It was 1991 when laparoscopic surgery was first introduced into our country in the treatment of inguinal hernias. Thereafter the surgical techniques have developed to go on greatly different histories between Japan and the US and Western countries. In those countries, the inguinal incision technique has been kept almost unchanged for a long time and they have employed the Lichtenstein method as the operative procedure of first choice. We Japanese surgeons, however, have entered in the era where we can freely select from various mesh methods according to every institution's guideline. In the World Guidelines for Groin Hernia Management in 2018, laparoscopic surgery is recommended for recurrent inguinal hernia after the Lichtenstein method in which preperitoneal repair has not been performed ; and the Lichtenstein method is recommended for recurrence after laparoscopic surgery. However, we are required carefully to read and understand the guidelines while we keep our own historical background of the development of inguinal hernia repair techniques in mind. Treatment of recurrent groin hernias after various mesh methods which are common in Japan is often difficult, where the surgeries must be carried out under the leadership of a surgeon experienced in the technique.

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Patients with aortic valve stenosis have high perioperative risk. We evaluated 5 patients (3 males and 2 females) diagnosed with severe aortic valve stenosis on echocardiography who underwent laparotomy for preoperative intra-aortic balloon pump (IABP) insertion in our hospital between January 2011 and December 2015. The mean age was 72.2 years. One patient underwent emergency and 4 underwent emergency surgery for a malignancy. The mean aortic valve pressure gradient was 33.68 mmHg. The mean valve area was 0.723 cm². The mean duration of IABP use was 3.4 days. No IABP complications or cardiac complications were noted. Insertion of an IABP before laparotomy for patients with severe aortic valve stenosis may be useful for perioperative management.

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A 53-year-old woman visited our hospital for a painful left breast mass. Mammography, ultrasound, and magnetic resonance imaging (MRI) showed multiple cysts bilaterally. Three years later, solid components emerged in one of these cysts, which needed to be distinguished from malignancy based on ultrasound and MRI findings. Although fine-needle aspiration results were negative for malignancy, the tumor was excised for definitive diagnosis. Subsequent pathological analysis revealed a cholesterol granuloma of the breast. Herein, we report a case of cholesterol granuloma of the breast wherein malignancy as a diagnosis should be excluded.

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There is no proven therapy for the distant metastasis of malignant phyllodes tumors. We report a case wherein radiotherapy was effective for metastases of a malignant phyllodes tumor in multiple organs. Case : A 27-year-old woman noticed a left breast mass. After observation for 5 years, she underwent lumpectomy because of the increasing size of the mass. She was diagnosed with giant fibroadenoma (14 cm). She presented with local recurrence and underwent resection 6 times sequentially. The pathological diagnosis was fibroadenoma based on the first resected specimen but was malignant phyllodes tumor based on the latter. She had lung metastases in the lobes bilaterally at 56 years of age, followed by multiple metastases in various organs, such as the left pulmonary vein, right atrium, left gastrocnemius, small intestine, fingers, and others. She received radiotherapy for fetal metastases in the left pulmonary vein and right atrium of the heart for local control and palliative radiotherapy for the right gastrocnemius and fingers. These approaches of radiotherapy were effective in preventing fetal events, pain, and suffering for 10 months from the first detection of lung metastasis until her death.

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Transcatheter aortic valve implantation (TAVI) is a novel less-invasive therapeutic technique for aortic stenosis (AS), and is especially useful for high-risk surgical patients, without need for cardio-pulmonary bypass. However, TAVI is still challenging because of fatal complications. An 88-year-old female with severe AS and narrow left ventricle were reviewed by our heart team for determination of an operative strategy. Transfemoral TAVI was performed in the operating room under general anesthesia. However, a left ventricular perforation occurred immediately after valve implantation. Emergency surgical repair of the perforation was performed under cardiopulmonary bypass. Fortunately, the post-operative course was uncomplicated.

