The surgical treatment of low rectal cancer has changed greatly in recent years. Intersphincteric resection (ISR) has emerged as a new option for anus-preserving surgery, and endoscopic surgery for rectal cancer has also been widely performed. A consensus on whether laparoscopic total mesorectal excision (TME) is equivalent to radical surgery through laparotomy has not been reached after some randomized, controlled, clinical trials. In recent years, a new surgical method based on a surgical assist robot and a transanal endoscopic approach (taTME) has also appeared, and it is expected to be an option that can provide better clinical results than laparoscopic surgery. Lateral lymph node dissection, which has conventionally been done in Japan, has undergone a randomized, controlled trial, and its clinical significance has been clarified. Preoperative chemoradiotherapy (CRT) in Western countries has become a standard treatment that can reduce the local recurrence rate. On the other hand, lateral lymph node dissection has also been shown to be an effective treatment method for suppressing local recurrence in the lateral region; the results became noticeable not only in Japan, but also abroad.

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A 61-year-old man presented to a hospital with swelling in the left supraclavicular region. Cervical ultrasonography revealed a cystic mass measuring about 5 cm in diameter in the left lobe of the thyroid gland and extending into the superior mediastinum. He was referred to our hospital with a diagnosis of mediastinal goiter. Cervical and chest enhanced computed tomography scan showed a multilocular mass in the left lobe of the thyroid, with a part extending into the mediastinum. We performed left hemithyroidectomy for the mediastinal goiter. Macroscopic examination of the resected specimen revealed a cystic tumor measuring 5.9 × 4.8 cm in the left lobe of the thyroid. Pathological examination revealed the large cyst with neighboring multiple cysts ; internal surface of the cyst was covered with stratified squamous epithelium and there were numerous lymphatic follicles with germinal centers beneath them. The lesion was diagnosed as lymphoepithelial cyst in the thyroid gland, this being a rare location for such cysts. No malignancy was evident. We herein report a case of lymphoepithelial cyst extending into the superior mediastinum.

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A 61-year-old woman presented with a mass in her left breast and was diagnosed with breast cancer (ductal carcinoma in sutu ; DCIS) below the nipple. There was a flat elevating skin lesion in the ipsilateral breast near the inframammary fold. She had been aware of it for 10 years at least, and we considered it as a “mole”. She underwent total mastectomy and sentinel lymph node biopsy without resecting the skin lesion. The sentinel lymph node biopsy resulted in negative and no axillary lymph node dissection was added. Histopathological diagnosis was DCIS, ER positive, PgR negative, and HER2 positive. No lesion was detected in the nipple or the skin. Three months later, she visited the department of plastic surgery with expecting the resection of the skin lesion like a “mole” and then underwent that operation. The histopathological diagnosis was Paget's disease in situ. Immunohistological findings were ER positive, PgR negative, and HER2 positive that were the same as DCIS. There was no invasive lesion in both tumors, and no macroscopic nor microscopic continuity between them. We report this very rare case of simultaneous occurrence of ectopic Paget's disease and DCIS in the unilateral breast.

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A 53-year-old woman had a left breast mass at age 41 years noted by another physician, and further workup yielded a diagnosis of breast cancer (scirrhous carcinoma) : cT2 N1 (SLNB1/2) M0. She received neoadjuvant (preoperative) chemotherapy, underwent breast-conserving surgery, and then started adjuvant hormonal therapy (LHRH agonist + tamoxifen). At 1 year 5 months after starting hormonal therapy, a solitary 4-cm liver metastasis in S4 was noted. Anticancer therapy with weekly paclitaxel led to a complete response (CR), and then oral capecitabine was started at the patient's request. Currently, 12 years 9 months postoperatively (10 years 1 month after the liver metastasis was diagnosed), imaging studies have confirmed a long-term CR with no evidence of further metastases in any organ.
In patients with oligometastases, even liver metastases in breast cancer, chemotherapy can have a favorable therapeutic effect in many cases. Oral anticancer drugs without established lifetime doses may help to maintain a long-term CR and should be considered as a therapeutic option.

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An aorto-duodenal fistula (ADF) is rare, but it can cause lethal massive gastrointestinal tract bleeding and sepsis. An ADF is a direct communication between the aorta and duodenum, most commonly due to surgical repair of a prior aortic aneurysm (secondary ADF). Primary ADF rarely occurs as the spontaneous development of a communication because of an abdominal aortic aneurysm (AAA), trauma, tumor, and so on. A case of a 68-year-old man with massive hematemesis and loss of consciousness after a traffic accident is reported. After diagnosis of primary ADF on enhanced computed tomography and upper gastrointestinal endoscopy, the patient underwent immediate stent-graft repair due to his pre-shock state. After surgery, he received long-term treatment with antibiotics for more than 1 year. Endovascular stent-grafting with long-term antibiotic therapy may be effective for maintaining long-term remission in the management of patients with an ADF.

