A major paradigm shift has recently occurred in laparoscopic incisional hernia repair. The methodology has evolved from a tension-free repair method to the reconstruction of abdominal wall function by suture closure of the hernial orifice. This was accompanied by changes in the repair layer from the intraperitoneal to extraperitoneal route to prevent mesh-related complications and fixation to the abdominal wall. The transversus abdominis muscle release (TAR) approach reported by Novitsky et al. is an epoch-making procedure that overcomes the limitations of the Rives-Stoppa method, the gold standard open procedure, and enables abdominal wall reconstruction for giant hernias. Laparoscopic abdominal wall reconstruction and extraperitoneal mesh placement have become possible with the advent of novel surgical procedures such as eTEP and EMILOS, which have a similar approach to that of open surgery.

This paper describes the history and changes of laparoscopic incisional hernia repair procedures, which were first reported by LeBlanc in 1993, along with the latest trends.

Introduction : When conducting surgical resection for patients with nipple discharge, residual lesions may be left in the responsible duct in the nipple. We have devised a technique using a biopsy trepan that easily enables the complete removal of the responsible duct in the nipple. Patients : This procedure was conducted using a biopsy trepan to remove the responsible duct in the nipple from 24 patients with nipple discharge. Results : The procedure was conducted during duct-lobular segmentectomy in 14 patients, during partial mastectomy in 8, and during nipple-sparing total mastectomy in 2. Postoperative histopathology showed intraductal papilloma in 11 cases, ductal carcinoma in situ in 10, and invasive ductal carcinoma in 3. A lesion was present in a duct within the nipple in 4 patients. Discussion : In patients with nipple discharge, sparing the nipple may leave a residual lesion. Although the lesion could be completely removed by nipple resection, this may be over-treatment. Our procedure, which is simple and reliably removes the responsible duct in the nipple without leaving any residual lesion, is reported.

We report a case of papillary thyroid carcinoma occurred on the caudal side of the hyoid bone. A 49-year-old woman presented with infrahyoid swelling and pain of the anterior neck. Ultrasonography showed a hypoechoic mass located on the caudal side of the hyoid bone and a hypoechoic mass with microcalcification in the left lobe of the thyroid gland. Both masses were diagnosed as papillary carcinoma by fine needle aspiration cytology. The preoperative diagnosis was papillary carcinoma in the left lobe of the thyroid gland, and pre-laryngeal node metastasis. On the other hand, it was also possible that the pre-laryngeal nodule was papillary carcinoma arising from the thyroglossal duct cyst or the pyramidal lobe. And therefore, total thyroidectomy with lymph nodes dissection in the central neck and pre-laryngeal nodule resection were performed. The pre-laryngeal nodule was continuous with the pyramidal lobe. Histopathologically, there were no findings suggestive of the structure of the thyroglossal duct cyst and the final diagnosis was papillary thyroid carcinoma located in the pyramidal lobe. In general, it is difficult to distinguish between thyroglossal duct cyst carcinoma and papillary thyroid carcinoma located in the pyramidal lobe, where an accurate diagnosis based on the adequately examined histopathological findings is required. The case was interesting to have papillary carcinoma in the left lobe of the thyroid as well.

An increasing number of cases with G-CSF induced aortitis have been reported in recent times. However, but sufficient information has not been provided yet. We report two cases of aortitis after pegfilgrastim administration during post-operative adjuvant chemotherapy. The first case was that of a 78-year-old woman who underwent right mastectomy and axillary lymph node dissection (invasive lobal carcinoma, ER+, PgR+, HER2-, Ki67<1%, pT2N2aM0 Stage IIIA). Pegfilgrastim was administered on day 3 of the first course, after post-operative TC (docetaxel + cyclophosphamide) therapy was started. Fever and inflammatory responses were observed from day 6 of pegfilgrastim adminstration.

The second case was that of a 70-year-old woman who underwent right mastectomy (invasive ductal carcinoma, ER+, PgR+, HER2(2+) : FISH(-), Ki67 20.2% pT1cN0M0 Stage IA). After post-operative TC therapy was started, Pegfilgrastim was administered on day 3 of the first course, after starting post-operative TC therapy. From Day 13 onwards, fever, low back pain, and an increased inflammatory response were observed. CT findings were useful for diagnosis in both cases. The spread of G-CSF preparations may cause an increase in the number of cases of aortitis. Further examination is therefore, considered necessary.