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Tumors rarely arise in the heart or pericardium, and malignant tumors are even more infrequent. If they arise in the heart or infiltrate the myocardium, total resection is difficult, and their prognosis is poor. The treatment of a patient with epicardial primary synovial sarcoma is reported. A 65-year-old man presented at another hospital complaining of precordial pain, and, since acute coronary syndrome was ruled out, he underwent detailed examination at a later date. Computed tomography (CT) showed a tumor on the inferior cardiac surface, and the patient was referred to our hospital 2 weeks after initial presentation. On admission to our department, the symptoms of epigastric pain, nausea, and hypotension rapidly worsened. This was considered to be due to cardiac tamponade caused by bleeding from the cardiac tumor, and emergency surgery was performed, both to save the patient's life and to control the bleeding. The cardiac tamponade was relieved, and as much of the cardiac tumor as possible was resected. This was a case in which a sudden deterioration in the patient's condition made determination of the treatment strategy difficult.

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An 83-year-old woman presented to our hospital in September 2016 complaining of left abdominal pain. Detailed examination suggested a possible inferior mesenteric artery aneurysm, and she was admitted for angiography and embolization. Angiography showed an arteriovenous malformation fed by a total of four arteries from the sigmoid artery and the superior rectal artery. Two of these were successfully blocked by embolization, but the procedure was terminated at this point because it was considered that further embolization would unavoidably result in ischemia of the sigmoid colon and rectum. It was decided that surgery was required, but since there were no signs of dyschezia or ischemic stenosis of the colon, and the abdominal pain was bearable, the patient did not consent to surgery and was instead kept under observation. In January 2017, on emergency admission for bowel obstruction. stenotic ischemic colitis of the descending colon was diagnosed. Since her condition did not improve with conservative treatment, left hemicolectomy was performed in May that year. The treatment of this patient who underwent left hemicolectomy for an inferior mesenteric arteriovenous malformation after embolization caused ischemic colitis is presented.

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A 56-year-old woman was detected having a small nodule on the left lower lobe of lung on a chest CT scan which was performed as a screening examination for rheumatoid arthritis. She was referred to us on suspicion of lung cancer. Thoracoscopic left lower lobectomy was scheduled, but a common trunk of the left pulmonary veins was detected on preoperative CT scan. During surgery, we confirmed the common trunk of the left pulmonary veins, peeled it off peripherally to disclose the junction of superior and inferior pulmonary veins, and then we cut the inferior pulmonary vein. Accordingly, we could safely accomplish thoracoscopic left lower lobectomy. The common trunk of the pulmonary veins is one of normal varieties of pulmonary vessels. If we cut the common trunk during pulmonary lobectomy without noticing the anatomical variant, we have to deal it with reconstruction of the vessels or completion pneumonectomy, and it may cause fatal complications. To perform the operation safely, it is important to confirm which pulmonary vein should be cut or not, both preoperatively and during surgery.

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Salvage surgery after definitive chemoradiotherapy (dCRT) for esophageal cancer invading the tracheal membranous portion has a high risk of complications such as membranous tracheal perforation and necrosis. A 67-year-old man who had received dCRT for upper thoracic esophageal cancer invading the tracheal membranous portion achieved a clinical complete response.
Subsequently, local recurrence occurred in the primary tumor bed, and the patient received salvage surgery. Operative procedures included right trans-thoracic and abdominal subtotal esophagectomy, gastric tube reconstruction via retro-sternal route, and cervical esophagogastric anastomosis. We covered the tracheal membranous portion with a latissimus dorsi muscle flap to avoid the complications related to the tracheal membranous portion. No complications occurred, though esophagogastric anastomotic leakage was observed which was successfully treated conservatively. Salvage surgery for esophageal cancer invading the tracheal membranous portion carries a risk of causing membranous tracheal perforation and necrosis, and it often becomes fatal if it once occurs. We successfully prevented such complications by using a latissimus dorsi muscle flap. This operative procedure is easy and effective.

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A 72-year-old woman who underwent subtotal gastrectomy with 6-month adjuvant chemotherapy with imatinib for a gastric gastrointestinal stromal tumor (GIST) was detected to have liver metastases and multiple peritoneal metastases 3 years after the surgery. So imatinib was administered again. This molecular targeted therapy once showed partial response of tumors, however, a computed tomography 6 years postoperatively revealed two new lesions ; one was on the dorsal side of the stomach and the other was on para-colic gutter of the descending colon. Although these tumors temporarily shrank after the treatment with sunitinib as a second line and regorafenib therapy as a third line therapy, the two tumors gradually grew up. The other lesions had not exhibited any progression. Positron emission tomography-computed tomography revealed abnormal fluorodeoxyglucose (FDG) uptake only in the two lesions, and we diagnosed that only these two lesions were tolerant to regorafenib and still in active status. These two lesions were resected by partial gastrectomy, distal pancreatectomy and partial resection of the descending colon. She was discharged on 12th day after the surgery with no postoperative complications and received adjuvant imatinib. No obvious active lesions and new metastatic lesions have been observed at one year after the resection of the metastatic lesions. A possibility that local resection for regorafenib tolerant lesions can be a treatment of choice is suggested.

