[in Japanese]

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This study was conducted to assess the usefulness of peritoneal lavage cytology as a prognostic factor in colorectal cancer patients. The subjects were 687 colorectal cancer patients who underwent resections for colorectal cancer and peritoneal lavage cytology from January 2005 to April 2014. Cases were considered ‘positive’ when diagnosed as class III-V. The association between positive peritoneal lavage cytology and clinicopathological features or prognostic factors was investigated. Multivariate analysis showed that depth of invasion (T4), lymphatic invasion (ly2-3), and peritoneal dissemination were independent risk factors for positive peritoneal cytology. In the patients who underwent curative resection, overall survival and disease-free survival two years after operation were significantly shorter in the positive cytology group. Positive peritoneal lavage cytology is a risk factor and a significant prognostic factor in colorectal cancer.

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The patient was an 86-year-old woman who had been followed after total mastectomy for left breast cancer at the age of 52. She was pointed out a right breast mass at the age of 84 and 2 years later, she noticed a 6-cm tumor with redness of the skin at the right breast. Ductal carcinoma in situ was diagnosed by preoperative fine needle biopsy cytology. However, clinical and imaging findings revealed the presence of invasive component of carcinoma and posed a strong suspicion of axillary lymph node metastasis. Right breast cancer, cT4bN3M0, cStage IIIC, was thus diagnosed. Right total mastectomy and axillary lymph node dissection were performed. The postoperative final histopathological diagnosis was microinvasive carcinoma with predominant non-invasive component associated with xanthogranulomatous inflammation ; axillary lymph node metastasis was absent and pT1miN0M0 in pStage IA was determined.
Xanthogranulomatous inflammation rarely affects the mammary gland. We present our experience with a case of breast cancer associated with xanthogranulomatous mastitis in which preoperative diagnosis of clinical stage was difficult.

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A 57-year-old woman presented to a local clinic with pain and discomfort in her left breast. She was diagnosed with c-T4bN1MO stage IIIb locally advanced breast cancer and referred to our hospital for treatment. Needle biopsy cytology performed at our hospital revealed squamous metaplastic triple-negative breast cancer. A clinically objective tumor response was evident at the conclusion of four cycles of EC100 therapy and four cycles of docetaxel (75 mg/m²) as preoperative chemotherapy, and pectoral muscle-preserving mastectomy and axillary lymph node dissection were performed. On histopathological testing of the resected specimens, there were no residual cancer cells in either the tumor or the axillary lymph nodes. Many patients with this type of breast cancer are resistant to preoperative chemotherapy, and it is hoped that regimens with a high cure rate will be established in the near future with the aim of achieving a complete response.

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An 84-year-old man came to the hospital with anorexia and a 10-kg weight loss over the past three months ; he also had frequent vomiting that had started the day before admission. On abdominal examination, the pulsing aorta was palpable. Abdominal computed tomography showed an abdominal aortic aneurysm (AAA), distal to the bifurcation of the renal artery, with a maximum diameter of 64 mm. The aneurysm compressed the third portion of the duodenum, so the stomach and the oral side of the duodenum showed prominent expansion. The patient was admitted with a diagnosis of duodenal obstruction by an AAA. An upper GI series showed delay of contrast material reaching the second to third portions of the duodenum, which confirmed the diagnosis of compression by the AAA. Abdominal aortic replacement was performed on the 17th day to allow him to resume oral intake. He was discharged on the 21st post-operative day. Duodenal obstruction caused by an AAA has rarely been reported, which implies that it is a rare disease.

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An 83-year-old woman was admitted for multiple rib fractures from the left 3rd to the 11th ribs, a flail chest, pulmonary contusion, hemo-pneumothorax, and abdominal injuries. Immediately after admission, tracheal intubation was performed and positive-pressure ventilation was initiated ; however, such internal fixation was not successful for improving the pain or the paradoxical movement of the chest wall. We decided to perform early surgical stabilization of the rib fractures on day 5 after admission, for the purpose of early weaning from mechanical ventilation and for providing pain relief. Preoperatively, we identified which rib fractures mainly affected her respiration and caused chest pain, and then we performed minimal fixation of these fractured ribs. Soon after the operation, the patient could be weaned off from the ventilator. Thus, early fixation of rib fractures causing flail chest should be considered in aged patients. Furthermore, identification of the rib fractures mainly causing the symptoms is crucial to improve the pain and dyspnea with minimally invasive intervention.

