Continuous exposure of the subserosal inner layer of the gallbladder wall to prevent from bleeding and bile duct injuries in laparoscopic cholecystectomy. We invented a novel technique of dissecting the subserosal layer after saline injection and appraised its efficacy and safety. In this study, ten cases with concave and wide gallbladder bed and thin subserosal layer were included. When the subserosal inner layer was exposed around the gallbladder body to a certain extent, saline solution was injected into the layer toward the gallbladder bed. The boundary between the inner and outer layers of the subserosa was dissected by energy devices. As a result, the amount of intraoperative bleeding was minimum, and the gallbladder was safely dissected from the gallbladder bed with easy identification of the subserosal inner layer by saline injection. All patients were discharged early from the hospital without postoperative complications. This technique would also be useful to young surgeons in understanging the surgical anatomy of the subserosal inner layer of the gallbladder.

A 52-year-old female patient underwent partial mastectomy, mastectomy and lumpectomy for malignant phyllodes tumor and in-breast tumor recurrence. Nearly a decade later, she developed a cystic lesion in the right axilla ; aspiration cytology was suggestive of regional recurrence of malignant phyllodes tumor. The patient underwent tumor resection and axillary lymph node sampling, which revealed a histopathological diagnosis of malignant phyllodes tumor with no axillary lymph node metastases. One year after removal of the axillary tumor, there was no recurrence. The recurrence after a long disease-free period and the fact that the axillary tumor was localized in a layer shallower than the deep thoracic fascia suggest that the malignant phyllodes tumor of the breast occurred heterotopically from an axillary ectopic mammary gland. To the best of our knowledge, this is the first report of such a rare case in Japan.

The patient was a 69-year-old woman presented with general fatigue. She was referred to our hospital for examination and treatment of hypercalcemia and multiple liver masses. Her initial blood test revealed high Ca level of 16.9 mg/dL, high PTHrP of 56.0 pmol/L, low intact PTH of 9 pg/mL, elevated CEA of 1,305.1 ng/mL, and elevated CA15-3 of 154.0 U/mL. FDG-PET/CT showed FDG uptake in the right breast, left upper lung lobe, liver, axillary and supraclavicular lymph nodes, sternum, and L4 vertebra. Following a biopsy, she was diagnosed with right breast cancer cStage IV (pleura, liver, bone) and primary lung adenocarcinoma cStage I A3. There was no evidence of bone destruction but tumor cells of the breast and lung were positive for PTHrP in immunohistochemistry, indicating that the hypercalcemia was caused by PTHrP-producing tumors. PTHrP-producing tumors in patients with concomitant overlapping breast cancer and primary lung adenocarcinoma are rare, and we report this case with a review of the literature.

Primary small cell carcinoma of the breast is a rare histological type with a poor prognosis. Although there is little evidence that pharmacotherapy is effective, advanced cases are treated with chemotherapy as with small cell lung cancer. Here, we report a case of metastatic and recurrent primary small cell carcinoma of the breast that was treated with programmed cell death ligand-1 inhibitor combination therapy as with small cell lung cancer. A 52-year-old woman noticed a mass in her left breast 3 months ago. She visited our hospital and was diagnosed with locally advanced metaplastic carcinoma. After preoperative chemotherapy, she underwent radical surgery and was finally diagnosed with primary small cell carcinoma of the breast. Two months after surgery, subcutaneous recurrence on the left chest wall, multiple lymph node metastases, and lung metastasis were observed. The subcutaneous recurrence on the left chest wall was diagnosed as small cell carcinoma via histological examination. After four cycles of cisplatin + etoposide + durvalumab therapy, all of the metastatic lesions except the left axillary lymph node were reduced ; the left axillary lymph node metastasis was also reduced via irradiation. However, the patient passed away 19 months after the first visit due to disease progression.

