In Western countries, neoadjuvant chemoradiotherapy is quite common as the standard therapy for locally advanced rectal cancer, and in Japan, the number of the hospitals where they incorporate this method due to its excellent local control has been increasing in recent years. In this review, we introduce the latest topics and evidences regarding chemoradiotherapy for rectal cancer, such as “Suppression of local recurrence by chemoradiotherapy and the limitation of it”, “Various protocols for chemoradiotherapy”, “Total neoadjuvant therapy”, and “The watch & wait strategy”.

Objective : The objective of the study is to consider optimization of centralization and distribution of surgical resources for aged gastric cancer patients who live in the marginal rural and depopulated region.

Methods : Of a total of 319 patients undergone surgery for gastric cancer for the past 23 years, we evaluated the outcomes of 87 patients over 80 years of age.

Results : Cases of stage IA, IB, IIA, IIB, IIIA, IIIB, IIIC and IV accounted for 24, 8, 12, 17, 9, 3, 5, and 22% of all cases, respectively. Sixty-three % of them underwent distal gastrectomy, 13% total gastrectomy, 14% non-resection and 26% R1-R2 operations. The 5-year-survival rate of stage IA cases was 74%, IB 83% (combined stage I 76), IIA 80%, IIB 62% (combined II 67), IIIA 57%, IIIC 67% (combined III 51), IV 18%, and total cases 59%. Hospital death rate was 12%. In stage I cases many patients died of non-gastric cancer and in II, III and IV cases, died of gastric cancer. In 28%, the life prognosis became unknown within 5 years.

Conclusion : In rural and depopulated regions, there live aged gastric cancer patients who wish to be treated in their own regions. Their surgical outcomes have been thought to be appropriate. It is necessary to distribute surgical resources which enable to manage gastric cancer in the standard treatment as a safety net.

The patient was a 66-year-old woman who underwent craniotomy for parasagittal meningioma in 1998, followed by re-excision for local recurrence in 2012. Thereafter, the local recurrence tended to enlarge, so she had been followed closely without treatment in consideration of a further risk of re-excision. A chest computed tomography (CT) conducted in 2011 showed left pulmonary nodules and an abdominal CT in 2019 revealed liver nodules. These nodules were growing apparently. We performed partial resection of the lingular segment and the left basal segmentectomy in 2019, and diagnosed as pulmonary metastases from meningioma. In 2020, we performed partial hepatectomy (S6, S5, and S2) and diagnosed as hepatic metastases from meningioma. We present a case of metachronous pulmonary and hepatic metastases from meningioma treated with surgical resections, with a review of the literature.

A 54-year-old woman visited a doctor because a growing left breast mass began to bleed. The patient had received outpatient chemotherapy with Mohs ointment and radiotherapy. After discontinuation of chemotherapy, she had received palliative care from a doctor who visited her at home, and she had received blood transfusion a total of six times because chronic bleeding continued. One year and 11 months after the first visit to the previous doctor, she was transferred to our hospital with significant persistent bleeding that was difficult to treat locally, accompanied by major complaints of sever fatigue and shortness of breath. Despite local treatment and blood transfusion in the hospital, progression of anemia could not be suppressed, and the patient underwent transcatheter arterial embolization (TAE) on day 5 of admission. After TAE, not only hemostasis but also exudate and odor notably improved. The patient had a peaceful end-of-life period of 21 days until her death. Here, we report a case of a woman with terminal breast cancer with a cancerous skin ulcer accompanied by persistent uncontrollable bleeding who underwent TAE and had a peaceful end-of-life. Moreover, we provide some discussion.

