A total of 267 cases of laparoscopy-assisted appendectomy in our hospital from July 1999 to December 2007 were divided into two groups, 117 cases operated on until June 2004 (the first term group) and the remaining 150 cases operated on after July 2004 (the latter term group), and were compared for incidence of wound infection and intra-abdominal abscess formation, and postoperative hospital stay between them. Placement of a drainage tube was decided by their operator's judgment in the first term group, but the placement was never done in the latter term group, regardless of the severity of contamination. Laparoscopic surgery was performed under three ports in the both groups, and the mesentery and root of the appendix were transected using by ultrasonically activated scalpel and by stapling device, respectively. Sufficient irrigation with physiological saline was done in case of severe inflammation. In the first term group, a Penrose drain was placed in 57 cases (48.7%). The incidence of surgical wound infection decreased to 1.3% in the latter term group from 7.7% in the first term group, with a statistically significant difference. Intra-abdominal abscess formation was seen in 4.3% in the first term group versus 2.0% in the latter term group, showing no significant difference between them. Our study has led to a conclusion that the placement of a drain is unnecessary after laparoscopic appendectomy regardless of the severity of inflammation.

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Background : Recently, several randomized clinical trials have questioned the value of preoperative mechanical bowel preparation (MBP) in colorectal surgery patients. The aim of this study was to assess whether colorectal cancer surgery can be performed safely without MBP.
Methods : 467 patients undergoing elective colon or rectal resection with primary anastomosis were prospectively randomized into two groups. One group had preoperative MBP, and the other group did not have MBP. The duration of surgery, amount of hemorrhage, and incidence of postoperative complications were compared between the two groups.
Result : The demographic and clinical characteristics of the two groups did not differ significantly. There were no significant differences between the two groups in intraoperative outcomes or in the postoperative complication rates.
Conclusion : These results suggest that elective colorectal surgery may be safely performed without MBP.

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Aim : In this paper, we aimed at to clarify factors affecting advantages and disadvantages in terms of acquiring curability and safety in laparoscopic lymph node dissection (LSD) for colorectal cancer. Methods : We conducted a questionnaire survey for 26 institutions in Hiroshima prefecture to make advantages and disadvantages clear in performing LSD. According to the number of their experienced cases of LSD, we classified these institutions into 3 groups, namely inexperienced institution, intermediately experienced institution, and experienced institution groups. Results : These were 8 experienced institutions, 7 intermediately experienced institutions, and 11 inexperienced institutions. In all groups, advantages of LSD were mainly good visual information representing “magnificent view” or “view that can not be acquired in open surgery”. In inexperienced institutions, the good visual information was disturbed by the inability to get good surgical fields. The inability might be caused by operator's unskilled directions, assistant's ineffective retractions of organs, or scopist's poor techniques. Conclusions : In order to acquire curability and safety in LSD for colorectal cancer, it is necessary for all operative lineups, namely operator, assistant, and scopist, to build up good visual informations in surgical fields.

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Radical retropubic prostatectomy (RRP) is considered to be a cause of provoking inguinal hernia. In this study we examined characteristics of patients with inguinal hernia after RRP in our hospital. We enrolled consecutive 77 male patients who were first operated on for inguinal hernia in our hospital from December 2005 to December 2008. They were divided into two groups according to their previous histories of undergoing RRP, the post-RRP group (n=14) and the control group (n=63), and were comparatively studied for involved site, cause, and procedures for the hernioplasty. No significant differences were noted in the patient side classification, but as for operative procedure used for repair, mesh-plug method was more frequently employed in the post-RRP group than the control group (85.7% vs. 31.7% with a significant difference).
It has been reported that procedures performed during RRP can impair the shutter mechanism of the internal inguinal canal and resultantly entail an increasing risk of indirect inguinal hernia. When RRP is scheduled for a patient with prostate cancer, we have to explain the possibility of having postoperative inguinal hernia to the patient, and we should also consider making a prophylactic repair of internal inguinal canal case by case.

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The proper management of recurrent inguinal hernias is controversial. We reviewed 62 adult patients surgically treated for recurrent inguinal hernias ; 43 (69.3%) of 62 recurrent inguinal hernias were direct hernias. The average interval from surgery to recurrence was 4.3±3.6 years after mesh plug hernioplasty and 1.2±1.0 years after Kugel hernia repair ; these intervals were shorter than the 19.2±13.7-year interval after tension-repair. From 1998 to 2005, the most frequent surgical technique for treating recurrence was the posterior preperitoneal approach. Starting in 2006, the Millikan modified mesh plug hernioplasty was the most frequently used surgical technique. No spermatic cord injuries or chronic groin pain due to nerve injury occurred despite the re-opening of the inguinal canals. The Millikan procedure is potentially useful for the treatment of recurrent inguinal hernias because it is particularly-well-suited for treating direct hernias, which are the most common type of recurrence ; it also has a good safety record.