An 83-year-old man who had fallen in his house and got a bruise on the right-sided chest was brought into the emergency room and was diagnosed with right multiple rib fractures, traumatic hemothorax and pneumothorax. Five hundred milliliters of bloody effusion were drained through a chest drain. A chest contrast-enhanced CT scan showed the bleeding from the intercostal artery. As his hemodynamics was stable, emergency angiography and transcatheter arterial embolization (TAE) were performed. The extravascular leakage disappeared after the procedure and the chest drain was removed on post-operative day (POD) 7. He was discharged home on POD27. The less invasive TAE can be a good option for treatment of chest trauma in the older people whose operations entail a high risk of causing postoperative complications.

A 71-year-old woman presented with a one-month history of high fever. Proteinuria and urine occult blood were detected by precise examinations and a renal biopsy revealed microscopic polyangiitis. Simultaneously, early gastric cancer was detected with a screening gastrointestinal endoscopy. Robot-assisted distal gastrectomy with D1+ lymph node dissection was performed following an introduction of immunosuppressive therapy against microscopic polyangiitis. Several previous reports suggested that malignant disease might be involved in the development of anti-neutrophil cytoplasmic antibody-related vasculitis including microscopic polyangiitis. However, in many cases, vasculitis developed after as long as several years from the diagnosis of malignant disease, and most cases were of hematologic malignancy. In this case, microscopic polyangiitis and gastric cancer were simultaneously diagnosed. This case was valuable to consider the relevance between malignant disease and vasculitis development. Moreover, the timing and method of surgery for malignant disease are important not to make vasculitis worse.

The case of a 61-year-old man who developed neuroendocrine cell carcinoma of the stomach is presented. Contrast-enhanced computed tomography (CT) showed no distant metastasis. Distal gastrectomy with D2 lymph node resection was performed based on the diagnosis of gastric cancer [T4a(SE)N2M0 ; cStage III]. The specimen showed poorly differentiated adenocarcinoma of the stomach. The patient's postoperative course was uneventful, and S-1 was started as adjuvant chemotherapy. However, CT showed metastasis in the right lobe of the liver 3 months later. Right lobectomy of the liver was then performed, and the specimen showed neuroendocrine cell adenocarcinoma of the stomach and liver. The patient's postoperative course was uneventful, and CPT-11 and CDDP were started as postoperative chemotherapy. Neuroendocrine cell adenocarcinoma of the stomach is relatively rare, has a poor prognosis, and requires multidisciplinary therapy. This case is reported in the context of the relevant literature.

A 59-year-old woman presented with abdominal pain and was diagnosed with mesenteric lipofuscinosis by an abdominal CT scan elsewhere. She was treated with antibiotics, but fever and abdominal pain flared up about one month after a temporary remission. She was referred to our hospital for further examination and treatment of a suspected jejunal mesentery perforation.

Enteroscopy revealed an irregular mucosal elevated lesion in the jejunum, which was biopsied, but the definite diagnosis was not confirmed. Partial jejunal resection was performed as a diagnostic treatment. Postoperative histopathological examination revealed that the lesion was caused by jejunal perforation due to acute exacerbation of ectopic chronic pancreatitis. The postoperative course was uneventful and she was discharged home on the 11th day after the operation.

Ectopic pancreas rarely shows clinical symptoms and is often discovered incidentally during examination or surgery. It is necessary to keep in mind that there is a possibility of ectopic pancreatitis as a cause of jejunal perforation.

A 75-year-old man underwent transabdominal preperitoneal repair (TAPP) for bilateral inguinal hernias in our hospital in 2019. On postoperative day 7, he returned to the hospital complaining of vomiting. Computed tomography showed an intestinal obstruction originating in the left inguinal region, postoperative adhesive intestinal obstruction was diagnosed, and a transnasal long intestinal tube was inserted for decompression. Since the obstruction was not resolved after decompression, surgery was performed. Laparoscopic observation showed dehiscence of the medial end of the peritoneal suture in the left inguinal region, and the small intestine was adhering to the exposed mesh. Without removing the mesh, this small bowel adhesion was detached, and the area of peritoneal dehiscence was resutured, after which an adhesion barrier was inserted to complete the procedure. Resection of the small intestine where the adhesion was detached was not required. Because intestinal obstruction due to peritoneal suture dehiscence may occur following TAPP, every effort must be made to ensure that the closure is strong and without gaps.

