A woman who was being followed for primary Sjögren's syndrome (SS) and breast cancer in another hospital was referred to our hematology unit for evaluation of thrombocytopenia (platelet count 8,000/μl). Increased levels of antinuclear antigen, platelet-associated IgG, anti-thyroid peroxidase, anti-thyroglobulin, thyroid-stimulating antibody, TSH receptor antibody, and anti-SS-A/B antibody were found. Idiopathic thrombocytopenic purpura (ITP) associated with Graves' disease and SS was diagnosed after ruling out other potential causes of thrombocytopenia, including infections by HIV, HCV, HBV, or drugs. Since her thrombocytopenia was considered refractory to standard treatment for ITP, splenectomy was performed 11 months after the diagnosis of ITP. One month after splenectomy, her dry eyes, dry mouth, and the concentration of each antibody were marked improved, and the platelet count and thyroid function improved to the normal range. Eight months after splenectomy, total thyroidectomy was performed because of increasing levels of each antibody and hyperthyroidism. Three years and five months after splenectomy, the high anti-SS-B antibody level decreased to 50% of that before splenectomy. In the present case, the improvements of the platelet count, thyroid function, and the concentration of each antibody by splenectomy were likely due to a common immunological imbalance between ITP, SS, Graves' disease, and Hashimoto's thyroiditis.

Methotrexate-associated lymphoproliferative disorders (MTX-LPDs) develop in patients treated with MTX. An extranodal lesion of malignant lymphoma in MTX-LPD rarely appears in the mammary gland.

A 77-year-old woman was referred to our hospital with masses in the left breast and left axilla. She had been treated with MTX for rheumatoid arthritis for 17 years. The masses were 68 × 55 mm in the left breast and 47 × 30 mm in the left axilla. Breast cancer was suspected at first, but malignant lymphoma was conclusively diagnosed by needle biopsy. PET-CT showed abnormal uptake in the left breast, left axilla, and various lesions in the body. On examination of an excisional biopsy specimen of a right femoral subcutaneous lesion seen as abnormal uptake on PET, the histological type was found to be diffuse large B cell lymphoma (DLBCL), and it was diagnosed as MTX-LPD because she had been treated with MTX. MTX treatment was stopped for two months, but the lesions did not shrink. She underwent chemotherapy for DLBCL, and it led to complete remission. A rare case of MTX-LPD diagnosed by pathological examination of a breast tumor specimen is presented.

In the recent years, due to advances in surgical techniques, the safety of hepatobiliary and pancreatic surgery has improved and the incidence of complications has decreased. However, a postoperative hemorrhage is often fatal, and a treatment method has not yet been established. Recently, transcatheter arterial embolization has used for the treatment of postoperative hemorrhage, but it may lead to peripheral tissue ischemia. A hemostatic procedure using a covered stent was previously reported for preventing ischemia ; however, it was not covered by insurance. In early 2016, the GORE VIABAHN stent was covered by insurance for use in treating traumatic and iatrogenic vascular injury. Here, we report 4 cases in which the GORE VIABAHN stent was used for hemostasis of intractable hemorrhage.

An 85-year-old man accidentally struck a pole in the road while driving a car. He was taken to another hospital by ambulance, where contrast-enhanced computed tomography showed a large hematoma around the head of the pancreas, with rupture and pseudoaneurysm of the middle colic artery, and the patient was transferred to our hospital. Angiography showed bleeding from the distal dorsal pancreatic artery, and arterial embolization was performed. The middle colic artery was ruptured at its root, and since embolization was considered not feasible, emergency surgery was performed. Intraoperatively, although there was only a small amount of bloody ascites, a large hematoma extended from the area around the head of the pancreas head to the transverse mesocolon. The transverse mesocolon was partly damaged, and rupture and pseudoaneurysm were apparent at the root of the middle colic artery. Although there was no active bleeding, the arterial root was ligated to prevent recurrence. The patient's postoperative course was uneventful, with no recurrent hemorrhage, and he was transferred to another hospital for rehabilitation on postoperative Day 21. The occurrence of sudden deterioration due to pseudoaneurysm rupture caused by mesentery damage and cases of delayed onset have been reported, and if a hematoma is present within the mesentery, the possibility of pseudoaneurysm formation must be borne in mind during treatment.