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An 87-year-old woman, with a history of right rib fracture 5 years earlier, was admitted to hospital complaining of epigastralgia and dyspnea that had started the previous night. Respiratory sounds were barely audible over the right lung. On chest X-ray, her right lung was almost radio-opaque, with odd niveau-like shadows. CT scan showed dilated small intestine and an effusion in the right pleural cavity. A diaphragmatic hernia was highly suspected. Since she was developing shock and respiratory distress, she underwent emergent laparotomy through an oblique incision in her right upper quadrant. An ileal segment was incarcerated in the right pleural cavity through an orifice about 2 cm in diameter at the top of the right diaphragm. The orifice was incised and widened enough to pull back the ileal segment. As the right lung was inflated, her vital signs improved remarkably. The necrotic segment was resected and anastomosed. The hernia orifice was closed by a running 3-0 monofilament nonabsorbable suture. Her postoperative course was uneventful, though intensive care was required for two days. This case demonstrates that posttraumatic diaphragmatic hernia can have an acute onset following a long dormant period and lead to a life-threatening event.

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A 72-year-old man underwent total gastrectomy for gastric cancer with a Roux-en-Y reconstruction. While the patient was stable soon after the surgery, on postoperative day 14, he developed left upper abdominal pain and a high-grade fever. Laboratory findings suggested liver dysfunction associated with cholangitis and an abdominal CT showed a markedly dilated duodenum with mild dilatation of the bile duct. Thus, a diagnosis of afferent loop obstruction associated with cholangitis was made. Percutaneous transhepatic cholangiodrainage (PTCD) was performed under US guidance, and the duodenal dilataion improved. Cholangiography using the catheter confirmed stenosis of the jejuno-jejunostomy causing the afferent loop obstruction. Continuous drainage of the duodenum using the PTCD catheter was effective for the management of the afferent loop obstruction. On day 66 after the start of the PTCD, the catheter was removed. Thus, PTCD appeared to be a very effective procedure for treating the afferent loop obstruction without surgery.

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Case 1 : A 54-year-old man visited our hospital with the complaints of fever, nausea, and lumbago. Examinations revealed space-occupying lesions (SOLs) in the liver and a gastric submucosal tumor. Case 2 : A 73-year-old man presented to our hospital with the complaints of fever, dizziness, and loss of appetite. A SOL in the liver and a gastric submucosal tumor were detected. Both patients were treated with intravenous antibiotics because of suspected liver abscesses based on the clinical findings, and their symptoms and liver lesions improved. After treatment of the liver abscesses, both patients were successfully treated by laparoscopic wedge resection. Histopathology revealed a schwannoma in Case 1, and a GIST in Case 2. The liver abscesses were assumed to have been caused by the intra-gastric bacteria in the infected necrotic tissue of the submucosal tumor reaching the liver via the portal vein. As there are few reports of liver abscesses caused by gastric submucosal tumors, we report our cases with a review of the relevant literature.

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A case of a 64-years-old man who was diagnosed as having idiopathic thrombocytopenic purpura 6 years earlier and was followed without therapy is reported. He was seen in our hospital because of complaints of anorexia and black stool. Gastrointestinal endoscopy showed a type 2 tumor at the gastric antrum, and the histopathological diagnosis was moderately well differentiated tubular adenocarcinoma. Thus, gastric cancer, cT2 (MP), cN0, cM0, cStage IB was diagnosed. For preoperative therapy he received steroid and high-dose immunoglobulin. Distal gastrectomy was performed safely without blood transfusion, the blood platelet count increased after surgery, despite tapering and stopping of the steroid in 2 weeks. The blood platelet counts have been more than 10×10⁴/μL for 2.5 years after surgery.