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A 66-year-old woman was referred for occlusion of a hemodialysis AV shunt in the right upper arm. Because the patient had an allergy to iodine contrast, carbon dioxide (CO₂) gas was used for contrast during balloon angioplasty after a surgical thrombectomy. The patient developed seizures and impaired consciousness postoperatively, and MRI showed a right cerebellar infarction.
With CO₂ angiography for dialysis shunt problems, retrograde flow of CO₂ contrast from the brachial artery to the cerebral vasculature resulting in loss of consciousness and hemiplegia has been reported, but these symptoms have been transient. However, our patient developed cerebellar infarction due to CO₂ angiography after thrombectomy of the AV shunt.
Because CO₂ gas does not mix with liquids, a faster injection rate compared to liquid contrast agents is necessary for imaging. Therefore, retrograde flow towards the CNS can occur, and residual microthrombi in an AV graft after thrombectomy may be propelled retrograde by the gas, thus possibly causing cerebral infarction. For this reason, extreme caution is required when CO₂ arteriography is performed after a thrombectomy.

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A 49-year-old man, who underwent ileocecal resection for superior mesenteric artery thrombosis 32 days earlier, was admitted with sudden and severe abdominal pain. Abdominal contrast-enhanced computed tomography (CT) showed superior mesenteric vein thrombosis and necrosis of the jejunum. Emergency resection of the necrotic jejunum and thrombolytic therapy through the recanalized umbilical vein were performed. After the operation, anticoagulant therapy with heparin and warfarin was started. The patient's postoperative course was good, and follow-up CT performed 2 months later showed reduction of thrombi and improvement of portal vein perfusion. Mesenteric vein thrombosis (MVT) is rare but can be life-threatening. Thrombolytic therapy through a recanalized umbilical vein is a minimally invasive and effective treatment option for MVT.

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A case of massive bleeding from esophageal varices during transcatheter aortic valve implantation (TAVI) is reported along with a literature review.
An 83-year-old man with type C hepatic cirrhosis was diagnosed with aortic valve stenosis (AS) three years prior. He was admitted to the hospital due to exertional dyspnea and was diagnosed with severe AS and coronary artery stenosis. Owing to his comorbidities, concomitant TAVI and off-pump coronary artery bypass grafting (OPCAB) were performed. During OPCAB, massive bleeding occurred in the oral cavity. He had been diagnosed with esophageal varices before surgery, and the bleeding was considered to be associated with the esophageal varices. Emergency gastrointestinal endoscopy was performed after the completion of both surgical procedures, and oozing-like bleeding from the esophageal varices was seen. Endoscopic esophageal varices ligation was performed to stop the bleeding.

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Peripheral arterial (PA) aneurysms show a frequency of 20% of whole aortic aneurysms, and deep femoral artery (DFA) aneurysms account for 0.5% of PA aneurysms. We report a case of a ruptured aneurysm of the medial circumflex femoral artery (MCFA) a branch of the DFA. A 76-year-old woman noticed swelling and pain of the right femur. We diagnosed aneurysmal rupture and performed an emergency operation because of the risk of compartment syndrome. DFA aneurysms are rare because : 1) PA are rarely affected by arteriosclerosis, 2) the DFA is surrounded by adductor muscles, and 3) DFA dilatation is rare because the vessel is composed of a muscle layer rather than elastic fibers. Thus, DFA aneurysms remain silent until they rupture. This patient revealed no history of trauma, catheter intervention, infection, or collagen disease ; thus, the cause of the MCFA aneurysm was unclear. An addition of further cases to the literature may reveal the mechanism underlying the development of DFA aneurysms and the associated risk factors, which could help to establish appropriate treatment guidelines.

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We report a case of right-sided spontaneous pneumothorax following herniation of an emphysematous bulla into the left anterior mediastinum. An 81-year-old man was brought into our emergency department by ambulance because of the sudden onset of right-sided chest pain and dyspnea. When he was seen at our hospital, he revealed decreased breath sounds in the right lung. He was diagnosed with right-sided spontaneous pneumothorax based on a chest plain X-ray film, and chest drainage was initiated. Chest computed tomography scan demonstrated a bulla in the right upper lobe extending into the contralateral hemithorax. As his pulmonary fistula persisted even 5^th day after drainage, surgical bullectomy was performed using an endoscopic stapling device. He was discharged from our hospital on the 7^th postoperative day, and he is doing well without recurrence as of 6 months after the operation. We emphasize that emphysematous bullae may herniate into the mediastinum.