Case 1. A 70-year-old man underwent esophagectomy for esophageal cancer and esophageal reconstruction using the stomach through the posterior mediastinal route. One year later, simultaneous bilateral spontaneous pneumothorax (SBSP) developed. SBSP was relived under observation in our hospital, but one week later he was readmitted to our hospital for recurred SBSP. Pleural effusion was present on only the left side, for which chest drainage was performed. SBSP was improved, thus we determined that SBSP had developed as a result of left side pneumothorax through pleuro-pleural communication. An operation was performed for the left side and the patient was discharged. However, 2 days later he was readmitted for SBSP. Consequently, we performed chest drainage for both sides, with additional operation on the right side for bulla resection and suturing for pleuro-pleural communication.

Case 2. A 70-year-old man who had undergone esophagectomy for esophageal cancer and esophageal reconstruction using the stomach through the retrosternal route was brought into our hospital by ambulance for cardiopulmonary arrest. The onset of SBSP was noted, and we performed bilateral chest drainage. Thereafter, air leakage on the left side persisted, thus we performed surgery resecting a left side bulla and suturing for pleuro-pleural communication.

SBSP is a disease stage that can be fatal and suturing for pleuro-pleural communication is important in affected patients.

A 63-year-old woman who was referred to our hospital for general fatigue was found having a tumor at the anterior mediastinum on a chest CT scan. She was admitted for further examination and treatment in January 2017. The chest CT scan showed a cystic mass of 30×20mm in diameter in the anterior mediastinum. A chest MRI showed the mass, with isointensity in comparison with the muscle on T1-weighted, and slightly high intensity on T2-weighted images. Based on these findings, we preoperatively diagnosed the mass as a thymic cyst or a cystic thymoma. We performed video assisted thymectomy. Histopathology revealed the cyst lined by bronchial epithelium in the regressed thymus. It was diagnosed as bronchogenic cyst in the anterior mediastinum.

Here, we report a case of bronchogenic cyst arisen in the anterior mediastinum with a review of the literature.

The metastatic mesenteric tumor from lung cancer is extremely rare. We report a case of resected solitary mesenteric metastasis 2 years after operation for lung cancer. A 57-year-old man had undergone right upper lobectomy for infectious giant bulla. Adenocarcinoma was histopathologically proved in the resected giant bulla. Beginning at 18 months after the lung resection, the serum carcinoembryonic antigen (CEA) level gradually increased. An abdominal computed tomography (CT) scan showed a tumor in the mesentery of the small intestine and 2-fluoro-2-deoxyglucose (FDG)-CT demonstrated high accumulation of FDG in the tumor. The tumor gradually enlarged in size for 6 months. We diagnosed the tumor as a solitary metastatic or primary mesenteric tumor. Laparoscopic-assisted resection of the small intestine including the mesentery where the tumor existed was performed. The pathological diagnosis was metastatic adenocarcinoma from lung cancer. Serum CEA level decreased after the operation. Although solitary mesenteric metastasis of lung cancer is rare, it mimics other mesenteric primary tumors. In order to address the diagnosis of metastasis from lung cancer, resection of solitary mesenteric metastasis from lung cancer should be considered, allowing for a proper general chemotherapy.

A 68-year-old man who had been pointed out having a left epiphrenic esophageal diverticulum at the age of 18 was referred to our hospital following a diagnosis of esophageal cancer with the chief complaints of vomiting and weight loss. Upper gastrointestinal imaging and endoscopy revealed a mainly submucosal tumor 7 cm in diameter in the left anterior wall of the lower thoracic esophagus. Biopsy indicated squamous cell carcinoma, while CT suggested tumor invasion into the pericardium, diaphragm crura, and left lower lung lobe. The epiphrenic diverticulum was not evident due to tumor involvement, but we diagnosed the patient with esophageal cancer arising from the diverticulum for two reasons : (ⅰ) The epicenter of the tumor coincided with the previous diverticulum. (ⅱ) The tumor was large but was located primarily in a submucosal region, and the mucosal lesion of the tumor was localized to the left anterior wall. Middle and lower esophagectomy with left thoracotomy was performed following neoadjuvant chemotherapy. Intraoperative findings revealed the tumor strongly adhered to the left diaphragm, the left lower lung lobe, and lateral segment of the liver. R0 resection was achieved through combined partial resection of each organ. Most of the tumor was under the mucosa in the resected specimen, suggesting a diverticulum origin. The tumor invasion into the diaphragm was evident, but adhesions to the left lung and the liver were inflammatory.

