because it is minimally invasive and enables the patient to return to his/her usual life relatively quickly. On the other hand, the cosmetic aspect and limitation of social life during drainage should be considered.

The patient was a 34-year-old man who had suffered from perforation of the small intestine due to an incarcerated right inguinal hernia and undergone inguinal hernia repair by the anterior approach with a temporary ileostomy at two months of age. The ileostomy closure was performed two months after the initial surgery, and an appendicostomy was created for the purpose of decompression of the anastomosis. The tube was removed a few months later and the appendicostomy closed naturally. At the age of 34, the patient noticed a swelling of the skin after the fistula was closed. After undergoing drainage at other hospitals, he was admitted to our hospital because of leakage of the bowel contents from the fistula. X-ray fluoroscopy under endoscopic guidance showed an appendico-cutaneous fistula. Therefore, laparoscopic appendectomy and resection of the fistula containing the skin were performed. We report the case of a patient who developed an appendico-cutaneous fistula after closure of an appendicostomy.

A 19-year-old man with a 5-day history of abdominal pain was transported to our hospital by ambulance. Enhanced abdominal computed tomography showed colonic intussusception, and a barium enema showed obstruction of the sigmoid colon. After endoscopic reduction of the intussusception, colonoscopy, enhanced computed tomography and magnetic resonance imaging showed a swelling, like a submucosal tumor, and intussusception at the orifice of the appendix, and mucus retention within the appendix. Based on these findings, we diagnosed the patient as having an appendiceal mucinous tumor, and performed a laparoscopy-assisted partial cecectomy. Histopathological examination revealed the tumor as a low-grade appendiceal mucinous neoplasm (LAMN), a newly classified entity in the Japanese Classification of Colorectal Carcinoma (eight edition). LAMN is more common in patients over 50 years of age, and is rare in young people. LAMNs are generally treated by surgical resection, but no standard operative procedure for these tumors has been established yet. There is a possible risk of development of pseudomyxoma peritonei after resection of LAMNs. Therefore, follow-up of these patients is necessary.

Herein, we report a case of pelvic malignant lymphoma with a rectovaginal fistula. A 75-year-old woman was admitted to our hospital with the complaint of anal pain. Rectal examination revealed a palpable mass 2 cm from the anal verge. Colonoscopy revealed an ulcerated tumor forming a rectovaginal fistula. Biopsy with immunohistochemical staining suggested the diagnosis of diffuse large B cell lymphoma　(DLBCL). Under the preoperative diagnosis of pelvic DLBCL, stage ⅣA, we performed total pelvic exenteration (TPE) to prevent further hemorrhage, urinary infection, and anal pain. Intrapelvic recurrence was recognized 4 months after the surgery. Although the patient was initiated on chemotherapy and received one cycle of R-THP-CVP, the patient died 8 months after the surgery of DIC. TPE was thought to have had some benefit in improving the clinical symptoms, such as hemorrhage, urinary infection, and anal pain.

A 48-year-old woman presented to our hospital complaining of irregular menstruation. Examination revealed a palpable non-tender mass in the upper abdomen. Hepatitis markers were negative, and the serum level of the tumor marker CA19-9 was slightly elevated. Abdominal computed tomography revealed a well-defined tumor in the lateral segment of the liver measuring 14 cm in diameter, as well as an ovarian tumor. The liver tumor was polycystic and heterogeneous and drained into several hepatic veins. There was no evidence of malignancy in the gastrointestinal tract. Hepatic angiomyolipoma was suspected, and left hepatic lobectomy was performed owing to the difficulty in fully excluding malignancy and the possible risk of rupture. The postoperative histopathological diagnosis was perivascular epithelioid cell tumor (PEComa). Hepatic PEComa is a rare tumor whose potential for malignant transformation is unknown and for which no treatment has been established.

A 53-year-old man received interferon therapy for hepatitis C at the age of 30, but the treatment failed. At the age of 50, he was initiated direct-acting antivirals (DAA) treatment after confirming the absence of any hepatic masses, and the serum HCV-RNA disappeared. Subsequently, the patient was checked by abdominal ultrasonography every 3 months, and a year and 7 months after sustained viral response was achieved, a 15-mm hepatic mass was detected in the lateral segment of the liver. The tumor was stained in the early phase on sonazoid-enhanced ultrasonography, showing hypoperfusion in the Kupffer phase. We made a preoperative diagnosis of hepatocellular carcinoma, and laparoscopic lateral sectionectomy of the liver was performed. On histopathological examination, the tumor was diagnosed as an intrahepatic cholangiocarcinoma. The postoperative course was uneventful, and the patient was discharged 10 days after the operation. At present, one year after the operation, the patient remains alive without recurrence.

