Purpose : Pancreatic fistulas (PFs) following pancreaticoduodenectomy (PD) are a problem that has yet to be overcome. The effectiveness of pancreatic duct-jejunum anastomosis formation by continuous suturing to the posterior wall utilizing the parachute technique used for vascular anastomosis in preventing PF after PD was evaluated.

Methods : The study subjects were 115 patients who underwent PD between 2015 and 2019. The rates of PF were compared between those in whom the pancreatic duct-jejunum anastomosis was formed by interrupted suturing (interrupted suture group, n = 81) and those in whom it was formed by continuous suturing to the posterior wall (continuous suture group, n = 34).

Results : Grade B or worse PF occurred in 18/81 (22%) of the interrupted suture group, but in only 1/34 (3%) of the continuous suture group, which was significantly lower. Multivariate analysis identified preoperative cholangitis and pancreatic duct-jejunum anastomosis method (interrupted suturing) as independent risk factors for Grade B or worse PF.

Conclusions : This new method of pancreatic duct-jejunum anastomosis formation significantly reduced the incidence of postoperative Grade B or worse PF compared with interrupted suturing.

A 58-year-old man presenting with acute development of a left neck mass was referred to our department with a suspicion of anaplastic thyroid carcinoma. On physical examination, an elastic-hard and ill-defined tumor in the entire left thyroid lobe was palpated. On blood biochemical examinations, the thyroglobulin level was as high as 4,970 ng/mL. Ultrasonogram revealed a 68-mm ill-defined heterogeneous hypoechoic tumor in the left thyroid lobe. A contrast-enhanced CT scan showed the heterogeneously enhanced tumor and bilateral cervical lymph node swellings. A core-needle biopsy revealed hyperplasia of spindle-shaped cells with clear nucleolus. The Ki-67 index was more than 50%. The mitotic figure was 6/10 HPFs. Necrosis was present. We thus made the diagnosis of anaplastic thyroid carcinoma (T3aN1bM0, Stage IVB). Total thyroidectomy, peritracheal dissection and left #6 sampling were performed. On the resected specimen, the section of the tumor was cystic and hemorrhagic and/or necrotic portions accounted for about 80% of the inner portion, which included infarction and ischemic change. In the periphery of the tumor, follicular structure was confirmed, indicating the tumor to be a follicular tumor ; and there was a part of capsular invasion. Consecuently we diagnosed the case as minimally invasive follicular thyroid carcinoma (pT3aN0M0, Stage II). The spindle-shaped cells seen at the tumor periphery preoperatively were associated with infiltration of inflammatory cells and granuloma, so we considered that reactive changes might occur. Here we present this case finally diagnosed through a rare process.

A 56-year-old woman was diagnosed with a right breast mass in a medical examination. Mammography revealed an elliptical, fine serrated, marginal, and highly dense tumor in the right breast U/O. Ultrasound revealed a well-demarcated low echoic mass with heterogeneity. Needle biopsy showed spindle-shaped cells with atypia and solid alveolar, cord-like, and sheet-like structures with dense proliferation and infiltration that suggested metaplastic carcinoma or reactive lesions. As the possibility of malignancy could not be ruled out, right partial mastectomy and sentinel lymph node biopsy was performed. Postoperative pathological findings showed low-grade adenosquamous carcinoma (LGASC) with atypical cells with prominent nucleoli proliferating invasively and a mixture of stratified squamous epithelium-like and ductal structures. LGASC is a rare disease with a frequency of 0.5-1%. The diagnostic criteria of LGASC for images and pathological findings have not yet been established. Therefore, this report will be beneficial for diagnosing future cases.