A 70-year-old woman presented with a 12-cm tumor with skin ulcer in the right breast. A biopsy revealed invasive ductal carcinoma, ER/PgR- and HER2-. We diagnosed the case as right breast cancer, T4bN3cM0 Stage IIIC, and triple negative. The white blood cell count was 98,600/μl (neutrophil : 93.5%). The serum granulocyte colony-stimulating factor (G-CSF) level was as high as 1,200pg/ml (standard value : less than 39.0 pg/ml) and the biopsied specimen was positive for G-CSF immunostaining. Accordingly, the tumor was diagnosed as G-CSF producing breast cancer. Despite 4 times of AC therapy and one time of docetaxel therapy as neoadjuvant chemotherapy, local progression was confirmed. We performed surgery including right radical mastectomy and axillary lymph node dissection. After the surgery, the white blood cell count was rapidly normalized and the serum G-CSF level declined, however, within only 2 postoperative weeks, multiple subcutaneous tumors and mediastinal lymph node swelling developed. The white blood cell count also elevated, and so we determined that recurrence had occurred. As the tumor invasion lymphocytes of the surgical specimen was programmed death ligand 1 (PD-L1) positive, atezolizumab + nab-paclitaxel regimen (AP regimen) was started. The regimen was effective and a total of 8 courses were carried out.

Although G-CSF-producing tumors have been reported in various carcinomas, they are rarely reported in breast cancers. Many of them are believed to be therapy-resistant and to carry poor prognosis, however, we could gain therapeutic effect with AP regimen in this case.

The congenital absence of the pectoralis muscles with breast cancer is quite rare. We report a case of bilateral breast cancer with congenital absence of the left pectoralis muscles in a 49-year-old woman who was operated on for a brain tumor at age 8 and was suspected of bilateral breast cancer during cancer screening. On pathological examination, the tumors were found to be invasive ductal carcinomas (IDC) measuring 2.2 cm and 1.7 cm in the left breast and 1.4 cm and 0.9 cm in the right breast. A bilateral modified radical mastectomy was performed. During surgery, the complete absence of the pectoralis major and minor was noted on the left side, the left axillary vein was close to the mammary gland, and the pectoral nerve was absent. On the right side, the pectoralis muscles were intact. Postoperative histology revealed IDC that stained positive for ER and PgR and negative for HER2, and the Ki-67 labeling index was 1% in the left breast (pT1cpN2aM0 pStage IIIA) and 2% in the right (pT2pN1aM0 pStage IIB). A heredity neoplasm syndrome like Li-Fraumeni syndrome could be considered due to her brain tumor and bilateral breast cancer, and genetic testing might be necessary to decide on the use of radiation therapy. However, radiation therapy was not performed due to a bone fracture in her right upper arm. Therefore, when performing breast cancer operations in patients with congenital absence of the pectoralis muscles, it is necessary to pay attention to the unusual surgical orientation.

We have experienced a case of HER2-positive metastatic recurrent breast cancer in which KL-6 was useful for determining the therapeutic effect during administration of the anti-HER2 antibody topoisomerase I inhibitor complex trastuzumab deruxtecan (T-DXd).

The case involved a 48-year-old woman who had been diagnosed with left breast cancer (cT4N1M0) with lymph node metastases and skin invasion (ER:80-90%, PgR1-3%, HER2:2+ FISH+) at the age of 45. As she refused an anti-cancer agent, we administered trastuzumab (HER) followed by trastuzumab emtansine (T- DM1). Lymph node metastases disappeared and at the age of 47, she had a mastectomy. After the operation, she was administered HER, but a PET scan revealed lung and liver metastases. She was administered T- DM1 followed by HER+pertuzumab+docetaxel. But tumor markers elevated and she was referred to our hospital for administration of T-DXd. The serum level of Krebs von den Lungen-6 (KL-6), a biomarker of the interstitial lung disease (ILD), was high, but a CT scan revealed no evidence of ILD. Both surfactant protein A (SP-A) and D (SP-D) were within normal ranges. We consider that KL-6 is not only a biomarker of ILD but also a tumor marker of breast cancer. She was administered T-DXd, sizes of liver metastases became smaller, and tumor markers and KL-6 level gradually declined.