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The author developed latex and chemical allergy due to the use of surgical latex gloves. Latex gloves should be powder-free and inner polyurethane gloves when double gloving can prevent chemical allergic reactions. The author has worked as a surgeon since 1985. He initially developed a skin irritation related to the use of surgical gloves. He then developed a latex-allergy (type I allergy) with asthma and latex-fruits syndrome, as well as a severe systemic delayed cutaneous type IV allergy. He had to discontinue practising surgery in 2004. Aerosol from latex glove powder can result in a latex-allergy. Thus, latex gloves should be powder-free. The author tried to resume his surgical practice by wearing synthetic gloves. However, he redeveloped a delayed cutaneous type IV chemical allergy. Subsequently, in 2008 he successfully employed a new double gloving technique which involves the use of an inner additive-free nonsterile polyurethane glove (DuraCLEAN^® with LYCRA^®) disinfected with alcohol to prevent chemical allergic reactions. The allergic reactions have markedly subsided. Therefore, latex gloves should be powder-free and inner polyurethane gloves should be used when double gloving to prevent allergic reactions.

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The patient was a 77-year-old man with carcinoma of the papilla of vater who underwent pylorus-preserving pancreatoduodenectomy. He developed rapidly progressive respiratory dysfunction 44 hours after the operation. Under assisted ventilation, his arterial blood gas tension continued to deteriorate. Neither anastomotic leakage nor intestinal ischemia was found at the time of emergency exploratory laparotomy 60 hours after the initial operation. Despite intensive medical efforts, he died of multiple organ failure, 83 hours after the initial operation. Aeromonas hydrophila (A. hydrophila) was isolated from blood and ascites. A. hydrophila septicemia is relatively rare. Furthermore, this septicemia is rapidly progressive and is associated with a high mortality rate before the final diagnosis. Taking adequate precautions against A. hydrophila would have an important role in preventing septicemia after surgical operations.

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A 44-year-old woman visited our hospital because of discomfort in her right axilla. A swollen lymph node with good mobility was palpable in the right axilla, and ultrasonography revealed a low echoic mass with irregular shape. Surgical biopsy was performed and the pathological findings suggested metastasis of poorly differentiated adenocarcinoma. Immunohistochemical study showed that estrogen receptor and progesterone receptor were positive. Positron emission tomography revealed standard uptake value max 6.6 in the rt. thoracic wall below the breast as well as in the axilla. A subcutaneous tumor was palpable in the right inframammary region. Extirpation of the tumor led to the diagnosis of invasive lobular carcinoma, pleomorphic type. She underwent additional excision of the right breast and axillary nodes dissection. The final diagnosis was accessory breast cancer with Level-I lymph nodes metastases. The patient underwent CEF therapy as adjuvant chemotherapy.

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A 79-year-old man who had been suffering from postprandial pain for 4 months, underwent gastroendoscopy which showed multiple ischemic ulcers of the stomach and duodenum. Computed tomography showed severe stenosis of the celiac, superior mesenteric and inferior mesenteric arteries. Our diagnosis was chronic intestinal ischemia and we performed reconstruction of the superior mesenteric and splenic arteries with auto-vein grafts. Ischemic ulcers and postprandial pain improved postoperatively.

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We sometimes see germ cell tumors which grow larger with the normal range of serum AFP after chemotherapy. And if only mature teratoma components are seen in the specimen of the resected tumor, they are called growing teratoma syndrome. The patient was a 25-year-old man. He had undergone resection of a testicular tumor for non-seminomatous germ cell tumor of the right testis. After the operation, left lung metastasis and peritoneal dissemination were found and BEP therapy (BLM+VP-16+CDDP) and TIP therapy (PTX+IFM+CDDP) were performed.
The serum AFP level was normalized, but the lung tumor became larger. Positron emission tomography with F-fluorodeoxyglucose showed little accumulation, which suggested growing teratoma syndrome. He consulted us for operation. Chest CT scan showed a tumor 103×82mm in diameter with smooth surface at a left lung hilar region and it looked larger than that after chemotherapy. CT scan also showed peritoneal dissemination 26×17mm in diameter. Extraction of the left lung and resection of the retroperitoneal tumor were performed. No recurrence has been observed for 24 months after the operation. We should remember the possibility of growing teratoma syndrome in following up a patient with non-seminomatous germ cell tumor, and when it is suspected, surgical treatment should be considered.

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We report a case of Morgagni's Hernia and Larrey's Hernia with breathing difficulty who needed emergency surgery.
A 79-year-old woman who was hospitalized due to nephrotic syndorome developed breathing difficulty. Computed tomography revealed mediastinal deviation due to Morgagni's hernia and Larrey's hernia.
Emergency surgery was performed via the celiac route. Herniation was found via the foramen of Morgagni, with the sac containing the transverse colon and via the foramen of Larrey with just an empty sac. After reducing the transverse colon, the sacs were inverted and removed. Each of the hernia openings was closed with direct sutures. The postoperative course was uneventful, and there has been no evidence of recurrence suice the surgery.

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A 67-year-old woman who had been treated with perctaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in the liver S5/8 6 months earlier was admitted to our hospital because of the sudden onset of right upper abdominal pain. A chest plain X-ray film and an abdominal CT scan revealed a diaphragmatic hernia, and then we performed urgent surgery. On laparotomy, we confirmed that the small intestine had slid into the right thoracic cavity through a defect of the diaphragm burned by RFA.
Hernia of the diaphragm following RFA often occurs when about one year has elapsed after the treatment and sometimes causes the fatal state. The follow-up observation after RFA is thus important and surgical treatment is recommended when the diaphragmatic hernia is found.