An 86-year-old man presented with abdominal pain and hematuria. An abdominal computed tomography (CT) scan showed small bowel wall thickening, marked bowel edema, and ascitic fluid in the pelvic floor, which appeared to be bloody, indicating strangulating bowel obstruction. Blood tests showed markedly prolonged APTT and PT ; hence, we decided to perform emergency surgery with blood transfusion for clotting factor replacement. Hemorrhage and hematoma were observed in the wall of the small intestine and the mesentery ; partial resection of the small intestine where manifested some findings was performed. The patient underwent massive transfusion, plasmapheresis, and immunosuppressive therapy with the diagnosis of abnormal blood clotting due to acquired factor V inhibitor, however, there was no response to the treatment. Coagulopathy remained unresolved, while the patient experienced intracranial hemorrhage on postoperative day 4 and died on postoperative day 12. Herein, we describe a case of spontaneous intramural small-bowel hemorrhage and hematoma due to acquired factor V inhibitor and subsequent remarkable abnormal blood clotting, in which we required differentiation from strangulating bowel obstruction. If an unexplained coagulation abnormality is observed, indications for emergency surgery should be considered, taking the possibility of a rare disease that cannot be prevented by another underlying condition or drug into account.

A 71-year-old female patient visited our hospital with a chief complaint of epigastralgia. Close examination revealed a right renal tumor and submucosal small bowel tumor. Right nephrectomy was performed in the urology department and the tumor was diagnosed as well-differentiated and partially dedifferentiated liposarcoma. Then, she was referred to our department for resection of a small intestinal tumor. Intraoperatively, we found a smooth, yellowish-white tumor which was 50 cm proximal to the terminal ileum, and multiple white nodules throughout the small bowel mesentery. We partially resected the small intestine with a part of white nodules. Histopathologically, the submucosal tumor was histologically similar to that of the right renal tumor, and immunostaining showed P16+, MDM2-, and CDK4+, to which we diagnosed a liposarcoma. Regarding the white mesentery nodule, the nodular adipose tissue that appeared to be contiguous from the fat of the mesentery grew irregularly, and immunostaining showed similar results, suggesting liposarcoma. We reported a rare case of multiple liposarcomas in the right perirenal retroperitoneum, ileum, and small bowel mesentery of the small intestine, along with a literature review.

A 46-year-old man bruised the lower abdomen by a 70 cm long wood popped out of a wood processing machine during work had severe abdominal pain. He was brought into the Emergency Department in our hospital because of suspected organ damage. On admission, his vital signs were stable, but physical exam revealed tenderness and rebound tenderness in his right lower abdomen. Abdominal computed tomography scan showed mild free fluid around the liver and a small amount of free air in the right lower abdomen. He was suspected of traumatic gastrointestinal perforation and emergency laparoscopic surgery was performed on the same day, which revealed that the appendix had been transected. Appendectomy was performed with a diagnosis of traumatic appendiceal transection. Other organs were intact.

Most gastroenteric injuries due to a blunt abdominal trauma affect the small bowel, and appendiceal transection is extremely rare. Conventionally, laparotomy has been performed for abdominal traumas, but in recent years, the usefulness of laparoscopic surgery has also been reported. Particularly, laparoscopic surgery in the early stage of injuries might be able to avoid delayed diagnosis and excessive laparotomy.

A 76-year-old woman presented at a local clinic complaining of generalized abdominal pain, diarrhea, and fever, and was referred to our hospital for further investigation and treatment. Diagnostic imaging showed generalized peritonitis due to appendiceal perforation, and emergency laparoscopic appendectomy was performed. The pathological diagnosis was appendiceal endocrine cell carcinoma. Since no lymph node or distant metastasis was evident on postoperative imaging, it was decided to carry out curative surgery after intraperitoneal observation by staging laparoscopy. In this second operation, no obvious disseminated nodules were observed, and ileocolic resection and D3 lymph node dissection were performed. There was no residual cancer in the resected specimen, and no lymph node metastasis was evident.