A 73-year-old woman underwent 2 surgeries for left breast cancer and its recurrence. Eighteen years after the first surgery for breast cancer, a colonoscopy was performed due to the presence of blood in her stool. A type 2 lesion was diagnosed in the ascending colon, which was revealed to be a group 5 tumor on biopsy. The patient was then referred to our hospital for surgery. Laparoscopic ascending colectomy was performed to treat the ascending colon cancer. Histopathological and immunochemical studies confirmed that the tumor of the ascending colon was a metastasis from the breast cancer. Although gastrointestinal metastasis from breast cancer is rare, and colon metastasis is even rarer, it might be necessary to rule out the possibility of a metastatic colon tumor from breast cancer when treating patients with a colon tumor who have undergone surgery for breast cancer. Colon metastasis of breast cancer can be managed through surgical resection and medical treatment to improve the patient's quality of life and life expectancy.

We report a 75-year-old man who needed bilateral thoracotomy for intractable mediastinal abscess due to an infected mediastinal cyst. He presented with precordial pain and a contrast-enhanced chest CT scan revealed a cystic tumor with fat stranding around suspected mediastinal abscess. We emergently removed the cyst wall and abscess by thoracoscopic surgery, but the inflammation and abscess recurred 5 days after the operation. On 12^th postoperative day, we secondly chose bilateral thoracotomy to control infection certainly. He was discharged 25 days after the second operation. Mediastinal cysts are often asymptomatic, but they can be infected with resultant lethal conditions such as mediastinal abscess, that need prompt treatments.

A 47-year-old woman with previous history of right pneumothorax had recurrence of right pneumothorax half a year after the initial episode. Responsible lesion such as bulla was unclarified on a chest CT scan. As her disease was recurrent pneumothorax, we performed thoracoscopic surgery, but responsible lesions were obscure histologically as well as macroscopically. During postoperative two years, she experienced two episodes of recurrent right pneumothorax, however, her menstruation onset had not occurred before or after each episode. The fifth episode of right pneumothorax occurred 4 years after the first episode, when her menstruation started 6 days after the onset of fifth episode. We thus performed reoperation and found a macroscopic small pores on the diaphragm. The diaphragm pores were resected. Histologically endometriotic tissue was also proved, and the case was diagnosed as thoracic endometriotic pneumothorax. The disease does not always occur in conjunction with menstrual cycle. In order to confirm pores on the diaphragm caused by endometriosis or to make the histologic diagnosis, thoracoscopic surgery is needed. However, such pores are repaired and closed due to periodic change of endometrial tissue so that histologic diagnosis cannot be gained in many cases. To gain the histologic diagnosis, consideration of timing of surgery is important and just before menstruation onset or early time after the onset would be desirable.

A 66-year-old woman referred to our hospital for treatment of a mediastinal tumor was found having a 56 × 35 mm poorly enhanced and clearly demarcated tumor at the anterior mediastinum with contrast-enhanced CT scan. The tumor had enlarged by 8 mm in diameter during the past 3 years. Upon MRI, the anterior mediastinal tumor exhibited homogeneous high signal intensity on T1-weighted images and a combination of high and low signal intensities on T2-weighted images. A mature cystic teratoma was suspected and the patient was operated on. As the left diaphragmatic nerve had firmly adhered to the tumor, the nerve and the tumor were combinedly resected, resulting in total thymectomy. Histopathology did not demonstrate malignant cells and we diagnosed the tumor as epidermoid cyst. The postoperative course was uneventful and the patient was discharged on 8^th postoperative day.

Epidermoid cyst of the thymus is so rare that only seven cases including our case have been reported so far. In considering a surgical indication to a gradually enlarging mediastinal tumor, we must remember that clinical observation can be a choice of therapy if the lesion would be an epidermoid cyst.

The case involved a 66-year-old man whose chest CT scan conducted in February 2009 revealed a 0.3-cm faint small ground glass nodule at the peripheral area S9 in the right lung. The nodule was considered not to pose serious problem and he had not been followed until 2018, when he underwent a chest CT scan for newly developed unstable angina pectoris. The chest CT scan demonstrated a 1.1-cm part-solid nodule in the same area S9 in the right lung. As a result of detailed radiologic interpretations comparing both CT findings, we confirmed that the 2009's existing lesion had enlarged with a solid part. We preceded the treatment with therapy for angina over that for the lung lesion, and surgery was performed for the lung lesion with a suspected diagnosis of pulmonary adenocarcinoma after his circulatory function became stable. Thoracoscopic partial resection of right lower lobe was employed. The histopathological diagnosis was invasive mucinous adenocarcinoma. Prior to surgery, we considered risk factors entailed by his previous medical histories and decided to select an alternative procedure and not to add right lower lobectomy. This case, in which a 0.3-cm ground glass nodule had grown to invasive carcinoma during as long as 10 years, appears instructive. It suggests that even small ground glass nodules may need our consideration of long-term follow-up bearing patient's background factors in mind.