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We describe a case with an esophageal hiatal hernia complicated by a gastric volvulus and review the relevant literature. A 59-year-old woman developed epigastric pain and vomiting. CT scans and an upper gastrointestinal series showed that the stomach was rotated in a mesenterioaxial fashion, and that the antrum of the stomach was incarcerated into the lower mediastinum. The patient was diagnosed as having an esophageal hiatal hernia complicated by a gastric volvulus. The attempted endoscopic reduction of the volvulus was unsuccessful. Therefore, a laparotomy was carried out. Adhesions were observed between the esophageal hiatus and the rotated lower body of the stomach. Following reduction of the hernia, the esophageal hiatus was repaired and a gastropexy was performed. Fundoplication was not performed, because the patient had no symptoms of gastroesophageal reflux. The multiplanar CT reformation technique provided detailed anatomical information and was useful for diagnosing the gastric volvulus.

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A 50-year-old woman had been found to have gastric polyposis when she was 45 years old. Gastrointestinal endoscopy at the time revealed numerous small and large polyps in the gastric body and antrum. Over time, the amount of the polyposis increased. The patient's sister was diagnosed as having juvenile gastric polyposis and had a total gastrectomy one year prior to the patient being reassessed. Familial juvenile gastric polyposis was diagnosed, and she had a total gastrectomy. The resected specimen of the stomach had many polypoid lesions of various shapes and sizes the located throughout the stomach. The pathological diagnosis was juvenile gastric polyposis ; in the antrum, adenocarcinoma was found on the surface of an adenoma. Juvenile gastric polyposis is rare. There have been only 22 reported cases in Japan. We present our case of familial juvenile gastric polyposis and review the relevant literature.

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A 64-year-old woman had a distal gastrectomy done 9 years prior for early gastric cancer ; on pathology, the diagnosis was por2>sig, T1 (SM), N2 (25/26), H0, P0 and Stage II. In March 2009, she developed a severe headache, nausea, and vomiting. A cerebrospinal fluid puncture was done adenocarcinoma cells were found, and meningeal carcinomatosis was diagnosed. Intramedullary administration of 10 mg methotrexate 6 times resulted in a remarkable decrease in the carcinoma cell count ; her headaches ceased. However, her general condition deteriorated. She developed multiple lung, liver and skin metastases. The patient died 102 days after being diagnosed. This paper reports a very rare case of leptomeningeal carcinomatosis in a patient treated for early gastric cancer.

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We report a rare case of small cell carcinoma of the stomach. Small cell carcinoma of the stomach accounts for only 0.06—0.2% of all gastric cancer cases.
An 80-year-old woman was found on gastric endoscopy to have a type 3 carcinoma at the lesser curvature of the antrum. On biopsy, an adenocarcinoma (por1) was diagnosed. A distal gastrectomy, a D2 lymphadenectomy, and a Billroth-I reconstruction were performed {T2 (MP), N2, M0, H0, P0, Stage IIIa}. On pathological evaluation. small cell carcinoma (medullary type, INF β, T2 (MP), ly1, v0, n2, stage IIIa) was confirmed. On histopathology, a diffuse proliferation of tumor cells with scanty cytoplasm and round, elliptical, or sphenodial nuclei was seen. Some tumor cells formed peripheral palisading. Immunocytochemistry and histochemistry confirmed that the cells were positive for synaptophysin and chromogranin A. The patient received adjuvant chemotherapy (CPT-11) for 2 years. At present, 61 months after surgery, she is alive without recurrence. Extensive gastrectomy with lymphadenectomy followed by long-term adjuvant chemotherapy is the treatment of choice for gastric small cell carcinoma.

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Case 1 was a 67-year-old woman. She was diagnosed with type 2 advanced gastric cancer. Computed tomography (CT) revealed metastatic lymph nodes around the celiac artery [cT3 (SE), cN2, cM0, cH0, cP0 : c-stageIIIB]. Case 2 was a 66-year-old man. He was diagnosed with type 2 advanced gastric cancer on gastrointestinal endoscopy. CT and staging laparoscopy revealed metastatic lymph nodes in the lesser curvature and around the celiac artery [cT3 (SE), cN2, cM0, cH0, cP0 (CY0) : c-stageIIIB]. Both patients were treated with combination TS-1 and paclitaxel chemotherapy for 2 cycles. After chemotherapy, there was no change in case 1 ; case 2 showed a partial response. Both patients had a total gastrectomy and regional lymph node (D2) dissection. On pathology, no cancer cells were noted in the main tumor area or the lymph nodes ; the histological efficacy was evaluated as grade 3.

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A 68-year-old man admitted for epigastric pain and pyrexia was found by laboratory tests to have elevated serum GOT, GPT, γ-GTP, ALP, amylase and lipase. CT showed bile duct dilation of unknown origin. The papilla of Vater was difficult to observe directly due to the patient having previously undergone total gastrectomy reconstructed by Roux-en-Y anastomosis.
Because his symptoms showed rapid relief, we assumed that a bile duct stone had become dislodged. However, the same symptom recurred seven months later, at which time CT showed a tumor in the horizontal duodenum. Drip infusion cholangiography-CT then clearly showed a pedunculate tumor 30 mm in diameter in the descending duodenum, but its location was different from that seen on the earlier CT.
We suspected that pancreatitis and cholangitis had occurred due to tumor impaction on the left side of the superior mesenteric artery. We then conducted pylorus-preserving pancreaticoduodenectomy. The definitive diagnosis was villous carcinoma in an adenoma of the papilla of Vater.