Primary appendiceal neuroendocrine cell carcinoma is extremely rare and has a poor prognosis, showing rapid growth and high rates of vascular invasion and metastasis. As in the present case, curative treatment may be possible for some patients, although they will still require careful follow-up, and this case suggested that two-stage curative treatment should be considered an option for patients with appendiceal perforation, without squandering the opportunity.

Interval Appendectomy (IA) has been increasingly selected for appendicitis in recent years. Sometimes we encounter IA cases in which a hidden malignancy was detected. We report two cases of appendiceal cancer diagnosed after IA in our hospital.

Case 1 : Involved a 49-year-old man who was diagnosed with simple appendicitis and successfully treated with antibiotics twice within four months. Two months later, IA was performed when he was diagnosed with well-differentiated adenocarcinoma. In the same month, laparoscopic ileocecal resection (D3) was performed. The final diagnosis was adenocarcinoma of the appendix, pT3N1aM0, Stage IIIb.

Case 2 : Involved a 76-year-old man who was diagnosed with simple appendicitis and successfully treated with an antibiotic. Two months later, he had a recurrence as complex appendicitis, and he was treated with an antibiotic again. Four months later, IA was performed when he was diagnosed with appendiceal adenocarcinoma. In the next month, laparoscopic ileocecal resection (D3) was performed. The final diagnosis was adenocarcinoma and mucinous carcinoma of the appendix, pT4aN0M1c, Stage IVc. In conclusion, even in the cases of appendicitis successfully treated with antibiotics, appendectomy should be performed earlier, considering a possible hidden appendiceal cancer.

Mass-forming appendicitis is often treated via interval appendectomy (IA). However, some studies have suggested that occult appendiceal neoplasm can be masked by mass-forming appendicitis. We report a case of a low-grade appendiceal mucinous neoplasm manifesting as acute mass-forming appendicitis. Thus, the definitive diagnosis was made during IA. The patient was a 78-year-old man who underwent conservative treatment for his mass-forming appendicitis. Follow-up computed tomography imaging allowed us to diagnose appendiceal mucinous neoplasm. Laparoscopic ileocecal resection was done. Pathological examination revealed a low-grade appendiceal mucinous neoplasm. The patient has remained free of recurrence for four years. Thus, we suggest that IA may be a therapeutic technique for mass-forming appendicitis, especially in patients with possible occult appendiceal neoplasms.

A 70-year-old man who was diagnosed with distal low rectal cancer with synchronous liver metastasis underwent 4 cycles of therapeutic chemotherapy with capecitabine and oxaliplatin (XELOX) plus bevacizumab. The primary tumor remarkably downsized and the liver metastasis disappeared. After 6 months of follow up, he had difficulty of defecation. Endoscopic examination showed a type 2 tumor emerged again at the lower rectum. After re-induction of systemic chemotherapy, 4 cycles of XELOX + bevacizumab, laparoscopic abdominoperineal resection was performed. On the postoperative day 7, he had pain around his left ear. And on the postoperative day 9, he had left sided fascial paralysis and the rash in the whole body. Ramsay-Hunt syndrome was diagnosed and medical treatment with antiviral agent and steroids was started. Although the disease did not become severe, facial paralysis has persisted up to now. Ramsay-Hunt syndrome is a shingles outbreak that causes one-side facial paralysis and hearing loss. Ramsay-Hunt syndrome is very rare, but caution is advisable because neoadjuvant chemotherapy and therapeutic chemotherapy for colorectal cancer have gradually been accepted in daily practice.

A 67-year-old man presented with a pulmonary nodule shadow in the right lung at a medical examination. Computed tomography images showed multiple pulmonary nodules and thickening of the wall of the ascending colon. Colonoscopy showed the stenosis completely encircling the ascending colon due to ulcerative lesions, through which the scope did not pass. Although there were no histological findings, he underwent laparoscopic right colon resection with a diagnosis of ascending colon cancer with multiple lung metastases. Histologically the resected specimen of the mesenteric lymph node showed an epithelioid cell granuloma with Langhans giant cells and caseous necrosis. Therefore, we diagnosed the case as intestinal tuberculosis. He received HREZ therapy and pulmonary nodules become smaller. As for intestinal tuberculosis, about 70% of the cases are of secondary associated with pulmonary tuberculosis and we have difficulties in making the definite diagnosis by proving the presence of tubercle bacillus. When recognizing intestinal lesions with pulmonary nodules, we should consider this disease as a possible diagnosis.