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A 16-year-old young woman with mental disorders was brought into our hospital after falling off from a height of approximately 10 meters. Computed tomography scan revealed acute subdural hematoma, blow-out fracture of left orbital floor, right mandibular fracture, bilateral pulmonary contusion, right pneumothorax without rib fractures, and multiple traumatic pulmonary pseudocysts (TPPs) in both lower lobes. After right chest drainage, massive air leak and hemosputum persisted. On the 25th hospital day, three-dimensional computed tomography revealed residual large two TPPs in the right lower lobe without being absorbed, each of which was considered to be the cause of intractable air leakage and hemosputum, respectively. Right lower lobectomy was performed because possible association of infection of the TPP was considered with elevated serum CRP. The patient's postoperative course was uneventful. A traumatic pulmonary pseudocyst develops following a blunt thoracic trauma and is generally treated conservatively. We should consider the surgical treatment as a therapeutic option for TPPs when they are associated with severe complications, such as refractory airway hemorrhage, persisting massive air leak, and secondary infection, or when they are kept unchanged.

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Unilateral isolated absence of pulmonary artery is a rare entity and often presents with recurrent bouts of hemoptysis and pulmonary inflammation. We have difficulties in managing these symptoms by internal treatments, where pneumonectomy can be employed.
A 62-year-old woman with a previous history of hemoptysis at the age of 10 was emergently admitted to our hospital because of recurrent bouts of hemoptysis in May 2014. Chest plain CT scan showed absence of the right pulmonary artery, hypoplastic right lung, blood aspiration image of the upper and middle lobes of the right lung. Bronchoscopy revealed bleeding from the upper lobe of the right lung. Cardiac ultrasonography revealed absence of intracardiac shunt. Contrast-enhanced chest CT scan revealed multiple collateral circulations from bilateral coronary arteries, and many branches of the developed bronchial arteries. In order to control air way bleeding as well as to decrease intraoperative blood loss, we performed transcatheter arterial embolization for a total of seven sites, including the accessory branches of the bilateral coronary arteries, internal thoracic, bronchial, intercostal, and subphrenic arteries, followed by right pneumonectomy.

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A 57-year-old woman presented to the emergency department because of the sudden onset of severe epigastric pain. She was pointed out having esophageal hernia by medical checkup five years previously, and had complained of mild postprandial distress. Abdominal CT scan revealed that the stomach including the esopagogastric junction and pyloric ring, and a part of the transverse colon were located in the mediastinum, but a part of the gastric wall retrogradely herniated to the abdominal cavity through the esophageal hiatus and was strangulated. One hour after her visit, the severe pain disappeared, when a thoracoabdominal CT scan with contrast medium also showed type IV esophageal hiatal hernia with the stomach and the transverse colon, but the retrograde herniation of the part of the stomach was dissolved. We speculated that the retrograde herniation might cause the severe abdominal pain. We performed laparoscopic repair electively because the severe pain had been relieved. Laparoscopically, we found a type IV esophageal hernia. The herniated stomach and colon were easily reduced into the abdomen and the hernia sac was resected. The hiatal hernia defect was closed by primary suture of the diaphragmatic crus and was reinforced by mesh placement. Nissen fundoplication was added. The patient is doing well without any recurrence of hiatal hernia, as of 10 months after the operation.

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A 77-year-old man presented to a local hospital due to dyschezia and bleeding on defecation. Colonofiberscopy revealed a tumor encircling the circumference of the upper rectum (RSa), and gastrointestinal endoscopy detected a protruded tumor in the middle esophagus. Therefore, the patient was referred to our hospital with a diagnosis of double cancer of the rectum and esophagus. The rectal cancer was diagnosed as cT3N0M0, cStage II, and the esophageal cancer, as cT2N0M0, cStage II according to the Japanese Classification. Chest computed tomography showed the right aortic arch with an aberrant left subclavian artery classified as type IIIB aortic arch anomaly based on the Edwards' classification. The patient underwent low anterior resection for the rectal cancer, and chemoradiotherapy for the esophageal cancer. We selected mFOLFOX6 as both chemotherapy for esophageal cancer and adjuvant chemotherapy for rectal cancer. The patient is now alive without recurrence of the diseases over 1 year and 4 months after the operation. In conclusion, we experienced a rare case of successful treatment of rectal and esophageal cancer associated with the right aortic arch, a rare anatomical anomaly. Multimodal therapies including surgery and chemoradiosurgery might be a potent treatment for this patient.

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A 66-year-old man underwent a total gastrectomy for gastric cancer with a Roux-en-Y (R-Y) reconstruction. The R-Y anastomosis was performed using a 21-mm circular stapler. He presented to our hospital with dysphagia 7 months postoperatively. Abdominal computed tomography showed a markedly dilated afferent loop extending between the stapled end of the R-Y anastomosis and the duodenal stump, and he was diagnosed with afferent loop syndrome secondary to R-Y anastomotic stenosis. Single-balloon endoscopy revealed the stenosis, for which balloon dilation was performed. He showed an unremarkable clinical course and was discharged on postoperative day 5. This case suggests that endoscopic balloon dilation is a minimally invasive and effective treatment option for afferent loop syndrome secondary to R-Y anastomotic stenosis.