A 38-year-old woman was treated at another hospital for a lung contusion and a right clavicle fracture following a traffic injury seven months ago. She visited our hospital with complaints of abdominal pain and nausea. Based on medical history and CT images, she was diagnosed with left traumatic diaphragmatic hernia. CT findings six days after the injury at another hospital showed slightly torn diaphragm. The patient was judged suitable for surgery and underwent elective laparoscopic left diaphragmatic hernia repair. The gastric fornix, colon, and greater omentum, which had invaginated into the left diaphragm, were pulled out. The hernia orifice was 6 cm. the orifice was sutured and covered with mesh to reinforce the repair. The postoperative course was uneventful, and the patient was discharged four days after the surgery. CT performed one month after the surgery confirmed no recurrence. We report a case of traumatic diaphragmatic hernia diagnosed seven months after the trauma, repaired successfully using laparoscopy.

Acute esophageal necrosis (AEN), which presents as a black esophageal mucosa on endoscopy, is a rare disease. The prognosis is favorable, but sometimes AEN is associated with esophageal stenosis that can make the treatment difficult. Since the AEN patients often have underlying diseases including diabetes mellitus as background factors, their surgical therapies for esophageal stenosis entail a high risk of causing perioperative complications. The case involved a 72-year-old man who had previous histories of diabetes and cerebral infarction. During an upper gastrointestinal endoscopy, black mucosa affecting from the middle to lower thoracic esophagus was found, and it was diagnosed as AEN. Thereafter the black color of the esophageal mucosa was improved, however, esophageal stenosis accompanying remarkable cicatrization appeared. We inferred that no improvement could be expected from non-surgical treatments such as endoscopic balloon dilation (EBD) and then performed right trans-thoracic and abdominal subtotal esophagectomy. After the operation, we challenged the drainage for suture failure associated with partial necrosis of the reconstructed gastric tube and repeated EBDs for stenosis at the anastomosed site. Finally, the patient was cured of the disease that required a great deal of effort. In treating the patient with AEN associated with esophageal stenosis, the early intervention such as EBD should be carefully investigated.

A 72-year-old man with unresectable duodenal cancer with vascular invasion underwent palliative laparoscopic gastrojejunostomy. Repeated vomiting was observed on postoperative day (POD) 3, followed by a high-grade fever of 39.7 °C on POD4. On POD6, abdominal computed tomography (CT) showed pneumatosis cystoides intestinalis (PCI) in the gastric wall accompanied by hepatic portal vein gas (HPVG) and intraperitoneal free air. Since there was no evidence of necrosis or peritonitis, the patient was managed conservatively with antibiotics and fasting. Liquid food and solid food intake were restarted on POD7 and POD9, respectively. After recovering, chemotherapy for duodenal cancer was started on POD23. To the best of our knowledge, this article describes the first case presenting with PCI accompanied by HPVG and free air after gastrojejunostomy.

A 37-year-old man was admitted to our hospital due to abdominal pain. Abdominal computed tomography showed thickening of the small intestine and free air, suggesting perforation of the small intestine. Laparoscopic surgery was performed, and perforation of the small intestine was confirmed. However, it was necessary to search the abdominal cavity in detail, and laparotomy was performed. A stenosis of about 30 cm was found in the small intestine, and a perforation about the size of a pin hole was observed in the small intestine about 40 cm on the oral side from the stenosis. The stenosis site and perforation site were resected together, and a small intestine to small intestine anastomosis was performed. The postoperative pathological findings showed a group of eosinophilic gastroenteritis muscular lesions. There was no relapse after surgery with steroid therapy. Severe eosinophilic gastroenteritis that causes perforation of the small intestine is not cured even after excision of the lesion site, and steroid therapy is necessary to prevent relapse after surgery.

A 69-year-old man was admitted to our hospital with acute-onset abdominal pain. Abdominal computed tomography showed complete occlusion of the portal vein (PV) and superior mesenteric vein (SMV) due to thrombus, and poor contrast filling in some of the small intestine. The patient was considered to have an intestinal infarction secondary to SMV/PV thrombosis. Exploratory laparotomy and thrombectomy were performed. Postoperative anticoagulant therapy improved intestinal blood flow and caused thrombus regression. Protein S (PS) activity level was reduced at 17%, suggesting that PS deficiency contributed to the thrombus formation. SMV/PVT caused by PS deficiency is extremely rare and is considered to have a high case fatality rate because it causes intestinal necrosis. In our case, intestinal resection was avoided by early thrombectomy, and the outcome was considered favorable.