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We report a case of a 20-year-old man with idiopathic intraabdominal bleeding without mechanical contusion. The patient swung a baseball bat for practice for 30 minutes immediately after excessive eating for dinner. A sudden abdominal pain occurred about four hours after the practice swing. When he presented to our hospital, no shock findings were seen but there were muscle guarding and rebound tenderness in the entire abdomen. Abdominal CT scan with contrast media revealed fluid retention suggestive of intraabdominal bleeding around the liver surface, Douglas fossa, left side of caeca without signs of bowel perforation. Emergent angiographic examination aiming at detection and embolization of ruptured artery was unable to demonstrate extravasation of contrast media in the celiac and superior mesenteric arteries. Thereafter he was found to be in a pre-shock state and was emergently operated on. At laparotomy, a gastro-colic menbrane was found torn by approximately 10 cm near the splenic flexure, where was inferred to be bleeding source, and the torn menbrane was resected. Resected specimen showed no structural abnormalities of vessels by pathological examination. The bleeding seemed to be due to the laceration of the gastro-colic membrane between the overloaded stomach and the transverse colon probably induced by quick and repeated twisting of the body trunk.

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An 81-year-old woman had undergone a Hartmann's procedure for sigmoid colon perforation at age 66 years, colostomy closure at age 67 years, and repair of an abdominal incisional hernia at age 72 years in another hospital. She visited our hospital because her abdominal pain persisted despite administration of antibiotic therapy. Dermal phlegmonous changes with swelling, redness, and tenderness were observed at the lower incision site. Computed tomography of the abdomen revealed deformed mesh and an abscess cavity in the abdominal wall. A delayed mesh infection was diagnosed. Initial incision and drainage were performed, and an operation was conducted a month after diagnosis. Intestinal adhesions and perforation of the mesh, which had been placed in the abdominal cavity, were observed intraoperatively. The mesh and a fistula were resected, and a small intestine perforation was sutured. We directly sutured the abdominal wall to close the defect. Repair using mesh for abdominal wall hernia is becoming standard treatment. With the increased use of mesh, reports of intestinal adhesions and late infection have increased. Secure fixing of mesh and observation for late infection are necessary.

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A 40-year-old woman who presented with upper abdominal pain and was pointed out having an intraabdominal tumor was referred to our hospital. An abdominal contrast-enhanced CT scan revealed a 12-cm cystic tumor on the left side of the jejunum in the vicinity of the ligament of Treitz. Ultrasonography confirmed peristalsis of the cyst and the cystic wall had the similar layer structure to that of the intestine, so that intestinal duplication was diagnosed preoperatively. Laparoscopic resection was performed for symptomatic non-communicating jejunal duplication in an adult. At surgery, we identified the tumor on the left side of the Treitz ligament, and dissected adhesions with the surroundings. Then we transected a feeding vessel which had shared the mesenterium with the jejunum around the tumor to remove the specimen.
Duplication of jejunum is a comparatively rare entity in adults, where ultrasonography was very useful in making the preoperative diagnosis. By keeping the concept of the disease in mind, we were able to search the presence or absence of other lesions and to perform minimally invasive surgery with a high esthetic effect.

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A 77-year-old man with a history of type 2 diabetes and pulmonary embolism who had undergone esophagectomy was brought to the emergency department with severe epigastric pain and imminent shock. Computed tomography showed abundant mesenteric air. We suspected peritonitis due to gastrointestinal (GI) tract perforation and performed emergency surgery. Operative findings showed no GI tract perforation, but obvious mesenteric emphysema and abscess were present. We diagnosed idiopathic mesenteric abscess. However, the literature indicates that mesenteric abscess is usually secondary to an intestinal perforation, diverticulitis, fish bone, Crohn's disease, or cancer. Idiopathic mesenteric abscess is rarely reported. In this case, we considered that impaired mesenteric blood flow and bacterial translocation due to diabetes type 2 and malnutrition after esophagectomy led to abscess formation.