Malignant psoas syndrome (MPS) is characterized by pain in the region innervated by the first to fourth lumbar nerves resulting from the invasion of malignant tumors into the psoas muscle. The syndrome typically manifests as pain that worsens with the hip joint extension on the same side as the invasion. In this specific case, the patient was a 76-year-old woman who was undergoing chemotherapy for recurrent postoperative left breast cancer. As a result of severe pain in her right leg, visiting the hospital was difficult for her, leading to her hospital admission for thorough tests and additional treatment 4.5 years after the initiation of treatment for recurrent breast cancer. Pain management was initiated using non-steroidal anti-inflammatory drugs, acetaminophen, opioids, analgesic adjuvants, and radiotherapy, which provided some relief for the patient's symptoms. However, she required emergency surgery for adhesive ileus during her hospitalization. Despite the temporary improvement in her condition, the patient's hospitalization was discontinued due to the progression of breast cancer metastases. The patient was subsequently discharged from the hospital for home-visit care and died 25 days later. Few reports on MPS have been published, the reason being low recognition of this condition among medical professionals. Moreover, MPS frequently occurs in patients with cancer of the abdominal organs but is less common among those with breast cancer, as in the case of this patient.

We present a case of synchronous bilateral Stage IV breast cancer. The patient is a 76-year-old woman who presented to the emergency room with a left breast mass, jaundice, and difficulty walking. She was diagnosed with hormone-positive locally advanced left breast cancer(cT4bN0) with multiple lung and pancreas metastasis. She had obstructive jaundice ; therefore, she underwent urgent endoscopic biliary drainage. Although endocrine therapy was initiated, the right breast mass enlarged and was diagnosed as HER2-positve breast cancer(cT2N0) after 1 year and 5 months. Despite anti-HER2 therapies, the right breast mass increased and right breast mastectomy was performed. She died of cancer pleurisy 6 years and 5 months after commencement of medication. Although pancreatic metastasis of breast cancer and molecular subtype discordance of synchronous bilateral Stage IV breast cancer are rare, biliary drainage, local control with mastectomy for early-stage breast cancer, and systemic pharmacotherapy may contribute to long-term survival.

A 76-year-old woman was admitted to the cardiology department of our hospital with a diagnosis of infective endocarditis. Contrast-enhanced computed tomography (CT) was performed after the onset of epicardial discomfort. An increase in fatty tissue density around the superior mesenteric artery was observed, leading to a diagnosis of infection of the superior mesenteric artery. During antibiotic treatment, the patient developed abdominal pain, and a CT was repeated, which revealed pseudoaneurysm formation in the main trunk of the superior mesenteric artery. The patient was considered to have poor infection control, and she underwent aneurysmectomy and reconstruction of the superior mesenteric artery using a great saphenous vein. Infection and rupture control are important in the management of superior mesenteric artery aneurysm caused by infective endocarditis, as they are often difficult to treat when ruptured. To diagnose and optimize treatment before rupture, aggressive imaging should be performed when abdominal symptoms appear during treatment of infective endocarditis or other bloodstream infections, even if the symptoms are mild.

Pulmonary aspergillosis presents with a variety of pathological and imaging findings due to the interrelationship between the host's immune status and pulmonary structures, and the patient is often in poor general condition due to comorbidities, so the indication for surgery should be carefully determined. We report a case of invasive pulmonary aspergillosis with multiple pulmonary nodules, which was diagnosed by surgery. The patient was a 67-year-old woman. She underwent autologous peripheral blood stem cell transplantation for diffuse large B-cell lymphoma. On day 4 of transplantation, an infiltrative shadow with a cavity appeared in the S⁸ of the left lung, and multiple pulmonary nodules also appeared on day 15 of transplantation. Bronchoscopy detected Aspergillus in the S⁸ lesion. A needle biopsy of the multiple pulmonary nodules was performed, but no definitive diagnosis was reached. Antifungal drugs were administered, but the left S⁸ lesion became lung abscess-like, and a left lung lower lobectomy plus partial upper lobectomy was performed for diagnostic treatment. Pathology showed Aspergillus in lesions other than S⁸, and the diagnosis of invasive pulmonary aspergillosis was made. One year and 10 months after surgery, the patient is taking antifungal medication and is alive with no worsening of condition.

Case 1 : A 31-year-old woman fallen down in her house was brought into our hospital because of aphasia and right-sided paralysis, and was diagnosed as having cerebral infarction in the middle cerebral artery region. A pulmonary arteriovenous fistula in the lower lobe of the right lung was noted during a systemic examination, and was considered to be the cause of the cerebral infarction. The patient required a lobectomy because the pulmonary arteriovenous fistula was situated on the central side.