A 16-year-old man without past medical history presented with upper abdominal pain after lunch. He was suspected to have strangulated ileus by an abdominal ultrasound and was transferred to our hospital on the same day. An abdominal CT scan showed a SMV rotation sign, a whirlpool sign, ascites and a branch of superior mesenteric artery to be twisted counterclockwise by 180 degree. We diagnosed the case as a midgut volvulus with malrotation. Our observation with a laparoscope revealed chylous ascites and midgut volvulus without intestinal necrosis. We repositioned the intestine and performed appendectomy without bowel resection. He was discharged from our hospital on the 19^th postoperative day, though he was associated with postoperative paralytic ileus.

We should try to check whether ascites is chylous or not and consider a necessary and sufficient treatment while keeping the fact in mind that a twisted intestine can be conserved in all cases of intestinal volvulus with chylous ascites.

A 13-year-old boy presenting with a 6-day history of abdominal pain was diagnosed as having acute enteritis, for which he received medication at a nearby clinic. However, no symptomatic remission was gained, and he presented to our hospital with fever in the 38-39°C range and tenderness in the entire lower abdomen. The abdomen was board like. A computed tomography (CT) revealed perforated appendicitis and an abscess cavity in the pelvis, so we made the diagnosis of abscess formation type appendicitis. As the abscess cavity was located close to the rectum, endoscopic ultrasonography (EUS) guided transrectal drainage was performed, and an external drainage tube was placed inside the abscess cavity. Following treatments with antibiotics and abscess cavity irrigation, the abscess rapidly disappeared. On hospital day 9, the external drainage tube was exchanged to an internal stent, which was spontaneously expelled on hospital day 29.

A laparoscopic interval appendectomy was performed 135 days after the EUS guided transrectal drainage. He was discharged 4 days after the operation without any postoperative morbidity.

We report a case of pediatric abscess formation type appendicitis treated using EUS guided transrectal drainage, with a literature review.

A 61-year-old man showed positive fecal occult blood test results and was referred to our hospital for further evaluation and treatment of a columnar protuberant lesion extending from the cecum to the ascending colon, which was detected on colonoscopy. Contrast-enhanced abdominal computed tomography revealed a cecal lesion with a fatty structure that contained vessels, which appeared to be mesenteric vessels within the columnar protuberant lesion that was detected on colonoscopy, and we suspected appendiceal intussusception. Histopathological evaluation of the resected specimen confirmed diagnosis of an adenocarcinoma in adenoma. The patient did not show any abdominal symptoms ; therefore, we decided to perform elective laparoscopic ileocecal resection. Intraoperatively, we observed appendiceal intussusception into the cecum, consistent with the preoperative diagnosis. It was difficult to reduce the intussusception ; therefore, we performed laparoscopic ileocecal resection (D3 dissection) as planned. Histopathological examination revealed a ductal adenoma involving the entire colonic circumference except the appendiceal root with adenocarcinomatous lesions in some areas. Appendiceal intussusception is relatively uncommon and can be treated with emergency surgery ; however, elective laparoscopic surgery may be indicated in patients without appendiceal ischemia or necrosis. We report a case of appendiceal intussusception in a patient with appendiceal cancer, along with a literature review.

An 83-year-old woman with anemia was diagnosed with multiple ascending colon tumors on colonoscopy and was referred to our hospital for surgery, considering the risk of tumor-induced bleeding or obstruction. Contrast-enhanced abdominal computed tomography revealed a tumorous lesion and invagination in the ascending colon. We performed open surgery, and intraoperatively we detected ascending colon carcinoma (pT3N1aM0, Ly1a, V0, pStage III b) and cecal liposarcoma, which showed anterograde invagination.