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There are various vascular anomalies in branches from the celiac artery. Careful procedure is necessary for such anomalies in gastrectomy. A 76-year-old woman was referred to our hospital because of anorexia. Upper gastrointestinal endoscopy revealed an ulcerated lesion on the angler region of the lesser curvature side, which was pathologically diagnosed as moderately differentiated tubular adenocarcinoma. Enhanced abdominal CT scan showed the common hepatic artery passed behind the portal vein. We performed laparoscopic distal gastrectomy, which included lymph node dissection around the common hepatic artery. By lifting gently the fat and connective tissue around the common hepatic artery and the portal vein, we could safely dissect lymph nodes around the common hepatic artery, and could easily expose the portal vein, which led to safe resection of the left gastric vein. The portal vein which is surrounded by loose connective tissue could be safely dissected. Therefore, exposing the portal vein seems to be the proper and safe procedure for the anomaly. The patient's postoperative course was uneventful, and no recurrence has been observed. Recognition of vascular anomalies prior to surgery and understanding of surgical procedures for them enable us to perform safe and accurate operation.

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A 69-year-old man who underwent upper GI endoscopy for an abnormality on gastric cancer (GC) screening was found to have type 2 GC of the gastric cardia and 0-II c GC of the gastric angle. A laparoscopic total gastrectomy and D2 lymph node (LN) resection were performed at our hospital. Histopathology showed a lesion depth of T2 in the cardia and T1a at the gastric angle, with no LN metastases. The diagnosis was stage I B GC.
One year 9 months postoperatively, the patient developed sudden dysarthria and a gait disturbance. Further evaluation showed a left cerebellar lesion, which was surgically resected, followed by whole-brain irradiation. Histopathology of the brain lesion showed adenocarcinoma, which was consistent with a brain metastasis from GC. However, systemic evaluation found no evidence of cancer recurrence other than in the brain. Subsequently, there was local recurrence in the brain, and the patient died 12 months after onset of brain metastasis. However, no metastatic lesions other than in the brain were ever found.
Brain metastases are rare in GC, occurring in only 0.5% of cases. However, a solitary brain metastasis without evidence of GC metastases in other organs is even rarer. This case of a solitary brain metastasis following GC surgery is reported, and the relevant literature is discussed.

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A 48-year-old woman whose fecal occult blood test was positive at a medical checkup presented to our hospital. Esophagogastroduodenoscopy revealed multiple flared Yamada type II polyps in the whole stomach and segmented polyps at the greater curvature of the cardia and at the lesser curvature of the angular notch. Chest and abdominal CT scan showed dilatation of the whole stomach and thickening of the mucous membrane. From these findings, juvenile polyposis localized in the stomach was suspected and we performed laparoscopic total gastrectomy + D1 lymph node dissection. Macroscopic study of the resected specimen revealed diffused polyposis in the whole gastric mucous membrane. Histopathology revealed dilatation of the glandular epithelium associated with interstitial edematous change, and mucus retention in the glandular space. Juvenile polyposis was thus diagnosed, and we identified five lesions of highly differentiated adenocarcinoma which retained within the mucosa.
This paper presents our case of juvenile gastric polyposis for which laparoscopic total gastrectomy was performed, together with some bibliographic comments.

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A 65-year-old man underwent an esophagogastroduodenoscopy due to a chief complaint of abdominal pain. A type 3 gastric cancer in the greater curvature of the lower gastric body was found and was proven to be moderately differentiated adenocarcinoma through biopsy. An enhanced abdominal computed tomography showed multiple liver metastases and paraaortic lymph node swelling. The gastric cancer was diagnosed as cT2(SS), cN1, cH1, cP0, cM1(LYM), cStage IV according to the Japanese classification of gastric cancer, 13^th edition. After 5 courses of chemotherapy with S-1 and cisplatin, liver metastases disappeared. Distal gastrectomy with D3 lymph node dissection was performed. Pathologically, it was diagnosed as pT1(SM), pN0, sH0, sM0, fStage IA, and the histological evaluation criterion of tumor response was Grade 1a. The patient took tegafur/uracil orally for 10 months and has been doing well without relapse for 125 months. Although simultaneous multiple liver metastases from the gastric cancer have poor prognoses, our case was successfully treated with chemotherapy and surgery.

