In the surgical field, types of hernia can be classified into four types ; I. hernia around the inguinal region, II. internal hernia, III. abdominal wall hernia, and IV. diaphragmatic hernia. In each category, extremely rare types of hernia are recognized, which general surgeons have not experienced in their career. Case reports contribute to the progression in managing such rare types of hernia. This article reviews current topics in the diagnosis and treatment of rare types of hernia based on the recent case reports published in academic journals. It is important to consider the name and concept of these rare hernias for appropriate management if encountered clinically.

Background : The currently reported indicators of intestinal ischemia in incarcerated obturator hernia surgery include “elapsed time after onset”, “incarcerated intestinal tract diameter”, and “incarcerated intestinal tract content CT value”. This study investigated whether these indicators are predictors of intestinal ischemia in surgical cases of incarcerated obturator hernia at our hospital. Methods : Between 2010 and 2022, 24 patients underwent surgery for incarcerated obturator hernia at our hospital. Of these, 8 patients underwent bowel resection due to intestinal ischemia (resection group : emergency surgery was performed for all cases), while 16 did not undergo bowel resection (non-resection group : 7 cases of emergency surgery, 9 cases of elective surgery after non-invasive reduction). We investigated three predictors in both groups. Result : The median time from onset to surgery or release of the incarceration was 36 hours in the resection group and 6 hours in the non-resection group, with no statistically significant differences (p=0.07). The diameter of the incarcerated intestine was 3.5 cm in both groups (resected vs. non-resected, p=0.99). The mean CT value of the incarcerated bowel content was 22 HU in the resected group and 8.3 HU in the non-resected group. This difference was statistically significant (p=0.04). Conclusion : Incarcerated intestinal content CT values may be a predictor of intestinal ischemia during non-invasive reduction.

The patient was a 71-year-old woman who had been diagnosed as having breast cancer, and then received left total mastectomy + sentinel lymph node dissection in another hospital three years previously. Postoperatively, she received adjuvant chemotherapy for one year, followed by administration of an aromatase inhibitor and a bisphosphonate, two years previously. She had continued to have hypercalcemia since before breast surgery. She was referred to our department by an internal physician in our hospital for evaluation of multiple nodular goiter. Laboratory analysis revealed hypercalcemia (10.4mg/dl) and high serum intact-PTH level (137pg/ml). The bone mineral density of the young adult mean of the lumbar spine was 55%. Hyperparathyroidism was suspected. Ultrasonography of the neck and contrast-enhanced CT findings revealed almost no parathyroid adenoma in the right thyroid lobe, and 99mTc-sestamibi scintigraphy revealed a nodule with increased radiotracer uptake only in the right thyroid lobe suggestive of the intrathyroidal parathyroid adenoma. Considering intrathyroidal parathyroid adenoma in the right thyroid lobe or small parathyroid adenoma, right hemithyroidectomy and exploratory parathyroidectomy were performed following identification of the dissection area. Histopathology of the right superior and right inferior parathyroid glands revealed normal parathyroid gland and left inferior parathyroid gland was a parathyroid adenoma measuring 0.8cm in diameter with 1-2mm thick. Histopathology of the intrathyroidal tumor revealed follicular adenoma in the thyroid gland. We should perform exploratory parathyroidectomy intraoperatively in order to prevent osteoporosis developing easily in postmenopausal women with breast cancer receiving an adjuvant aromatase inhibitor associated with primary hyperparathyroidism, even if it is difficult to identify the location of no obvious parathyroid adenoma by preoperative imaging.

A 55-year-old female patient had been aware of a tumor in her left breast for one year, but had not consulted a doctor. She presented at the hospital with bleeding from the tumor. A 15-cm fungating mass was found in the left C region. The patient also had severe anemia. A needle biopsy was performed on the left breast mass, and the patient was diagnosed with breast cancer. Since no clear distant metastases were observed, we administered preoperative chemotherapy. However, it was difficult to continue this chemotherapy regimen owing to continued bleeding from the tumor. We performed an endovascular embolization to achieve hemostasis. An embolization was performed on the branches of the axillary, lateral thoracic, and internal thoracic arteries. This stopped the bleeding from the tumor, and the tumor shrank. A total mastectomy with a skin graft was performed after preoperative chemotherapy. Postoperative chemotherapy and radiotherapy were administered successfully. In this case, endovascular embolization was useful for resolving the tumor bleed.