A liposarcoma most commonly occurs in the extremities and retroperitoneum, and a colonic liposarcoma is rare. We report a case of cecal liposarcoma and concomitant ascending colon carcinoma that occurred as multiple primaries, along with a literature review.

A 44-year-old man got a hard blow on the left side of the abdomen when he had fallen down three meters. On arrival at the hospital, he was in a state of shock, but he responded to bolus doses of intravenous infusion. A contrast-enhanced computed tomography (CT) scan revealed a large retroperitoneal hematoma behind the descending colon with active extravasation of the contrast medium. We made a diagnosis of active bleeding from the inferior mesenteric artery (IMA). Then we decided to perform transcatheter arterial embolization (TAE) to control the bleeding, though colon ischemia might occur. Selective angiography of the IMA showed active bleeding from a marginal artery of the IMA branches. Soon after the TAE, hemodynamics became stable even without sustained catecholamine injection. A CT scan on the next day showed an edematous descending colon, which was confirmed as segmental mucous membrane necrosis of the descending colon by the colonoscopy. Then resection of the partial descending colon was performed with an uneventful postoperative course. He came home at 8 p.o. day.

A 63-year-old man, who was diagnosed with DIC, sigmoid colon cancer, multiple bone and lymph node metastases, and myelocarcinomatosis, was admitted to our hospital. He received chemotherapy with mFOLFOX6 ; 22 days later, right hypochondriac pain and hematemesis were observed. Due to acute hemorrhagic cholecystitis and DIC, emergency surgery was performed. Gallbladder necrosis and blood clots in the common bile duct were observed. Intraoperative cholangioscopy revealed diffuse mucosal redness and fluid oozing from the intrahepatic duct to the lower bile duct. Cholecystectomy was performed, and a biliary decompression tube was placed in the common bile duct via the remaining cystic duct (C tube). It was considered that acute hemorrhagic cholecystitis occurred due to coagulopathy caused by myelocarcinoma. Moreover, increased pressure in the gallbladder led to necrosis, clotting, and obstructive cholangitis. After surgery, biliary bleeding stopped completely, and chemotherapy was restarted. Even in patients with myelocarcinomatosis, cholecystectomy may be a treatment option in patients with relatively good ADL before the onset of acute cholecystitis and in cases where prognosis can be prolonged and chemotherapy can be restarted after cholecystectomy.

A 48-year-old woman came to our hospital complaining of bloody stools. Colonoscopic examination by a local doctor found rectal cancer at the rectosigmoid colon. On abdominal computed tomography (CT) in our hospital, the diagnosis was rectal cancer. In addition, 3D-CT angiography showed Type 2a double inferior vena cava (DIVC) with no interiliac communication. Laparoscopic anterior resection of rectal cancer was safely performed in a patient with DIVC. There are a few reports of colorectal cancer with DIVC. Since some patients with DIVC have multiple gonadal veins or ureter anomalies, the surgery needs to be performed carefully.

A 77-year-old woman was noted to have a tumor, gradually increasing in size on the dorsal side of her rectum on follow-up pelvic computed tomography (CT) after surgery for cervical cancer. Pelvic magnetic resonance imaging revealed a cystic mass with a nonuniform signal inside the tumor on T2-weighted images. She underwent transrectal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy and was discharged without any problems. However, 10 days later, she visited our hospital with the chief complaint of perianal pain. Pelvic CT showed gas retention in the perianal region. Therefore, the patient was diagnosed with Fournier's gangrene due to transrectal EUS-FNA. Urgent drainage was performed on the same day. She was discharged 10 days after this procedure but required repeat drainage because of abscess recurrence. EUS-FNA is a minimally invasive and safe procedure, but infection sometimes is a major complication. Especially with cystic masses, as in this case, it is necessary to consider the risk of infection when performing transrectal EUS-FNA.