A 69-year-old man underwent computed tomography, which revealed a 12 mm sharply marginated nodular lesion with a contrast effect in the rectal mesentery. Magnetic resonance imaging (MRI) showed a low signal on a T1-weighted image, a high signal on a T2-weighted image, and a high signal on a diffusion-weighted image, while positron emission tomography-computed tomography (PET-CT) showed mild accumulation with SUV-max of 2.2. Endoscopic ultrasound fine needle aspiration (EUS-FNA) showed histological images of suspected cancer : nuclear enlargement and scattered atypical cells with high chromatin content. Immunohistochemical staining showed CK7(+), CK20(-), CD20(-), desmin(-), S-100(-), c-kit(-), synaptophysin(-) and chromogranin A(-), which was suggestive of an adenocarcinoma. The lesion was considered to be a primary tumor in the rectal mesentery. However, qualitative diagnosis was not made, and laparoscopic tumor resection was performed. The mass was an isolated lesion in the rectal mesentery. It was a 12 mm, yellowish white, sharply marginated solid mass. Pathologically, the lesion consisted of an ill-defined bilayer duct with lipofuscin granules and estrogen receptor-positive smooth muscle components. Since the mass was in the pelvis of the patient, it was diagnosed as an accessory seminal vesicle. We reported a case in which the accessory seminal vesicle found in the rectal mesentery was resected. Isolated accessory seminal vesicles are extremely rare. We reported one such case along with some literature review.

An 83-year-old man with diarrhea was referred to our hospital in July 2019. Colonoscopy revealed a 4.0cm rectal carcinoma. A robot-assisted laparoscopic Hartmann operation was performed in October 2019. The patient was discharged 13 days after the procedure. Positron emission tomography-computed tomography conducted a year after surgery revealed a remnant rectum with lymph node metastasis. Colonoscopy showed a rectal carcinoma on the anal side from the remnant rectum. A Hartmann operation was performed in November 2020. Histopathology examination showed local recurrence. His postoperative course was unremarkable, and he was discharged seven days after the procedure. Intramural metastasis is rare in rectal carcinoma cases, and the frequency and specifics of its pathophysiology remain unknown. We report a case of intramural metastasis on the anal side of the remnant rectum, after a previous operation for rectal carcinoma with intravenous tumor thrombus.

Angiosarcomas tend to occur in the head and neck region, and those on the trunk are associated with better convalescence. A case of hemangiosarcoma appearing in multiple organs and showing rapid development is presented. The patient was a 78-year-old woman diagnosed with a hemangioma. After resection of a buttock tumor, computed tomography showed a nodular lesion in the lower lobe of the right lung. A partial lung resection was therefore performed. The relationship of this lesion to the buttock tumor was unclear. One year later, computed tomography identified a growing tumor in her right hepatic lobe. A right hepatic lobe resection was necessary, but due to insufficient residual liver capacity, a right portal vein ligation and tumor biopsy were performed. The pathology was hemangiosarcoma due to metastases from the skin and lung lesions. A right hepatic lobectomy was attempted ; however, she developed hemorrhagic shock on the 19th postoperative day. Computed tomography showed growth of the liver tumor and intratumoral hemorrhage. She died 56 days after surgery as a result of disseminated intravascular coagulation (DIC). An autopsy showed multiple hemangiosarcomas throughout her liver. Her cause of death was determined to be liver failure and DIC associated with Kasabach-Merritt syndrome.

A 42-year-old man visited our hospital for epigastric pain and was diagnosed with acute gallstone cholecystitis. He was admitted to our department after being treated with percutaneous transhepatic gallbladder drainage (PTGBD) in the Department of Gastroenterology. Preoperative cholangiography showed a bile duct-like structure connecting the cystic duct and the anterior branch of the right hepatic duct and a thin bile duct branching from it. There were complex bile duct abnormalities. Laparoscopic cholecystectomy was performed with the diagnosis of cholecystitis with a communicating accessory bile duct. During surgery, the gallbladder was removed while preserving the communicating accessory bile duct. The bile duct abnormality was confirmed by intraoperative cholangiography, and the surgery was performed safely. Although biliary tract abnormalities have many variations, a communicating accessory bile duct is extremely rare and increases the risk of intraoperative bile duct injury in cases with severe inflammation. This case of acute cholecystitis with a communicating accessory bile duct that was diagnosed preoperatively and could undergo laparoscopic surgery safely is reported.