A 64-year-old man presented to our hospital after noticing a left chest mass. Ultrasonography showed a 15-mm solid mass, 5 cm away from the nipple at the 11 o'clock position. MRI revealed a linear structure without enhancement between the irregular shaped tumor and the nipple. Invasive ductal carcinoma was diagnosed by a vacuum assisted biopsy. Because of his past-history of chronic obstructive pulmonary disease and pneumonia caused by COVID-19 infection 3 months earlier, to avoid lung damage by postoperative irradiation, mastectomy and sentinel lymph node biopsies were performed instead of breast conserving surgery. Postoperative pathological examination revealed the duct-like structure between the nipple and the tumor that was diagnosed as invasive ductal carcinoma, pT1b(9mm), pN0(SN), M0, Stage I. Immunohistochemistry showed the positivity of both estrogen and progesterone receptors. As the adjuvant medication therapy, oral tamoxifen for 5 years was chosen. Although most male breast cancers are located under the nipple, few of them have been reported to occur away from the nipple. It is important to recognize that even male breast cancer can develop in sites distant from the nipple.

We report a case of a patient who had a bilateral silicone breast implant (SBI) placed on the anterior surface of the pectoralis major muscle and presented with extensive swelling of the left breast and induration. Invasive ductal breast carcinoma was diagnosed based on core needle biopsy results. Imaging revealed direct tumor invasion into the capsule, massive fluid accumulation around the SBI, morphological changes suggestive of compression impaction and breakage of the outermost shell of the SBI, and nodules suggestive of capsular dissemination. A total mastectomy involving both the SBI and capsule was performed. Pathological examination of the resected specimen confirmed direct tumor invasion and dissemination into the capsule. This showed that the SBI was not damaged, and that a large amount of bloody exudate had accumulated between the SBI and capsule. In cases such as this where capsular dissemination as a nodule is suspected on prior imaging, or where direct tumor invasion into the capsule and fluid accumulation between the SBI and capsule are observed, it is necessary to perform a total mastectomy in addition to complete resection of the capsule surrounding the implant without allowing the fluid within the capsule to leak, keeping in mind the capsular dissemination.

Metaplastic thymoma is a rare thymic epithelial tumor that shows a biphasic structure with a mixture of polygonal and spindle cell components and accounts for 1-2% of all thymomas. In this report, we describe a case of metaplastic thymoma and its bibliographic consideration. The patient was a 58-year-old man. A computed tomography (CT) scan performed upon the patient's visit to our Emergency Outpatient Department for urinary calculus indicated an anterior mediastinal tumor. A chest plain CT scan revealed a 68×40mm, well-circumscribed, internally homogenous tumor in the anterior mediastinum. Fluorodeoxyglucose (FDG)-positron emission tomography (PET)-CT revealed hyperaccumulation of FDG with a maximum standardized uptake value (SUVmax) of 8.37, coinciding with the anterior mediastinal tumor. The patient was diagnosed as having a thymic tumor, and thymo-thymectomy including the surrounding lymph nodes was performed via a median sternotomy approach. No pericardial, mediastinal or pleural infiltration was observed. The excised specimen was 77×57×32 mm in size and had formed from the lower pole of the left lobe in the thymus. The section was white and sharply well-circumscribed, with no obvious invasion of the capsule. Pathological findings indicated a biphasic structure with a mixture of polygonal cell components forming a solid nest and bundle-like spindle-shaped cellular components surrounding the nest. Immunostaining showed strong positivity for CK (AE1/AE3) in the polygonal cells and for vimentin in the spindle cells, leading to the diagnosis of metaplastic thymoma.