A 77-year-old man underwent esophagogastroduodenoscopy, which revealed a flat ulcer with a raised margin along the lesser curvature of the lower gastric body. Based on biopsy findings, he was diagnosed with diffuse large B-cell lymphoma. During the procedure, we observed a mass adjacent to the gastric wall along the lesser curvature of the upper gastric body, which was suspicious for an enlarged lymph node. The tumor in the lower gastric body disappeared following a course of 5 cycles of rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine sulfate, and prednisone chemotherapy. However, the tumor in the upper gastric body remained unchanged, and ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography-computed tomography revealed low FDG uptake, leading to a suspicion of a gastrointestinal stromal tumor (GIST). Endoscopic ultrasound-guided fine-needle aspiration is associated with the risk of dissemination ; therefore, we performed open partial gastrectomy. The tumor was identified in the lesser omentum and originated from the gastric wall. We performed en bloc resection, and the patient was discharged 8 days later. Histopathological examination revealed the tumor measured 33 mm in size, and immunohistochemical examination revealed immunopositivity for CD34+ and c-kit+. Based on these findings, he was diagnosed with low-risk GIST of the stomach. Until the time of writing this report, the patient has shown no relapse for 17 months without adjuvant therapy.

A 76-year-old woman presented to our hospital with anemia. Further investigation showed Type 3 gastric cancer of the lesser curvature of the antrum, and open distal gastrectomy was performed. The staging was T4a (SE) N1 M0 pStage IIIA, and since the patient did not wish to undergo postoperative chemotherapy, she merely underwent regular follow-up examinations. In postoperative Year 2, tumor markers were elevated, and positron emission tomography-computed tomography showed a solitary site of uptake in the spleen. However, the patient did not wish active treatment. In postoperative Year 3, the tumor in the spleen had grown in size, and since the patient requested surgical treatment, open splenectomy and diaphragmectomy were performed. Histopathological testing showed that the tumor was a metastasis of gastric cancer. Today, 3 years after the second operation, the patient remains recurrence-free. Splenic metastasis of gastric cancer is regarded as one form of distant metastasis, but cases of long-term survival after the resection of metachronous solitary splenic metastasis have been reported, and proactive resection should be performed.

Two years ago, a 57-year-old woman with neurofibromatosis type 1 (NF1) underwent an abdominal hysterectomy for a uterine myoma and a wedge-shaped excision of the jejunum for gastrointestinal stromal tumor (GIST). A follow-up computed tomography revealed a 32-mm tumor in the duodenum, and endoscopic findings revealed a submucosal tumor on the contralateral and anal side of the duodenal papilla. Hence, a diagnosis of duodenal GIST was made and an open surgery was performed. A part of the jejunum (15 cm in length) was removed using local excision and a jejunal mucosal patch was grafted. After the surgery, no deformation or stenosis of the surgical lesion was found following fluoroscopy. In general, 7% of NF1 patients have GISTs, and 68% of the lesions often occur in multiples in the small intestine. The malignancies are often low grade. There is an increased risk in surgery and reconstruction when a large lesion is located in the duodenum ; however, it is possible to prevent deformation and stenosis using a jejunal mucosal patch for the duodenal defect.

A patient with primary squamous cell carcinoma of the duodenum that was definitively diagnosed by p16 immunostaining is reported. An 81-year-old woman underwent plain chest computed tomography (CT) during a regular examination in which a tumor of the descending part of the duodenum was identified incidentally. Upper gastrointestinal endoscopy showed signs suggestive of Type 2 advanced carcinoma. Biopsies were taken from four sites in the lesion, all of which contained squamous cell carcinoma with invasive proliferation of keratinized cells. Since contrast-enhanced CT and positron emission tomography-CT did not show any obvious distant metastasis, pancreaticoduodenectomy was performed. Due to its morphology, the possibility of squamous cell carcinoma of the pancreas was also suggested during pathological testing, but p16 immunostaining demonstrated that it was actually primary squamous cell carcinoma of the duodenum.