Case 2 : A 61-year-old woman was emergently brought into our hospital for nausea and dizziness, and was diagnosed as having cerebral infarction in the cerebellar vermis. A systemic examination revealed a pulmonary arteriovenous fistula in the right lower lobe of the lung, which was considered to be the cause of the cerebral infarction as in Case 1. A partial resection was performed for the peripheral pulmonary arteriovenous fistula. Pulmonary arteriovenous fistulas without Rendu-Osler-Weber disease, which are usually detected due to cerebral infarction, are considered to be rare. In this report, we describe two surgical resection cases of pulmonary arteriovenous fistulas, one central and the other peripheral, presented with cerebral infarction.

The case involved a 69-year-old man who had previous history of undergoing laparoscopic distal gastrectomy for early gastric cancer at the age of 64. He had been free from recurrence until a periodic CT scan performed 4.5 years after the operation that showed two pleural tumors. He was referred to our hospital. PET-CT scan revealed abnormal uptake of FDG to the two tumors. We thus decided to conduct surgery. Since the rib involvement of the tumor was noted, we removed tumor combined with 8th rib and intercostal muscle resection. The histopathological diagnosis was small cell carcinoma in the two lesions. Although the most likely diagnosis was pulmonary origin, no lung lesion was detected on imaging. Metastatic pleural tumor of unknown primary cancer was diagnosed. Postoperative MRI of the head revealed no metastasis. Postoperative clinical observation without adjuvant chemotherapy detected recurrent metastases in the mediastinal lymph nodes and left iliac bone, so that chemotherapy was started on the 6^th postoperative month. It was reported that mediastinal lymph nodes were metastatic organs of small cell carcinoma of unknown primary cancer, however, no cases have been reported so far in which the disease presented with a localized pleural tumor. Here we report a case of small cell carcinoma of unknown primary cancer presented with a pleural tumor.

A 65-year-old man presented to our hospital with a chief complaint of epigastric discomfort. Upper gastrointestinal endoscopy showed a submucosal tumor at the esophagogastric junction. Histopathological examination was positive for c-kit and CD34, and he was diagnosed with a gastric gastrointestinal stromal tumor (GIST). Computed tomography showed several swollen lymph nodes with a diameter of 3-5 mm in #1 and #2. Intraoperatively, lymph node #2 was sampled for a rapid pathological diagnosis, and metastasis was detected. Laparoscopic proximal gastrectomy with D1+ lymph node dissection was performed. Postoperative pathological examination showed a GIST, 30 mm in diameter, and one lymph node metastasis in #2. In general, gastric GISTs are treated with partial resection only, and lymph node dissection is not performed. However, it is necessary to recognize that there are rare cases of lymph node-positive GISTs, and this case is reported along with a review of the literature.

The prognosis of gastric cancer with distant metastasis is generally poor. Distant metastasis of gastric cancer is often recognized as a terminal stage of malignancies. We have experienced a long-survival-gastric-cancer patient after the excision of the axillary lymph node metastasis. The patient was a 61-year-old man diagnosed with gastric cancer. He had been on hemodialysis (HD) for polycystic kidney disease and chronic renal failure since 1998. Distal gastrectomy with D2 dissection was performed for gastric cancer at the pyloric antrum in April 2010. The final diagnosis was Stage IIA (T1b, N2, M0). Without adjuvant therapies, the patient had been under surveillance. A left-axially mass was pointed out and removed in September 2011. Histopathologically, the lymph node was diagnosed as metastasis from gastric cancer. The patient is surviving without any recurrences for 13 years after the first therapy. This case is unusual in terms of the metastatic site and no use of adjuvant therapies. There are few reports on long survival cases of gastric cancer with distant metastasis, and we report on our case together with them.

Follicular dendritic cell sarcoma is a rare neoplasm originating from follicular dendritic cells.

A 69-year-old woman presented with right upper abdominal pain. An abdominal computed tomography scan showed a 6 × 6cm well-circumscribed mass which was located anterior to horizontal portion of the duodenum. A duodenal gastrointestinal stromal tumor, a neurogenic tumor of the mesentery, or a neuroendocrine neoplasm arisen in the pancreatic uncinate process was suspected and tumor resection was performed. The tumor was situated in the small bowel mesentery. Microscopically, the tumor consisted of ovoid to spindle-shaped nuclei cells arranged in a diffuse and nest-like pattern. Immunohistochemistry demonstrated that the tumor cells were positive for CD21, CD23, CD35, and D2-40 (only in pleomorphic cells). According to the clinicopathological features, the diagnosis of follicular dendritic cell sarcoma was made. There has been no tumor recurrence as of 8 years of postoperative follow-up.