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A 66-year-old male patient underwent laparoscopy-assisted distal gastrectomy for cancer of the pyloric antrum. High fever and an increase in the CRP level developed on the 6^th postoperative day. Abdominal abscess due to a pancreatic fistula was diagnosed following a CT scanning. Conservative therapy was started which resulted in a temporary relief of inflammatory reaction, but the symptoms recurred on the 17^th hospital day. We determined the patient to be a candidate for drainage. However, we could not gain any safe route for percutaneous puncture and then performed endoscopic ultrasonography (EUS)-guided drainage. Thereafter his high fever and increased CRP level rapidly dropped. After an abdominal CT scan confirmed a significant decrease in the retained fluid, the patient was discharged from our hospital on the 47^th hospital day.
In instances in which conservative therapy is unsuccessful and percutaneous fine needle drainage is difficult for pancreatic fistula formed after surgery for gastric cancer, EUS-guided drainage can be the treatment of choice.

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A 20-year-old woman with no previous histories including laparotomy was referred to our hospital complaining of abdominal pain. An abdominal contrast-enhanced CT scan revealed an extensively dilated small intestine with poor imaging effect, wall thickening with hemorrhagic necrosis and massive ascites in the pelvic space. We diagnosed the case as strangulation ileus and performed an emergency laparotomy. In intraoperative findings a loop of the ileum was wrapped by another loop of the ileum. Both loops became necrotic. Strangulation ileus due to knotting two loops of the ileum was diagnosed and we performed an ileocecal resection including a 130-cm long segment of intestine proximal to the necrotized terminal ileum. She resumed to have meal from the 4^th post operative day. The clinical course was good and she was discharged on the 11^th postoperative day.
Ileo-ileal knot causing strangulation ileus is very rare. The disease can evolve into ischemia and progress rapidly. In treating strangulation ileus, a possibility of this disease should be kept in mind.

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Primary volvulus of the small intestine not caused by congenital malrotation or postoperative adhesions is a relatively rare entity, and in such cases as it is accompanied by a gangrenous small intestine, the prognosis is poor. We encountered a very elderly female patient with primary volvulus of the small intestine for whom massive resection of the small intestine was performed. Although she developed short bowel syndrome after the surgery, she had a good outcome.
A 90-year-old female admitted to another hospital for treatment of enteritis developed abdominal distention and vomiting, and was referred to our hospital with a diagnosis of small bowel obstruction. Abdominal CT scan showed a whirl-like sign suggestive of small bowel volvulus. Upon laparotomy, we found a gangrenous small intestine with mesenterium twisted clockwise by about 360°. After detorsion, the extensive gangrenous small intestine was resected. The residual small intestine was about 50 cm in length with the ileocecal junction which was kept intact. Since there were no apparent causes such as operative adhesion, anatomical abnormalities, and malformation, primary small intestine volvulus was diagnosed. Postoperatively, she had frequent bouts of watery diarrhea and was diagnosed with short bowel syndrome, but thereafter diarrhea got better. She was able to take orally without IVH on and after 48^th postoperative day.

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A baby girl delivered at the gestational age of 38 week's was referred to our department because of an intraabdominal cyst diagnosed prenatally. There were no specific symptoms after birth. USG revealed a cyst-like structure with gut signature, and CT showed a cystic mass in the abdomen containing air. A preoperative diagnosis of duplication of the alimentary tract or Meckel's diverticulum was made, and a laparoendoscopic single-site surgery was performed when the baby girl was ten months old. An inverted Y-shaped incision was made at the umbilicus, and laparoscopic exploration revealed a cystic mass sharing a common wall and blood supply with the ileum on the mesenteric side. We exteriorized the duplication cyst with normal ileum from the umbilical incision, and performed resection of the segment of the small bowel including the cystic mass. Histopathology revealed that the ileal duplication cyst was lined with gastric epithelium. The postoperative course was uneventful.