Neuroendocrine carcinoma is a disease carrying an extremely poor prognosis. We have recently experienced a case of neuroendocrine carcinoma of the anal canal adjacent to signet ring cell carcinoma of the rectum. The case involved a 73-year-old man who presented with bleeding at defecation and anal pain. Colonoscopy revealed a concave lesion in the rectum Rb and a tumor in the anal canal. A CT scan showed lymph node metastasis at the left inguinal region. We thus made the diagnosis of anal canal carcinoma with left inguinal lymph node metastasis, and performed abdominoperineal resection, bilateral lateral lymph node dissection, and left inguinal lymph node dissection. Histopathological findings of the rectal carcinoma showed signet ring cells which had invaded full thickness of the wall and the adventitia ; those of the anal canal carcinoma showed solid acinous hyperplasia of atypical cells which had invaded up to the adventitia. Immunohistochemistry resulted in Synaptophysin and Chromogranin positive. Consequently, we made the diagnosis of neuroendocrine carcinoma. The rectal and the anal canal carcinomas were adjacent to each other, and the almost all dissected lymph nodes involved metastases of rectal signet ring cell carcinoma. The patient developed recurrence in an early time after the operation and underwent chemotherapy, however, he died of the present disease 2 years and 2 months after the operation.

A 75-year-old man presented at a local clinic complaining of jaundice and was referred to our hospital for further investigation and treatment. Contrast-enhanced computed tomography (CECT) showed a 22-mm mass in the head of the pancreas and an elevated growth extending into the bile duct. Endoscopic retrograde cholangiopancreatography showed irregular stenosis of the lower bile duct and dilatation of the upper bile duct. Lower bile duct cancer was diagnosed, and subtotal stomach-preserving pancreatoduodenectomy was performed. Small-cell neuroendocrine carcinoma (NEC) was diagnosed on the basis of the histopathological findings. The patient's postoperative course was uneventful, and the patient was discharged on postoperative Day 27. Five courses of postoperative chemotherapy with cisplatin and irinotecan were administered, and as of 12 months after surgery, the patient is alive with no recurrence. Primary NEC of the bile duct is extremely rare, and its prognosis is extremely poor. The classification of NEC was amended in the WHO 2017/2019 editions, and since further investigations of multimodal treatment are required, this case is reported along with a short discussion of the literature.

A rare case of pancreaticobiliary maljunction associated with gallbladder and pancreatic cancers is presented. A 65-year-old-woman was diagnosed with gallbladder cancer associated with pancreaticobiliary maljunction, and cholecystectomy, resection of the extrahepatic bile duct, and resection of segments 4a and 5 of the liver (pT2N0M0 stage II) were performed. Three years after the operation, some tumor markers were elevated, and abdominal enhanced computed tomography showed a 20-mm, hypovascular tumor in the tail of the pancreas. Metachronous cancer of the tail of the pancreas was diagnosed, and surgery was performed. Because multiple peritoneal metastases were confirmed by intraoperative pathological examination, radical resection was not possible. The patient underwent chemotherapy, but she died of the original disease 13 months after the operation. Patients with pancreaticobiliary maljunction are considered at high risk for biliary tract cancer, but only rarely for pancreatic cancer. Attention should be paid to the possibility of pancreatic cancer in patients with pancreaticobiliary maljunction.

A 63-year-old man presented to our department because of diarrhea with tarry stool and halitosis. He had undergone pylorus-preserving pancreaticoduodenectomy for a pancreatic neuroendocrine tumor 11 years earlier. Esophagogastroduodenoscopy (EGD) conducted for tarry stool, of which he was aware 6 months before, showed an ulcer at the duodenal-jejunal anastomosis, and he had been administered an oral proton pump inhibitor. EGD taken in our department showed a fistula with the transverse colon at the same site. A Jejunal transverse colon fistula due to anastomotic ulcer was diagnosed and surgery was performed. A duodenal-jejunal anastomosis was performed by the anterior colonic route, which caused a mass due to inflammation. Gastrectomy was performed including the anastomosis forming the fistula and the transverse colon. Histologically, an ulcer was found in the jejunum near the anastomosis, but no neoplastic lesion was found. The postoperative course was favorable, and the patient was discharged on the 15th postoperative day. No recurrence of ulcerative lesions has been observed as of 12 months after the surgery. Gastrointestinal fistula caused by anastomotic ulcer after pancreaticoduodenectomy is rare.