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A 60-year-old man with a reducible left inguinal hernia had undergone surgery for a perforated duodenal ulcer 6 months ago. He was admitted with the chief complaint of abdominal pain and underwent emergency surgery for peritonitis caused by an idiopathic small intestinal perforation. On the 6^th postoperative day, a non-reducible palpable mass was detected in his left inguinal region. Computed tomography with contrast showed an abscess in the left inguinal hernia sac, and we performed aspiration drainage. On the 25^th postoperative day, we performed resection of the residual hernia sac abscess and repair of the inguinal hernia. To our knowledge, this is the first reported case of abscess in an inguinal hernia sac after small intestinal perforation, in the absence of an abscess after duodenal ulcer perforation.

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A 72-year-old man with a suspected incarcerated right inguinal hernia was referred to our hospital. Laboratory data indicated the presence of inflammation. Abdominal computed tomography showed a fluid collection extending from the right scrotum to the abdominal cavity, a swollen appendix, and surrounding panniculitis. Emergency surgery was performed for appendicitis with abscess in a right inguinal hernia. Laparoscopic examination showed that the right internal inguinal ring was occluded by the cecum and terminal ileum. The root of the appendix was necrotic and perforated with abscess formation. Copious purulence drained from the right internal inguinal ring. Appendectomy was performed laparoscopically, and iliopubic tract repair was performed for the right inguinal hernia. Laparoscopic surgery was useful for diagnosis and treatment of appendicitis with abscess in a right inguinal hernia.

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A 68-year-old woman was admitted to our hospital because of severe anemia. She had undergone total colectomy and ileorectal anastomosis for ulcerative colitis when she was 19 years old. She was administered immunosuppressive drugs based on the diagnosis of pure red cell aplasia. Endoscopy revealed a neoplastic lesion at the ileum adjacent to the ileorectal anastomosis, and biopsy showed signet-ring cell carcinoma. We performed partial resection of the ileum, and the postoperative course was uneventful. The occurrence of ileal cancer after proctocolectomy for ulcerative colitis is rare. We report a patient with ileal cancer that might have developed because of long-standing inflammation after total colectomy. We recommend regular endoscopic examination of the ileal mucosa after proctocolectomy for ulcerative colitis.

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A 3-day-old boy who was born at 41 weeks of gestation with a birth weight of 3,440 g developed bilious vomiting a day after birth. He was diagnosed as having colonic atresia by a contrast enema study that showed a microcolon, and surgery was performed. A type III colonic atresia was found and the proximal end of the atretic segment was located in the ascending colon 7 cm distal to the ileocecal valve. The bowel caliber ratio between the normal and atretic segment was 11 : 1. An ascending colostomy and tube enterostomy were performed. Postoperatively, the proximal colon was deflated and the distal colon was grown by feeding. At the anastomosis, the bowel caliber ratio was reduced to 2 : 1. The postoperative recovery was uneventful. Treatment for congenital colonic atresia differs depending on the type and condition of the colon at the time of the primary surgery. When the bowel caliber ratio is high, we advocate the use of a primary anastomosis with appendicostomy or tube enterostomy. If this is judged to be risky, a staged procedure should be performed, with the bowel caliber ratio reduced using a temporary colostomy.

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A 62-year-old woman with a past history of undergoing surgery for solitary cerebral hemangioblastoma visited our hospital for positive reaction to the fecal occult blood examination. She was diagnosed with ascending colon cancer by colonoscopy. Preoperative enhanced computed tomography findings showed small masses around the ascending colon and a hyper-vascular mass around the right branch of the middle colic artery, which were diagnosed with #211 and #222 lymph nodes metastases, preoperatively. Laparoscopic right hemicolectomy with D3 lymph nodes dissection was performed. The #222 lymph node was within the excision area. A white tumor was found beside the right branch of the middle colic artery during the surgery. Moreover, no abnormal findings such as hypertension were observed during the surgery. Based on the histopathological examination, the #211 lymph nodes were diagnosed as lymph nodes metastasis of ascending colon cancer, however, the mass considered as #222 lymph node metastasis was diagnosed with paraganglioma. Since she had the medical history of developing solitary cerebral hemangioblastoma, she was clinically diagnosed with von Hippel-Lindau disease. Paraganglioma is a very rare tumor in the mesocolon, however, when hyper-vascular tumors are found in the mesocolon by preoperative tests, the possibility of paraganglioma should be considered with attention to past medical history.