A heterotopic gastrointestinal gland polyp (HGGP) is a lesion with a polypoid morphology that indicates submucosal expansive growth and is characterized by marked cystic growth of dilated glands in the gastrointestinal submucosal layer. It is also known as hamartomatous inverted polyp (HIP) or hamartoma. A patient with a suspected gastric submucosal tumor that was found by gastrectomy to be HGGP (55mm) is presented. A 59-year-old woman had been examined at a local clinic for melena and left hypochondralgia 6 months previously, and since investigations suggested the possibility of a gastric submucosal tumor, she was referred to our hospital. Preoperative investigations did not lead to a definitive diagnosis, and laparoscopic local resection was conducted for the purpose of diagnosis and treatment. The tumor in the resected specimen measured 55×40×35 mm and weighed 32 g. It was a mucinous, multilocular cystic lesion located in the submucosa and covered in crypt epithelium. Pathological investigations showed that non-tumorous mucosa had folded inward on itself. The invaginated mucosa contained dilated glands and hyperplasic crypt epithelium and HGGP was diagnosed. Our investigation of reported cases in Japan indicated that nonpedunculated HGGP lesions in the stomach must be treated with local resection to enable full-thickness resection.

A 65-year-old woman presented complaining of abdominal pain and vomiting. Computed tomography (CT) showed a foreign body in the upper jejunum, and intestinal obstruction due to this object was suspected. A gastric tube was inserted, and the patient's course was monitored. Since CT then showed that the object had moved toward the anus, enteroscopy was performed with the aim of observing it. An enterolith was seen in the jejunum 150 cm from the ligament of Treitz, and it was determined that this was the cause of the intestinal obstruction. However, it could not be crushed enteroscopically and it was therefore decided to perform surgery. When the abdomen was opened, the enterolith was found to be impacted at the site where it had been observed by enteroscopy, and enterotomy was performed to remove it. The enterolith measured 5.0×4.5×4.5 cm, and component analysis showed that it was a bile acid enterolith. The duodenal diverticulum had been identified previously, and a shadow thought to represent the enterolith had been evident within it on previous CT. This shadow in the duodenal diverticulum had disappeared on CT images scanned when the intestinal obstruction occurred, and the obstruction was therefore considered to be due to the enterolith having dropped. Although some cases of intestinal obstruction by a dropped enterolith have been reported, intestinal obstruction due to the dropping of a true enterolith formed in a duodenal diverticulum is extremely rare, and this case is reported together with a short discussion of the literature.

A 49-year-old man who had a history of bipolar affective disorder was brought into the emergency room after taking large doses of several antihypertensive drugs for suicide attempt. He had hypotension, high fever, and abdominal pain, but these symptoms rapidly subsided. However, the symptoms worsened after resuming eating, and a colonoscopy and an enterography visualized multiple irregular ulcers from the lower part of the ascending colon to the end of the ileum, and a distal ileum with marked stenosis. We determined that conservative cure could not be expected and performed surgery. A 75-cm long portion of the distal ileum was resected because of ileal discontinuous wall thickening and stenosis. The patient was discharged on 27th day after the surgery. Histopathological findings showed ulceration of the mucosa, extensive fibrosis from the submucosa to the upper layers of the muscularis mucosa, congested capillaries and veins, but no thrombus or arterial stenosis was found in any parts of the resected specimen. Therefore, we concluded that the lesion was caused by mucosal damage and fibrous stenosis in the deeper layers of the mucosa due to non-occlusive mesenteric ischemia (NOMI) caused by high doses of antihypertensive drugs.

