In patients who have undergone radical retropubic prostatectomy (RRP), the preperitoneal space may be difficult to dissect during inguinal hernia repair. In such patients, we avoid using methods that require dissection of this preperitoneal space, such as transabdominal preperitoneal (TAPP) repair, and instead use the Lichtenstein technique. To evaluate this choice, adult male patients who underwent primary unilateral inguinal hernia repair by the Lichtenstein technique in our department between January 2011 and December 2017 for elective inguinal hernias, excluding type III ones, were compared according to whether or not they had previously undergone RRP. Of the total of 364 patients, 47 had previously undergone RRP, and 317 had not undergone this procedure. The patients in the RRP group were older, and their hernias were type I in all cases. There were no intraoperative complications in either group, and there were no differences between the groups in operating time, hemorrhage, postoperative complications, recurrence, or chronic pain. These results suggest that the Lichtenstein technique is relatively unaffected by previous RRP, and it may be a good choice for inguinal hernia patients who have previously undergone this procedure.

Objective:We examined factors related to “awareness of a physician shortage” via a questionnaire administered to surgeons in Oita Prefecture and compared them with previous questionnaire results from 2010 to determine whether the perceptions of a physician shortage had improved.

Method:We conducted a questionnaire survey with surgeons in Oita Prefecture.

Results:Of the responses, 171 were valid, with a response rate of 82%. Of the valid responses, 131 surgeons (76.7%) were aware of a physician shortage, almost identical to the 77% rate in 2010, and they felt that the physician shortage had not improved. Multivariate analysis of the factors contributing to “awareness of a physician shortage” showed factors such as “in charge of more than 11 inpatients,” “more than seven meetings per month,” “more than five hours per week dedicated to hobbies,” “having a degree,” and “good communication” to be related to “awareness of a physician shortage.”

Conclusion:Many surgeons in Oita Prefecture continue to perceive a shortage of physicians. In particular, surgeons in charge of many inpatients are acutely aware of this shortage. However, they appear to be coping with the present physician shortage through good information sharing.

Aim : For metastatic breast cancer treatment, biopsies of metastatic lesions are often performed. Although biopsy is an important technique, it is intractable because of its invasiveness. We investigated the usefulness and safety of biopsy in metastatic breast cancer treatment.

Methods : Biological characteristics of the primary lesion were compared and the presence and degree of complications were examined among 10 patients who underwent liver biopsy for suspected liver metastasis from breast cancer after September 2016.

Results : The average age was 56 years, and the average interval from breast cancer diagnosis to liver biopsy was 90 months. Three patients had primary liver malignancies, and seven were diagnosed with liver metastasis from breast cancer. The discordant rate of biological subtypes was 43% among the primary and metastatic lesions in the seven patients with liver metastasis. The treatment was determined based on liver biopsy results in 6 of 10 patients. In the seven liver metastasis cases, the average survival after biopsy was 11 months. The complications were pain (2 patients), hemorrhage (1 patient), and fever (1 patient) ; none of the complications were serious.

Conclusion : Liver biopsy causes mild complications ; it is useful and affects the treatment plan.

A 46-year-old man who had been diagnosed as having a thyroid mass 15 years earlier was hospitalized to our hospital for severe ulcerative colitis, when neck ultrasonography (US) revealed the thyroid tumor again. Neck US showed the hypoechoic mass with coarse calcification in the right thyroid lobe. A fine needle aspiration cytology showed papillary carcinoma (cT2N0M0). The patient underwent right thyroidectomy and central lymph node dissection. Cut the specimen in half, we found a metallic foreign body inside the thyroid tumor. It looked like an inner needle of core needle biopsy equipment. We confirmed that the patient might have received needle biopsy of the thyroid gland 15 years earlier. It was a very dangerous situation where the needle could have penetrated the adjacent organs such as the trachea and esophagus. Foreign bodies migrating into the thyroid glands are extremely rare. The thyroid has no connection to any other organs and natural course of foreign body migration into the thyroid gland is unthinkable.