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The patient was a 68-year-old woman who underwent left colectomy for descending colon cancer elsewhere 12 years earlier when the tumor was diagnosed as moderately differentiated adenocarcinoma and was staged as T2, N0, M0, Stage I(TNM classification). She was referred to our hospital, because abdominal ultrasonography and CT scan in a local doctor detected a tumorous lesion with calcification in the right hepatic lobe. Esophagogastroduodenoscopy and colonoscopy revealed no findings suggestive of malignant disease, and abdominal CT and MRI scans showed an enhanced tumor with calcification in the segment 5 of the liver. Serum carcinoembryonic antigen level also increased. Because it was likely to be a malignant disease, we performed partial hepatectomy (S5). Microscopic examination of the resected specimen showed the same pathological images as the primary descending colon cancer. We diagnosed the tumor as hepatic metastasis of descending colon cancer 12 years after surgery for the primary lesion. Although it is rare that Stage I colorectal cancer recurs after a lapse of over 5 years after surgery, we should always keep a possibility of the recurrence in mind, if the patient has a history of colorectal cancer.

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Obstructive colorectal cancer is an oncologic emergency and requires urgent treatment. The presence of severe aortic valve stenosis (AS) is a risk factor for noncardiac surgery. Two patients with obstructive colon cancer with AS who underwent cardiac surgery before subsequent sigmoidectomy are reported. The first patient was a 73-year-old man who was transferred to our hospital with severe AS and obstructive sigmoid colon cancer. Fasting therapy, which was used at the previous hospital, was stopped after the insertion of a colonic stent. Aortic valve replacement and subsequent conventional sigmoidectomy were performed under controlled nutritional conditions. The interval stent between insertion and sigmoidectomy was 57 days. The second patient was a frail 79-year-old man with severe AS, angina pectoris, obstructive sigmoid colon cancer, and liver metastasis. After insertion of the colonic stent and removal of the ileus tube, oral intake was initiated. Percutaneous coronary intervention, transcatheter aortic valve implantation, and subsequent laparoscopic sigmoidectomy were performed uneventfully. The interval between insertion and sigmoidectomy was 45 days. A colonic stent could be useful in maintaining the perioperative nutritional condition and activities of daily living of patients who require staged surgical treatment.

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A 58-year-old woman without history of undergoing abdominal surgery presented to our hospital because of persisting lower abdominal pain and vomiting. An abdominal contrast-enhanced CT scan showed a small intestine forming a closed loop in the left lower abdomen. Internal hernia was thus suspected. Since the loop was short in distance and was located on the dorsal aspect of the sigmoid mesocolon and on the ventral aspect of the left common iliac artery, sigmoid mesocolon-related internal hernia, especially an intersigmoid hernia, was strongly suspected. CT scan showed no findings of bowel ischemia and there were few previous reports on that the incarcerated intestine became necrotic, so that elective laparoscopic surgery was performed after decompression by using a long tube. After retraction of the small intestine, the incarcerated bowel was reduced and the hernia orifice about 2 cm in diameter was closed by sutures.Furthermore, around the hernia orifice, an about 1 cm opening in the same morphology as the orifice was found. The hernia lumen was located between the mesentery of the descending colon and the parietal peritoneum, and so intersigmoid hernia was diagnosed.
As intersigmoid hernia rarely causes intestinal ischemia and the incarcerated bowel is short, the disease can be a good candidate for elective laparoscopic surgery following the tube decompression.

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A 53-year-old man was evaluated for a positive fecal occult blood test. Since colonoscopy showed a carcinoid tumor in the rectum below the peritoneal reflection, he was referred to our hospital and underwent laparoscopic low anterior resection. A drain adjacent to the colorectal anastomosis and a transanal tube were placed. A gastrografin enema on postoperative day (POD) 5 showed no anastomotic leakage and compression of the posterior wall of the sigmoid colon by the transanal tube. This tube was removed on the same day. Fecal liquid discharge drained from the abdominal drain on POD 6. Because fistulography showed a communication with the sigmoid colon through the fistula of the transanal tube, colon perforation caused by this tube was diagnosed. The patient had massive melena on POD 9. Computed tomography demonstrated active bleeding from the anterior surface of the sacrum, and emergency surgery was performed. Diverting ileostomy was also performed on POD 63, because conservative therapy for colon perforation was not successful. He then recovered and was discharged 81 days after the initial surgery. Colon perforation caused by a transanal tube is a rare postoperative complication. This case is reported along with a review of the literature.