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A 78-year-old man consulted his doctor for a mass in the left side of the abdomen. Abdominal computed tomography scan revealed a multilocular tumor in the left side of the abdomen. Considering the possibility of the mass being malignant, a laparotomy was performed. The tumor was found located in the mesentery of the jejunum and adhered closely to the jejunum wall. Therefore, tumor removal with partial resection of the jejunum was performed. The final pathological diagnosis was lymphangioma of the jejunal mesentery. The patient was discharged 10 days after the surgery. This report documents a rare case of lymphangioma of the jejunal mesentery in an adult.

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We report a case of ileocecal intussusception due to Burkitt lymphoma. A 17-year-old male was admitted to the hospital for right lower abdominal pain. He was treated with antibiotics. The next day, he was transferred to our hospital and diagnosed as having an ileocecal intussusception by computed tomography.
Ileocecal resection was then performed. Laparotomy showed intussusception due to an ileocecal tumor. The histological diagnosis was Burkitt lymphoma. A cytogenetic analysis showed a specific translocation of t (8 ; 22) (q24 ; q11). CODOX-M/IVAC chemotherapy was administered, and the patient achieved remission.
Burkitt lymphoma is a rare disease, and the prognosis is poor. Recent developments in chemotherapy have introduced the possibility of a complete cure. Therefore, combined therapy including immediate surgery is needed for accurate diagnosis.

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An 89-year-old man was referred to our hospital because of fever, anorexia, and dyspnea. An enhanced CT scan showed pneumonia and acute appendicitis with an abdominal abscess. Interval appendectomy was performed after improvement of the pneumonia. Pathological findings showed gangrenous appendicitis with many old ova of Schistosoma japonicum in the submucosal layer of the appendix.
There have been no new patients with Schistosoma japonicum in Japan since 1978 because of the eradication of Miyairi shellfish, the intermediate host, and a few cases with old ova of Schistosoma japonicum have been reported. However, imported infections of Schistosoma japonicum have recently been increasing. We should consider the possibility of active infection with Schistosoma japonicum when its ova are detected in the resected specimen.

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A 66-year-old woman underwent barium gastrography as part of a medical check-up in 2010. After she took the laxative, passage of watery stools was observed but not of white stools. On day 4 after the examination, she visited a nearby clinic because of abdominal pain, and an abdominal CT showed ileus. When she developed persistent vomiting, the patient visited our hospital, and a repeat abdominal CT obtained at our hospital revealed free air around the sigmoid colon with leakage of barium. The patient was diagnosed as having perforation of the sigmoid colon, and an emergency Hartmann operation was performed.
Perforation of the colon after a gastrointestinal barium series is rare ; while 2-4 cases per 10,000 have been reported following barium enema, there are scarce reports after gastrography. We suggest that as the number of subjects with constipation is likely to increase because of an aging society, it is necessary to monitor subjects undergoing gastrointestinal barium series very carefully, for example, ensuring excretion of the barium.

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We performed right hemicolectomy for diverticular perforation in a 65-year-old man who had undergone pancreaticoduodenectomy for bile duct cancer three years earlier. Macroscopic examination of the resected specimen showed diverticular perforation and irregularity of the colon on the anal side of the diverticulum. Histopathological examination showed a tumor infiltrating the submucosa and muscularis propria. The expression pattern of cytokeratin and Cdx2 on immunohistochemical examination was consistent with bile duct cancer origin rather than colon cancer origin, and we diagnosed the patient as having developed colonic metastasis from bile duct cancer.