A 70-year-old man presenting with a feeling of weakness was found having an 18×14×16 cm left retroperitoneal tumor with a bleeding inner part on a contrast-enhanced CT scan. A left adrenal tumor was likely, but a blood analysis denied any functional tumors. We performed the resection of the left retroperitoneal tumor, with the operating time of 256 min and the blood loss of 400 ml. The patient was discharged from our hospital on the 7^th postoperative day. The resected spacemen included a cystic lesion with a thin wall composed of fibrous connective tissue ; within the cyst wall, endothelial cells which appeared to be adrenocortical cells existed over the almost entire circumference of the lesion ; and there were many vessels of all sizes in the inner part. Consequently, we made the diagnosis of adrenal hemangiomatous endothelial cyst.

Adrenal cystic lesions account for about 2.3% of all incidentally found adrenal tumors, and hemangiomatous tumors which account for about 3% of the adrenal cystic lesions are extremely rare. The adrenal cystic diseases have nonspecific clinical symptoms, they often progress silently and are incidentally detected in many cases. It is difficult to make the definite diagnosis preoperatively and surgery is selected if the patient is symptomatic. In this paper we present a pathologically very rare case of adrenal hemangiomatous endothelial cyst.

An 86-year-old woman who had undergone rectal amputation for rectal cancer 5 years previously was found to have a parastomal hernia with an incisional hernia 2 years after the operation. But she did not want to undergo any operation. She had been followed for subsequent 2 years when she complained of abdominal distension and felt a difficulty in her daily life. We were afraid of abdominal compartment syndrome because the parastomal hernia sac was as large as 17×19×8 cm in dimension. So, we performed the operation under intra-bladder pressure monitoring which is considered to refer the intra-abdominal pressure. Laparoscopic hernioplasty was made safely with the Sugarbaker-method using a sheet of mesh and the patient was discharged uneventfully. No recurrence signs have been found as of one year after the last operation. We report our experience with a case of a huge parastomal hernia with an incisional hernia treated surgically under intra-abdominal pressure monitoring, together with a literature review.

A 68-year-old man presented to our department complaining of a swelling in the right inguinal region. On physical examination, two swellings in the right inguinal region were observed. Abdominal computed tomography showed signs suggestive of a medial inguinal hernia and a lateral inguinal hernia, but since the lateral inguinal hernia was prolapsed in the craniolateral direction along the line of the abdominal wall, an interparietal hernia was suspected, and surgery was performed. Intraoperatively, the lateral hernial sac was seen to be prolapsed from the internal inguinal ring and to extend between the external and internal abdominal oblique muscles rather than toward the inguinal canal, and an interparietal hernia was therefore diagnosed. A medial inguinal hernia was also identified, and both were repaired simultaneously by the ONSTEP technique. An interparietal hernia is a rare subtype of inguinal hernia. In Japan, it is usually repaired by laparoscopic surgery, but open surgery has the advantage that the direction in which the hernial sac extends can be confirmed directly by identifying anatomical landmarks during surgery. In cases of concomitant hernias, as in the present case, the ONSTEP technique is useful because it enables their simultaneous repair.

A 76-year-old man presented to the emergency department complaining of scrotal swelling.

On physical examination, the right scrotum was swollen and erythematous, with erosion and necrosis in a part of the inguinoscrotal area. Computed tomography showed the abscess spreading from the ileocecal to the scrotal region with subcutaneous gas. We suspected an abscess in an inguinal hernia sac and Fournier's gangrene and performed an emergency operation. During laparotomy, the inflamed appendix was adhered to the inguinal hernial sac. Debridement of gangrenous subcutaneous soft tissue via inguinoscrotal incision was performed and the appendix was reduced into the peritoneal cavity.

Ileocecal resection was performed and the inguinal hernia was repaired by suturing the peritoneum of the inguinal fossa. The patient was admitted to the ICU due to septic shock. After several days, he recovered and daily bedside debridement of the inguinoscrotal wound was performed. Secondary skin suturing was done under general anesthesia on the 31^st hospital day. The postoperative course was uneventful and he was discharged on the 56^th hospital day.