A 48-year-old woman visited a doctor with a chief complaint of fever and abdominal pain. She was diagnosed with acute appendicitis and referred to our hospital. Since the symptoms improved with conservative treatment but became worse again after the start of a meal, she underwent emergency surgery. A necrotic appendix that had disintegrated near the root with abscess formation was found. The ileum ruptured into the abscess cavity. Partial cecal resection, partial small bowel resection, and abscess drainage were performed. Extremely poor postoperative infection control resulted in abdominal wall necrosis, cecal perforation, and acute heart failure due to infectious myocarditis. Therefore, the patient was managed in the CCU. Since Entamoeba histolytica was detected in the drainage on postoperative day 20, metronidazole treatment was started. Since the inflammatory reaction improved rapidly with adequate infection control, the patient was discharged on postoperative day 99. Despite the difficult postoperative management of acute appendicitis, anti-amoebic therapy effectively saved the patient's life after the diagnosis of entamoebiasis. This case is reported in the context of the literature.

A 26-year-old female patient presented with right lower quadrant pain with a history of hereditary retinoblastoma ; she had undergone a unilateral ophthalmectomy in infancy. Computed tomography and magnetic resonance imaging revealed an 11 cm right lower quadrant mass. A primary mesenchymal tumor was suspected, and surgery was performed. Intraoperative findings revealed that the mass was located in the proximal ascending colon mesentery, and ileocecal resection was performed. The pathological diagnosis was leiomyosarcoma, and immunohistochemistry showed loss of retinoblastoma protein expression. Hereditary retinoblastoma is an autosomal dominant hereditary disease caused by a pathogenic germline variant of the RB1 gene. It is known to give rise to secondary malignancies such as osteosarcoma and soft tissue sarcoma, mainly triggered by radiation therapy. This case suggests the need for treatment of hereditary retinoblastoma, as the secondary sarcoma can occur ectopically without therapies, causing additional gene mutations in the long term.

The patient was a 65-year-old man. In October 2020, he visited a nearby clinic doctor with a chief complaint of bloody stools. Colonoscopy revealed a mass lesion in the rectosigmoid colon, and he was referred to the department of internal medicine at our hospital in the same month. After close examination, he was diagnosed with rectosigmoid colon cancer and was referred to general surgery for the surgical procedure. Preoperative CT showed a 5 cm venous tumor thrombus or clot formation in the inferior mesenteric vein continuous from the primary lesion. No metastasis was found in distant organs, and preoperative evaluation revealed stage IIIB cancer based on the UICC TNM Classification System (8th edition). In November, he underwent laparoscope-assisted colectomy with D3 lymph node dissection. The postoperative course was uneventful, and he was discharged from the hospital. Postoperative pathological examination also revealed stage IIIB cancer, and the lesion in the inferior mesenteric vein, pointed out preoperatively, was diagnosed as a tumor thrombus. Currently, postoperative adjuvant chemotherapy with mFOLFOX6 is being performed, and no recurrence has been observed to date.

A 26-year-old man was admitted to our hospital with an anal tumor being present from 1 year ago. Rectal examination revealed a 5 cm mass that protruded from the anus on the anal skin at the 5 o'clock position. The mass was brown with a wrinkled surface, resembling testicles, and the root had a long clear stem that was connected to the vicinity of the anal papilla. Since it was expected that it could be safely removed through root ligation, it was resected in the outpatient department without anesthesia. The pathology revealed a fibrovascular polyp, which is a so-called anal polyp. Anal polyps are enlarged anal papillae that are usually approximately 2-5 mm in size and very rarely larger than 2 cm. Those with a size ≥3 cm should be distinguished from malignant tumors such as leiomyosarcoma, anal canal cancer, and malignant lymphoma. In this case, it was 5 cm large, and surgery was indicated. It had a testicle-like shape, different from the usual smooth surface, had a long stem, and could be resected immediately on the day of the first visit without anesthesia. Since it was an anal polyp with a peculiar shape, we report it with some bibliographical considerations.