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The patient was a 72-year-old woman who consulted a local doctor for a chief complaint of dizziness. Upon examination, she was found to have marked anemia with a hemoglobin level of 4.7g/dL, and she was then referred to our hospital for detailed examination and treatment. After examination, she was diagnosed with ascending colon cancer, and right hemicolectomy was planned. During the surgery, a lesion (sSS) was noted about 6 cm from the oral end of the ileum. A combined resection of the ileal lesion and right colon was performed. Histopathological examination revealed a type II lesion in the resected specimen of the ileum, and the patient was diagnosed as having ascending colon cancer (por1 > muc) and small intestinal cancer (muc > tub2). The ileal lesion was considered to be the primary small intestinal cancer because the mucosal lesion was the principal lesion with no exposure of the serous surface, and also because the lesion exhibited the type II form on visual inspection. The patient is alive 21 months after the surgery. Synchronous cancer of the small and large bowel is rare, with only 25 cases found in Japan.

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A 77-year-old woman underwent a left hemicolectomy for transverse colon cancer. Histopathological examination revealed poorly differentiated adenocarcinoma (SS, N1, H0, P0, M0, Stage IIIa). The patient then received adjuvant chemotherapy for 6 months (capecitabine and oxaliplatin). Nine months after the hemicolectomy, computed tomography (CT) revealed a tumor in the left adrenal gland. Positron emission tomography-CT did not detect any other metastatic lesions. The patient was diagnosed as having solitary adrenal metastasis, and a left adrenalectomy was performed. Pathological findings of the resected specimen indicated metastatic adenocarcinoma from the colon cancer because of the similarities between the histological characteristics of the two lesions. The patient is still alive at 12 months after the adrenalectomy with no evidence of recurrence.
We report a rare case of solitary adrenal metastasis from colon cancer. Surgical resection might improve the prognosis of such lesions.

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A 68-year-old woman presented to a local doctor with the chief complaint of weight loss in August 2011. She was referred to our hospital for detailed examination and treatment of a suspected liver tumor. A computed tomography scan of the abdomen revealed multiple masses in the liver, and lower gastrointestinal endoscopy revealed sigmoid colon cancer. Tumor marker testing showed normal carcinoembryonic antigen (<0.5 ng/mL) and carbohydrate antigen 19-9 (10.9 U/mL) levels, but elevated alpha-fetoprotein (AFP) levels to 123.3 ng/mL. The patient was diagnosed with multiple liver metastases concurrent with sigmoid colon cancer and underwent laparoscopic sigmoidectomy. After the operation, the AFP level decreased to 20.4 ng/mL. Mild immunostaining of AFP was found in the tumor, leading to a diagnosis of AFP-producing sigmoid colon cancer. Postoperatively, systemic chemotherapy was performed for the treatment of liver metastatic lesions. However, the patient died 7 months after surgery of extensive metastases. We report a rare case of AFP-producing sigmoid colon cancer with a review of the literature.

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The patient was a 58-year-old man who underwent sigmoidectomy for sigmoid colon cancer. The tumor was diagnosed as moderately differentiated adenocarcinoma and was staged as T3 N0 M0 Stage II (TNM classification) by histopathological examination. Seven years later, abdominal computed tomography and MRI examinations showed a tumorous lesion, 14 mm in diameter, at segment 6/7 of the liver. Laparoscopic partial hepatectomy was performed. Histopathological examination revealed a moderately differentiated adenocarcinoma, which was immunohistochemically diagnosed as a metastasis from the sigmoid colon cancer.
Postoperative recurrence of colon cancer occurs mostly within 5 years from the primary resection, and the Japanese guidelines for the treatment of colorectal cancer recommend 5-year follow-up after surgery. The recurrence rate after the first five years from primary surgery in our institution was 0.56%. Recurrence after 5 years from surgery has been reported in various stages of colorectal cancer progression, with a favorable prognosis after resection. Regular screening examinations should be conducted even after 5 years of follow-up in the group at high risk of late recurrence.