Superior mesenteric venous (SMV) thrombosis is a rare complication of diverticulitis, and mesenteric venous thrombosis (MVT) is a serious condition that can lead to debilitating intestinal ischemia. A 62-year-old man presented with fever-related right abdominal pain, no medical history, and no thrombotic predisposition. Imaging including contrast-enhanced computed tomography (CT) showed perforation of the terminal ileum, SMV thrombosis, and cholecystitis. After one month of anticoagulant and antibacterial treatment for venous thrombotic sepsis, his systemic symptoms were alleviated with the development of collateral circulation. To prevent recurrence, laparoscopic ileocecal resection and cholecystectomy were performed simultaneously. After three-month oral anticoagulant therapy, contrast-enhanced CT demonstrated alternative venous development compensating for the lacking SMV flow. Japanese guidelines for diverticulitis did not mention MVT associated with diverticulitis, but the present case report provides novel evidence that a surgical approach after a medical approach is a valid treatment for a perforated diverticulum of the terminal ileum with SMV thrombosis.

A 72-year-old woman underwent laparoscope-assisted total gastrectomy with Roux-en-Y reconstruction for gastric cancer, and she complained of abdominal pain 7 months after the operation. The patient was diagnosed as having a strangulated ileus, and emergency surgery was performed. The surgical findings showed the small intestine prolapsed into the left thoracic cavity through the hernial orifice located in the left diaphragmatic crus at the site of an esophageal tear, and the small intestine was strangulated through the space between the mesentery of the Roux-limb and transverse mesocolon (Petersen's defect). The strangulation was reversed, and both hernia orifices were closed.

A 73-year-old male patient underwent laparotomy 60 years ago for abdominal trauma. Computed tomography (CT) performed by the urological department of our hospital showed that part of the small intestine was dilated into a cyst and numerous stones were observed inside. He was referred to our surgical department and was diagnosed with a giant jejunal diverticulum or cystic dilation with enteroliths. One year later, laparotomy was performed. During the operation, we observed a side-to-side anastomosis of the small intestine from the previous surgery ; the jejunum was dilated like a cyst, and the intestine was continuous on the oral and anal sides.

The partial small intestine, including the dilated part, was resected, and end-to-end anastomosis was performed. The cyst measured 17×9 cm, and 10 stones of up to 4 cm in length were found inside the cyst. The stones consisted of 98% deoxycholic acid and were true enteric stones made of bile acid. The patient was followed-up until the second postoperative year ; however, no recurrence of intestinal stones was observed.

This case demonstrates that the previously performed side-to-side anastomosis seemed to have caused peristaltic insufficiency, cystic dilatation of the anastomotic part, and stagnation of the intestinal contents, which eventually led to the formation of true enteric stones.

The patient was a 66-year-old woman. Total gastrectomy (Roux-en-Y reconstruction) was performed for gastric cancer. A computed tomography (CT) scan performed 1 year and 6 months after the operation incidentally revealed a target sign in the small intestine on the anal side of the Roux-Y limb, and the patient was diagnosed with retrograde intussusception. Two days after the CT imaging, we attempted its endoscopic reduction asymptomatic intussusception. No abnormal findings were found near the jejuno-jejunal anastomosis, and a subsequent CT scan confirmed that the intussusception was kept resolved. A CT scan 10 months after the onset of intussusception showed similar intussusception findings. At this time, the patient was also asymptomatic, and a spontaneous reduction was confirmed by CT, so the patient was followed up. Intussusception after gastrectomy is a rare complication, accounting for about 0.07-2.1% of all complications, but its pathogenesis has not been clarified. Regarding intussusception after gastrectomy, there are few cases treated conservatively, but no cases of asymptomatic intussusception after gastrectomy like the present case have been reported. We report our experience with asymptomatic intussusception after gastrectomy, with a review of the literature.