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A 75-year-old man with epigastric discomfort and weight loss was referred to our hospital and diagnosed with gastric cancer (GC) and gastric malignant lymphoma. Upper GI endoscopy showed a protruding lesion at the anterior wall of the lesser curvature near the gastric angle and an ulcerative lesion at the lesser curvature of the gastric antrum. Both lesions were diagnosed as GC. In addition, a large ulcerative lesion extending from the upper to lower gastric body near the greater curvature was diagnosed as B cell lymphoma.
Cervical, thoracic, and abdominal CT showed wall thickening from the gastric body to the antrum, as well as partially indistinct margins with the transverse colon. Lymph nodes along the lesser curvature and near the right gastroepiploic artery were enlarged, and ascites was present. The diagnosis was multiple GCs and gastric malignant lymphoma, and a total gastrectomy was performed. Histopathology showed well-differentiated adenocarcinoma at two sites (pStage IA, pStage IB) and diffuse large B cell lymphoma (Lugano classification : Stage IIE, transverse colon invasion, ascites cytology positive).
This very rare case of multiple GCs together with gastric malignant lymphoma is reported along with a discussion of the relevant literature.

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An 89-year-old woman complained of abdominal pain after undergoing coronary angiography. Further evaluation showed occlusion of the ileocolic artery, and thrombolytic therapy was performed. No intestinal perforation was noted, so conservative therapy was continued. The patient improved, oral intake resumed, and she was discharged from the hospital. However, two months after discharge, intestinal obstruction due to small intestinal stenosis at the same site was noted, so an elective laparoscopic-assisted partial small bowel resection was performed. Histopathology showed small intestinal stenosis due to cholesterol crystal embolization.
Gastrointestinal perforation, necrosis, and stenosis due to cholesterol crystal embolization have rarely been reported in Japan. Surgeons should keep in mind the possibility of this condition.

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Delayed intestinal stenosis after bowel-preserving reductions of incarcerated hernias have rarely been reported. Two patients who developed delayed bowel obstruction after bowel preservation during surgery for incarcerated femoral hernias are reported. Laparoscopic surgery was performed, and ischemic small bowel stenosis was diagnosed in both cases.
In one patient after preservation of small bowel without any changes in color of the serosa, stenosis still developed later. In the other patient with linear color changes of the small bowel serosa, indocyanine green (ICG) fluorescence angiography showed enhancement of almost the entire bowel wall, but some areas of poor linear enhancement corresponding to the serosal changes were noted. Although bowel preservation was still considered safe, cicatricial changes causing stenosis later occurred in the areas of poor enhancement.
The possibility of delayed ischemic small bowel stenosis after surgery for incarcerated hernias should always be kept in mind. Patients with even only slightly poor enhancement on ICG fluorescence angiography require careful follow-up, and surgery must be considered if any symptoms of intestinal obstruction develop.

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The patient was a 90-year-old man hospitalized at the department of nephrology of our hospital. He had no evident difficulties in defecation or oral intake. At the hospital, after he ingested a bowel cleansing agent prior to a scheduled colonoscopy, he developed severe vomiting. Findings of abdominal CT were suggestive of small bowel obstruction. The patient also developed aspiration pneumonia, necessitating respiratory management. A long ileus tube was inserted for managing the ileus, however, no improvement was observed. A repeat abdominal CT revealed evidence of small bowel intussusception with bowel ischemia. Emergency surgery was performed. Ileoileal intussusception was observed, with evidence of intestinal necrosis. Partial resection of the invaginated segment was performed. No tumor or diverticulum was observed in the resected specimen. Small bowel intussusception is rarely encountered in adults. We encountered a case of intussusception developing after oral intake of a bowel cleansing agent in a patient scheduled for colonoscopy. We have presented the case herein, with some review of the literature.

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An 80-year-old man was referred to our hospital to undergo gastrostomy because of anorexia with dementia. He underwent jejunostomy instead of gastrostomy, because previous gastrectomy interfered with gastrostomy. On the 2^nd postoperative day, we started enteral nutrition, but he complained of stomachache on the next day. His abdomen was hard with some tenderness. Abdominal CT scan showed pneumatosis intestinalis and portal hepatic venous gas. Although his vital signs were stable, there were findings of peritonitis and dark-red discharge was drained from a jejunostomy tube. We suspected intestinal necrosis, and an emergency operation was performed. Intestinal expansion was found, but there were no findings of strangulation and intestinal necrosis. We diagnosed the case as pneumatosis intestinalis and only conducted decompression via the jejunostomy tube. On the 12th postoperative day, pneumatosis intestinalis and portal venous gas disappeared on abdominal CT scan, so we restarted enteral nutrition.
Since the onset of pneumatosis intestinalis and hepatic portal venous gas associated with the start of enteral nutrition after jejunostomy is rare, this case is presented here, with a review of the literature.