A 72-year-old woman presented to our hospital with abdominal pain. A thoracoabdominal CT scan showed a sliding esophageal hiatal hernia and herniation of the stomach, duodenum and transverse colon into the right thoracic cavity, leading to a diagnosis of Morgagni hernia. As she had no prominent strangulation findings, we employed an elective laparoscopic repair through a one-step approach. As for the esophageal hiatal hernia, we performed plication suture of the esophageal hiatus and Toupet fundoplication. For Morgagni hernia in which the transverse colon had prolapsed, we could easily reduce it into the abdomen. The hernia opening was 50 × 60 mm in diameter. We did not resect the hernia sac and repaired with mesh. The patient is doing well without recurrence as of one year after surgery. Morgagni hernia is a rare diaphragmatic hernia in adults, especially the hernia associated with esophageal hiatal hernia is rarer. A laparoscopic approach for both hernias is a beneficial procedure with which we can easily reduce the herniated organs and easily observe the hernia opening. We consider that the approach might be more useful than minimally invasive ones. We report a case of Morgagni hernia with esophageal hiatal hernia, with some bibliographic comments.

The patient was an 83-year-old man. In October 2019, laparoscopic deroofing of a giant liver cyst with right upper quadrant pain was performed. The patient was discharged on postoperative day 8 without any complications.

Three years after the operation, in November 2022, he was examined with a chief complaint of left abdominal pain. Computed tomography (CT) showed a hernia of the right diaphragm and a decrease in the contrast enhancement effect of the small intestine. Delayed diaphragmatic hernia incarceration was diagnosed, and emergency surgery was performed on the same day. The abdominal cavity was observed laparoscopically. A thinned diaphragm was seen, and the small intestine was incarcerated from its dorsal side. Reduction of the small intestine from the abdominal cavity was difficult. When the thoracic cavity was observed with a thoracoscope, the small intestine with mesentery was prolapsed, and no hernial sac was observed. After thoracotomy, the hernia gate was enlarged, and the small intestine was reduced into the abdominal cavity. The hernia gate was closed with needle sutures using 2-0 non-absorbable threads.

The patient's postoperative course was uneventful, and he was discharged on postoperative day 12 without any complications.

A 69-year-old woman received neoadjuvant docetaxel, cisplatin, and fluorouracil (DCF) therapy for lower thoracic esophageal cancer (cT2N1M0, Stage II). Pegfilgrastim had been administered on Day 3 of the first course. Abdominal pain and arthralgia developed on Day 12, and increased fever and an inflammatory reaction were observed on Day 14 when she visited our hospital. Contrast-enhanced computed tomography (CT) showed a soft tissue shadow around the aorta, and a diagnosis of aortitis due to granulocyte colony-stimulating factor (G-CSF) preparation use was made. The inflammatory reaction gradually improved, and the symptoms improved without the use of steroids. Although the number of reported cases of aortitis due to administration of G-CSF preparations has been increasing in recent years, it is still rare. The case of a patient with esophageal cancer who developed aortitis after administration of pegfilgrastim during neoadjuvant chemotherapy before surgery is reported.

A 66-year-old man with early oropharyngeal cancer was diagnosed with type 1 esophageal cancer with a diameter of 2 cm in the middle thoracic esophagus and a liver tumor with a diameter of 8 cm that extended across S4, S5, and S8 during the pre-treatment screening for early oropharyngeal cancer. Considering the high surgical invasiveness, the patient underwent transoral partial oropharyngectomy, thoracoscopic subtotal esophagectomy, and laparoscopic central bisegmentectomy of the liver with gastric tube reconstruction as the first, second, and third stages of surgery, respectively. In the second-stage surgery, the esophagus was cut at the upper thoracic level, and an esophagostomy was made at the left anterior neck. A distal esophageal stump was made at the lower thoracic level. Four weeks after the esophagectomy, the patient underwent laparoscopic central bisegmentectomy of the liver, followed by hand-assisted laparoscopic gastric tube reconstruction. However, conversion from laparoscopic to open surgery was needed for the gastric reconstruction due to severe adhesion of the esophageal stump at the lower mediastinum surrounding the esophageal stump. It was possible to successfully complete the patient's treatment by planning consecutive three-staged surgery. On further consideration of the interval period between the esophagectomy and hepatectomy, improved treatment of the esophageal stump is necessary to avoid severe adhesion and to complete the three-staged surgery without conversion to open surgery.