A 70-year-old woman who had undergone mastectomy for breast cancer at the age of 61 years underwent follow-up computed tomography (CT) 7 years after the operation. CT showed a new 7-mm cystic tumor in the liver, and a repeat CT 2 years later showed that the lesion had increased to 10 mm in diameter. Therefore, malignancy was suspected and hepatectomy was performed. The histopathological diagnosis of the resected liver “tumor” was hepatic echinococcosis. No recurrence has been observed until now, 3 years after the surgery. Hepatic echinococcosis is a parasitic cystic disease of the liver caused by Echinococcus multilocularis, which is mainly found in Hokkaido, Japan. However, it is extremely rare to encounter new onset of hepatic echinococcosis during follow-up for malignancy. Herein, we report a rare case in whom we performed hepatectomy for a hepatic cystic lesion that developed 9 years after treatment for breast cancer, and histopathological examination of the resected liver “tumor” was hepatic echinococcosis.

A 67-year-old female patient with mild splenomegaly and abdominal lymph node enlargement was admitted to our hospital. FDG-PET/CT showed excessive uptake of FDG in the abdominal lymph nodes and spleen. Laboratory data revealed elevation of the serum IL-2 receptor level. Based on these findings, we suspected malignant lymphoma and performed laparoscopic splenectomy. Histopathological examination of the resected specimen revealed the presence of granulomas with epithelioid cell clusters with foreign body giant cells, features consistent with the diagnosis of sarcoidosis.

This case serves to underscore the importance of bearing in mind the possibility of sarcoidosis in the differential diagnosis of splenomegaly.

A 72-year-old woman was admitted to our hospital complaining of severe abdominal pain. Abdominal computed tomography showed thickening of the sigmoid colon wall and free air in the peritoneal cavity. Therefore, we performed an emergency laparotomy. Intraoperative inspection revealed a sigmoid colon tumor that was adhering to the uterus. The uterus had a perforation in the anterior wall measuring 10 mm in diameter, and was filled with pus. Based on the findings, we diagnosed the patient as having sigmoid colon with a uterine perforation and pyometra, and performed a Hartmann’s procedure with en bloc hysterectomy. Histological examination of the resected specimen revealed sigmoid colon cancer with serosal invasion and inflammatory cell infiltration of all layers of the uterine wall.

Our patient reported herein had pyometra caused by uterine invasion of sigmoid colon cancer. The possibility of perforation with pyometra should be considered in women suspected as having gastrointestinal perforation.

A 70-year-old man with alcoholic liver cirrhosis had undergone four sessions of radiofrequency ablation (RFA) for the treatment of recurrent liver cancer. Nine months after the final session of RFA (which had been performed to treat a lesion in S8), the patient was referred to our hospital with complaints of cough and right upper quadrant abdominal pain. On admission, laboratory data showed increased inflammatory markers, and imaging examination revealed dilated loops of small intestine in the right upper abdomen and an infiltrative opacity in the lower right lobe of the lung, along with a right pleural effusion. On the basis of these findings, we diagnosed the patient as having ileus and aspiration pneumonia, and treated him with antibiotics and gastric tube insertion. However, the symptoms only worsened steadily, and on day 8 of admission, the patient developed fever (38℃) and increase in the levels of inflammatory markers. Contrast-enhanced computed tomography revealed a right diaphragmatic hernia with incarceration of the small intestine. Emergency laparoscopy was performed to repair the hernia and relieve the obstruction of the incarcerated bowel in the diaphragmatic hernia. Herein, we present a rare case of a patient who developed diaphragmatic hernia complicating transdiaphragmatic RFA for S8 liver cancer and was treated by a laparoscopic approach, along with a discussion of the relevant literature.

A 78-year-old male who had undergone surgery for gastric ulcer perforation developed a huge abdominal incisional hernia in the upper abdomen. The patient was being followed up by a visiting doctor as an asymptomatic case of abdominal incisional hernia, because he had difficulty in walking. He was referred to our hospital with the complaint of abdominal pain upon coughing. However, the visiting doctor found the systolic blood pressure of the patient at his residence to be only about 40 mm Hg, and transferred the patient to the hospital as a case of shock. Findings of abdominal CT led to the suspicion of intra-abdominal hemorrhage around the surface of the liver and small omentum. Contrast-enhanced CT revealed left gastric artery stenosis and blockage of the peripheral portion of the artery. We performed temporary hemostasis and coil embolization. We initiated conservative therapy: arrested the hemorrhage, but did not repair the abdominal incisional hernia. The patient was discharged on day 13 of admission. Asymptomatic abdominal incisional hernia patients are not candidates for surgery. However, huge abdominal incisional hernias may need to be repaired to avoid emergency operation and bleeding.