A 67-year-old man presented with anemia. Endoscopic examination showed a type 3 tumor located at the greater curvature of the stomach. Examination of the biopsy specimen showed gastric cancer, and he was referred to our hospital. An enhanced computed tomography (CT) scan showed a low-density area at liver S7, as well as a soft tissue neoplasm in the right branch of the portal vein. He was diagnosed as having advanced gastric cancer with liver metastasis and portal vein tumor embolus because abdominal ultrasonography and MRI (EOB) showed the same findings. Since the tumor embolus and liver metastasis enlarged after 3 courses of S-1 plus CDDP chemotherapy, it was changed to S-1 plus CPT-11. The liver metastasis vanished, and the tumor embolus shrank markedly with 2^nd-line chemotherapy. Since curative resection was judged possible, he underwent distal gastrectomy and right lobectomy. Pathological examination of the resected specimen showed that there was no metastasis in the liver, and the soft tissue neoplasm suspected to be tumor embolus was a thrombus. He has been alive with no tumor recurrence for the past 8 years and 4 months without adjuvant chemotherapy. This case was extremely difficult to diagnose because portal vein thrombus showed an irregular course similar to that of tumor thrombosis.

We report a case of long-term survival in a patient with gallbladder carcinoma and para-aortic lymph node metastasis who underwent extended cholecystectomy, para-aortic nodal sampling, and 3 years of adjuvant chemotherapy. A 63-year-old woman with epigastric discomfort and mass lesions detected in the pancreatic head on ultrasonography was diagnosed with gallbladder carcinoma and No. 12p lymph node metastasis. We performed extended cholecystectomy with regional lymph node dissection and para-aortic lymph node sampling. The histopathological diagnosis was pT2 (pSS), N1 (No. 12p), M1 (No. 16b1int), pStage IVB. After surgery, the patient received gemcitabine plus cisplatin for 1 year, then tegafur and uracil for another 2 years. The patient survived 8 years without recurrence. No. 16 lymph node sampling is useful to stage and select the adjuvant chemotherapy. Multidisciplinary therapy including radical surgery and adjuvant chemotherapy may improve prognosis in selected cases.

We report a case of intraductal papillary mucinous carcinoma (IPMC), which was diagnosed as a ruptured cyst. The patient was an 82-year-old man with abdominal computed tomography (CT) showing multiple cystic lesions with substantial components in the tail of the pancreas and a small amount of ascites around the lesions. A ruptured pancreatic cyst was diagnosed and ultrasonographic endoscopic transgastric drainage was performed on the fluid components around the cysts. Ascitic fluid cytology was classified as Class II. Pancreaticoduodenectomy was performed 62 days after symptom onset. The final diagnosis was IPMC (T2, N0, M0 pStage Ib [pancreatic cancer treatment protocol, 7th edition]). The IPMC transitioned to anaplastic carcinoma. Six months after surgery, metastatic bone tumors and fractures were observed in the femur, tibia, and humerus. He underwent osteosynthesis, but his general condition gradually deteriorated and he died 1 month later.

A 57-year-old woman had a non-reducible 30 × 30 cm abdominal incisional hernia for more than 10 years. She developed sudden abdominal pain and vomiting and visited our hospital 15 hours after onset. She complained of severe abdominal pain, and signs of peritoneal irritation were present. Computed tomography (CT) showed findings suggesting strangulated bowel obstruction and ischemic change of the intestine. Emergency surgery was performed. The small intestine with complex adhesions formed an internal hernia orifice in the incisional hernia sac and the other intestine were strangulated and twisted, leading to necrosis. The necrotic intestine was resected and anastomosed. The incisional hernia orifice was 10 × 8 cm², too large to close by direct suture, so it was repaired by component separation repair. After the operation, she developed a wound infection. Puncture drainage of the subcutaneous abscess was performed, and the symptoms improved. Fifteen months after surgery, she has not had a relapse of the infection or a recurrence of the hernia. The selection of hernia repair when the surgical field is contaminated is still controversial, especially regarding the use of mesh. This time, this method without using mesh was selected, and healing was achieved by minimizing the effect of postoperative wound infection.