An 87-year-old woman was brought into the emergency department by ambulance for evaluation of hematemesis and melena. She was diagnosed with Mallory-Weiss syndrome following emergency upper gastrointestinal endoscopy ; however, post-endoscopy computed tomography revealed perisplenic ascites and an upside-down stomach (UDS). The patient was preoperatively diagnosed with intraperitoneal bleeding and underwent emergency laparotomy. Intraoperatively, we detected bleeding from the gastrosplenic mesentery. Therefore, we performed suturing and hiatal hernia repair to ensure hemostasis. Postoperatively, she developed stroke ; however, she improved and was transferred to a rehabilitation facility without recurrent UDS. In this case, UDS led to excessive stretching of the gastrosplenic mesentery, and the physical stimulus associated with vomiting and endoscopic manipulation resulted in gastrosplenic mesentery hemorrhage. Intraperitoneal hemorrhage associated with esophageal hiatal hernia is rare. We report a rare case of this clinical presentation, with a literature review.

An asymptomatic 67-year-old woman was incidentally detected to have a 7-cm tumor on the greater curvature side of the stomach by a CT scan. Following close examination, gastrointestinal stromal tumor (GIST) of the stomach was suspected and partial gastric resection was performed. The histopathological diagnosis was extramedullary plasmacytoma, and there was no continuity between the lesion and the stomach. Additional examination confirmed there were no distant metastases. She was decided to be followed without treatment under the diagnosis of extramedullary plasmacytoma. She is doing well without recurrence as of 2 years and 3 months after the operation.

Extramedullary plasmacytoma is a type of plasma cell tumors. Only 5 cases of the disease arisen in the intraperitoneal lymph node, including our case, have been reported in Japan, except for those arisen in the retroperitoneum. We report a case of extramedullary plasmacytoma with difficulties in making preoperative diagnosis.

A 70-year-old man was admitted to our hospital because of palpitations, staggering gait, and melena. Endoscopy showed multiple gastric cancers and a submucosal tumor. Total gastrectomy, cholecystectomy, and splenectomy were performed. The pathological diagnoses for three lesions were gastric carcinoma with lymphoid stroma. The submucosal tumor with similar pathological findings to the primary region was diagnosed as intramural metastasis. The patient received postoperative adjuvant chemotherapy and has survived 13 months without recurrence. Intramural metastasis of gastric cancer, especially gastric carcinoma with lymphoid stroma, is rare.

A small bowel diverticulum is a rare condition, and there have been few reports of diverticular perforation. The case of a patient in whom a jejunal diverticulum that had been identified during surgery for strangulated bowel obstruction rapidly became perforated due to adhesive bowel obstruction in the early postoperative period is described. An 81-year-old man was referred to our hospital with strangulated bowel obstruction and underwent emergency surgery the same day. During the operation, it was found that the root of the small bowel mesentery was strangulated by an internal hernia, and the entire small intestine was ischemic. Multiple diverticula were also identified in the ischemic small bowel. Only the strangulation was released, and the patient was discharged improved on postadmission Day 17. On Day 38, the patient developed adhesive bowel obstruction, and since this did not respond to conservative therapy, surgery to release the adhesions was performed on Day 44. One of the small bowel diverticula that had been identified during the initial surgery had perforated, and an intra-abdominal abscess was present. A small portion of the jejunum that included the perforation site was resected, and the patient was discharged on Day 59. Pathological examination showed that this was a pseudodiverticulum. The jejunal pseudodiverticulum may have been weakened by ischemia and perforated due to the elevated intestinal pressure caused by the adhesive bowel obstruction.