Primary squamous cell carcinoma of the duodenum is a rare condition. Immunostaining is useful for definitive diagnosis, and this may be helpful for diagnosis of future cases.

We report a case of a 48-year-old woman who received emergency surgery following sudden abdominal pain. She had no history of surgery, complained of strong intermittent pain, and had confirmed muscle defense. Contrast computed tomography revealed strangulated bowel obstruction due to mesenteric hiatal hernia of the small intestine creating a pore with a diameter of about 20 cm approximately 70 cm from the ileum. Hence, she underwent an emergency operation. The abdominal cavity contained bloody ascites, and the small intestine appeared dark red and had disturbances in blood flow. After releasing the strangulation, we were able to observe the pulsation of the mesenteric artery and the color of the intestinal tract ; the small intestine resection was limited to about 40 cm. Small intestine hernias are rare, and preoperative diagnosis is often difficult in adults. However, it is important to consider this condition as a possible cause of strangulated bowel obstruction.

A 64-year-old woman was admitted to our hospital with vomiting and malaise. On admission, she was administered conservative treatment due to the diagnosis of diabetic ketoacidosis (DKA) with fulminant type 1 diabetes mellitus (FT1DM).

Her abdominal pain worsened after hospitalization. Abdominal computed tomography revealed pneumatosis cystoides intestinalis involving the terminal ileum and portal venous gas in the liver. Emergency laparotomy revealed necrosis of the terminal ileum, and hence, bowel resection was performed. Histopathological findings revealed nonocclusive mesenteric ischemia (NOMI). We report a rare case of NOMI induced by DKA secondary to FT1DM.

A 25-year-old woman was admitted to our hospital because of an abrupt onset of upper abdominal pain. Abdominal contrast-enhanced CT scans revealed a multilocular tumor in the left lateral abdominal region. Because the position of the mass changed by MRI scan, a small bowel mesentery lymphangioma was suspected.

Laparoscopic observation of the abdominal cavity revealed a multilocular cystic mass existed in the small bowel mesentery. We confirmed that the mobility of the mass was good. We performed partial resection of the small intestine including the lesion under minor laparotomy.

The histopathological diagnosis was lymphangioma of the jejunal mesentery. This report documents a relatively rare case of lymphangioma of the jejunal mesentery in an adult.

A 44-year-old woman diagnosed with bilateral ovarian tumors underwent left salpingo-oophorectomy and right ovarian cystectomy. Bilateral ovarian tumors were diagnosed as primary ovarian mucinous adenocarcinoma [CK7(+), CK20(+), CDX2(-), ERα(-)], because computed tomography and upper and lower gastrointestinal endoscopy could not identify another lesion. However, intraoperatively, we detected a small intestinal tumor, and partial resection of the small intestine was performed. Histopathological examination of the resected tumor showed findings resembling those of ovarian adenocarcinoma, and the small intestinal tumor was diagnosed as ovarian metastasis of small intestinal adenocarcinoma. She developed recurrent peritoneal dissemination within 2 years postoperatively, necessitating radical Hartmann's operation with resection of peritoneal dissemination and partial resection of the small intestine. Until the time of writing this report, she has not shown recurrence for 4 years and 2 months since her initial surgery. We report a rare case of recurrence-free long-term survival in a woman with ovarian adenocarcinoma, despite the known poor prognosis of this malignancy. We have additionally described the histopathological presentation of this tumor.

A 64-year-old man who presented with right lower quadrant abdominal pain and fever was diagnosed with acute appendicitis with a retroperitoneal abscess by an abdominal CT scan. Transretroperitoneal CT-guided drainage was performed for the abscess. Following disappearance of the abscess, laparoscopic interval appendectomy was performed. Histopathology disclosed the presence of a duplicated appendix which was parallel with the appendix and had not communicated with it.