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The life of a patient with severe Fournier gangrene associated with a high mortality rate as judged by Fournier's Gangrene Severity Index (UFGSI) was saved by extensive debridement. A 73-year-old man was brought to our hospital by ambulance because of redness of the gluteal region and pain. The skin of the perianal region and scrotum was necrotic, and the whole gluteal region was red. A computed tomography (CT) scan showed wall thickening of the lower rectum, and turbid adipose tissue was seen to the level of the right 12th rib. His diagnosis was severe Fournier gangrene caused by perforated rectal cancer, so a colostomy and perianal drainage were performed. However, even after surgery, the range of infection extended to the level of the lower edge of the scapula, and sepsis and DIC occurred (UFGSI 18). On postoperative day 8, abdominoperineal resection, vesiculectomy, orchiectomy, and debridement of his back and right femoral region were performed. He recovered from DIC and sepsis and was discharged from hospital after skin grafting. Resection of the primary lesion and extensive debridement are necessary to treat uncontrolled severe Fournier gangrene caused by perforated rectal cancer.

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A 68-year-old man presented with abdominal pain and bloody stool. Rectal cancer was identified on lower gastrointestinal endoscopy, and further investigations resulted in a diagnosis of T3N2M0c Stage IIIb. Preoperative contrast-enhanced computed tomography (CT) showed that the patient also had Leriche syndrome, but this was asymptomatic, and imaging also showed that blood was supplied to the legs and intraperitoneal organs via highly developed intraperitoneal collateral flow. Laparoscopic low anterior resection was carried out without revascularization. There were no perioperative complications, and the patient was discharged on postoperative Day 7. It was possible to safely perform laparoscopic surgery for rectal cancer in a patient with Leriche syndrome.

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A 62-year-old woman presented to our clinic because of anal pain was found having a palpable anal tumor by digital examination of the rectum. Colonoscopy revealed a ridging lesion with ulcer at the anal canal. A biopsy offered a diagnosis of neuroendocrine carcinoma. Apart from the anal canal tumor, an extramural tumor of the rectum and a presacral tumor were revealed on a CT scan. PET-CT scan showed abnormal uptakes of FDG in all the three tumors. Lymph node metastases of anal canal carcinoma were diagnosed, and abdominoperineal resection + D3 lymph node dissection was performed. The resected specimen included the anal canal tumor with the size of 25 × 25 mm in diameter. Histopathologically the tumor was substantially composed of proliferation of large oval-shaped cells with a large N/C ratio and the progression was rated as Stage IIIb. On immunohistochemistry, the anal canal tumor was strongly positive for synaptophysin and positive for chromogranin A, with the Ki-67 positive rate of 60%. Furthermore, we also confirmed well-differentiated adenocarcinoma and villous adenoma in the oral margin of the tumor. Neuroendocrine carcinoma arisen in the anal canal was thus diagnosed. We performed mFOLFOX (6) as adjuvant chemotherapy.

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A 31-year-old woman living in Chiba prefecture visited a medical clinic with a history of abdominal pain and diarrhea. Abdominal CT showed multiple cystic lesions in the liver. The serological test for anti-echinococcal antibody was positive, confirming the diagnosis of alveolar echinococcosis of the liver, and the patient was referred to our department. The CT images revealed multiple cystic lesions in segments 3/2, 5, 7/8, and 8, and the lesion in segment 8 was adjacent to the right hepatic vein. Extended posterior segmentectomy, including concomitant resection of the right hepatic vein, left lateral segmentectomy and partial hepatectomy (S5), was performed. The postoperative course was uneventful, and the patient was discharged on the 18th day after surgery. Histopathological examination revealed epithelioid granulomas and large necrotic lesions in the cysts. The necrotic lesions were associated with microcysts having a cuticular layer and protoscoleces with brood capsules. At present, three years since the surgery, the patient remains alive without recurrence. Although she lives in the Kanto area, she had a history of travel to Hokkaido and of contact with foxes when she was 2 years old. We report a case of alveolar echinococcosis of the liver, in which the disease showed slow progression over 29 years after the infection by echinococcus multilocularis.