A 79-year-old woman was presented to our hospital complaining of vomiting, fever, and abdominal pain. Abdominal computed tomography scan showed a solid 17.5 cm wide air-filled structure in the lower abdomen attached to small bowels, free air, and portal venous gas. Emergency surgery for peritonitis due to perforated viscera was performed, and intra operative findings revealed a perforated tumor-lesion, the size of a child's head in the ileum approximately 100 cm from the ileo cecal junction with internal necrosis. Partial ileal resection with primary small bowel anastomosis was performed. The resected specimen showed a submucosal tumor protruding in a sac-like shape on the ileum's anti-mesenteric boarder while histopathological and immunohistological examination revealed a gastrointestinal stromal tumor. She developed prolonged jaundice because of constitutional jaundice and sepsis. The patient was discharged on postoperative day 16 and treated with imatinib as adjuvant therapy because of high risk of recurrence.

A 78-year-old woman presented with abdominal pain and vomiting. A blood analysis showed an increase in the hepatobiliary enzyme. A CT revealed a tumorous shadow associated with air in the proximal small bowel. She was diagnosed with cholangitis and was admitted to our hospital. Endoscopic retrograde cholangiopancreatography (ERCP) did not reveal any biliary stones. An ileus tube was placed, but it failed to resolve the bowel obstruction. A review of the CT findings showed the tumor within the small bowel to have distally moved. We performed laparoscopic surgery with the diagnosis of dietary or enterolith-caused bowel obstruction on the 13^th hospital day. A spherical hard object was found in the small bowel and enterotomy disclosed the object to be a atone, so that the stone was removed and the small bowel was sutured to close. The stone was 3.0 × 2.0 cm in size. As the deoxycholic acid level was more than 98% in a chemical analysis, the diagnosis of bile acid enterolith was made. A CT detected a 3.0 × 2.0 cm paraduodenal papillary diverticulum, but biliary duodenostomy and cholecystoduodenal fistula were clinically abscent. We considered that her small bowel obstruction might be caused by a falled enterolis from a paraduodenal papillary divrticulum. Contrary to plenty of cases of intestinal obstruction caused by gallstones, there are few cases caused by falled enterolith.

A 10-year-old girl presented to the emergency department with pain in the right lower quadrant of abdomen. An abdominal contrast-enhanced CT scan revealed findings consistent with acute appendicitis, showing a swollen appendix with a high attenuation area, having coproma-like appearance, and high absorbance of peripheral fat. She underwent laparoscopic appendectomy. The histopathological examination showed a 1.1 × 1.5 cm mass at the middle portion and the lumen was almost obstructed. Histopathological examination detected relatively evenly sized tumorous cells with near-circular-shaped nucleus and sickly eosinophilic cytoplasm spreading from the submucosal layer to the subserosal layer in the middle of the appendix and forming a funicular sequence. Abnormal mitosis was also seen and the Ki67 labeling index was 8.4%. We diagnosed the case as NET G2 of the appendix. Lymph vessel investigation was slightly positive, but no vascular investigation was detected. We selected close observation and the patient showed good progress, with no recurrence for 6 months postoperatively. Prognosis of NET in children is good, but it is a rare entity and no clear therapeutic guidelines have been established. Further accumulation of clinical cases is expected.

The presence of intraperitoneal free gas is generally regarded as an important criterion for emergency surgery due to its association with gastrointestinal perforation. However, cases of spontaneous pneumoperitoneum with the appearance of intraperitoneal free gas despite the absence of clear signs of gastrointestinal perforation may occur, albeit rarely, and the cause may never be identified in some cases. The case of a patient with spontaneous pneumoperitoneum considered to be associated with the development of sigmoid elongation is reported along with a discussion of the literature.

An 84-year-old man presented with abdominal pain, and imaging showed signs of intraperitoneal free gas. Although signs of inflammation were mild, since symptoms of peritoneal irritation were present, gastrointestinal perforation was suspected, and emergency surgery was performed. However, no obvious site of perforation could be identified, and spontaneous pneumoperitoneum was diagnosed. Sigmoid elongation was also present, and since the colon was also significantly dilated, it was considered that intestinal wall dysfunction and elevated intra-intestinal pressure may have contributed to the development of spontaneous pneumoperitoneum.