An 82-year-old man underwent laparoscopic hernia repair of bilateral direct inguinal hernias. He was discharged on the day after surgery, but on postoperative Day 6, he presented to our outpatient clinic complaining of epigastric pain. Small bowel obstruction was diagnosed by diagnostic imaging, and he was readmitted. It was considered that the small bowel obstruction was due to dehiscence at the peritoneal suture site, and he was started on conservative therapy with the placement of a long intestinal tube. The symptoms of small bowel obstruction improved immediately, enabling the removal of the tube and the start of oral food intake. Although there has been no subsequent recurrence of small bowel obstruction, elective diagnostic laparoscopy was performed. Dehiscence of the peritoneal suture site was confirmed, and this was closed laparoscopically by simple suturing. The patient started food intake again on the day after the revision surgery, and since no subsequent major complications occurred, he was discharged home on Day 6 after the operation. The possibility of peritoneal suture dehiscence must be borne in mind when treating small bowel obstruction that occurs after laparoscopic hernia repair. This case suggests that conservative therapy should be started first, and that surgery should be considered at the earliest opportunity.

A 44-year-old woman presented with abdominal pain and was diagnosed with appendicitis.

Abdominal computed tomography that day showed a 2.5-cm retroperitoneal cyst located on the dorsal side of the inferior mesenteric vein and on the right margin of the left ovarian artery. There was no evidence of malignancy on imaging. The appendicitis surgery was performed first, and the cyst was laparoscopically resected in the second postoperative month. Postoperative pathological testing resulted in a diagnosis of a primary retroperitoneal Müllerian cyst.

Müllerian cysts are covered with epithelium derived from the Müllerian ducts. They are more common in the male pelvic cavity, where they are discovered in less than 1% of autopsy cases, but they are extremely rare in women.

Although the vast majority are benign, since there have been a few rare reports of malignant transformation, en bloc resection should be considered.

An 83-year-old man visited our hospital because of difficulty urinating and a huge right scrotum that had started enlarging one month earlier. The scrotum reached the middle point of the thigh, and an irreducible giant inguinal hernia was diagnosed. Computed tomography showed that the right inguinal hernia contained a part of the small intestine, and the bladder, bilateral ureters and renal pelvis were dilated. Serum creatinine levels were elevated. After placement of an indwelling urethral catheter, kidney dysfunction improved. Elective surgery was performed and the hernia orifice and myopectineal orifice were repaired with a transabdominal preperitoneal approach. After the operation, difficulty urinating was improved. Thus, it seemed that the hernia had been compressing the urethra, and surgery relieved the abdominal pressure on the urethra, permitting urination. A giant inguinal hernia associated with difficulty urinating requires early repair.

A 90-year-old woman was brought to our hospital by an ambulance with complaints of vomiting. Plain abdominal computed tomography showed an incarcerated left obturator hernia with short bowel obstruction and hepatic portal venous gas. She was admitted to our hospital and underwent ultrasound-guided reduction of the incarceration. The next day, computed tomography showed the disappearance of the hepatic portal venous gas, and we decided to perform elective surgery. Under local anesthesia with sedation, radical surgery was performed via the inguinal approach using the direct Kugel method. The postoperative course was good, and she was discharged from our hospital on postoperative day 4. In this case, after the improvement of the overall status of the patient that worsened because of bowel obstruction due to an incarcerated hernia, we were able to conduct an elective surgery more safely. Elective surgery under local anesthesia can be chosen as a treatment when the incarcerated obturator hernia with portal vein gas is reduced without intestinal ischemia and necrosis.

A 77-year-old man was referred to our department for further investigation and treatment of a suspected left inguinal hernia and left Spigelian hernia. Preoperative computed tomography (CT) resulted in a diagnosis of indirect inguinal hernia with an interparietal hernia sac, and it was decided to perform laparoscopic surgery. The intraoperative findings were consistent with the CT results, and from the laparoscopy findings it was determined that routine laparoscopic inginal hernia repair was feasible. An inguinal interparietal hernia is an unusual type of hernia in which the hernia sac may extend into the abdominal the fascial layers. Since a bilocular type of interparietal hernia is particularly unusual, this case is reported along with a short discussion of the literature.