From April 2020, genetic testing for BRCA mutations for diagnosing hereditary breast and ovarian cancer (HBOC) in breast cancer patients, risk-reducing mastectomy, and risk-reducing salpingo-oophorectomy in BRCA mutation carriers began to be covered by the National Health Insurance in Japan, so that medical treatment of HBOC has reached a turning point. We examined the current status and issues in 11 surgical cases of BRCA mutation carriers after insurance coverage at our hospital. Out of the 11 cases, only surgery for primary breast cancer was performed in 5 cases, and various procedures, depending on the individual situations, were performed in the remaining patients. It is necessary to secure a surgical frame depending on the surgical procedure, and building a system for surgery across other departments is a future task. In addition, as the number of genetic tests for BRCA is expected to increase further in the future, it is important that there is smooth cooperation among not only the breast surgeons, but also among breast surgeons, gynecologists, plastic surgeons, and genetic counselors for patients who have just been diagnosed with cancer or HBOC, so as to ensure that the best surgical decisions are made within a relatively shorter period of time.

Purpose: Extended totally extraperitoneal Rivers-Stoppa repair for abdominal wall hernia (eTEP RS) has been introduced, and we examined the results in 20 cases at our institution.

Method: The eTEP RS method was adopted in 20 patients with abdominal wall hernia at our institution between April 2018 and April 2021, and the treatment results were analyzed retrospectively.

Result: The median operation time was 254 (165-378) minutes, the median bleeding volume was 20 (3-80) ml, and the median postoperative hospital stay was 6 (4-21) days. Complications included one case of postoperative paralytic bowel obstruction and two cases of seroma.

Conclusion: The eTEP RS method is a useful procedure that combines the advantages of endoscopic surgery and the Rives-Stoppa method. While issues of eTEP RS that need to be addressed include shortening of the operation time by standardizing the surgical procedure and long-term treatment results, this method may be one of the surgical choices for abdominal wall hernias in the future.

The patient was a 61-year-old woman who presented with a history of dysphagia and weight loss, and was diagnosed as having esophageal squamous cell carcinoma, LeAe cT4aN2M0 Stage Ⅲ. She also had severe respiratory dysfunction, nutritional disorders and hypothyroidism. She received chest physical therapy and home oxygen therapy for the respiratory dysfunction,　nutrition through a PEG for the nutritional disorders, and levothyroxine　for hypothyroidism, along with DCF as neoadjuvant therapy. Thereafter, the tumor shrank and her general condition recovered slightly, and we performed subtotal esophagectomy, three-field lymph node dissection and gastric tube reconstruction after checking for surgical resistance with one-lung ventilation. She had no complications during the perioperative period and was discharged 49 days after the surgery. The histopathological diagnosis was pT3N1M0 and therapy evaluation chemotherapy was Grade Ⅱ. At present, 3 years after the surgery, she remains alive without recurrence.

The patient was a 73-year-old woman with gastric cancer who had undergone total gastrectomy and D2 lymph node dissection.

Approximately 4 months after the surgery for primary gastric cancer, abdominal CT showed metastasis in liver S7. Partial liver resection was performed, as PET-CT showed no evidence of other-organ metastasis.

About 1 year 11 months after resection of the primary lesion, abdominal CT and PET-CT revealed a solitary right adrenal metastasis, and right adrenalectomy was performed.

Subsequently, the patient was diagnosed as having recurrent liver metastasis and right renal vein thrombosis and received chemotherapy; however, she died of aortic dissection 3 years 6 months after resection of the primary lesion.

Metastasis recurrenced of gastric cancer is often unresected, And treatment is often chemotherapy alone, but long-term survival could be expected by combining multiple surgeries and chemotherapy.

A 28-year-old man visited our hospital with a one-week history of severe intermittent abdominal pain. Findings of abdominal contrast-enhanced CT suggested small bowel obstruction due to Meckel’s diverticulum, and emergency diagnostic laparoscopy was performed. Intraoperative findings showed small bowel obstruction caused by an enterolith in the ileum, which had spilled from the enteroliths in the Meckel’s diverticulum. Resection of a segment of the small intestine including the Meckel’s diverticulum was performed through a small umbilical incision. Infrared absorption spectrometric examination of the enteroliths showed a similar pattern to that of bile acids; thus, the enterolith was confirmed as a true enterolith. It should be noted that Meckel’s diverticulum can cause small bowel obstruction. Laparoscopic surgery is the treatment option of first choice for this condition, although careful consideration of the indication from the viewpoint of safety is necessary.

