Breast tumors are generally detected by self-palpation or during medical check-ups that include a radiological examination; however, sometimes they are detected as incidental findings by computed tomography (CT) performed for other diseases. Since September 2017 our hospital has been using an incidental CT finding follow-up system to prevent missing incidental findings. In the study reported here we assessed the clinicopathological features of breast lesions incidentally detected by CT performed for further examination of other diseases, not for evaluation of breast lesions. The 20 cases detected by our system between September 2017 and September 2023 were referred to breast specialists for further examination and included in our study. Nine (45.0%) of the cases were diagnosed as primary breast cancer. The median age of the nine patients was 72.7 (51-89) years, and 5 of the 9 lesions were difficult to detect by palpation. Eight of the nine were early-stage lesions, and more than half of the 9 were of the luminal A-like subtype, which has a good prognosis. Careful examination of CT scans for possible breast lesions an incidental findings is essential for treatment and a better outcome.

A 79-year-old woman with a diagnosis of gastrointestinal perforation, presenting with abdominal pain and intra-abdominal free air on computed tomography scan. Prior to the perforation, she had received chemotherapy for advanced breast cancer for 3 months, and the chemotherapy had shown efficacy: a tumor in the right axilla involved lymph nodes reduced in size from 54 mm to 21 mm, and the serum level of the tumor marker, CEA, decreased from 17.4 ng/ml to 10.5 ng/ml. Emergency laparotomy revealed an 8-mm perforation of the jejunum, 20 cm from the Treitz ligament. We performed a partial small bowel resection. Histopathological examination showed tumor cell invasion of the submucosal to subserosal layers. The tumor cells exhibited edematous changes, suggesting cellular degeneration and the antitumor effects of chemotherapy. Intestinal perforation due to breast cancer metastasis is extremely rare, and the mechanism of such perforation remains unclear. In this case, evidence of the efficacy of chemotherapy was obtained from the imaging findings, serum tumor marker levels, and histopathological findings. Based on the findings, we considered that the intestinal perforation was caused by the response to chemotherapy in this case.

The patient was a 57-year- old male patient with a history of swelling and pain from the left thigh to the lower leg and breathlessness on exertion who was referred by his local doctor to the dermatology department of our hospital, and was examined 4 days later by us at the surgery department. Computed tomography showed thromboembolism in the pulmonary and below the left common iliac vein, and he was hospitalized urgently. On the same day, an inferior vena cava filter (IVCF) was placed through the right internal jugular vein. The patient developed chest pain, decrease in percutaneous arterial oxygen saturation, and fall of blood pressure on the 4th day after placement of the IVCF. Computed tomography on the 7th day showed improvement of the pulmonary embolism, but a trapped thrombus in the IVCF, upward deformation of two arms of the IVCF, and perforation of the inferior vena cava by one of the bent arms. The IVCF was retrieved via a right internal jugular vein approach, and no findings of bleeding were found out of inferior vena cava. The swelling in the left lower limb decreased, breathing difficulties were confirmed, and the patient was discharged from the hospital on the 24th day. There are no previous reports of deformation of the arms of an IVCF due to a trapped thrombus in the early phase after IVCF placement.

A 45-year-old man presented to an emergency department because of the sudden onset of chest pain. Contrast-enhanced CT showed a Stanford type B aortic dissection extending from the subclavian artery to the bilateral external iliac arteries and creating a dynamic obstruction of the superior mesenteric artery (SMA). After consultation with cardiovascular surgeons, the patient was admitted for conservative treatment, but when a few hours later his abdominal symptoms became progressively more severe, emergency thoracic endovascular aortic repair (TEVAR) and exploratory laparoscopy were performed. Because some parts of the small intestine showed poor contrast on an indocyanine green (ICG) test, we decided on open abdomen management for follow-up purposes and performed a second-look operation 48 hours later. The ischemic intestinal area showed improvement macroscopically, and an ICG test showed improved blood circulation. In the end, we did not resect the small bowel.