Duplication of the appendix is a very rare anomaly. Although the anomaly has been described in the Japanese literature, no cases presented with retroperitoneal abscess formation have been reported so far. Furthermore, in our case, percutaneous drainage for the retroperitoneal abscess followed by laparoscopic interval appendectomy (LIA) was useful. This paper deals with our case, together with a review of the literature.

We report on the first case of a tumor of the round ligament of the liver in a patient with IgG4-related disease. The patient was a 75-year-old man who was undergoing regular evaluation for an intraductal papillary mucinous neoplasm. Follow-up CT showed a tumor (size 20 mm) in the falciform ligament of the liver. The pathological diagnosis was not confirmed with ultrasound-guided biopsy. The tumor enlarged slowly, and FDG-PET revealed mild uptake (SUVmax = 4.4). We suspected the tumor to be a leiomyosarcoma or mesenchymal neoplasm derived from the ligamentum falciforme and performed laparoscopic surgery. The tumor existed in the round ligament of the liver. We cut the G4 pedicle, which was in contact with the tumor, and resected the tumor including S4, which showed ischemia. A biopsy specimen from the round ligament of the liver showed infiltration of abundant IgG4-positive plasma cells with fibrosis. After surgery, elevated serum IgG4 levels were observed and IgG4-related disease was diagnosed.

A 54-year-old man was admitted to our hospital with abdominal pain and fever lasting from the previous day. He had the past history of type 2 diabetes. Jaundice was noted and there was tenderness in the abdomen. Blood tests revealed strong hemolysis, high inflammatory reaction, and multiple organ failure. An abdominal computed tomography scan revealed a mass containing gas in the S5 of the liver and the presence of intraperitoneal free air. Acute generalized peritonitis due to rupture of a gas-producing liver abscess was suspected. We performed an emergency open drainage, while his respiratory condition rapidly deteriorated. We observed ascites with bad smell and rupture of the liver abscess during the surgery. After the surgery, we started intensive care for sepsis and multiple organ failure. Clostridium perfringens was isolated from ascites fluid on the 3rd postoperative day, and we started the administration of clindamycin. But he died on the forth day after the surgery. Hepatic abscess due to Clostridium perfringens is extremely rare, but it can rapidly progress to the termination. In the treatment of sepsis with hemolysis and gas-producing liver abscess. Clostridium perfringens should be kept in mind.

A 30-year-old man who was pointed out having a tumor in the right lobe of liver on an abdominal ultrasonography at a medical checkup was referred to our hospital for the purpose of close exploration. No impaired hepatic function was noted, and the serum HB and HC virus markers were negative. He had not routinely used any drugs and had no family history of hepatic disease. Tumor markers were negative. An abdominal CT scan revealed a 10 × 11 × 12 cm tumor at the posterior segment of liver. MRI scan showed heterogeneous high signal intensity on T2-weighted images and low signal intensity on T1-weighted images. No fatty components were involved and the solid part revealed decreased diffusion. Malignant tumor arisen from the liver was suspected, and we decided to perform operation for the diagnosis and treatment. Right lobectomy was employed. The histopathological diagnosis was poorly differentiated hepatocellular carcinoma and the non-cancerous part was normal liver. He has been followed in our clinic without having recurrence, as of 10 months after the operation. Hepatocellular carcinoma affecting juveniles who have not HCC risk in the background is very rare and its etiology and prognosis have still been obscure. We present our case together with the literature review.

Compared to laparotomy, there are few surgical site infections following laparoscopic cholecystectomy, but umbilical wounds occasionally become infected. A case of a delayed abscess caused by Mycobacterium abscessus subsp. abscessus is reported.

A 45-year-old woman previously in good health presented with epigastralgia and fever. The diagnosis was acute cholecystitis caused by a gallstone, and conservative treatment with antibiotics was performed. With an interval of a month and a half, laparoscopic cholecystectomy was performed. She was discharged without any postoperative complications, but two months later, she complained of a tumor that had appeared under the operative scar at the umbilical site. Although no inflammatory findings were observed on blood examination, enhanced CT showed findings suggestive of an abscess. The wound was incised, and pus was drained. It took a month for the wound to heal while being washed. Around that time, the culture was reported to be positive for Mycobacterium abscessus subsp. abscessus. This case is reported along with a literature review.