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Patient 1 : An 87-year-old man was admitted for abdominal pain. Abdominal computed tomography (CT) showed torsion of the small intestine and emergency operation was performed. The small intestine was dilated and twisted about 360° clockwise around the superior mesenteric artery. Patient 2 : A 74-year-old woman was admitted for nausea, diarrhea and anorexia. Abdominal CT showed torsion of the small intestine and emergency operation was performed. Patient 3 : A 28-year-old woman was admitted for lower abdominal pain and diarrhea after excessive consumption of nuts. Abdominal CT showed a positive whirl sign and emergency operation was performed. No necrosis of the small intestine was present, therefore, reduction of the torsion was performed in each of the cases. Excessive consumption of nuts was considered to be the trigger of the torsion in patient 3. We wish to emphasire that attention must be paid to non specific symptoms, such as abdominal pain, vomiting and diarrhea. Early diagnosis can be made from the characteristic abdominal CT findings and a good prognosis can be expected by early treatment without resection of the small intestine.

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A new herniation with strangulation of small bowel complicated a chronically incarcerated, large incisional hernia that contained parts of the right colon ; the incisional hernia had been present for over 40 years. A 68-year-old woman in pre-shock was admitted to hospital. A large incisional hernia in an old appendectomy incision was noted ; it was painful, and there was rebound tenderness. Computed tomograms showed a large amount of evisceration and strangulated small bowel with venous congestion. An emergency laparotomy was performed. The entire ileum was ischemic and the right colon, including the ileocaecal area, that adhered to the sac, as well as elongated and thickened mesentery, were all present in the sac. The hernia porte, 5 cm in size, was opened, and the ischemia of the ileum resolved ; necrosis was avoided. The bowel had been strangulated for 10 hours. The peritoneal space was too small to reduce the hernia due to its chronic nature and the large amount of content present in the hernia. A volume reduction was performed by partial omentectomy. The hernia was repaired using the Composix Kugel patch. The patient was discharged 10 days after surgery. There have been no complications noted on follow-up.

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An 83-year-old male had been hospitalized since he was 79 years old with paralysis of the right side of his body secondary to a brain infarction. A paralytic ileus was diagnosed on single-row detector CT sigmoidoscopy, and X-ray examinations. Then, two days later volvulus of the cecum was diagnosed on multi-row detector CT (MDCT) ; no changes in the patient's general condition or in the abdominal findings were noted compared to two days prior. Emergency surgery was done and the preoperation diagnosis was confirmed. The second case was a 25-year-old female who lived in a facility for the handicapped. She was transferred to the hospital since a strangulated ileus was suspected. Volvulus of the cecum was diagnosed on MDCT, and an emergency operation was performed without delay. Commonly, the diagnosis of volvulus of the cecum is difficult to make because it is rare, and many complications which can obscure the diagnosis can develop prior to presentation. However, an accurate diagnosis has to be made before therapy is given to prevent a fatal outcome. Recently, the rate of diagnosing volvulus of the cecum has improved due to the use of MDCT. We report two cases and review the literature.

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A 59-year-old woman with complaints of fever and abdominal pain consulted her local physician. She was diagnosed with infectious gastroenteritis and received antibiotic treatment. However, owing to a poor treatment outcome, she was admitted to our hospital. Computed tomography (CT) revealed a swollen appendix : we diagnosed acute appendicitis and performed an emergency operation. The appendix and lymph nodes were found to be swollen : we performed ileocecal resection owing to the possibility of a malignant tumor. Histopathological analysis indicated an increased number of lymphocytes in the mucosa of the appendix and the presence of L26-positive cells. We diagnosed malignant lymphoma of the diffuse large B-cell type. This disease should be considered in the differential diagnosis of cases with acute appendicitis associated with a formed mass.

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In April 2009, a 66-year old man with loss of consciousness was admitted to emergency ; blood test results included evidence of a significant acidosis and hyperglycemia. After admission, he complained of left lower abdominal pain ; on CT, portal venous gas and pneumatosis cystoides intestinalis were noted. Emergency surgery was done under a diagnosis of hepatic portal venous gas due to intestinal necrosis ; the necrotic descending colon up to the rectosigmoid was resected. Microscopic findings included necrosis and emphysema in all layers of the intestine ; there were many Klebsiella pnuemoniae organisms in the necrotic intestine. Polymyxin B immobilized five column therapy was given after surgery. His postoperative course was uneventful. The patient was discharged on postoperative day 28.

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Recently, laparoscopic surgery has come to be widely accepted for the treatment of colorectal cancer and has even been employed for advanced carcinoma. Although functional end-to-end anastomosis has been established as an excellent technique, postoperative recurrence at the site of anastomosis using this method has been reported increasingly in recent years. Herein, we report a case of anastomotic recurrence after laparoscopic-assisted functional end-to-end anastomosis for sigmoid cancer. The patient was a 60-year-old woman. We performed laparoscopic-assisted sigmoidectomy for early carcinoma of the sigmoid colon. At 1 year after the operation postoperative recurrence was found at the site of the functional end-to-end anastomosis. We performed resection of the anastomotic recurrence and transanal re-anastomosis with a circular stapler after rectal washout. At present, 6 years 7 months after the first operation the patient remains in good health without evidence of recurrence. Because it is difficult to perform colon washout to prevent tumor implantation during laparoscopic surgery, it is important to handle the intestine gently to prevent to spread of tumor cells into the lumen and resect the tumor while securing a safe surgical margin.