TEVAR may be effective in treating some types of SMA occlusion associated with acute aortic dissection. Moreover, exploratory laparoscopy with the use of ICG and OAM may be possible to preserve the intestinal tract if necrosis is suspected.

A patient was a 48-year-old man with mental retardation and pica admitted to a care facility. He underwent laparoscopic partial resection of the small intestine for accidental ingestion of a newspaper on January,20XX. At one month after hospital discharge, he was referred to us for severe vomiting because of accidental ingestion of a vinyl glove. Endoscopic extraction failed because of incarceration at the lower esophagus. We then removed the vinyl glove by cooperative single-incision intragastric surgery and endoscopic surgery. The vinyl glove was moved into the stomach using an endoscopic and laparoscopic forceps and then removed via a gastrostomy.

Single-incision intragastric surgery is less invasive and more esthetic as compared with open or laparoscopic surgery. Cooperative single-incision intragastric surgery and endoscopic surgery may be considered as a useful, minimally-invasive strategy for removal of foreign bodies from the esophagus.

A 77-year-old man with hematemesis was transported to our hospital. He had undergone aortic valve replacement and was taking antiplatelet medication. Enhanced abdominal computed tomography revealed highly absorbable contents in the stomach, suggesting bleeding. Laboratory findings showed anemia and hypoproteinemia. An emergency esophagogastroduodenoscopy (EGD) revealed a coagulum in the stomach and active bleeding from the upper gastric body. We attempted to control the bleeding by clipping and hypertonic saline epinephrine injection; however, an EGD performed on the following day revealed that the bleeding was persistent, and we performed total gastrectomy. Histopathological examination of the resected specimen showed dilated gastric glands. The patient was discharged on postoperative day 22. We report a case of Ménétrier’s disease with severe hemorrhage.

A 53-year-old man consulted our department due to ascites detected by ultrasonography during admission for a transient ischemic attack caused by occlusion of the right internal carotid artery. He was diagnosed as having a ruptured right gastroepiploic artery aneurysm and hemoperitoneum due to segmental arterial mediolysis, because contrast-enhanced CT showed high-density ascites in the subphrenic and pelvic region, irregular dilatation with narrowing and interruption of the right gastroepiploic artery, and a 40-mm high-density mass at the site of interruption of the artery. As the patient’s vital signs were stable, it was considered that hemostasis had already been achieved. We performed laparoscopic partial resection of the greater omentum, including the aneurysm in the right gastroepiploic artery, the day after the consultation. Histopathological examination revealed segmental arterial mediolysis as the cause of the aneurysm rupture in the right gastroepiploic artery.

Case 1. The first case of perforation at a gastrojejunostomy after subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) was in a 70-year-old woman. Esophagogastroduodenoscopy (EGD) one year postoperatively revealed an ulcer on the efferent loop of the gastrojejunal anastomosis (GA). Six years postoperatively, the patient came to our hospital complaining of left lower abdominal pain. A CT scan revealed perforation of the GA ulcer, and surgery was performed. The perforation was found on the efferent loop of the GA.

Case 2. The second case of perforation of a gastrojejunal anastomosis after SSPPD was in a 63-year-old man. EGD one year postoperatively showed multiple erosions in the efferent limb of the GA. At 64 months postoperatively he was admitted to our hospital with a chief complaint of left flank pain, and a CT scan revealed perforation of the GA ulcer. The symptoms and signs were mild and improved in response to conservative treatment, but 7 years postoperatively, the GA ulcer perforation recurred, and we reoperated. The patient’s compliance with his antacid medication was poor. It is important to perform regular EGD examinations after SSPPD, and if a GA ulcer is found, continuous antacid therapy is necessary. Conservative treatment may be an option in mild cases of perforation at a gastrojejunal anastomosis after SSPPD.