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Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract, and its overall incidence is low. Extra-gastrointestinal stromal tumor (EGIST) is a special type of GIST which occurs at a lower frequency outside the gastrointestinal tract. We report a rare case of EGIST originated from the mesentery.
An 85-year-old man who had been treated for liver cirrhosis type C was admitted to our hospital because of acute abdominal pain, fever and progressive anemia in November 2015. He was incidentally found to have an intraabdominal tumor (3cm in diameter) 3 years before and was followed without treatment. Abdominal CT scan showed the remarkably swollen tumor (8 cm in diameter) and abnormally retained ascites. From these findings and deteriorating anemia, we estimated the tumor to be spontaneously ruptured and performed an emergency operation.
The unmovable and elastic-soft tumor was located next to the upper small intestine, and showed a deep slit accompanied with active bleeding. Only the tumor was resected, because it was not connected with any other organs including the gastrointestinal tract. The tumor was histologically composed of spindle cells with bundle-like growth, which was similar to the ordinary GIST. The tumor cells were immunohistochemically positive for KIT, CD34 and DOG1. From these histopathologial characteristics and the clinical findings, the tumor was finally diagnosed as EGIST of the mesentery origin.

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Mesh repair of ventral hernias (MRVH) is a standard treatment modality used for this condition. If an operation is required after MRVH, it may require mesh incision on mesh removal with extensive abdominal wall reconstruction, and preventing mesh infection is essential in such cases. General abdominal surgery after MRVH has not been sufficiently investigated. A 74-year-old woman was diagnosed with acute appendicitis 8 months after MRVH. We performed laparoscopic appendectomy without mesh incision. We had performed a small laparotomy at the site of the camera port during the previous surgery. Using a Cattelan needle, we confirmed that the port could be placed at the same site without mesh incision. The patient's postoperative course was unremarkable without mesh infection. A laparoscopic approach is useful in patients undergoing general abdominal surgery after MRVH because it is associated with a low risk of wound infection and can avoid mesh incision, which may cause mesh infection.

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A 46-year-old man presented with right lower quadrant pain of abdomen revealed a swollen vermiform appendix and an increase in density of periappendicular fatty tissue on an abdominal contrast-enhanced CT scan. He was referred to our hospital with a diagnosis of acute appendicitis. When he was first seen at our hospital, the right lower quadrant pain was already relieved and there were no findings suggestive of perforation. We thus selected conservative therapy with antibiotics and he was admitted to our hospital. However, on the 2^nd hospital day, he had recurred and aggravated right lower quadrant pain, so that emergency laparoscopic operation was performed. The surgical findings included an appendix which changed in color to dark violet, absence of perforation, and no pus adhesions to the surroundings. It was confirmed that severe ischemic change had been caused by torsion of the appendix at the root. We thus reduced the torsion and performed appendectomy. Since we successfully conducted appendectomy before appendiceal perforation due to the torsion, his postoperative course was uneventful and he was discharged from our hospital on the 4^th postoperative day.
We report a case of torsion of the vermiform appendix in which laparoscopic operation for diagnosis and treatment was useful, with some bibliographic comments.

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A 34-year-old woman presented with abdominal pain and constipation was found to have rectal cancer and left urinary extravasation, and then she was referred to our hospital. Colonoscopy offered the diagnosis of cancer of the sigmoid colon. Retrograde pyeloureterography revealed defluxion of contrast medium from the renal pelvis, so that rupture of the renal pelvis was diagnosed. During surgery, we confirmed the primary lesion and discontinuous intramesenteric tumor of the colon which had invaded the left ureter and the left common iliac artery that caused obstruction of the ureter with resultant rupture of the renal pelvis. We performed high anterior resection with associated resection of the left ureter and part of left common iliac artery. Histopathology revealed the nodule invading the ureter and the common iliac artery to be extramural cancer deposits without lymph node structure (EX).
This paper deals with a case of rectal cancer presented with rupture of the renal pelvis due to EX.

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Situs inversus totalis (SIT) is a rare congenital anomaly, in which the major internal organs are oriented on the opposite side. It poses a challenge for surgeons, especially those performing complex laparoscopic procedures such as hepatectomy. We present the case of a 75 year-old-male patient diagnosed as having hepatocellular carcinoma (HCC), who was found to have SIT. The liver tumor was discovered during a routine enhanced abdominal CT performed as part of routine monitoring for prostate cancer. The HCC tumors were located in segments 4 and 8, measured approximately 3 cm in diameter, and showed capsular enhancement, characteristic of HCC, on contrast-enhanced imaging. In addition, CT angiogram revealed several anatomic variations of the abdominal vasculature. We performed laparoscopic hepatectomy and the patient's recovery was uneventful. Patients with SIT have a relatively complex abdominal anatomy, and in relation to surgery on the liver, complex anatomic variations of the vasculature are frequently encountered. Therefore, detailed planning and precise investigation of these variations are necessary for safe surgery and good clinical outcomes.