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The patient was a 76-year-old man who had undergone total gastrectomy, splenectomy and cholecystectomy for gastric cancer in September 2001. At that time general findings showed tub2+sig, T3, N2, H0, P0, CY0, M0, and Stage IIIb. Thereafter his clinical course had been followed, without recurrence, until April 2006 when he was seen at the hospital because of constipation. We confirmed stricture encircling the entire lumen of the rectum and then performed abdominoperineal resection with a diagnosis of intestinal obstruction due to a rectal tumor. Histopathological findings did not reveal any abnormalities on the mucosal surface but invasive findings of poorly differentiated adenocarcinoma showing scirrhous pattern arising from the submucoal layer extending to the full thickness of the rectum. Accordingly metastasis of the former gastric cancer was diagnosed.
Metastatic rectal carcinoma is relatively rare and accounts for 0.1-1.0% of all cases of colorectal cancer. Only 23 cases of diffuse invasive metastatic carcinoma of the rectum have been reported in Japan. Although hematogenic and lymphogenic metastatic patterns are probable metastatic pathways, diffuse metastasis is considered to occur in this case.

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A 57-year-old man undergoing maintenance hemodialysis for chronic renal failure was admitted for investigation of the cause of dyschezia. After endoscopic and radiological examinations, low-anterior resection was performed for advanced rectal cancer showing a submucosal tumor-like appearance. Seven months later, elevation of the serum CEA level and multiple lung metastases were found. The patient was administered FOLFIRI therapy (CPT-11 65mg/m²), followed by FOLFOX4 therapy (Oxaliplatin 32mg/m²), FOLFIRI therapy (CPT-11 80mg/m²) and finally, bevacizumab + FOLFOX4 therapy (bevacizumab 5mg/kg, oxaliplatin 85mg/m²), without severe side effects. A colorectal cancer presenting with a submucosal tumor-like appearance is rare and sometimes difficult to diagnose preoperatively. Although no standard adjuvant chemotherapy has been established for renal failure patients with colorectal cancer, we could safely administer the above-mentioned chemotherapies to this patient. Herein, we report this rare tumor and the valuable experience of chemotherapy in a chronic renal failure patient with colorectal cancer.

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A 65-year-old woman, who had been diagnosed with autoimmune hepatitis (AIH) at age 49, was referred to our hospital because of a mass lesion in the S8 region of the liver detected by abdominal CT scan. Hepatitis B virus and hepatitis C virus markers were negative, and serum antinuclear antibody was positive. Abdominal CT scan and hepatic angiography indicated that the mass lesion was a hepatocellular carcinoma (HCC), and partial hepatectomy was performed in April 2006. The resected specimen from the non-tumorous lesion showed AIH, and the 4 cm in diameter tumorous lesion was a moderately differentiated HCC. Although many studies have speculated that the development of HCC based on AIH might be related to immunosuppressive therapy, hepatitis virus and liver cirrhosis, there was no history of these disorders in this case. Therefore, the possibility of HCC should regularly be considered when following up AIH long-term.

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A 10-year-old boy was admitted due to epigastric pain and vomiting. He had a history of recurrent abdominal pain ; malposition of the gallbladder had been noted on abdominal ultrasonography. Abdominal ultrasonography and CT done on admission showed that the gallbladder was deviated medially, and that its wall was thickened. MRCP failed to show apparent obstruction of the cystic duct. However, torsion of the gallbladder could not be ruled out. Thus, a laparoscopic examination was done. The gallbladder was twisted counterclockwise, 270 degrees, around the cystic duct ; torsion of the gallbladder was diagnosed. The gallbladder was untwisted, and a laparoscopic cholecystectomy was done. Laparoscopic cholecystectomy is useful in such patients, though the surgery must be done with caution.

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An 82-year-old man was admitted due to pyrexia and abdominal pain. Computed tomography scans with contrast medium showed a solitary lesion encircling the superior mesenteric artery, as well as dilatation of the intrahepatic bile duct and the common bile duct. Endoscopic guided fine needle aspiration biopsy was performed, and no histological evidence of malignancy was found on cytology. The patient had high serum IgG4 levels. Based on the diagnosis of IgG4-related sclerosing cholangitis, oral predonisolone was started at 30 mg/day. Although the tumor decreased in size after steroid therapy, the stenosis of the bile duct persisted. Five months after the admission, cholangiojejunostomy was performed because the bile duct stent became occluded frequently.

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We report a case of a left-sided gallbladder and two concomitant descending colon cancers, treated successfully by laparoscopic cholecystectomy and partial colectomy. A 60's man was found to have a gallstone and two descending colon cancers. Preoperative abdominal computed tomography confirmed the presence of a gallstone, but it was not possible to determine whether the gallbladder was left-sided. Based on the diagnosis of cholelithiasis and two descending colon cancers a standard laparoscopic cholecystectomy and partial colectomy were done. Laparoscopy revealed that the gallbladder was located on the left side of the hepatic falciform ligament. The operation was performed safely, and the patient had an uneventful postoperative course. Left-sided gallbladder is a rare congenital anomaly, which was first documented in 1886. We report this case to discuss the key procedures required to perform a safe laparoscopic cholecystectomy of a left-sided gallbladder based on our experience and a review of the relevant literature.