A 64-year-old man was detected to have a small bowel tumor incidentally on abdominal CT, while being followed up for Deep Vein Thrombosis (DVT). Double-balloon enteroscopy showed several expanded lymphatic vessels in the mucosa, and biopsy revealed the diagnosis of small bowel lymphangioma. Intraoperatively, a 10-cm multilocular cystic tumor was found to be located in the ileum about 110 cm to the left of the terminal ileum. Partial resection of the ileum was performed. Histopathologically, a multilocular cystic lesion was detected, extending from the submucosa to beyond the serosa and into the mesentery, and immunohistochemistry was positive for D2-40. Based on the findings, the tumor was diagnosed as a small bowel lymphangioma. Small bowel lymphangioma in adults, diagnosed preoperatively by double-balloon enteroscopy and biopsy in our case, is very rare.

We report two cases of laparoscopic surgery performed for perforated acute appendicitis during pregnancy, with a review of the literature.

Case 1: A 32-year-old woman, 12 weeks pregnant. She was diagnosed as having perforated acute appendicitis and underwent laparoscopic surgery. The appendix was perforated, and appendectomy and intra-abdominal lavage were performed. She was discharged on the eighth postoperative day. She gave birth to a healthy baby at 39 weeks of gestation. Case 2: A 37-year-old woman, 26 weeks pregnant. She was diagnosed as having perforated acute appendicitis and underwent laparoscopic surgery. The appendix was perforated, and appendectomy and intra-abdominal lavage were performed. Signs of preterm labor were observed before the operation, and she was administered tocolytics. Both signs of inflammation and preterm labor subsided. She was discharged on the 17th postoperative day. She gave birth to a healthy baby at 37 weeks of gestation. Laparotomy for perforated acute appendicitis during pregnancy may be difficult: the enlarged uterus may make it difficult to locate the appendix and drain the intra-abdominal cavity. Therefore, laparoscopic surgery is considered as being a useful treatment option, as it allows observation of the entire intra-abdominal cavity.

A 67-year-old woman was admitted to our hospital with the chief complaint of right lower abdominal pain. Abdominal CT revealed swelling and wall thickening of the appendix, and a septum within the appendix showing contrast enhancement. Under the suspected diagnosis of appendicitis with appendiceal tumor, the patient was initially treated with antibiotics. A colonoscopic examination performed after completion of the antibiotic therapy showed no abnormalities around the orifice of the vermiform appendix. We performed laparoscopic ileocecal resection with D2 lymph node dissection. Histopathological examination, including immunohistochemistry, showed a poorly differentiated signet ring cell adenocarcinoma at the root of the appendix, parts of which showed positive staining for synaptophysin, chromogranin-A, and CD56. The findings were suggestive of goblet cell carcinoid (GCC); the histopathological examination also showed a low-grade appendiceal mucinous neoplasm (LAMN) at the tip of the appendix. We report this case here, because simultaneous occurrence of a GCC and LAMN in the appendix is quite rare.

Background: Desmoid tumors are histologically benign tumors, but are locally aggressive, in that they show invasive growth and local recurrence. Sporadic desmoid tumors with no abnormalities of the APC gene are rare tumors with few characteristic imaging findings, and it is often difficult to make a diagnosis preoperatively.

Case 1: A 65-year-old male. CT examination performed 2 years after surgery for ascending colon cancer revealed an irregular mass measuring 42 mm in diameter in the transverse mesentery, and the mass was resected.

Case 2: A 70-year-old male. CT examination performed 1 year after surgery for descending colon cancer revealed a round-shaped mass measuring 14 mm in diameter in the mesentery of the jejunum, and the mass was resected.

Conclusion: Desmoid tumors lack characteristic imaging findings and are rare. It is difficult to distinguish them from recurrent tumors after surgery for malignant disease. The possibility of desmoid tumors should be considered when the clinical course is not typical of recurrent lesions, and T2-weighted MRI shows hypointense bands.

The prognosis of cases of advanced colorectal cancer with abdominal wall invasion is good after abdominal wall resection, but extensive abdominal wall defects may require abdominal wall reconstruction. A 74-year-old male patient who had undergone abdominoperineal rectal resection for rectal cancer 30 years previously presented to us and we identified colorectal cancer with abdominal wall invasion just below the colostomy site. We performed partial colon resection with combined abdominal wall resection and reconstruction jointly with the Plastic Surgery Department, and reconstructed the colostomy. A combination of a free tensor fascia lata flap and anterolateral thigh flap was used for the abdominal wall reconstruction. The histopathological findings were pT4b (abdominal wall) N0M0, and pStageIIc, and radical resection was performed. There was no evidence of recurrence at 13 months after the surgery. The combination of a free tensor fascia lata flap and anterolateral thigh flap is a good surgical option for abdominal wall reconstruction in patients with extensive colorectal cancer with abdominal wall invasion.