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The patient was an 87-year-old woman diagnosed as having hepatocellular carcinoma in liver segment S6. She had undergone transcatheter arterial chemoembolization (TACE) twice and remained in a stable condition during and after the procedures. However, she developed epigastric pain immediately upon injection of lipiodol for the third session of TACE.
The following day, abdominal CT revealed a high-density area in the gallbladder wall, suggestive of stagnation of the injected lipiodol and inflammation of the gallbladder wall. She was diagnosed as having acute cholecystitis due to embolization of the cystic artery, and open cholecystectomy was performed.
Histopathological examination revealed mollification of the gall bladder wall and full-thickness necrosis, leading to the diagnosis of gangrenous cholecystitis. The patient had a satisfactory postoperative course and was discharged on day 12 after the operation.

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We have performed single incision laparoscopic cholecystectomy for three cases of cholelithiasis with previous histories of abdominal surgeries. Their previous surgeries included gastrectomy under laparotomy, Cesarean section and appendectomy in Case 1 ; laparoscopic ileocecal resection for Crohn disease and laparoscopic dissection of adhesions with partial enterectomy for ileus in Case 2 ; and gastrectomy under laparotomy in Case 3. Extensive adhesions were confirmed in the periumbilical area and the upper abdomen in Case 1 and 2. We performed dissection of the periumbilical adhesions under direct vision and placement of a multichannel port, followed by laparoscopic dissection of adhesions in the upper abdomen and around the gallbladder to remove the gallbladder. In Case 3, intraoperative injury of the cystic artery caused hemorrhage, for which rapid taking out and putting in of gauzes through the periumbilical port enabled us to see the bleeding point directly, leading to successful hemostasis.
Compared to the conventional or needlescopic cholecystectomy, the single incision laparoscopic cholecystectomy demands a high degree of technical difficulty. However, we consider the method to be excellent, because it can dissect periumbilical adhesions under direct vision and it can reach at the gallbladder in the minimal dissecting areas. And if emergency complications such as bleeding may occur, easy taking out and putting off gauzes as well as hemostatic agent can be done by getting on and off the port, showing a superiority even in emergency situations.

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A 76-year-old man presented to us with upper abdominal pain of sudden onset. Plain abdominal CT revealed a high-density mass (68.4 HU) in the gallbladder, suggestive of an acute hematoma formed as a result of gallbladder hemorrhage. Enhanced abdominal CT showed no extravasation of contrast material in the gallbladder. Under the diagnosis of acute cholecystitis due to gallbladder hemorrhage, we selected conservative management. By two days after admission, the patient's symptoms improved. Repeat enhanced CT revealed disappearance of the gallbladder hematoma and localized thickening of the gallbladder wall. Diffusion-weighted MRI revealed the affected region as a hyper intensity. Under a tentative diagnosis of gallbladder hemorrhage due to gallbladder carcinoma, we planned surgery, and cholecystectomy with gallbladder bed resection was performed. As histopathological examination during the surgery confirmed the diagnosis of gallbladder carcinoma with subserosal invasion, we additionally performed regional lymph node dissection. He was discharged on day 9 after the surgery with no postoperative complications. A review of the literature revealed that gallbladder carcinoma presenting as hemorrhagic cholecystitis is rare. In this case, gallbladder carcinoma as the cause of the gallbladder hemorrhage was suspected based on the findings on preoperative CT and MRI, and we successfully provided appropriate treatment.

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A 33-year-old woman was referred to our hospital for further examination of two retroperitoneal tumors that were found incidentally on abdominal USG. CT and MRI 1ed to the diagnosis of intrapelvic retroperitoneal tumors. Surgical resection was planned. We started the operation by the laparoscopic approach. There were two tumors that were adherent to the hypogastric nerves of either side, which 1ed us to suspect that the tumors originated from nerve tissue. The tumors were also too tightly adherent to the anterior side of the sacrum to allow easy separation. Therefore, we converted to open surgery and successfully removed the two entirely separate encapsulated tumors without injury. The histopathological diagnosis of both the tumors was schwannoma. Occurrence of multiple schwannomas in the same patient is extremely rare and worthy of reporting.

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A 67-year-old man was referred to our hospital because of a growing left femoral mass. We diagnosed him with mucinous liposarcoma in the left femoral biceps fascia and performed enlarged tumorectomy with free surgical margin. Four months postoperatively, an abdominal enhanced computed tomography revealed an abnormal tumor in the retroperitoneum. The tumor located in front of the sacrum with clear boundaries and mild contrast effect (CT value: -10-66) was diagnosed as retroperitoneal metastatic liposarcoma ; thus, laparoscopic retroperitoneal tumorectomy was performed. By mobilizing the sigmoid and rectosigmoid colon, the tumor was identified and resected with enough margin and no tissue damage. Histologically, the tumor with myxomatous changes was consistent the finding of metastatic left femoral liposarcoma. The patient has been free from recurrence and metastasis one year after the second operation. The significance of close observation postoperatively and the usefulness of laparoscopic surgery for intraperitoneal recurrence cases were suggested.