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There is a disease group characterized by intraductal papillary growth, mucin overproduction, gastric and intestinal epithelium formation, and expression of MUC2 and CK20. It is called intraductal papillary neoplasm of the bile duct (IPNB) and is acquiring increasing interest. Patient 1 was 65-year-old man who underwent expansion lobus sinister excision with a diagnosis of S4 cholangiocarcinoma. The definitive pathological diagnosis was intrahepatic cholangiocarcinoma with IPNB. Patient 2 was a 49-year-old woman who underwent liver 3 segmentectomy, extrahepatic bile duct excision and bile-duct anastomosis with a diagnosis of hilar cholangiocarcinoma. The definitive pathological diagnosis was IPNB, borderline. In the treatment of cholangiocarcinoma, a possibility of IPNB must be kept in mind.

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Although mucin-producing carcinoma of the pancreas and bile duct have been well documented, there are few reports on mucin-producing carcinoma of the gallbladder. Here we report a case of gallbladder carcinoma with marked production of mucus. The case involved a 49-year-old woman who was admitted to our hospital because of upper abdominal pain. Abdominal US and CT showed a 40mm-sized papillary tumor of the gallbladder and a swollen lymph node no.12c. MRCP showed a shadow defect in the gallbladder without abnormalities of the bile duct. Abdominal angiogram showed tumor staining and encasement of the cystic artery. Based on these findings, the tumor was diagnosed as advanced cancer of the gallbladder and S4a+S5 resection, bile duct resection, lymph node dissection, and choledocho-jejunostomy were performed. An abundunt yellow mucus and a papillary tumor were recognized in the gallbladder. Histopathological diagnosis of the tumor was moderately differentiated tubular adenocarcinoma, ss, pT2, pN2, and Stage III. The postoperative course was uneventful. At the last follow-up, 4 years after discharge, the patient remained well. We also reviewed the Japanese literature of mucus-producing cancer of the gallbladder.

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We report a case of signet-ring cell carcinoma of the gallbladder. A 66-year-old woman was seen at another hospital because of epigastric pain. Abdominal ultrasonography and computed tomography (CT) demonstrated a polypoid lesion in the gallbladder. The patient was admitted to our hospital with a diagnosis of gallbladder polyp or gallbladder cancer. She underwent a laparoscopic cholecystectomy. The resected specimen revealed an irregular-shaped tumor on the mucosal surface of the gallbladder. Histological findings showed signet-ring cell carcinoma infiltrating into the subserosa. The diagnosis of gallbladder cancer was made and S4a, 5 bisegmentectomy of the liver with regional lymph node dissection (D2) was performed for the purpose of curative operation. She had no postoperative complications and the pathological examination indicated no residual carcinoma cells. She has been alive without recurrence as of 27 months after the operation. Signet-ring cell carcinoma of the gallbladder is so rare that only 14 cases including this case have been reported in Japan.

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A 57-year-old man was found to have a lateral abdominal mass which was suspected of being a malignant pancreatic tumor. Abdominal CT scan showed a 15-cm-diameter cystic tumor with a partly thickened wall originating from the pancreatic body. FDG-PET accumulation in the tumor and ascites were observed indicating peritoneal dissemination. On aspiration biopsy results, an islet cell tumor was diagnosed. Given a diagnosis of islet cell tumor with peritoneal dissemination, which was thought to have induced an episode of unconsciousness and progressive anemia, a surgical resection was done. On pathology, a well-differentiated neuroendocrine carcinoma was diagnosed. Peritoneal dissemination and liver metastasis were noted three and five months, respectively, after the operation. Chemotherapy was not effective, and the patient died 13 months after surgery.

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We report four cases of pancreatic cancer with intraductal papillary mucinous neoplasm (IPMN). In all cases, the IPMN was an intraductal papillary mucinous adenomas, and the accompanying pancreatic cancer had an advanced stage : 2 cases had stage III, one stage IVa, and one had stage IVb. The prognosis was poor in all cases. Other investigators have suggested that the synchronous or metachronous occurrence of pancreatic cancer of the ordinary type occurs in 10% of IPMN cases. All 4 of our IPMN cases were identified based on symptoms or imaging studies, results as also having advanced stage invasive ductal carcinoma of the pancreas. Therefore, the prognosis of these patients was poor. Given these findings, careful follow-up of IPMN patients is important, to facilitate the early diagnosis of pancreatic cancers.

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We report the case of a 30-year-old woman with a big cavenous hemangioma on her right arm by birth. Who was referred to our hospital with abdominal distention. Laboratory data revealed evidence of DIC, therefore, she was admitted to our hospital.
Abdominal CT and ultrasonography revealed splenomegaly and massive ascites. We diagnoused a rupture of the spleen and emergency operation was performed immediately. Histopathological examination of the resected specimen revealed hemangiomatosis of the spleen.
The cavenous hemangioma of the spleen was a component of systemic hemangiomatosis. Systemic hemangiomatosis is extremely rare. Splenic hemangiomas are at a mgh rsk of rupture, hemorrhage and DIC, therefore, early diagnosis and treatment are necessary. We have reported our case and presented a review of the literature.