The patient was a 75-year-old man who had undergone sigmoid colectomy + D3 lymph node dissection for sigmoid colon cancer. The histopathological findings were pT3(SS), pN0, pM0, pStageⅡ. Computed tomography performed 18 months postoperatively revealed a pancreatic neoplasm with ring enhancement in the tail of pancreas, which was diagnosed as either a metastatic or primary pancreatic cancer. We performed distal pancreatectomy and D2 lymph node dissection. Histopathologically, the lesion characteristics were similar to those of the sigmoid colon cancer and the tumor was diagnosed as a pancreatic metastasis. Four years have passed since the surgery, and the patient remains alive without recurrence. Isolated pancreatic metastasis from colorectal cancer is relatively rare and has not been sufficiently investigated. We report this case with some review of the literature.

The patient was a 76-year-old woman who presented with a positive test for fecal occult blood, and colonoscopy revealed a tumor in the rectum and cecum. Histopathological examination of biopsy specimens revealed a benign tumor, however, abdominal CT showed a mass in the rectum that was in contact with the cecum. FDG-PET/CT showed strong accumulation in the rectal tumor. Based on the findings, our preoperative diagnosis was rectal cancer directly invading the cecum, and low anterior resection and ileocecal resection were performed, uneventfully. Histopathological diagnosis of the resected specimen was appendiceal cancer invading the rectum. The patient received no additional treatment after the operation, and at present, 5 years after the operation, she remains free of any evidence of recurrence. A literature search of Igakutyuuouzassi for appendiceal cancer invading the rectum revealed only one case report. Preoperative diagnosis of appendiceal cancer invading the adjacent organs is not easy. In patients with an ileocecal tumor invading the adjacent organs, the possibility of appendiceal cancer, for which radical resection with lymph node dissection is mandatory, should be borne in mind.

An 83-year-old man with chronic hepatitis C received interferon therapy, and a sustained virological response (SVR) was achieved 12 years earlier. Three years later, he developed transverse colon cancer and laparoscopic transverse colectomy was performed. However, the serum concentration of CA19-9 was elevated, and positron emission tomography (PET) showed a tumor showing abnormal uptake of 18F-deoxyglucose in the lateral segment of the liver; therefore, the patient was referred to our hospital. The tumor measured 40 mm in diameter and showed peripheral enhancement in the late phase of contrast-enhanced CT. Magnetic resonance cholangiopancreatography revealed stenosis of the left hepatic duct. Therefore, the patient was diagnosed as having intrahepatic cholangiocarcinoma (ICC) with left bile duct invasion, rather than hepatic metastasis from colon cancer, and left hepatectomy was performed. Histopathological and immunohistochemical examinations revealed the tumor as a moderately differentiated ICC. We report a case of ICC that developed 12 years after the patient achieved SVR to interferon therapy administered to treat chronic hepatitis C.

A 61-year-old man was referred to our hospital for a hepatic mass in segment 6 detected by abdominal ultrasonography. All serologic markers for HBV and HCV infections were negative. The serum concentration of protein induced by vitamin K absence or antagonist Ⅱ was elevated to 86 mAU/ml. Enhanced computed tomography revealed enhancement of the tumor in the early phase and washout during the late phase. Gadolinium-ethoxybenzyl-diethylene-triaminepentaacetic acid-enhanced MRI showed no tumors except for the tumor detected in the hepatobiliary phase; this tumor was diagnosed as hepatocellular carcinoma (HCC), and hepatic resection was planned. At laparotomy, intraoperative ultrasonography indicated a 3-mm nodular lesion close to the tumor in segment 6. Therefore, we performed partial hepatic resection including this small nodule during the operation. On histopathological examination, the tumor in segment 6 was diagnosed as a moderately differentiated HCC, and the small nodule was found to be composed of proliferating small irregular tubules. Immunohistochemical examination showed positive immunoreactivity of the carcinoma cells for cytokeratin (CK)-7, CK-19, NCAM and c-kit, and especially of the luminal surfaces of the tubules for EMA, findings which are typical of cholangiolocellular carcinoma (CoCC). We report a case of CoCC with a concurrent HCC.

Case 1 was a 70-year-old woman who visited a neighborhood doctor with the complaints of swelling and pain in the upper abdomen. Abdominal ultrasonography led to the suspicion of linea alba hernia, and she was referred to our hospital. We confirmed the diagnosis of linea alba hernia by further examination. Laparoscopic surgery was performed, and the hernia orifice (1 × 10 mm) was closed with a TiLENE lightweight mesh via the transabdominal preperitoneal (TAPP) approach. Case 2 was an 82-year-old woman who visited our emergency outpatient department complaining of upper abdominal pain. She was diagnosed as having linea alba hernia by CT, and was referred to our department. We performed conventional anterior approach laparotomy, and closed the hernia orifice (8 × 25 mm) with a Parietex mesh. Laparoscopic surgery for linea alba hernia is not yet common due to the rarity of the disease itself. Herein, we report two very rare cases of linea alba hernia, in one of whom, we were able to safely perform laparoscopic repair of the hernia by the TAPP approach.