The frequency of mammary phyllodes tumors is less than 0.5% of all mammary tumors and the tumors most commonly affect women in their forties and very uncommonly affect teens. We experienced a surgical case of a rapidly growing juvenile-onset giant phyllodes tumor. Case : A 17-year-old woman had noticed a lump in her left breast from April 2015. It rapidly grew, prompting her to make her first visit to our department in July of the same year. On physical examination, a 13-cm smooth elastic soft tumor was found, principally located in the B region from the border of the lower left breast. Contrast enhanced CT findings revealed a 13.5 × 8.5 cm huge lump in the ABD region of her left breast, with clear boundaries and edge alignment, which was relatively uniformly and lightly contrasted. A needle biopsy revealed fibroadenoma. However, the tumor was large with the possibility of it being a phyllodes tumor, so a tumor resection was performed with a margin of 1.5 cm. The left lower mammary sulcus was dissected and thus no postoperative breast deformation was observed. The postoperative pathological results yielded a diagnosis of benign phyllodes tumor and there has been no recurrence as of 4 years following the surgery. Conclusion : Fibroadenomas and phyllodes tumors may be difficult to distinguish ; however, esthetic care, preservation of future lactation function, and mental aspects, in addition to completely curing the tumor, must be taken into consideration when treating young women.

An 81-year-old woman presented with a palpable mass in the left breast. On palpation, a movable and rough-surfaced mass was found in the subareolar region. Mammography showed a coarse calcification-lined mass, which indicated a benign lesion. Ultrasonography revealed a mass measuring 1.2 cm in diameter with some malignant signs such as a high D/W ratio (depth-width ratio) and blood flow. The dynamic study pattern on breast magnetic resonance imaging indicated malignancy. Based on the fine-needle aspiration cytology findings, we suspected a mixed tumor or hamartoma, however, we could not confirm if the tumor was malignant. Core-needle biopsy findings, which indicated adenomyoepithelioma or metaplastic carcinoma with obvious cartilaginous and osseous tissue. Excisional biopsy was performed to obtain a definitive diagnosis. The final diagnosis was pleomorphic adenoma of the breast, with no finding of malignancy. We report a case of pleomorphic adenoma, which is rarely found in the breast.

We encountered two cases of radiation-induced angiosarcoma after breast-conserving surgery (BCS), which is a rare disease with poor prognosis.

Case 1 : An 86-year-old woman was admitted to our hospital with a complaint of a lump and bleeding in the left chest. She had undergone BCS and received adjuvant radiotherapy for left breast cancer at the age of 79 years. She was diagnosed with recurrence based on core-needle biopsy. She was administered weekly PTX + bevacizumab. It was difficult to continue treatment due to adverse events ; hence, she underwent mastectomy with a wide range of skin resection of the breast. She was diagnosed with angiosarcoma. She developed local recurrence one month after her second surgery and died three months later.

Case 2 : A 67-year-old woman noted a skin eruption on the left side of her chest. She had undergone BCS and adjuvant radiotherapy after neoadjuvant chemotherapy for left breast cancer at the age of 61 years. She was diagnosed with angiosarcoma based on a skin biopsy. She also underwent surgery similar to the patient in Case 1. One year after her second surgery, she is alive without recurrence.

A 48-year-old woman presenting with microcalcifications of the right breast revealed to have a 12.7×6.4 mm irregular hypoechoic mass in the right A area. It was diagnosed as invasive ductal carcinoma containing intraductal spreading of the right breast by means of ultra-sound-assisted biopsy with vacuum-assisted breast biopsy device. We performed Bp + SN with the diagnosis of Stage I breast cancer. Although breast-conserving surgery was proceeded without neoadjuvant chemotherapy, there were no residual cancer cells in the specimen. Only severe acute inflammatory changes such as infiltrating lymphoid cells, multinucleated giant cells, and foam cells were found in it. We determined that cancer remnants were absent. A comparison between the biopsied and the resected tissues was made.

Immunohistochemical staining of CD8, for the marker of the cytotoxic T-lymphocyte, revealed that acute inflammatory reaction, suggesting immunological reaction to the cancer tissue, had started at the time of biopsy and had increased in the surgical specimen. Although there might have been tumor immunity to the breast cancer at the time of biopsy in this case, destruction of the tumor tissue by vacuum-assisted breast biopsy device might induce stronger immunological and inflammatory reactions that might contribute to the vanished cancer.