A 35-year-old man presented to our emergency clinic with abdominal pain persisting from the previous day. When he was first seen, there was tenderness from the right lower quadrant to the midline of the abdomen. A blood analysis revealed increased inflammatory response. An abdominal CT scan showed a cystic lesion adjacent to the intrapelvic small intestine and a swollen appendix. Suspecting that inflammation or abscess formation might occur due to duplication bowel, Meckel's diverticulum, and acute appendicitis, we performed emergency laparoscopic surgery. Laparoscopic surgery was started with three-ports method that revealed an intestine-like structure continuing to the ileum and sharing the mesentery. It was determined to be a duplication bowel based on intraoperative findings. It had twisted by 360 degrees at the base and the volvulus of the duplication bowel was reduced in the celom. A small laparotomy was made at the navel, from where an ileum involving the duplication bowel was taken out, and small bowel resection including the normal intestine was performed. Histopathology revealed that the cystic wall had mucosa, muscularis mucosae, proper muscle layer, and subserosal layer ; and it also had the common mesentery with the ileum. Accordingly, we diagnosed the case as duplication bowel. Here we report a case of volvulus of duplication bowel performed laparoscopic surgery.

The patient a 77-year-old male was admitted to the hospital with a diagnosis of paralytic ileus. Blood tests revealed abnormal lymphocytes and an abnormally high interleukin-2 receptor level (130,000 U/mL) As the patient's condition worsened, he developed perforated peritonitis and was transferred to our hospital for emergency surgical treatment. Laparotomy revealed blood pooling in the small intestine from the ligament of Treitz to the ileocecum, and a tumor perforation measuring approximately 25 cm from the ileocecum. Postoperative pathological diagnosis revealed that the small intestinal perforation was caused by tumor cell infiltration of adult T-cell leukemia-lymphoma (ATLL). Perforation of the small intestine due to gastrointestinal infiltration of ATLL has been reported in nine cases, and the prognosis for sush cases is generally poor. In this report, we describe a case of ATLL with small intestinal perforation.

A 92-year-old woman presented with abdominal pain, and computed tomography showed a mass lesion with a contrast effect at the end of the ileum and a dilated bowel. The diagnosis of obstructive ileus due to a small intestinal tumor was made, and an open ileal resection was performed. The resected specimen showed narrowing of the ileum 7 cm from the distal end of the ileum with serosal traction and paving stone-like mucous membrane elevation on the anorectal side, but no ulcerative lesion suggestive of carcinoma was observed. Histopathological examination showed heavy infiltration of lymphocytes and IgG4-positive plasma cells mainly in the deep mucosa and floral mat-like fibrosis. Immunostaining showed 32 IgG4-positive cells in a high-power field, with an IgG4-positive cell/IgG-positive cell ratio of 51.6%. The postoperative serum IgG4 level was 23.8 mg/dl, which was within the reference range. Although the patient was considered to have probable IgG4-related disease based on the diagnostic criteria, other neoplastic lesions were negative, and IgG4-related small intestinal pseudotumor was strongly suspected. Five cases of IgG4-related disease involving the small intestine, including four previously reported cases and an autopsy case, are reported.

A 71-year-old man was admitted to our emergency department with fever and acute right lower abdominal pain. Computed tomography showed an enlarged appendix and enlarged lymph nodes around the ileocecal artery. Laparoscopic appendectomy was performed on day 1 for acute appendicitis and a suspected appendiceal tumor. The appendix was resected along with part of the cecum wall due to enlargement at the base of the appendix. The excised specimen showed a 13-mm mass, 3 cm distal to the appendiceal orifice. Histological examination showed proliferation of spindle-shaped cells, and immunostaining showed KIT(+), CD34(+), and desmin(-). Based on the above, a diagnosis of appendiceal gastrointestinal stroma tumor (GIST) was made. The patient was discharged from the hospital without complications 7 days after surgery. Appendiceal GIST is a very rare condition with limited reports. A case of appendiceal GIST was presented along with a review of the literature.

A 51-year-old woman developed sudden abdominal pain and was brought to our hospital by ambulance. Sigmoid volvulus was diagnosed, and endoscopic reduction was performed. On further investigation, the cause of the sigmoid volvulus was dolichocolon associated with mesenterium commune. Since the patient had a long-standing history of intractable constipation and abdominal pain since youth, laparoscopic-assisted colectomy and prophylactic appendectomy were performed at her request. Postoperatively, the chronic constipation and repeated abdominal pain that had troubled the patient for many years disappeared, and her quality of life improved dramatically. This case suggests that mesenterium commune should be included in the differential diagnosis of intractable constipation dating from infancy, and that if mesenterium commune is diagnosed on imaging, then surgical treatment is a useful option.