A 66-year-old man who had undergone laparoscopic abdominoperineal resection and open lower left lymph node dissection for rectal cancer was diagnosed with a perineal hernia on computed tomography one year postoperatively. The hernia increased gradually, and by 5 years postoperatively, his quality of life was severely impaired by a bulge in his perineum the size of a child's head and by pain from skin ulceration, curative treatment was performed. A mesh was placed laparoscopically to cover the hernia orifice in the pelvic floor, and this was covered by the greater omentum and reinforced from the perineal side with a gluteal fold flap, a skin flap containing a perforating branch of the internal pudendal artery. One year postoperatively, there has been no recurrence. This method was used in this case because a transabdominal approach alone entailed not just the risk of postoperative seroma, but also the risk that the repair would not withstand pressure from the abdominal organs, resulting in recurrence, and the use of a transperineal approach alone risked the repair being inadequate. The laparoscopic approach is useful from the viewpoints of minimal invasiveness and cosmetic results, and this method may be a useful procedure for treating postoperative perineal hernias. A search for case reports of perineal hernia in Japan was conducted, and the present case is reported along with a discussion of the literature.

A 53-year-old woman presented to a clinic because of right lower quadrant abdominal intermittent pain once every two months for three years. An ovarian tumor was found by examinations, and she was referred to the department of gynecology in our hospital. A trans-vaginal ultrasound showed no evidence of the disease involving the uterus, bilateral ovaries and salpinx. An abdominal contrast-enhanced computed tomography (CT) scan showed an enhanced intra-pelvic ovoid tumor 3.5 cm in size which was adjacent to the small intestine. A pelvic contrast-enhanced magnetic resonance imaging (MRI) showed a high-intensity lesion with internal heterogeneous enhancement in T1 weighed fat suppression. A positron emission tomography scan showed an abnormally high FDG uptake in the tumor. She was diagnosed with GIST of the small intestine and was referred to our department. Laparoscopic surgery showed that the tumor was ovoid in shape with smooth surface and well movable and both the size and localization of the tumor accorded with those in the images. We found that the tumor had the origin of the round ligament of the uterus after the explosion of the tumor and then performed laparoscopically completely excision of the tumor. The histological findings showed that spindle-shaped tumor cells proliferated in disarray that were immunohistochemically positive for α-SMA and Desmin and negative for DOG-1. The tumor was diagnosed as leiomyoma of the round ligament of the uterus. The leiomyoma originated from the round ligament of the uterus is rare and we report this case with review of the literature.

A 72-year-old woman underwent endoscopic choledocholithotomy for choledocholithiasis. Computed tomography scanning also confirmed a cystic mass in liver S8. Although bile juice cytology showed no inflammatory change or malignancy,the mass had enlarged gradually. Aspiration cytology suggested hepatic cystadenoma. Thus, since the findings could not rule out the possibility of a malignant liver tumor, segmentectomy was scheduled. Intraoperatively, the tumor was diagnosed as originating from the right diaphragm without involving the liver. However, histopathological examination confirmed the diagnosis of disseminated AGCT. Later, it was determined that the patient had undergone oophorectomy for an AGCT 10 years earlier. It is sometimes difficult to distinguish a disseminated tumor from the liver or a tumor of the diaphragm. Moreover, it is essential to take a detailed history when the patient has a past operative history of ovarian tumors.