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A 62-year-old woman was referred to our department by our hospital's Department of Gastroenterology because a cyst in the right lobe of the liver that had measured 10.2 × 10.5 cm when it was identified on computed tomography (CT) three years earlier had since grown to 30.0 × 20.1 cm. CT also showed severe displacement of the inferior vena cava (IVC) by the cyst and luminal hypodensities from the bilateral femoral veins to the inflows of the bilateral renal veins into the IVC, suggesting that displacement by the hepatic cyst may have caused IVC thrombosis. To prevent postoperative embolism, an IVC filter was inserted before laparoscopic liver cyst fenestration was performed. Histopathological tests showed that the cyst was isolated and showed no signs of malignancy. The patient's subsequent course was uneventful ; the IVC filter was removed on Day 11, and on Day 12 she was discharged improved. The treatment of this patient with a huge liver cyst that was growing over time, who was fitted preoperatively with an IVC filter before safely undergoing laparoscopic liver cyst fenestration, is reported.

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The case involved a 78-year-old man. Colonoscopy performed for anemia revealed a type 2 tumor encircling about three-fourths of the circumference of the lumen at the ascending colon. Tissue biopsy of the tumor was performed, and the immunostaining resulted in S100 negative, desmin positive, α-SMA positive, CD34 negative, c-kit negative, and the Ki-67 labelling index of 30%. It was diagnosed as highly malignant leiomyosarcoma. As there were no demonstrable distant metastases, right hemicolectomy + D3 lymph node dissection was performed. Hepatic recurrence (S4) was identified 18 months after the operation, for which left lobectomy of the liver was carried out. Metachronous hepatic metastasis affecting the S5 of the liver remnant was found 23 months after the initial operation, so that partial hepatectomy was performed. Thereafter, he has been doing well without having recurrence as of 33 months after the initial operation.
The frequency of leiomyosarcoma arising in the colon is very low and few cases operated on for its hepatic metastasis have been reported. We present a case of the disease with metachronous hepatic metastases which were treated by twice operations that is rare.

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A 78-year-old man who had undergone laparoscopic ileocolic resection and lymph node dissection for ascending colon cancer visited us for follow-up. Abdominal CT revealed three nodular lesions on the surface of the liver. PET-CT revealed abnormal accumulation in all the three nodular lesions, leading to the suspicion of peritoneal recurrence of colon cancer. The possibility of residual abscess formation caused by spilled gallstones was also considered, because laparoscopic cholecystectomy (LC) for chronic cholecystitis had been performed six months earlier, and gallstones had spilled into the peritoneal cavity during the LC. Surgical excision of the tumors was performed due to possibility of peritoneal recurrence of colon cancer. Histopathological examination of the excised specimens showed that the lesions were actually abscesses. Thus, in patients presenting with peritoneal lesions after gallstone surgery, the possibility of abscess formation or granuloma formation from spilled gallstones must be borne in mind.

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Delayed tumor recurrence is well known in cases of renal cell carcinoma. We performed successful resection of synchronous liver and pancreatic metastases in a patient 32 years after the primary radical operation for renal cell carcinoma. The patient was an 82-year-old man who had undergone right nephrectomy for renal cell carcinoma at the age of 50 years. When he was 80 years old, he had been diagnosed as having follicular lymphoma in an inguinal lymph node and received R-CHOP therapy, with complete remission. The liver and pancreatic lesions were detected incidentally on abdominal CT conducted as a follow-up examination for the follicular lymphoma. Both the lesions showed hypervascularity. Definitive diagnosis of the liver metastasis from renal cell carcinoma was made by liver biopsy. We were convinced that the pancreatic lesion was also a metastatic tumor from the renal cell carcinoma, based on the CT findings. We judged that radical resection of the metastatic liver and pancreatic tumors would be possible because there was no evidence of any other metastatic lesions. Histopathologically, both lesions were confirmed to be synchronous liver and pancreatic metastases from the renal cell carcinoma diagnosed 32 years previously. Despite delayed recurrence being well known in cases of renal cell carcinoma, recurrence detected over 30 years after the primary resection, as in our case, is very rare.