The patient was a 70-year-old man who was referred to our institution with a diagnosis of highly advanced rectal cancer with sacral invasion, bladder invasion, and a pelvic abscess. A colostomy was constructed at the transverse colon, and 10 courses of mFOLFOX6 + panitumumab were administered as chemotherapy. The primary tumor was decreased markedly in size, and the patient underwent total pelvic exenteration combined with sacral resection as conversion surgery. Postoperatively, the patient developed a perineal wound infection mainly at the sacrectomy site, and drainage of the abscess by open wound surgery was not sufficient to improve his condition. Therefore, negative pressure wound therapy was provided, and the patient was discharged from the hospital on the 82nd postoperative day with excellent wound healing. Even in the field of gastrointestinal surgery, many reports have shown the usefulness of negative pressure wound therapy for surgical site infections, which may increase the wound healing rate and shorten the hospital stay. In the present case, negative pressure wound therapy was an effective treatment for a refractory pelvic dead space infection after total pelvic exenteration.

A 77-year-old woman with melena was referred to our hospital. Colonoscopy showed an advanced rectal cancer located approximately 3 cm from the anal verge. Abdominal contrast-enhanced computed tomography (CT) showed an asymptomatic aneurysm, 8 mm in diameter, at the root of the middle colic artery. The patient underwent abdominoperineal excision of the rectal cancer, and the aneurysm of the middle colic artery was also resected in view of the high risk of rupture. The middle colic artery was then reconstructed by end-to-end anastomosis to preserve blood flow to the left side of the colon. Postoperative CT angiography demonstrated patency of the reconstructed artery, and the patient's postoperative course was uneventful. The therapeutic strategy for asymptomatic visceral aneurysms remains unclear, especially in patients who are scheduled for abdominal surgery. In this situation, intervention for the aneurysm depends on various issues, such as the location of the aneurysm, the risk of rupture, the primary disease status, and whether reconstruction is required.

Fouriner's gangrene is rapidly progressive necrotizing fasciitis in the scrotal, perianal, and perineal regions. Without early and appropriate treatments, the patient's general condition can take downhill course. We have treated two cases of Fouriner's gangrene caused by rectal cancer. We used antibiotics and performed drainage and debridement in both cases. However, we were not able to control local infection, so we emergently performed colostomy, followed by low anterior resection of the rectum after his infection was well controlled.

Urological diseases, anal fistula, and perianal abscess are thought to be main causes of this disease. It is rather rare that rectal cancer causes this disease, where the time until intervention of treatment might determine the prognosis. We can find only 29 cases of rectal cancer with Fournier's gangrene in the Japanese literature from 2000 to 2022. We report our two cases with a review of the literature.

The patient was a 57-year-old man with a history of liver transplantation from a living donor for decompensated liver cirrhosis due to Budd-Chiari syndrome at the age of 46 years. Although he had repeated enterocolitis and hepatic encephalopathy due to portal hypertension caused by postoperative portal vein stenosis, there were no signs of hepatic failure, and he was being followed on an ambulatory basis. While on steroid therapy for acute interstitial pneumonitis, he developed Clostridium difficile enterocolitis. The symptoms of enterocolitis were improved by oral metronidazole, but the symptoms of enterocolitis were not completely cured, and oral metronidazole 1 g/day was resumed and continued. Approximately two months later, difficulty in oral medication management, dysarthria, and finger tremor appeared. One week after the symptoms appeared, aggravation of consciousness disturbance was observed. Magnetic resonance imaging of the head showed bilaterally symmetrical high signal intensity areas in the dentate nucleus of the cerebellum. The patient was diagnosed as having metronidazole-induced encephalopathy. Metronidazole was discontinued immediately, and the patient's level of consciousness improved gradually. The development of metronidazole-induced encephalopathy is rare, and there have been few reports related to liver transplantation and liver injury. This case is reported together with a review of the literature.