A 76-year-old woman underwent continuous ambulatory peritoneal dialysis (CAPD) for 11 years and hemodialysis for 5 years because of chronic kidney disease. She had been diagnosed with small bowel ileus two months prior and was hospitalized twice. The day after her last discharge, her abdominal symptoms recurred. The patient underwent an emergency intestinal adhesion dissection that day. Intraoperative findings showed that the small intestine in the pelvis was wrapped in a white capsule forming a lump. These findings are consistent with those of encapsulating peritoneal sclerosis (EPS). Since we did not find any evidence of intestinal necrosis during the operation, we removed the capsule and dissected the intestinal adhesions without performing intestinal resection. She started eating on postoperative day 11. The patient was discharged on postoperative day 22. The EPS has not recurred from discharge to the present. Following the removal of her CAPD catheter at the time of operation, the patient is hemodialysis dependent. With EPS in mind, we should treat ileus patients who have undergone long-term CAPD.

In incisional hernia repair, reconstruction using an artificial material is not indicated because of the risk of infection in surgery involving surgical field contamination. A case of a huge incisional hernia with ileus caused by sigmoid colon cancer, which was reconstructed by tumor resection and component separation, is presented. A 55-year-old man was transported by the emergency services because of difficulty moving. Computed tomography showed ileus due to sigmoid cancer and a huge incisional hernia, 21 cm in length and 15 cm in width, in the upper abdomen, and the dilated intestinal tract had escaped. Decompression was performed by an intestinal stent, but 11 days later, abscess formation occurred due to stent occlusion and retroperitoneal penetration, so semi-emergency surgery was performed. Tumor resection by Hartmann's procedure and abdominal wall reconstruction by the component separation method were performed. A stoma was created in the lower left abdomen, and it was possible to close the wound while maintaining the strength of the abdominal wall. The wound was treated with negative pressure wound therapy, and the patient was discharged without complications.

A 75-year-old woman was admitted to our hospital because of abdominal pain and vomiting. Abdominal examination revealed localized tenderness and a mass that seemed like the intestine in the lower left quadrant. An abdominal computed tomography scan showed part of the small intestine with a linear, high-density lesion in the inguinal region and distension of the oral side of the small intestine. She was diagnosed with incarcerated inguinal hernia, and an emergency operation via the open anterior approach was performed. During the surgical procedure, a hernia sac containing an incarcerated small intestine was observed. Opening of the hernia sac revealed a perforation in the small intestine caused by a fish bone. The perforated bowel was resected, and inguinal hernia repair was performed using the McVay operation. The postoperative course was uneventful, and she was discharged 15 days after the operation. In this case, when the fish bone reached the prolapsed small intestine in the inguinal hernia sac, it could not pass through because the degree of the freedom of mobility of the small intestine was restricted. In addition, the intestinal wall was inflamed and thickened due to the perforation. It was considered that the intestinal wall could not return to the abdominal cavity and became incarcerated.

Femoral hernias are relatively rare and usually occur in elderly females. They are sometimes found in patients who have previously undergone inguinal hernia repair. We report the cases of two males with femoral hernias induced by anatomical changes after inguinal hernia repair. Both patients underwent laparoscopic transabdominal preperitoneal repair. Patient 1 was a 73-year-old man who had undergone mesh plug repair for a right inguinal hernia three months previously. Laparoscopy showed that the iliopubic tract was displaced superiorly due to contraction of Hesselbach's triangle by scar tissue where the mesh plug was placed. The inguinal ligament was displaced and the femoral ring expanded. Patient 2 was a 62-year-old man who underwent left inguinal hernia repair during childhood. Laparoscopy showed that the iliopubic tract was displaced, and the femoral ring expanded. We suggest that the posterior wall of the inguinal canal was damaged in the previous operation during high ligation of the hernial sac. In both patients, we consider that the traction forces used affected the inguinal ligament, resulting in expansion of the femoral ring and development of a femoral hernia.