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We report a case of successful stent-grafting of a hepatic artery pseudoaneurysm after pancreaticoduodenectomy (PD). A 59-year-old man underwent PD for an intraductal papillary-mucinous neoplasm of the pancreatic head. He developed pancreatic anastomotic leakage on postoperative day (POD) 8. Sentinel bleeding was seen in the drainage tube on POD 15. Emergency angiography revealed a pseudoaneurysm without bleeding at the gastroduodenal arterial stump. The next day, a stent-graft was placed in the common hepatic artery to stop bleeding from a pseudoaneurysm and preserve patency. Pancreatic anastomotic leakage subsequently improved. The patient was discharged on POD 50 with no other significant complications.

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A 72-year-old man who was under observation for prostatic hyperplasia was found to have multiple hypoechoic masses in the spleen and mild splenomegaly on abdominal ultrasound. Metastatic splenic tumor was suspected, but whole-body evaluation did not identify a primary lesion. All of the multiple splenic tumors (maximum diameter 10 mm) were observed to have grown on computed tomography (CT) 6 months later, with the largest reaching 23 mm in diameter. Although there was no systemic lymphadenopathy or elevation of lactate dehydrogenase (LDH), soluble interleukin-2 (IL2) receptor was mildly elevated, and the fact that the tumors were growing meant that the possibility of malignant lymphoma or other primary malignant tumors of the spleen could not be ruled out. Therefore, it was decided to remove the spleen for both diagnosis and treatment. Hand-assisted laparoscopic splenectomy was performed, and the undamaged spleen was sent for pathological testing. This led to a diagnosis of asymptomatic splenic marginal zone lymphoma, and the patient was discharged with no complications. Six years postoperatively, no recurrence has been identified to date. This case is reported along with a short discussion of the literature.

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A 54-year-old man who had undergone a left hemi-colectomy for transverse colon cancer presented on day 10 after the operation with severe epigastralgia. Abdominal CT revealed an obstruction in the proximal portion of the jejunum. The patient was diagnosed as having postoperative intestinal obstruction and received conservative therapy, but with no improvement. Therefore, on day 17 after the operation, exploratory laparotomy was performed. The proximal portion of the jejunum was tightly adherent to the omentum, therefore, it was dissected along with the omentum. After re-operation, the intestinal obstruction improved. A case of omental panniculitis occurring in response to a foreign body causing intestinal obstruction is rare.

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Post-herniorrhaphy chronic pain can lead to a marked decrease in quality of life. We report a case of neuropathic post-herniorrhaphy pain in which mesh resection and triple neurectomy successfully relieved inguinal pain.
A 77-year-old male on dialysis for chronic renal failure underwent open left inguinal herniorrhaphy with the mesh plug method. Three months postoperatively, he complained of left inguinal paresthesia and radiating pain from the left inguinal area to the left thigh. We suspected neuropathic chronic pain associated with herniorrhaphy. Various analgesic therapies failed to relieve the pain, and we performed mesh resection and triple neurectomy at 5 months postoperatively.
The chronic pain was dramatically relieved after surgery. Histopathological findings showed fat necrosis and scarring around the inguinal branch of the inguinal femoral nerve and nerve retraction in the same region. We believe that nerve retraction was one of the reasons for chronic pain.

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A 74-year-old man, had undergone right external inguinal hernia repair with a mesh plug. After the operation, he had persistent right inguinal pain. Six months postoperatively, he complained of inner thigh pain along with persistent right inguinal pain, and physical examination revealed a recurrent right inguinal hernia. Surgery was performed 7 months after the initial operation. Laparoscopic observation showed that the recurrence was due to an internal inguinal hernia (type II-1). The plug was removed laparoscopically, and the inguinal canal was opened via an anterior approach. The onlay patch was flipped over on the pubic bone, and recurrence was found in the same area. The cause of chronic pain was adherence of the iliac hypogastric nerve to the onlay patch. The onlay patch was removed, and the iliac hypogastric nerve excised. After closing the incision, the hernia was again repaired laparoscopically via transabdominal preperitoneal approach. After the operation, the chronic pain disappeared. At 1 year postoperatively, there has been no recurrence of chronic pain or inguinal hernia. The combination of laparoscopic surgery and an anterior approach was useful in this case.

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