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A 74-year-old woman who had had anal bleeding at defecation since December 2012 presented to the Department of Gastroenterology in our hospital in March 2013. Colonoscopy revealed a type 2 tumor encircling three-fourths of the circumference of the rectosigmoid junction. An abdominal CT scan showed a fused kidney in the pelvic cavity. She was referred to our department for the purpose of surgery in May of the year. Crossed renal ectopia is believed to be a comparatively rare congenital anomaly of the kidney. Among crossed ectopic kidneys, the lump kidney is characterized by that the fused kidney is located in a portion where is lower than the normal location and is often associated with anomalies of the ureter and renal artery and vein. Accordingly anatomical understanding of locations of them is important in performing surgery for rectal cancer. This time we have experienced a case of rectal cancer associated with a lump kidney. Since the patient had undergone operations for gastric ulcer and for a myoma of the uterine, we employed anterior resection under laparotomy. Before the surgery, we used fusion images with 3D CT and other various images to understand locations of the intestine, ureter, and vessels, for that we could complete surgery without causing intraoperative complications such as injury of the ureter. The 3D-CT fusion imaging might be beneficial in performing surgery for rectal cancer associated with kidney anomalies.

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A 50-year-old man visited our hospital with the chief complaints of abdominal pain and vomiting. An abdominal CT revealed ileus and pneumobilia, and the patient was admitted. A gastroduodenography performed during insertion of the ileus tube revealed a cholecystoduodenal fistula. Upper gastrointestinal endoscopy was performed and an incarcerated piece of gall-stone was taken out from the fistula. DIC-CT was performed for evaluation of the biliary tract, which revealed a filling defect at the site of obstruction of the small intestine, and gall-stone ileus was strongly suspected. An urgent operation was performed and another piece of a broken gall-stone was taken out from the small intestine. No operation for the cholecystoduodenal fistula was performed as the biliary tract could not be clearly visualized by radiologic examination. Four weeks later, the cholecystoduodenal fistula was closed endoscopically. The patient was discharged without symptoms and has been under close follow-up without operative surgery.

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We report a case of gallbladder metastasis from renal cell carcinoma. A 72-year-old man who was being followed up for liver cirrhosis had undergone left nephrectomy for renal cell carcinoma 2 years ago. A gallbladder polyp detected on abdominal ultrasound 1 year before the nephrectomy was found to have enlarged to 10 mm over the follow-up period. The patient underwent laparoscopic cholecystectomy to remove the gallbladder tumor. Histological examination revealed clear cell carcinoma that had developed under the mucosal epithelial layer of the gallbladder. The gallbladder tumor was diagnosed as metastasis from the renal cell carcinoma, which is rare.

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A case of splenic peliosis growing like a solid tumor that was difficult to distinguish from a submucosal tumor of the stomach is reported. An asymptomatic 63-year-old woman was found to have an abdominal tumor on CT examination while she was being investigated for other disease. On CT, there was solid tumor between the stomach and spleen. It looked like a solid tumor arising from the stomach. Upper gastrointestinal endoscopic examination showed that the tumor was covered with normal gastric mucosa. Endoscopic ultrasound examination also showed similar findings. The preoperative diagnosis was a submucosal tumor of the stomach. Laparotomy demonstrated that the tumorous lesion was arising from the spleen, and splenectomy was performed. The pathological diagnosis of the resected specimen was splenic peliosis.

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A woman in her sixties, who had an abdominal abscess with a long-term placement of an intrauterine contraceptive device and received removal of the device, had multiple abdominal masses including a left ovarian mass. An ovarian tumor with multiple peritoneal metastases was suspected, and she received detailed examinations. During the examinations, the ovarian mass was found to have penetrated into the sigmoid colon and then she had to undergo an emergency operation because of acute peritonitis with severe inflammation due to an enlargement of the abdominal mass. Resection of the uterus and ovarium with drainage of the abscess and temporary ileostomy was performed. Numerous Gram-positive bacilli were observed in the resected tissue, and Actinomyces israelii was detected by the bacterial culture. In this case, it was considered that abdominal actinomycosis might be caused by the long-term placement of the intrauterine contraceptive device. After oral administration of penicillin for postoperative 6 months, she has had no recurrence as of 2 years and 8 months.
This case report suggests that the long-term placement of an intrauterine contraceptive device can cause abdominal actinomycosis.

