Purpose: Incarcerated obturator hernia often requires emergency surgery and has a poor prognosis with a high mortality rate. We devised a repositioning maneuver for this condition that we refer to as “Four hand Reduction for incarcerated Obturator hernia under Guidance of Sonography (FROGS)” and here we report this procedure and its advantages. Materials and Methods: FROGS requires a surgeon and an assistant, and use of sonography. The surgeon detects the tip of the hernia sac with sonography. The assistant holds the patient’s leg on the lesion side, and bends, stretches or rocks it inward and outward, slowly and repeatedly. Meanwhile, the surgeon manually compresses the tip of the hernia sac under observation with sonography. Thirty-six patients with incarcerated obturator hernia were treated at our hospital between April 2016 and September 2020. FROGS was introduced in November 2019. The patients were divided into those treated before and after introduction of FROGS. The rates of successful reduction, bowel resection, complications, and mortality, and the length of hospital stay were retrospectively compared between the non-FROGS and FROGS groups. Results: There were 13 patients in the FROGS group and 23 in the non-FROGS group. There were no significant differences in patient characteristics between the two groups. Successful reduction was achieved in all patients in the FROGS group (100%), but in only one patient in the non-FROGS group (4.3%) (P<0.001). The rate of bowel resection was significantly lower in the FROGS group than in the non-FROGS group (P=0.03). The FROGS group had lower rates of complications and mortality and a shorter hospital stay than the non-FROGS group, although without significant differences. Conclusion: FROGS is a useful repositioning maneuver for incarcerated obturator hernia that has advantages of simplicity and reproducibility.

A 69-year-old woman was admitted to our hospital after suffering from dysphagia, left cervical tenderness and hoarseness for 1 month. A diverticulum from the left side of the esophagus was detected, and resection of the diverticulum was performed through an external cervical incision. During surgery, balloon-assisted endoscopy was used for diagnosis of a Killian-Jamieson diverticulum. When suturing the muscular layer of the esophagus, balloon-assisted endoscopy was used again to prevent stenosis of the esophageal lumen. The operation was performed without complications and the patient has been free of dysphagia, esophageal stricture, and recurrent diverticula postoperatively. Killian-Jamieson diverticulum is relatively rare and often asymptomatic, but may occasionally cause dysphagia or esophageal reflux symptoms. Compared to a Zenker diverticulum, a Killian-Jamieson diverticulum arises anatomically closer to the recurrent laryngeal nerve, and the cricopharyngeal muscle may not be implicated as a cause. To avoid intraoperative injury of recurrent laryngeal nerve and unnecessary cricopharyngeal myotomy, it is important to distinguish between Killian-Jamieson and Zenker diverticula. Our case shows that balloon-assisted endoscopy is useful for diagnosis of the diverticulum and prevention of intraoperative complications.

A 32-year-old woman visited our hospital with complaints of abdominal pain and vomiting. Six months earlier, she had been diagnosed with diaphragmatic hernia, but this was left untreated due to being asymptomatic. Two months after this diagnosis, she became aware of abdominal discomfort after a meal, and subsequently she had weight loss of 5 kg. A CT scan revealed that the stomach prolapsed into the thoracic cavity from the left outside of the esophageal hiatus, and diaphragmatic tissue was found between the hernia orifice and esophagus. From these findings, parahiatal hernia was diagnosed. We returned the contents of the hernia under laparoscopy and then closed the hernia orifice with sutures. Parahiatal hernia differs from paraesophageal hiatal hernia, in that there is diaphragmatic tissue between the esophageal hiatus and hernia orifice. Diagnosis is generally difficult, but can be made by detailed observation with CT. Laparoscopic surgery, which is minimally invasive and has a good field of view, is useful for curative treatment of this condition.

Juvenile gastric gastrointestinal stromal tumors (GISTs) are rare and differ from the common variety of GISTs. We present a case of a patient with juvenile gastric GIST with lymph node metastasis. A 25-year-old woman presented for treatment of a gastric tumor (7 cm). Esophagogastroduodenoscopy revealed a main submucosal tumor in the mid-body of the stomach and two other submucosal tumors. Abdominal CT revealed a phyllodes tumor (7 cm) with calcification on the stomach wall. PET/CT showed fluorodeoxyglucose uptake in the main tumor and in one regional lymph node. The patient was diagnosed with juvenile multiple gastric GISTs with lymph node metastasis and underwent total gastrectomy with D2 lymph node dissection. We detected four tumors in the stomach, and all were diagnosed as GISTs. Metastasis in regional lymph nodes was also confirmed. Genetic analysis did not show mutations in the KIT or PDGFRA genes; therefore, the patient was diagnosed with wild-type GIST and follow-up was planned without initiation of adjuvant chemotherapy. The patient has shown no recurrence for 1 year postoperatively. Juvenile multiple gastric GISTs frequently metastasize to lymph nodes, and molecular-targeted drugs such as imatinib are ineffective in such cases. Therefore, these tumors warrant a therapeutic strategy that differs from the approach used for the common type of GISTs.