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A 59-year-old man was injured when his umbilical region was compressed between the handle of an agricultural cart and a tree trunk. He was transported to the Emergency Department via an ambulance with abdominal pain and distention. Examination revealed a bulge and subcutaneous hemorrhage in his umbilical region ; however, no rebound tenderness was elicited. Abdominal ultrasonography and computed tomography showed a rupture of the linea alba and herniation of the small intestine through the defect. He was diagnosed with traumatic linea alba hernia. His abdominal viscera demonstrated no obvious damage ; thus, we performed an elective operation. A hernia orifice measuring 5×7 cm was identified just below the wound site, and the small intestine was directly exposed. A hernia sac was absent. We sutured the fascia of the linea alba using a TiLENE^® mesh to reinforce the abdominal wall. He showed no complications or recurrence. We report a rare case of traumatic linea alba hernia with a review of the relevant literature.

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A 48-year-old woman presented with a palpable painful mass in the left lower abdomen. Abdominal computed tomography scan revealed a heterogeneous enhanced mass of 5 cm in diameter originating from the transverse abdominal muscle. A part of the mass spread to the intraperitoneal area. The patient underwent tumor resection with 2 cm margin because percutaneous core needle biopsy indicated a possible liposarcoma. The tumor did not infiltrate the organs in the abdominal cavity. The definitive pathological examination revealed high-grade myxofibrosarcoma (MFS) invading the peritoneum. The patient received adjuvant chemotherapy with doxorubicin and ifosfamide. No recurrence was found 10 months postoperatively. MFS usually occurs in the extremities of elderly people and is one of the most aggressive types of soft tissue neoplasms. MFS originating from the abdominal wall is rare.
Surgical excision has to be as large as possible as MFS may spread over a considerable distance beyond the gross tumor margins owing to high risk for local recurrence. Moreover, the follow-up management of patients with MFS should be very thorough to properly assess possible local recurrences.

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A 63-year-old woman underwent sigmoidectomy with D3 lymph node resection for colon cancer. At the end of the operation, a 5-mm port drain was inserted in the lower left abdomen. The drain was withdrawn on the seventh postoperative day. She started to complain of abdominal pain, vomiting, and bulging at the site of the 12-mm port incision in the lower right abdomen. Abdominal computed tomography (CT) showed bowel obstruction due to incarceration of the small intestine at the site of the 12-mm incision port in the lower right abdomen. An urgent operation with a diagnosis of port site hernia was performed. First, the aponeurosis of the abdominal oblique muscle was tightly sutured. After the aponeurosis was opened, strangulated small intestine was observed in the free space under the aponeurosis. It was concluded that suturing of all abdominal wall layers including the peritoneum was necessary at the time of port site closure.

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A 64-year-old man reported right-sided scrotal pain following laparoscopic repair of a right-sided inguinal hernia 7 months prior. Tinel's sign was positive, and the patient's pain was attributed to iatrogenic injury of the genital branch of the genitofemoral nerve. Owing to persistent pain over 6 months despite treatment with oral analgesics, we performed a triple neurectomy comprising resection of the genital branch of the genitofemoral nerve, and the ilioinguinal and iliohypogastric nerves via a groin incision. The patient's scrotal pain resolved on the first postoperative day, and he has shown no recurrence. Chronic pain after inguinal hernia repair has been reported in 0.7-43.3% of patients and may markedly affect their quality of life. Therefore, effective treatment is important. This case report describes a patient in whom triple neurectomy effectively treated chronic scrotal pain.

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An 84-year-old man presented with a 2-week history of discomfort in his right lower quadrant. Although he was initially diagnosed with an incarcerated right inguinal hernia, the induration could not be repositioned. Computed tomography showed that the induration was not connected to the intestine. The patient had been observed in the outpatient clinic because of suspected spermatic cord dropsy. However, his inguinal induration had not improved. To establish a definitive diagnosis, he underwent surgical intervention under local anesthesia for a tentative diagnosis of inguinal hernia. The lesion had enlarged at the time of surgery, and we identified an infiltrative mass containing fragile tissue under the aponeurosis of the external abdominal oblique muscle. We performed a biopsy and completed the operation because the lesion was suspected to be a recurrent nodule secondary to peritoneal metastasis from gastric cancer. Histopathological examination showed inflammatory granulation tissue caused by actinomycetes induced infection. The induration gradually reduced in size following the oral administration of amoxicillin.
To our knowledge, solitary actinomycosis of the inguinal region has not been reported in Japan.

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