Portal annular pancreas (PAP) is a rare congenital anomaly in which the portal vein is encased by the pancreatic parenchyma. A 70-year-old man was admitted to our hospital because of epigastric discomfort and jaundice. Lower bile duct cancer was diagnosed, and subtotal stomach-preserving pancreaticoduodenectomy was performed. Intraoperatively, PAP was found. Therefore, we cut the dorsal pancreas at the left edge of the portal vein. Owing to the wide cut surface of the remnant pancreatic body, pancreaticogastrostomy was performed as a reconstruction procedure. PAP could be diagnosed preoperatively. Recognizing this rare anatomical variant in the pancreas is important to prevent postoperative complications.

Acute gallstone pancreatitis occurs when a gallstone is impacted into the duodenal papilla and occludes both the main pancreatic duct (MPD) and the bile duct. However, migration of the gallstone from the bile duct into the MPD is a rare situation. Here, we report a case where the bile duct stone migrated into the MPD and thereby induced acute gallstone pancreatitis. A 61-year-old man was admitted to our hospital with a complaint of epigastric pain. He was diagnosed with choledocholithiasis, and endoscopic lithotomy was planned. After 4 days, epigastric pain reappeared, and the patient was urgently hospitalized with a diagnosis of acute gallstone pancreatitis. Abdominal CT scan showed suspected migration of a bile duct stone into the MPD. Emergency endoscopic retrograde cholangiopancreatography was performed, which showed no filling defect in the common bile duct, while a filling defect was seen in the MPD, consistent with migration of a bile duct stone. Temporary pancreatic stent placement was performed, and acute pancreatitis symptoms improved. Finally, endoscopic lithotomy was successfully performed following laparoscopic cholecystectomy. Spontaneous migration of a gallstone into the MPD is extremely rare and has not previously been reported. However, we should keep it in mind as a cause of acute gallstone pancreatitis.

A 74-year-old man underwent transverse colostomy to treat simple intestinal obstruction due to the infiltration of intraductal papillary mucinous carcinoma (IPMC) of the pancreas into the colon. He subsequently continued chemotherapy with gemcitabine (plus nab-paclitaxel) and FOLFIRINOX. The tumor decreased in size, but chemotherapy was nevertheless continued at the patient's request. However, 39 months after the initial surgery it became impossible to continue chemotherapy due to repeated infected pancreatic pseudocysts, and he was referred for surgery. Resection of the stomach, jejunum, colon, left kidney, and pancreatic tail was performed. Histopathologically, the tumor was invasive IPMC, pT3, S1, RP1, OO1 (small bowel and colon), N1a, pStage IIB, and RP-positive, but no exposure of the carcinoma was evident on the dissected surface. S-1 was administered as postoperative adjuvant chemotherapy, and today, 9 months after surgery, the patient is surviving recurrence-free. There have been few cases of pancreatic cancer requiring resection of the left kidney, and this case is reported together with a short discussion of the literature.

Schwannomas, benign tumors that arise from the nerve sheath, rarely occur in the abdominal wall. A 76-year-old man was diagnosed with a tumor in the right upper abdominal wall and was referred to our hospital for further evaluation. Abdominal ultrasonography showed a well-defined circular tumor close to the liver, and abdominal computed tomography revealed a solitary oval tumor measuring 23 × 20 × 18 mm with slight contrast enhancement. The tumor diameter had been slowly increasing over the past 10 years ; hence, tumor excision was planned using a single incision laparoscopic procedure. The hemisphere-shaped tumor was located in the right upper abdominal wall and projected into the abdominal cavity. Hence, the tumor and surrounding peritoneum were resected. The tumor was a yellow-white smooth mass measuring 20 × 20 × 16 mm and was composed of spindle cells. The tumor cells stained positive for S-100 protein and negative for c-kit. Therefore, the tumor was diagnosed as a schwannoma. The patient currently has no signs of recurrence 1 year after the operation.