We report a rare case of hematogenous colonic metastasis from hepatocellular carcinoma (HCC) which followed multidisciplinary therapy for recurrent HCC and was successfully resected. A 65-year-old man underwent lateral sectionectomy for HCC. Ten months later, a recurrent HCC in the segment 4 and recurrent disseminated nodules (DN) were diagnosed. Intrahepatic recurrence was treated with radiofrequency ablation, and the DN were surgically extirpated. Nineteen months after the initial surgery, another DN was found again, and the patient underwent re-resection. During adjuvant chemotherapy with lenvatinib, a new DN was detected, and the anticancer drug was changed to sorafenib, which kept the DN reduced in size for one year and two months. Then the CA19-9 level became elevated and colonoscopy revealed a sigmoid colon tumor, which was pathologically diagnosed to be a metastatic HCC. Laparoscopic sigmoidectomy and resection of the DN were carried out. Intraoperative inspection and histopathological findings revealed that the sites of colonic tumor and the DN were distant and the colonic tumor did not invade the serosa of the colon. We finally diagnosed it as hematogenous colonic metastasis of HCC. The patient is alive without recurrence in 8 months after the last operation.

Lenvatinib is a multityrosine kinase inhibitor that rarely causes acute acalculous cholecystitis. The treatment of acute acalculous cholecystitis should carefully be selected for patients receiving lenvatinib as it can potentially delay wound healing due to inhibition of vascular endothelial growth factor and receptor tyrosine kinase. In this case, a 73-year-old man was undergoing treatment with lenvatinib and pembrolizumab for locally advanced left-sided renal cancer. On the 64^th day of drug administration, the patient developed a fever and abdominal pain on the right side. Computed tomography revealed acute gangrenous cholecystitis, leading to the decision to perform a laparoscopic cholecystectomy. The patient had no postoperative complications. In situations where acute acalculous cholecystitis results from lenvatinib administration, emergency laparoscopic cholecystectomy may be considered a viable treatment option.

A 7-year-old boy with an unremarkable medical history presented to our hospital after having developed right abdominal pain the previous day. Computed tomography showed enlargement and thickening of the gallbladder wall, and he was admitted with a diagnosis of acute cholecystitis. Treatment with cefmetazole sodium was started, but there was no improvement in either the abdominal findings or the inflammatory reaction. Abdominal ultrasound conducted on postadmission Day 3 showed severe thickening of the wall of the neck of the gallbladder, and on magnetic resonance cholangiopancreatography (MRCP) , there were signs of hemorrhagic changes and stenosis in this region. Gallbladder torsion was therefore diagnosed, and laparoscopic cholecystectomy was carried out on the same day. Oral intake was started from postoperative Day 2, and on postoperative Day 6, the patient was discharged without complications. Gallbladder torsion is a comparatively rare condition in children, and abdominal ultrasound and MRCP were helpful in the diagnosis of the present case. This case is reported together with a short discussion of the literature.

An 82-year-old man presented to our hospital with fever and impaired hepatic function. Imaging studies confirmed wall thickening and stenosis of the distal bile duct. A biopsy revealed adenocarcinoma. We diagnosed the case as distal bile duct cancer cT2cN0cStage IB and performed subtotal stomach-preserving pancreaticoduodenectomy with D2 lymph node dissection. Histopathology of the resected specimen showed the lesion to be composed of two kinds of tumors;namely, adenocarcinoma and NEC (chromogranin positive, synaptophysin positive, and Ki-67:73.8%). This case was of combined /biphasic type where adenocarcinoma and NEC owned respective area (adenocarcinoma versus NEC was 40% vs 60%). NEC invaded deeper than adenocarcinoma, reaching to the subserosal layer (pT2, ITT:5mm, SS). No vascular and neurotic infiltration and lymph node metastasis were seen in both adenocarcinoma and NEC (pLy0, pV0, pN0). A CT scan conducted 9 months after the operation revealed appearance of multiple hepatic metastases, for that the patient is now on chemotherapy. In this case adenocarcinoma mainly existed in the membranous surface so that we had difficulties in making diagnosis of MiNEN preoperatively. Furthermore, it is likely that NEC components had infiltrated into deeper layers that might cause the hepatic metastasis.

The patient was a 60-year-old man who had previously undergone Hartmann's procedure. He was referred to our department for surgery to treat a parastomal hernia the size of a child's head. The hernia was repaired laparoscopically using Sugarbaker's procedure. The hernia orifice was 8-cm long, and since the inferior epigastric artery and vein were involved on the caudal side, peritoneal dissection was required. A Symbotex^TM composite mesh was folded so that it measured 18 cm overall with a 14-cm folded portion, and it was positioned so that an adhesion-preventing collagen film on the folded part covered the stomal intestinal tract. Parastomal hernias are reported to have a low recurrence rate after Sugarbaker's procedure, but the mesh used for this procedure is not yet commercially available in Japan. Cases in which Symbotex^TM composite mesh has been shaped for use as an alternative have been reported, and in the present case, the repair was carried out using this method. Our mesh-shaping method and intraoperative points to note are reported.