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We present two cases of umbilical urachal sinus which were successfully treated by laparoscopic resection. A 23-year-old man (case 1) and a 17-year-old woman (case 2) presented to the hospital with omphalitis. After conservative treatment with antibiotics and drainage, both underwent a laparoscopic resection using a three-port method under pneumoperitoneum. After the resection of bilateral medial umbilical ligaments, the umbilical urachal remnant was resected from the bladder and dissected off the abdominal wall. The confluence of the urachus and the bladder was ligated using absorbable sutures and the intracorporeal knot tying technique. In case 1, the umbilicus was completely resected due to the presence of chronic inflammation ; subsequently, an umbilical plasty was done. In case 2, since the infection had subsided by the time of the operation, her umbilicus could be preserved. Laparoscopic resection of the umbilical urachal remnant using the intracorporeal knot tying technique is useful as it results in a good cosmetic outcome that is cost-effective.

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The patient was a 41-year-old male who visited a clinic because of an abscess around the umbilicus in 1999, when the symptom was improved by drip infusion of an antibiotic. Although urachal remnant was suspected no further treatment was done at that time. The abscess recurred on August 29, 2008 and he visited our hospital. A fistulogram revealed a cavity localized in the umbilical tail side. A CT scan of the abdomen confirmed a funicular structure adhered to the abdominal wall from the umbilical tail side to the bladder side. As a result, the patient was diagnosed as to have urachal remnant. Due to recurrent bouts of omphalitis and strong desire of the patient, laparoscopic operation was performed on October 16, 2008. The patient's postoperative course was favorable. The patient was discharged on the next day after the operation. Histopathological examinations disclosed that urachal tissue consisted of fibrous tissue alone on the umbilical side but it was covered with columnar epithelium only on the bladder side.
This patient was the 23^rd case of laparoscopic extraction of urachal remnant in Japan. Due to the anatomical characteristic that the lesion was located in the abdominal wall in this case, some devices were needed in the position to insert the trochars and the development of surgical field, which led to safe and complete removal of the urachal remnant.

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A 72-year-old woman was admitted due to lower abdominal discomfort. She had had a simple hysterectomy with bilateral salpingo-oophorectomy for rupture of the right ovary 20 years ago, and the surgical removal of an intraabdominal synovial sarcoma tumor 10 years ago. Imaging studies revealed an intraabdominal tumor ; a synovial sarcoma relapse was diagnosed. However, the detailed examination of both the present specimen and the tissue resected 10 years ago suggested that the current lesion was histologically similar to the granulosa cell tumor, which had been noted in the ruptured ovary 20 years ago. Thus, an intraabdominal granulosa cell tumor of the ovary recurred 20 years after initial surgery. Our case highlights that recurrent disease should be included in the differential diagnosis when evaluating an intraabdominal tumor in a patient with a history of a gynecological tumor such as a granulosa cell tumor.

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An 88-year-old woman had been admitted with a fracture of the right thigh bone. She complained of abdominal pain on the night of POD 10. Her symptoms then worsened. The next day abdominal computed tomography (CT) showed dislocation of the small intestine into the omental bursa with ascites. The diagnosis was strangulated ileus due to a transomental hernia. The same day she was treated by emergent laparoscopic surgery. The strangulated small intestinal loop had prolapsed into the omental bursa through the omental orifice. It was revealed that strangulated ileus hael been caused by the transomental hernia. The intestinal loop was repositioned without resection of the small intestine and the omental hiatus was repaired by laparoscopic surgery. Laparoscopy is very useful for clarifying the true cause and, moreover, the treatment of internal hernias.

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A 32-year-old female visited a hospital because of epigastralgia. Abdominal ultrasonography and abdominal computed tomography (CT) revealed an intra-abdominal tumor. She was referred to our hospital for diagnosis and treatment. The 35×30mm tumor was located in the great omental space. The tumor was homogenously enhanced on abdominal CT. In order to obtain a definite diagnosis and perform adequate treatment, a diagnostic single incision laparoscopy (single 25mm horizontal incision at the lower edge of umbelicus) was performed. The resected tumor was histopathologically confirmed to be Castleman's disease of the hyaline-vascular type. The post-operative course was uneventful and the patient was discharged on postoperative day 7. It is very difficult to diagnose a small abdominal tumor. The diagnosis was achieved only by histologic evaluation of the surgical specimen. The single incision laparoscopic approach alloweel resection of the lesion with consequent histological diagnosis and exploration of the peritoneal cavity with the advantages of minimal invasiveness. The pathology was thereby totally resolved with satisfactory results in terms of recovery, postoperative pain, and cosmetics.

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In evaluating the long-term intensive treatments essential for short bowel syndrome, we analyzed 10 cases of acute superior mesenteric arterial (SMA) occlusion. Abdominal CT scan detected a smaller superior mesenteric vein (SMV) sign in five out of seven cases, which was useful in making preoperative diagnosis even in noncontrast-enhanced CT. The greater part of the small intestine and part of the colon which became necrotic were resected in all 10 cases. Six patients who were able to be eventually discharged from the hospital had a mean residual jejunum length of 75 cm. Four patients requiring no parenteral nutrition had a mean intestinal length of 95 cm, compared to 35 cm for the two still requiring parenteral nutrition. We report here a case of a 68-year-old man with a 20-cm residual jejunum after surgery for SMA occlusion. He has been unable to eat orally and requiring total parenteral home nutrition, and suffered from catheter infection requiring 24 catheter replacements. Despite survival exceeding for more than 5 years, longer than that of reported cases so far, his quality of life is not necessarily good.