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A 65-year-old woman was referred for abdominal distention. CT and MRI of the abdomen showed massive ascites and a soft-density mass with an irregular surface in the lower abdomen. High FDG uptake by this tumor was seen on positron emission tomography. The patient's serum CA125 level was high. Aspiration cytology of the ascites showed agglomeration of atypical cells.
No abnormal findings were seen in the gastrointestinal tract, ovaries, and uterus. The patient underwent exploratory laparoscopic surgery, and the omental tumors were resected as much as possible. Pathological examination showed serous papillary adenocarcinoma with infiltrative growth, diagnosed as peritoneal serous papillary adenocarcinoma. Chemotherapy with paclitaxel+carboplatin, commonly used for ovarian cancer, was conducted postoperatively. Chemotherapy was temporarily successful, but the tumor and ascites increased. She remained in good general condition for concentrated ascites reinfusion therapy (CART), but she died 18 months after surgery. It is important to consider this type of case in the differential diagnosis of primary carcinoma of unknown origin.

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A 66-year-old woman admitted to our hospital because of a 2-day history of back pain. She had neither fever nor stomachache. The laboratory data showed high inflammatory reaction, including the white blood cell count of 22,290/μl and the CRP of 35 mg/dl. Abdominal simple CT scans revealed a low density area in the retroperitoneal space which was 8 cm in diameter. The space was located in the left side of the abdominal aorta and from the 3rd to 5th lumbar vertebrae. Abdominal ultrasongraphy showed a low echoic lesion of homogeneous density. We diagnosed it as retroperitoneal abscess formation, and an emergent operation was performed on the same day. Midline laparotomy disclosed fluid collection in the retroperitoneal space, and 350 ml of milky fluid was drained. We washed the space using saline and placed a closed suction drain. The fluid was odorless and showed a high TG finding (1,129 mg/dl), so we diagnosed it as chylorrhea. She took low fat diet from the 2nd postoperative day and the drain was removed on the 9th postoperative day. She was discharged from our hospital on the 12^th postoperative day. Because she had no previous histories of recieving operations or injury, idiopathic retroperitoneal chylorrhea was diagnosed. We report the case with a review of previous reports of similar cases.

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A 24-year-old woman was admitted to the hospital because of nausea after a meal. Abdominal CT scan showed a cystic tumor in the left posterior side of the descending colon.
Her abdominal wall was flat and soft ; the tumor was not palpable. A well-demarcated, 50 mm × 32 mm, cystic tumor was detected in the same location as CT on T2-weighted magnetic resonance imaging (MRI). The tumor had no solid component. Under a diagnosis of benign retroperitoneal tumor, laparoscopic resection was performed without rupturing the tumor capsule. The cyst content was filled with mucus, and the cytology was benign.
On biochemical examination, CEA and CA125 levels were high. Pathologically, the tumor was diagnosed as a mucinous cystadenoma that originated from the retroperitoneum. The patient has been well, without evidence of tumor recurrence, for 9 months since surgery.

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A 50-year-old female visited our hospital because of an abdominal mass detected at a medical checkup. She was affected with tuberous sclerosis. Contrast enhanced CT scan revealed a 10-cm retroperitoneal tumor with fatty density at the dorsal aspect of the ascending colon. We performed laparotomy and found a retroperitoneal angiomyolipoma. Renal angiomyolipoma is the major comorbidity of tuberous sclerosis, and in this case there were findings of renal angiomyolipoma as well. However, extrarenal angiomyolipoma rarely occurs in tuberous sclerosis patients. Retroperitoneal angiomyolipoma has been reported in 32 cases to date. This is the first case report of retroperitoneal angiomyolipoma associated with tuberous sclerosis.