A 53-year-old woman visited our hospital and was diagnosed with a left superior lumbar hernia. Computed tomography (CT) performed 12 years ago revealed a hernia in the same area. Surgery was considered because the hernia was causing symptoms, with a tendency to enlarge over time. Surgery was performed in the right semilateral decubitus position using a three-port intraperitoneal approach. A peritoneal incision was made from the lateral side of the descending colon, and dissection was performed around the dorsal side of the left kidney. A 1.5-cm hernia orifice was identified, and the surgery was terminated by fixing a mesh with a tucker to prevent injury to the inferior iliac abdominal nerve. The patient was discharged on postoperative day four. The patient was asymptomatic 12 years prior, and the hernia had not been noted on CT. Diagnosing a lumbar hernia is difficult when the patient is asymptomatic ; however, surgery should be performed, as soon as possible, if it is diagnosed incidentally.

An 89-year-old man presented to our hospital with left groin pain. A contrast-enhanced computed tomography (eCT) scan revealed sigmoid colon prolapse into the left inguinal canal with fecal impaction, resulting in bowel obstruction. Following manual reduction, he was admitted for observation for delayed bowel perforation ; however, he developed shock the same day. The eCT showed contrast defects primarily in the transverse to sigmoid colon, leading to a diagnosis of intestinal necrosis and necessitating emergency surgical bowel resection. He was placed on a ventilator in the intensive care unit, but his liver and kidney function deteriorated ; he eventually died of multi-organ failure on postoperative day 12. Histopathological examination revealed necrosis and desquamation, mainly within the mucosa, and a diagnosis of obstructive colitis was made. There was no obvious organic vasculopathy and he was believed to have concomitant bacterial translocation from colitis obliterans. The occurrence of obstructive colitis in inguinal hernia is rare and is reported here, including a review of the literature.

A 45-year-old woman presented with pain in the left inguinal region during body movement, referred to our hospital on suspicion of inguinal hernia by a previous doctor. Abdominal computed tomography and magnetic resonance imaging showed soft tissue prolapse in the left inguinal region not contiguous with the intestinal tract. Owing to the history of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, rudimentary uterine prolapse was suspected. Laparoscopic surgery was planned in collaboration with the gynecology department. Intra-abdominal examination revealed a rudimentary uterus contiguous with the fallopian tube and the round ligament of the uterus in the left inguinal region. The patient was diagnosed with sliding hernia with rudimentary uterine prolapse and underwent laparoscopic repair. The pain disappeared, and she has remained without recurrence to date. Disorders of sex development, such as MRKH syndrome, can from the canal of Nuck embryologically, with likely co-existence of inguinal hernia. Laparoscopic diagnosis of inguinal hernia is considered to be useful in such a rare condition, in which a definitive diagnosis based on the imaging finding of the prolapsed organ is difficult.

Herein, we report three cases of incarcerated inguinal and obturator hernias repaired using laparoscopic-assisted total extraperitoneal repair (TEP).

Case 1 : An 83-year-old woman was admitted to our hospital with pain and nausea in the left femur. Computed tomography revealed an incarcerated left obturator hernia. Intraoperative exploration showed that the left incarcerated obturator hernia had already reduced, and laparoscopic-assisted TEP was performed.

Case 2 : A 72-year-old man was admitted to our hospital with pain in the left inguinal region. Computed tomography revealed a left external inguinal hernia with an incarcerated epiploic appendage in the sigmoid colon. Intraoperative exploration revealed that the right incarcerated external inguinal hernia had already reduced, and an epiploic appendage of the sigmoid colon was dark red. We resected the epiploic appendage and performed laparoscopic-assisted TEP.

Case 3 : A 96-year-old woman was admitted to our hospital with right lower quadrant and right inguinal pain. Computed tomography revealed a right-sided incarcerated obturator hernia. Intraoperative exploration revealed that the small intestine was incarcerated in a right obturator hernia. The incarcerated small intestine was reduced, and laparoscopic-assisted TEP was performed. After the repair, the intestine was dark red, and wedge resection of the small intestine was performed.

Laparoscopic-assisted TEP is useful because the intraperitoneal and extraperitoneal cavities are divided, enabling assessment of the hernia content.