A 77-year-old woman presented to our hospital because of precordial distention after the meal. There was a previous history of undergoing pedicled omental grafting for mediastinitis following coronary artery bypass operation. She had been aware of precordial distention from the postoperative period, but recently precordial distention and pressure sensation after the meal were aggravated. She thus presented to our hospital. Thoracoabdominal CT scan revealed that the greater omentum and the stomach had prolapsed from the subxiphoid to presternal area. Subxyphoid hernia after pedicled omental grafting for mediastinitis after open heart surgery was diagnosed, and hernia repair was performed under laparotomy. At surgery, the grafted omentum was preserved and keyhole was created in a mesh, with which the hernia orifice was covered. The hernia recurred about 2 months after the operation. Laparoscopic reoperation was performed, when we confirmed that the keyhole created at the former operation had become the hernia orifice. We transected the omentum, covered the entire hernia orifice with a mesh and completed the repair. Thereafter no findings suggestive of recurrence and omental necrosis have been encountered. Although incisional hernia is known as a complication after omental grafting for mediastinitis, few cases performed laparoscopic hernia repair have been reported. We present our case with a review of the literature.

An 89-year-old woman with rectal prolapse underwent laparoscopic ventral rectopexy. Five ports were used : a 12-mm umbilical camera port, and four 5-mm upper and lower abdominal right and left ports. She started to complain of nausea and vomiting on the 3^rd postoperative day, was diagnosed with paralytic ileus, and her oral intake was restricted. Upper left abdominal pain occurred on the 4^th postoperative day. Abdominal CT showed incarceration of the small bowel at the 5-mm port site in the upper left abdomen. Re-operation was performed. Initially, part of the intestine was seen to be incarcerated into the muscle through the defect. Partial intestinal resection and functional end-to-end anastomosis was then performed, because the part of the intestine was necrotic. The frequency of port site hernias in the literature is reported to be 1%, and a 5-mm port site hernia is an extremely rare complication, but attention should be paid to the possible occurrence of a hernia. When the diagnosis is delayed, the risk of intestinal necrosis and bowel resection increases. A case of a 5-mm port site hernia that occurred in the early postoperative period is reported.

The patient was a 77-year-old man with a 10-year history of right inguinal hernia, and he had repeatedly reduced the hernia by himself until the morning of the day when he was eventually referred to our hospital. Around the noon of the day, he developed abdominal distension, abdominal pain and vomiting and visited a neighboring hospital. Since an abdominal plain x-ray revealed small bowel dilatation and air-fluid level, he was referred to our hospital with a diagnosis of intestinal obstruction. An abdominal CT scan showed a cystic structure at the right lower quadrant which continued from the parietal peritoneum and contained ascites and an edematous bowel loop inside. We diagnosed the case as intestinal obstruction due to reduction en masse of the inguinal hernia and performed emergency laparoscopic surgery on the same day. Operative findings showed that the small bowel loop was impacted in the pre-peritoneal space with the bowel loop remaining incarcerated into the hernia sac. Reduction was easily done by tugging with a clamp. No apparent necrosis was encountered in the small bowel, so that laparoscopic hernia repair was performed by using a mesh.

Reduction en masse of the inguinal hernia is a comparatively rare disease where the prolapsed organ is reduced into the pre-peritoneal space remaining incarcerated into the hernia sac. Thorough questioning and imaging diagnoses may afford to make preoperative diagnosis. Laparoscopic surgery that can promise less invasiveness and definite diagnosis and treatment appears beneficial.

A 77-year-old man who was born healthy presented to our hospital because of obstructive jaundice. Close examination revealed distal bile duct cancer, cancer of the right upper lobe of lung, and right renal cancer. Following biliary drainage, he underwent thoracoscopic right upper lobectomy followed by pancreatoduodenectomy with an interval of 1 month. Then laparoscopic right nephrectomy was performed for the renal clear cell carcinoma 3 months after the pancreatoduodenectomy. The lung tumor was moderately differentiated adenocarcinoma (pT1aN0), the bile duct tumor was carcinosarcoma spread via the pancreas (pT3aN0), and the kidney tumor was well-differentiated clear cell carcinoma (pT1a). He finished three radical surgeries over 4 months from the start of treatment. No signs of recurrence were observed clinically as of 2 years after the surgery. He has been followed in our hospital.

Diagnosis of multiple primary cancers increases with the advances in diagnostic instruments and the known increase in malignancies among the elderly. Radical resection is possible by devising a treatment method for each case with the expectation of a good prognosis.