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A lumbar hernia rarely occurs in the lumbar triangle. We report a case of a superior lumbar hernia that was repaired using a Direct Kugel Patch.
A 68-year-old female presented with a mass located in the right lumbar area. She was diagnosed as having a superior lumbar hernia based on computed tomography findings. During surgery, a defect measuring 3×3 cm in size was found in the transversalis fascia, and fat tissue was observed to have prolapsed through it. Hernia repair was carried out using a Direct Kugel Patch. The postoperative course was uneventful, and she was discharged on postoperative day 4.
To date, several reports of a lumbar hernia repaired with a prosthesis have been published. However, this is the first repair using a Direct Kugel Patch reported in Japan.

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In November, 2008, an 83-year-old man was admitted to the hospital with a left flank mass, first noticed about ten years earlier. The mass prolapsed into the left back in the upright position and disappeared in the prone position. The diagnosis was confirmed by magnetic resonance imaging (MRI), which revealed a lumbar muscle defect and prolapsed fatty tissue around the kidney. With the diagnosis of superior lumbar hernia, hernioplasty was performed in January 2009. The hernial orifice was surarounded by the 12th rib, the serratus posterior inferior, the internal oblique muscle, and the quadratus lumborm muscle. The fatty tissue was prolapsed according to breath. The hernial orifice was repaired with a PHS because the surrounding tissue was fragile. Lumbar hernia is rare. Petit's operation involving suture of the muscles surrounding the hernia orifice has been popular. Recently, the use of artificial materials such as a Mesh plug, PHS, and the Kugel patch has increased, based on the concept of tension-free repair. We report this case of lumbar hernia, which was repaired using a PHS.

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A 57-year-old woman was admitted to the hospital because of a soft mass in the left lumbar region. The mass measured 7cm in size. Abdominal computed tomography and magnetic resonance imaging revealed the dignosis of left superior lumbar hernia. At operation, the hernia orifice was found to be about 2cm in diameter, with the retroperitoneal fat tissue prolaping through the orifice. A mesh plug was inserted into the orifice and an onlay patch was fixed to the superior lumbar triangle. The postoperative course was uneventful, and the patient has been followed up for 15 months without any evidence of recurrence.
Lumbar hernia is a very rare condition. Hernia repair using the mesh plug method is advantageous, as it allows tension-free repair without complications.

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Vesicoceles and obturator hernias are rare entities. An obturator hernia involving the urinary bladder is even rater. A 96-year-old female developed a fever. A right obturator hernia was found on CT. Since, there was no evidence of intestinal invcivement on obturator hernia involving the urinary bladder was suspected. On retrograde cystography, an obturator hernia of the urinary bladder was diagnosed. Since, the patient had no symptoms related to a hernia, and her fever subsided with conservative therapy, she is being followed. This is the first case of an obturator hernia of the urinary bladder reported in Japan.

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An 84-year-old female developed paroxysmal right inguinal pain one year prior to admission. The pain had been present for a few days when abdominal MRI and CT scan revealed incarcerated small intestine between the right pectineus and internal obturator muscles. Incarcerated right obturator hernia was diagnosed, but the symptoms disappeared, Abdominal CT scan was performed again and demonstrated no small intestine incarceration. This finding confirmed that the incarcerated obturator hernia had been spontaneously reduced. Thereafter, we employed an inguinal approach. The hernia opening was closed using a Direct Kugel Patch. We confirmed adequate patch range by laparoscopy. This method appears to be a very beneficial approach in that it is less invasive and allows prevention of other hernias.

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A 69-year-old man developed right inguinal pain associated with a right inguinal mass swelling about 20 cm×15 cm in size ; the skin was erythematous, A plain abdominal computed tomography scan showed an indirect right inguinal hernia with bowel loops within the sac. Laboratory test results reflected a very pronounced inflammatory state. Emergency surgery was done for the entrapped hernia. An acute appendicitis was found in the hernia sac. Thus, this case was diagnosed as having an Amyand's hernia. Usually, a strangulated inguinal hernia is diagnosed in patients with groin swelling and pain. However, Amyand's hernia should be considered in the differential diagnosis of patients with an entrapped inguinal hernia.

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A 74-year-old male visited our hospital complaining of a left inguinal mass that had gradually enlarged over a 4-month period. On CT and ultrasonography, a hematoma was diagnosed. An aspiraton biopsy was done, but the hematoma gradually re-expanded. Thus, a chronic expanding hematoma (CEH) was diagnosed based on the patient's clinical course. Therefore, a partial resection of the mass was done. The postoperative course was uneventful, but the hematoma recurred two months later. The residual capsule of the mass was the likely cause of the recurrence. Thus, a total en-bloc resection was performed. The patient has been well for 19 months ; there has been no recurrence. On pathology, amyloid deposition was found in the capsule. It is likely that the expansion of the hematoma was due to chronic inflammatory stimulation.

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