The patient was a 16-year-old boy who had suffered from vomiting and been treated conservatively by a local pediatrician for more than 3 years. He was referred to our department due to no improvement in the symptom. The angle and distance between the aorta and the superior mesenteric artery (SMA) were reduced to 13° and 5.6 mm, respectively, indicating SMA syndrome. Conservative treatment was continued at our department, but there was still no improvement and surgical treatment was considered unavoidable. From among various reported treatment options, we selected laparoscopic double tract reconstruction with the goals of a maximum therapeutic effect and an acceptable aesthetic outcome, given the young age of the patient. The procedure involved two anastomoses and thus the operative time was relatively long (205 minutes), but the whole procedure was completed under a laparoscopic view. The patient had an uneventful postoperative course and was discharged from hospital 10 days after surgery. The surgical technique used in this case is a viable treatment option for SMA syndrome because it can maintain the physiological pathway while keeping the advantages of duodenal transposition.

Herein we present a case of laparoscopic cholecystectomy in a patient who was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient was a 56-year-old man with acute cholecystitis. During preoperative workup, he was revealed to be SARS-CoV-2-positive, but without any signs of pneumonia. As treatment of acute cholecystitis was complicated by asymptomatic coronavirus disease 2019 (COVID-19), nonoperative management with antibiotics was initiated. However, his condition deteriorated to gangrenous cholecystitis and obstructive cholangitis on the 8^th day of symptom onset. A multidisciplinary team discussed the treatment and perioperative risk mitigation strategy against viral transmission. After sharing information and simulation of preventive measures, laparoscopic cholecystectomy and C-tube drainage were performed on the 11^th day of symptom onset, when we thought that infectiousness should have declined significantly. During surgery, protective measures against surgical smoke were applied using pneumoperitoneum devices equipped with an ultralow particulate air filter. We report our experience of perioperative risk mitigation strategies in laparoscopic surgery for a patient who was positive for SARS-CoV-2.

A 65-year-old man was introduced to our hospital with a complaint of back pain. He had undergone several abdominal surgeries in childhood and was recognized to have a short bowel. Hyperuric acidemia, hypertension, hyperlipidemia, and chronic nephropathy were also observed. He was found to have distal cholangiocarcinoma with regional lymph node involvement on contrast-enhanced abdominal CT and was diagnosed with distal cholangiocarcinoma of Class V on bile cytology. From the standpoint of nutrition, the remnant length of the small intestine was a concern, and the influence of pancreas resection needed to be carefully evaluated. The length of the residual small intestine was measured using a Synapse Vincent system to determine the surgical indication for pancreaticoduodenectomy. After, subtotal stomach-preserving pancreaticoduodenectomy, we started mainly with central venous nutrition management from the viewpoint of digestion and absorption. After confirming improvement of intestinal function with elemental diets, eating with pancreatic enzyme administration was started. There are few reports of pancreaticoduodenectomy in a patient with a short bowel. The indication for pancreaticoduodenectomy may be feasible by careful examination of residual pancreatic function and residual small intestinal function.

A 74-year-old man underwent construction of a sigmoid colon stoma by a laparoscopic Hartmann operation for perforation of the sigmoid diverticulum. The patient subsequently underwent stoma closure, but then had an abdominal wall hernia in the midline wound and stoma closure site. We performed Endoscopic Mini/Less Open Sublay (EMILOS) repair for two large abdominal incisional hernias in the midline wound and stoma closure site. There were no significant postoperative complications, and currently, at 4 months after surgery, there has been no hernia recurrence. There have been several recent useful reports of laparoscopic incisional hernia repair. In this case, we were able to perform abdominal wall reconstruction by the EMILOS procedure with a small incision and single incision laparoscopic surgery.

We analyzed the characteristics and clinical courses of 7 patients with ulcerative colitis complicated with non-toxic megacolon who underwent surgery in our department. All cases were total colitis, and the median age at the time of diagnosis of megacolon was 51 years. Treatment before diagnosis of megacolon was 5-ASA and an intensive intravenous regimen in 6 cases, while 1 case was untreated. After diagnosis, the intensive intravenous regimen was continued in 3 cases, infliximab was started in 3 cases, and an intensive intravenous regimen was started in the untreated case. The surgical indications were perforation in 2 cases and refractory in 4 cases. Postoperative histopathological findings revealed ulcers deeper than the muscular layer in all cases, and we found that one of the refractory cases had covered perforation after surgery. Postoperative complications were intraabdominal abscess in 3 cases, SSI in 1 case, ileus in 1 case, leakage in 1 case, pneumonia in 1 case, and myocardial infarction in 1 case. These findings show that even if a case with megacolon is asymptomatic, it is likely to be accompanied by ulcers deeper than the muscular layer. Therefore, there is a possibility of perforation such as toxic megacolon, and this is considered to be an indication for surgery.