A 63-year-old man visited our hospital for a gastrointestinal endoscopy. Endoscopy revealed a submucosal tumor located in the anterior wall of the duodenal bulb. Histopathological examination of the tumor revealed the diagnosis of neuroendocrine tumor (NET) G1. We performed Single Incision Laparoscopy and Endoscopic Cooperative Surgery in this patient. The patient was discharged on the 7th postoperative day without any complications. Several surgical options have been reported for treating NETs in the duodenum, but our method is considered as being a more useful, minimally invasive therapeutic option for NETs of the duodenum as compared with endoscopic surgery or the conventional LECS procedure.

A 66-year-old female patient who was diagnosed as having superior mesenteric artery (SMA) syndrome was referred to our department for surgical intervention, after failure of conservative therapy. Abdominal computed tomography revealed narrowing of the aorta-SMA angle to 14°, and an upper gastrointestinal series showed a contrast filling defect dorsal to the SMA in the first part of the duodenum. Consequently, we performed a laparoscopic bypass with a double tract. The patient was discharged on the 10th postoperative day without complications; no postoperative recurrence of the symptoms was observed thereafter. Based on our experience of this case, we believe that a laparoscopic bypass with a double tract is a minimally invasive and effective procedure for SMA syndrome that is refractory to conservative therapy.

The patient was a 74-year-old male who had undergone repair of a right inguinal hernia using a mesh plug 16 years earlier. He visited our hospital complaining of pain and swelling of the right groin.

Abdominal computed tomography revealed abscess formation in the right lower abdominal wall, and colonoscopy revealed an exposed mesh plug in the cecum. We diagnosed the patient as having cecal penetration caused by the mesh plug and performed laparoscopic cecal resection and mesh plug removal. Since no infected granulation tissue or pus accumulation was found between the mesh plug removal site and the onlay patch, we determined that the infection could be controlled with preservation of the onlay patch and decided not to remove it. There were no signs of infection or hernia recurrence eight months after surgery. If the mesh plug and onlay patch were completely removed in cases of infection after mesh plug surgery, there would be concern about the hernia recurring in the long term. We encountered a case of delayed gastrointestinal perforation accompanied by infection, which was treated by preserving the onlay patch.

The patient was a man in his 70s who presented with gastrointestinal bleeding. Repeated endoscopy for colonic diverticular bleeding was performed on four consecutive days, but the source of bleeding could not be identified. After the fourth endoscopy, the patient developed extensive retroperitoneal, mediastinal, and subcutaneous emphysema. Although the clinical symptoms were mild, we decided to perform emergency laparotomy because hemostasis could not be achieved for the diverticular bleeding. During surgery, macroscopic serosal lacerations were found in the splenic flexure and sigmoid colon, and we performed left colectomy. Histological examination revealed tears in the muscularis propria corresponding to the macroscopic serosal lacerations and abscess formation in the subserous layer at the site of the preoperative hemostatic clip placement. These were findings of severe invasion that could not have been predicted from the mild clinical symptoms.

There have been some reports of cases in which retroperitoneal penetration after endoscopic examination has been cured conservatively, but the degree of invasiveness associated with endoscopic procedures must be taken into consideration in each individual case, and the appropriative approach must be carefully selected.

We present the case of a patient with an extremely rare variant of the left hepatic vein that drained directly into the right atrium through the diaphragm. We treated the condition in this case by resection of the left lateral segment of the liver along with this venous variant. This is the first reported case of this type of venous anomaly in which the anomalous hepatic vein and its related liver segments were resected in a living human. Although this presentation is extremely rare, it is important for safe hepatectomy to keep in mind that such an anomalous hepatic vein draining directly into the heart could be encountered during liver surgery.

A 27-year-old woman had been diagnosed with a splenic cyst as an incidental finding by a previous physician, and she subsequently complained of pain in the left hypochondrium. She was referred to our institution when a computed tomography examination showed that the splenic cyst had enlarged. Her serum C-reactive protein, carcinoembryonic antigen, and carbohydrate antigen 19-9 concentrations were high. Laparoscopic splenectomy was performed to remove the splenic cyst. To avoid rupturing the cyst and thereby prevent peritoneal dissemination, as well as reduce the risk of bleeding, we ligated the splenic artery early, used 3D retractors, and tried not to grasp the cyst directly. These precautions enabled us to safely perform the laparoscopic splenectomy without any cystic fluid leakage. The pathological diagnosis was epidermoid cyst.