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The patient was a 54-year-old woman, who had mainly been treated by adrenocortical hormone therapy since she was diagnosed with systemic lupus erythematosus (SLE) in 2004. She noticed a fist-sized bulge in the left flank in the mid-June of 2012. An abdominal CT scan for the bulge revealed a diagnosis of ventral hernia at the left flank and she was referred to our hospital. When she was first seen, she had no abdominal symptoms and we decided to observe her clinical course, considering a risk of postoperative complications due to a long-term steroid therapy. Thereafter the hernia rapidly enlarged and she complained of pain and nausea, so that we performed surgery. Operative findings included an about 8 × 22 cm rupture of the abdominal wall muscle and an infant's head sized hernia sac which prolapsed through the rupture. The repair of the hernia was done by turning the sac inside out and by fixing a Ventrio^TM Hernia Patch between the peritoneum and transverse muscle of the abdomen. The postoperative course was uneventful and she was discharged from our hospital on 9^th postoperative day.
We here present a case of an a ventral hernia which might be caused by long-term steroid administration and an increase in the abdominal pressure, together with a review of the literature.

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A 59-year-old woman, who drove a car after she had taken a hypnotic, lost consciousness and ran into a telephone pole. She was brought into the hospital by ambulance, when she complained of right flank pain, but was decided to be followed. About one month later, she noticed a bulge on the right flank and presented to our department because it gradually enlarged. A painless elastic-hard tumor 15 cm in longer diameter was palpated in the right flank. Based on the finding together with those of imaging procedures, superior lumber hernia containing a transverse colon as the hernia content was diagnosed. It was inferred that the abrupt increase in the abdominal pressure which was caused by a seat belt at the traffic accident might lead to the onset of the hernia. Using Parietex Optimized Composite Mesh^TM (PCO), laparoscopic repair for the inferior lumber hernia through a transabdominal route was performed. The patient was discharged from the hospital without having complications on the 3^rd postoperative day. A follow-up examination done 9 months after the operation revealed no adverse events including recurrence and chronic pain.
Lumber hernia is a rare entity and so far few cases repaired by laparoscopic surgery have been reported. Compared with the conventional procedures, the palaroscpic repair is less invasive, offers cosmetic benefits, and can shorten postoperative hospital stay.

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A 73-year-old woman was admitted to our hospital complaining of an upper abdominal bulge. She underwent cardiac coronary bypass graft and aortic valve replacement in the previous year (2012). At that time, she had undergone median sternotomy and partial incision of the linia alba of the upper abdomen. Abdominal computed tomography showed disappearance of the linea alba and a bulge of adipose tissue prolapsed through fascial plane. We diagnosed the case as subxiphoid incisional hernia (SIH) and applied laparoscopic approach with ordinary technique using mesh. The patient's postoperative course was uneventful. Postoperative pain was controlled with NSAIDs. The patient was discharged on 7th postoperative day.
The merits of the approach are to minimize the size of wound, to provide less pain and to shorten the length of hospital stay. Due to the special anatomic structure of the subxiphoid region (sternum, ribs and diaphragm), the laparoscopic approach has minimal disadvantage because it allows us to observe the hernia orifice from the abdominal cavity. We conclude that laparoscopic repair of subxiphoid incisional hernia may have advantages in techniques and results.

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We report a case of a patient with femoral hernia containing incarcerated Meckel's diverticulum.
The patient was an 86-year-old man with a right-sided, painful inguinal swelling. An abdominal computed tomography (CT) scan was performed, which showed a low-density area in tne right inguinal region, diagnosed as a localized inguinal tumor. Based on this diagnosis, the patient was scheduled for surgery. The surgery revealed that the tumor continued through the femoral canal, and the diagnosis of an incarcerated femoral hernia was made. The hernia sac was opened, and a Meckel's diverticulum located approximately 50 cm toward the oral side from the ileocecum was noted. Although the upper portion of the Meckel's diverticulum showed ischemic change, diverticulectomy along with a McVay repair of the femoral hernia was performed.
Regardless of the location, a hernia that contains a Meckel's diverticulum is called Littré's hernia. Incidence of a femoral hernia involving Meckel's diverticulum is rare in elderly men. It is important to suspect this condition in patients with inguinal pain, even if there is no obvious sign of bowel obstruction.

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