Intestinal amyloidosis can cause ischemia and fragility of the intestinal mucosa. It disturbs blood flow at anastomosed site in the intestinal reconstruction to be a high risk of inducing suture failure. There are some cases in which immediate anastomosis is avoided and a surgical stoma is created.

A 67-year-old man with a 20-year history of chronic rheumatoid arthritis presented with anemia. Colonoscopy showed a 20-mm elevated polyp in the sigmoid colon. A biopsy of the colon revealed well differentiated adenocarcinoma. In addition, a biopsy in the normal mucosa showed that direct fast scarlet (DFS) positive substance was deposited. There was a thickening vascular wall with DFS positive. We diagnosed the case as sigmoid colon cancer and intestinal amyloidosis. He underwent endoscopic mucosal resection. Pathological findings of resected specimen showed that vertical margin was positive, and additional surgical resection was recommended. Abdominal CT revealed marking clips in the sigmoid colon. There was no evidence of distant metastases or swollen lymph nodes. We performed laparoscopic sigmoidectomy. We used indocyanine green fluorescence imaging to assess anastomotic perfusion. Blood flow of the colon using for reconstruction was confirmed good. Then we mobilized the splenic flexure to release tension of the anastomotic site. Finally, we inserted a trans anal tube. Postoperative course was uneventful, and he was discharged from our hospital on postoperative day 10.

An 85-year-old man presented with a painful anal tumor and was referred to our hospital for further examination. Anal canal cancer was suspected on CT, but tumor markers were not increased. Endoscopic biopsy was performed, but epithelial cells could not be identified, and the tissue was severely crushed, so no definitive diagnosis was made. To relieve the anal pain and to make a definitive diagnosis, a colostomy and an excisional biopsy were performed. Pathological findings showed that the epithelium had disappeared, large lymphocyte-like cells were diffusely proliferated, and B cell lineage markers such as CD20 were positive. A definitive diagnosis of diffuse large B cell lymphoma of the anal canal was made. Chemotherapy was performed, and a complete response was obtained on CT evaluation 2 courses later. For gastrointestinal malignant lymphoma, chemotherapy is the first choice in principle. Lymphoma tissues are relatively soft, and the epithelium may disappear. Thus, excisional biopsy is thought to be useful if a definitive diagnosis cannot be made by endoscopic biopsy.

A 79-year-old man underwent coronary arteriography for arrhythmia examination. As a percutaneous coronary intervention, coronary artery stent placement was performed to treat significant stenosis in the left anterior descending branch. Immediately afterwards, he felt chest discomfort, and ventricular fibrillation occurred. Chest compression and defibrillation were performed. Because low blood pressure persisted and anemia developed even after sinus rhythm recovery, contrast-enhanced computed tomography was performed, revealing a shrinking hepatic cyst in the lateral segment and an intraperitoneal hematoma around the spleen and stomach. Therefore, hemorrhagic shock attributed to traumatic hepatic cyst rupture was diagnosed. Selective arterial embolization was performed for extravasation in the hepatic cyst, and the cardiopulmonary condition stabilized. We report a case of hemorrhagic shock attributed to traumatic hepatic cyst rupture after cardiopulmonary resuscitation.

A 60-year-old woman visited our hospital due to vomiting, and abdominal CT showed findings of suspected colorectal obstruction due to descending colon cancer, and the liver had multiple low-absorption nodules with suspected cysts. Forty days after a colonic stent was placed for colorectal obstruction, laparoscopic left hemicolectomy was performed. During the operation, two 5-mm, white nodules suspected to be metastatic liver tumors were found on the surface of liver S5 and S8. EOB-MRI showed only two suspected metastatic liver tumors at the same site. Two months after the initial surgery, laparoscopic partial hepatectomy was performed. Histopathologically, these nodules proved to be hepatic reactive lymphoid hyperplasia (RLH). RLH is a benign tumor, and there have been many reports in the lungs, orbits, and skin. However, it is rare in the liver, especially in multiple cases. There is little need to treat hepatic RLH, but it is difficult to follow up because of the difficulty of making a preoperative diagnosis and the difficulty of differentiating it from malignant liver tumor. A case of multiple nodules of hepatic RLH suspected to be metastatic liver tumors of colorectal cancer is presented along with review of the relevant literature.