A 69-year-old woman visited our emergency department with a 2-day history of right inguinal pain and swelling. Abdominal enhanced computed tomography revealed an incarcerated appendix in a right femoral hernia. We diagnosed the patient as having a de Garengeot hernia and performed emergency laparoscopic surgery.

Laparoscopic exploration of the abdomen revealed an ischemic appendicitis and contaminated ascites in the hernia sac. Therefore, we performed only laparoscopic appendectomy to prevent infection of the mesh, and covered the hernia defect with a polyglycolic acid （PGA） sheet to prevent re-incarceration of the femoral hernia during the waiting period for the second surgery. Five months later, we performed transabdominal preperitoneal hernia (TAPP) repair. Physical examination showed no recurrence of the femoral hernia at six months after the surgery. A femoral hernia with an incarcerated appendix is termed a de Garengeot hernia. It is a rare disease and its treatment is controversial. We treated it safely by TAPP repair after laparoscopic appendectomy. Herein, we report this case with a review of the literature.

Herein, we report the case of a patient who suffered from traumatic mesenteric injury secondary to a direct hit to his inguinal hernia. A 70-year-old man with a 10-year history of a left inguinal swelling fell while working as a carpenter and hit his left inguinal region against a square timber. He was transported to our emergency department with severe abdominal pain about 1 hour after sustaining the injury. A 2-cm square abrasion was observed in the left inguinal region, and the inguinal bulge, which could be easily retracted in the supine position, became distended later. A plain abdominal computed tomography revealed no free gas, but an intestinal membrane hematoma with a large amount of high-density ascites. We performed surgery with a midline incision. A large coagulum extending from the left paracolonic groove to the small pelvis was observed. Intraabdominal exploration revealed mesenteric contusion, hematoma formation, as well as active bleeding, with no evidence of intestinal perforation. We resected the intestine in a fan shape at the site of the mesenteric injury followed by a functional end-to-end anastomosis. The patient had no postoperative complications and was discharged on the eighth day.

The patient was a 47-year-old man with no past medical history who sought medical advice with the chief complaints of swelling and pain in the left groin area since the previous two months. Manual reduction of the swelling in the left groin area proved impossible. Abdominal CT and MRI revealed a left indirect inguinal hernia and a flat soft tissue mass measuring 28×13 mm in size located in the left inguinal canal. No testis was found in the left scrotum and we diagnosed the patient as having an inguinal mass with left cryptorchidism. We referred the patient to a urologist, who found no evidence of malignancy in the testis but recommended its removal because of the possibility of malignant transformation. Orchiectomy and hernia repair were performed via a left inguinal incision. Histopathological examination of the resected testis revealed no evidence of malignancy. Cryptorchidism is one of the most common diseases in pediatric urology and most cases are detected and treated during childhood health checkups. Herein, we report a rare adult case of an inguinal hernia associated with cryptorchidism who was treated by surgery.

Obturator hernias are most common in thin, elderly women. Although surgery is the primary treatment, patient factors can make general anesthesia challenging. We report two cases of obturator hernia treated by laparoscopic hernia repair using a totally extraperitoneal (TEP) approach under epidural anesthesia.

Case 1: The patient was a 71-year-old woman who presented with symptoms of ileus secondary to an obturator hernia. Surgery was performed following bowel decompression. Case 2: The patient was a 98-year-old woman who experienced recurring groin pain caused by an obturator hernia, and since her symptoms were mild, she was treated by elective surgery. Both cases were in thin, elderly women in whom general anesthesia was deemed risky because of their overall health condition. We therefore performed surgery under epidural anesthesia, and both patients had favorable postoperative outcomes.

Our experience suggests that performing surgery under epidural anesthesia is a viable treatment option for patients in poor general condition and that it provides a safe alternative to general anesthesia.