Purpose：Acute care surgery （ACS） has been shown to improve patient outcome and treatment efficiency in the U.S. ACS was introduced to the Department of Surgery, Yonsei University College of Medicine, Seoul to solve the problems associated with delays in surgical evaluation of non-trauma patients who needed emergency surgery, and to offer exposure to a wide variety of surgical cases to general surgical fellows and residents. The objective of this study was to describe the 10-year experience of the ACS department in a single center. Methods：A retrospective chart review was conducted at the Department of Surgery, Yonsei University College of Medicine, Seoul, for all patients admitted from March 2008 to February 2018. Patients were grouped into either the trauma or non-trauma group, and were further classified according to their diagnosis, and the type of operations they had undergone. Results：There was a total of 2,805 patients, including 1,001 trauma patients and 1,804 non-traumapatients. The average hospital length of stay was 14 days and the total in-hospital mortality rate was 3.6%. Trauma mechanisms included blunt （92.6%）, penetrating （7.0%） and burn （0.4%） trauma. The majority of non-trauma patients were admitted for appendicitis （37.1%）, followed by cholecystitis （21.7%）. There was a total of 1,561 operations conducted. The most frequent operations were appendectomy （38.3%） and cholecystectomy （19.5%）, followed by adhesiolysis （7.8%）. Conclusion：A working ACS department has been implemented in a Korean medical center.

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A 70-year-old man with a history of diverticulitis of the colon was diagnosed with acute cerebral infarction and received intravenous thrombolysis with recombinant tissue-type plasminogen activator （rt-PA）. During the therapy, the patient went into hemorrhagic shock due to massive melena. Abdominal computed tomography showed extravasation in the transverse colon, and embolization by angiography was performed. Two days after the therapy, there was a recurrence of the diverticular bleeding. An emergency left hemicolectomy and transverse colostomy on the right upper abdomen were performed. According to the Japanese guidelines for intravenous thrombolysis with rt-PA in a patient with a history of gastrointestinal diverticulitis, it is classified as careful administration. This is because rt-PA may cause hemorrhagic shock due to extracranial hemorrhage, and prompt treatment is required. In addition, it is necessary for the patients who underwent colostomy after the cerebral infarction to consider postoperative activity of daily living and long-term management.

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The management of esophageal perforation is still controversial. Recently, we take the minimally invasive management for patients with non-contained leakage and who is not stable. We treated 10 cases of esophageal perforation at our hospital between April 2016 and December 2020. All cases improved without death. There were two cases of primary operation therapy and median length of stay in ICU and hospital were 12.5 and 58 days. There were eight cases of minimally invasive management, included five cases with non-contained leakage and three cases with circulatory or respiratory failure and median length of stay in ICU and hospital were 6.5 and 27 days. Minimally invasive management for esophageal perforation might be reasonable and useful, even patients is not stable with non-contained leakage.

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The patient was a 27-year-old woman. One month after delivery, she presented with a uterine perforation during evacuation of the uterus at a local hospital. She was then transferred to our center due to prolapse of the small bowel into the uterine cavity. The small bowel that had prolapsed into the uterine cavity had also prolapsed into the vagina, and emergency surgery was performed. Operative findings showed that the ileum 50–75 cm oral from the terminal ileum had prolapsed and was incarcerated in the uterine cavity, for which partial resection of the small bowel and uterine suture were performed. On examination of the extracted specimen, Meckel’s diverticulum was found adjacent to the ileal perforation. It was assumed that during the evacuation of the uterus, a Meckel’s diverticulum was misrecognized as uterine content and extracted, resulting in prolapse of the ileum involving the Meckel’s diverticulum, located at the tip of the prolapsed ileum. To our knowledge, this is the first reported case of uterine perforation during evacuation of the uterus resulting in incarceration and perforation of the ileum in a patient with Meckel’s diverticulum. We report this case with a literature review.

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A 77-year-old man receiving anticoagulant therapy following aortic valve replacement for aortic regurgitation 2 months ago, developed persistent abdominal pain in the right upper quadrant after breakfast. Although vital signs were stable, the Murphy sign was positive, and plain abdominal computed tomography （CT） revealed a swollen gallbladder with high-density bile, suggestive of hemorrhage. Enhanced abdominal CT showed extravasation of the contrast medium in the gallbladder. An emergency laparoscopic cholecystectomy was performed based on the diagnosis of intra-gallbladder hemorrhage. No bleeding complications were noted, and he was discharged five days post-operatively. No pathological malignancy or aneurysm was found, and the patient was pathologically diagnosed with intra-gallbladder hemorrhage due to chronic cholecystitis. Although intra-gallbladder hemorrhage is relatively rare, proper diagnosis and treatment may improve the prognosis of patients.

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A 73-year-old woman treated with steroids for exacerbation of ulcerative colitis visited our hospital with a chief complaint of watery diarrhea. Despite conservative treatment for acute gastroenteritis, her general condition deteriorated rapidly. On examination, she was detected with pulmonary embolism and acute cholecystitis on the 5th hospital day. We administered anticoagulant therapy and antimicrobial treatment; however, her general condition deteriorated rapidly, and she died on the 19th hospital day. Autopsy findings showed pulmonary embolism, deep vein thrombosis, megacolon and intestinal perforation in the right side of the colon, and ileal backwash ileitis. We suspected that she developed multiple thrombosis caused by exacerbation of ulcerative colitis, and died of intestinal perforation and panperitonitis. Despite a decrease in the number of operations because of the advances in medical treatment, surgical intervention without delay is crucial in cases showing acute exacerbation.

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We report a case of intercostal neuralgia after rib fixation using KANI^®, which was treated by plate removal. A 53-year-old woman suffered an injury after falling while riding a motorcycle. She was admitted to our hospital with multiple left rib fractures, pulmonary contusion, and hemothorax. On the 23rd day after the injury, she underwent rib fixation. One month after the surgery, she developed a sensation of a foreign body and lateral chest pain due to body movement and was diagnosed with intercostal neuralgia caused by physical stimulation of a partially deviated KANI^®. She was treated with Pregabalin, but her condition continued to worsen, and at 12 months postoperatively, removal of the deviated plate was performed. Judet-like struts, including KANI^®, may cause intercostal neuralgia; however, there are no reports of this in Japan. Further, although there is no definitive treatment for such cases, plate removal was effective in the present case.

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A 70-year-old woman visited our emergency room for abdominal pain and vomiting. Five days prior, she had undergone robotic gynecological surgery at another hospital and had been discharged. Computed tomography revealed intestinal obstruction and incarceration of the small intestine at the port site on the left abdomen. Emergency surgery was performed because the obstruction and incarceration could not be reduced manually. Incarceration of the small intestine was observed at the site of a 10-mm defect in the external oblique fascia. There was no evidence of necrosis, and the fascia was sutured closed after reduction. The postoperative course was good and the patient was discharged on day 5. Port-site hernia is a rare complication, which is likely to become more common in the future as the number of robotic surgeries increase. Port-site hernia hould be considered when diagnosing intestinal obstructio after robotic surgery.

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