A 79-year-old woman underwent upper gastrointestinal endoscopy to investigate chronic anemia, and an elevated lesion with an irregular surface and redness was detected at the site where the minor duodenal papilla should have been. The pathological diagnosis of the biopsy specimen was suspected adenocarcinoma. This tumor was not detected by computed tomography (CT), but positron emission tomography (PET) showed faint accumulation of FDG in the duodenum. Since there were no other metastatic lesions, subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) was performed. After surgery, a nasogastric tube was placed for over a month because of delayed gastric emptying, which then improved gradually, and she was discharged on postoperative day 54. Pathological findings of this resected specimen showed poorly differentiated adenocarcinoma with infiltration into pancreatic parenchyma. There were no findings of lymph node metastasis. No recurrence or metastasis has been detected for about 70 months after surgery. Most tumors of the minor duodenal papilla have been previously reported to be adenomas, neuroendocrine tumors, or, rarely, gangliocytic paragangliomas. Adenocarcinoma is extremely rare. A rare case of primary adenocarcinoma of the minor duodenal papilla is described.

Case 1 involved a 67-year-old woman who underwent abdominoperineal resection after chemoradiotherapy for anal canal cancer. Six months after the operation, local recurrence was observed in the posterior wall of the vagina, and local resection was performed. Case 2 involved a 71-year-old woman. Abdominoperineal resection with combined resection of the posterior wall of the vagina was performed for rectal cancer invading the vagina. We used a transpositional flap for the reconstruction of the defected vaginal posterior wall in both cases.

The reconstruction using a transposition flap can be completed in the same operative field of abdominoperineal resection, where the patient's body position is kept intact. It permits to perform surgery only by a surgeon at a facility without a plastic surgeon, because it is a minimally invasive and easy method compared with other methods. In addition, by mastering this procedure, we can avoid easy detachment from the vaginal wall and resection with insufficient margins.

This procedure can be a useful reconstruction method for resection that requires combined resection of the posterior wall of the vagina.

An 84-year-old woman presented to our emergency clinic with epigastric pain and vomiting. Abdominal plain X-ray showed gastric bubbles that were compressed to the left lateral side and a dilated small intestine in the region of the gastric lesser curvature. A plain CT scan showed a small intestine forming a niveau in the region surrounded by the stomach and the liver. Strangulated ileus was suspected, and emergency surgery was performed on the same day. The dilated small intestine had entered the omental bursa through a defect in the greater omentum. In addition, the small intestine prolapsed from the dorsal surface of the stomach through a defect in the lesser omentum and was thereafter strangulated. Based on these findings, the final diagnosis of the greater and lesser transomental sac hernia was made. The lesser omentum was incised to reduce the strangulation. The wall of the small intestine was not resected because it improved with time.

We report a case of an elderly patient with a greater and lesser transomental sac hernia with some discussion of the literature.

Amyand's hernia is a rare type of inguinal hernia containing the vermiform appendix. Its treatment strategies vary regarding timing of surgery (emergency or elective), surgical procedure (anterior or laparoscopic approach), and whether performing appendectomy and using mesh. Herein, we describe two cases of Amyand's hernia treated with laparoscopic appendectomy and hernia repair through an anterior approach simultaneously with a literature review of previous cases in Japan. Case 1 ; a 48-year-old man diagnosed with Amyand's hernia by computed tomography (CT). Although it was concomitant with acute appendicitis, we considered that simultaneous use of mesh could be possible by changing the approach of appendectomy and hernia repair. As emergency surgeries, we performed laparoscopic appendectomy and hernia repair through an anterior approach. Case 2 ; a 69-year-old man diagnosed with Amyand's hernia concomitant with acute appendicitis by CT. As he had a history of surgery for right inguinal hernia and conservative treatment for appendicitis, laparoscopic appendectomy and hernia repair through an anterior approach were performed as elective surgeries after conservative treatment for appendicitis. Postoperative course was uneventful in both of cases.