A 72-year-old man received abdominoperineal resection, extended left hepatectomy, and partial hepatectomy of the segment 7 after mFOLFOX6 + panitumumab as neoadjuvant chemotherapy for rectal cancer with synchronous liver metastasis. We performed ileocecal resection on 7th postoperative day because of strangulated obstruction caused by a small intestine impacted into the pelvic dead space. Six months later, an abdominal CT scan showed a homogeneous mass 20 mm in diameter at the right lower quadrant of abdomen, and fluorodeoxyglucose positron emission tomography (FDG-PET) revealed intense FDG uptake at the mass. Peritoneal metastasis was suspected, and we performed surgical resection. The mass was found in the mesentery of the ileocolic anastomosis at the last operation, and we resected the intestine including the anastomosis. Pathological examination showed that silk suture material was surrounded by multinucleated giant cells with an abscess which was surrounded by cicatrized tissue and there were no malignant cells. We diagnosed it as suture granuloma. It was considered that foreign body reaction might occur by silk suture material which was used for ileocecal resection, because we sutured the mesentery by silk threads after ileocolic resection. We had difficulties to distinguish a suture granuloma from peritoneal metastasis after surgery of a malignant tumor.

A 70-year-old man who was diagnosed with cancer of the mesopharynx as a result of close exploration for pharyngeal pain and odynophagia was also pointed out having a 2-cm tumor shadow at the dorsal aspect of the trachea by CT scanning of the neck, chest and abdomen. A CT-guided needle biopsy provided a diagnosis of recurrence of cancer of the thoracic esophagus for which a radical resection had been done at the age of 60. PET-CT scan revealed abnormally high uptake of FDG to the tumor, but any findings suggestive of metastases to other sites were absent. We diagnosed the case as cancer of the mesopharynx and local recurrence of esophageal cancer and performed radiation therapy alone to the lesions including the affected mesopharynx area at the total dose of 60 Gy/30Fr. In 6 months after the irradiation, the tumor at the dorsal aspect of the trachea disappeared, and thereafter no enlargement of the tumor occurred, a complete cure being achieved. When 2 years had elapsed after the irradiation, thickening of the pharyngeal wall was identified and recurrence of the mesopharyngeal cancer was diagnosed. Three months later, the patient died. As it is rare that esophageal cancer recurs more than 5 years after radical operation, we present our case with some bibliographical comments.

A 74-year-old woman who had been treated for descending colon diverticulitis 2 months earlier was admitted to our hospital because of a one-day history of left lower abdominal pain and vomiting. Abdominal computed tomography revealed descending colon diverticulitis and gallstone in the duodenum, suggesting gallstone ileus. The gallstone spontaneously passed into the descending colon and abdominal symptoms improved conservatively, however, fever up and left lower abdominal pain occurred when she started to take meal. Computed tomography revealed free air around the descending colon, suggesting perforation caused by the impacted gallstone. Emergency operation was performed 13 days after admission. Laparotomy disclosed perforation of the descending colon at the site of gallstone. Descending colectomy and loop ileostomy were performed. The resected specimen showed stenosis and perforation of the descending colon due to diverticulitis. It is etiologically inferred that the gallstone had impacted into the stenosed lumen of the descending colon due to diverticulitis that might cause perforation. Gallstone ileus is a rare disease and few cases have been reported on intestinal perforation caused by gallstone ileus.

A 67-year-old man who was diagnosed as having hepatocellular carcinoma (segment 7) underwent laparoscopic hepatectomy. We injured a peripheral branch of the right hepatic vein, but we pursued surgery by applying pressure hemostasis. During liver parenchymal dissection, the SpO₂ suddenly dropped to 86%, and the EtCO₂ level decreased to 25 mmHg. On the other hand, a PaCO₂ level increased to 95.4 mmHg.

Based on the discrepancy between the PaCO₂ and EtCO₂, the patient was diagnosed as having pneumoperitoneum-induced carbon dioxide embolism. After 60 min of interruption of the surgical procedure, general status was recovered to the normal condition. We restarted the operation with conversion from pure laparoscopic surgery to hand-assisted laparoscopic surgery (HALS). Thereafter, extended right posterior sectionectomy was completed uneventfully without any signs of gas embolism, and the postoperative course was also uneventful. When carbon dioxide embolism occurs during laparoscopic hepatectomy, conversion to HALS can be a useful therapy of choice, if an injured site of the hepatic vein is apparent as an inflow site of carbon dioxide, and if effective hand pressure hemostasis can be expected. Here, we report this case with a review of the literature.

A 44-year-old woman presented with abdominal distention. Abdominal computed tomography showed a huge adrenal tumor in the left upper quadrant. A malignant adrenal tumor was suspected, and surgical resection was performed. Histopathological examination confirmed a diagnosis of Stage II adrenocortical carcinoma. One year later, she developed multiple recurrent lesions in the liver and lungs. Gradual enlargement of the hepatic lesion was observed despite long-term systemic chemotherapy including mitotane, necessitating the first hepatectomy (posterior segmentectomy). Unfortunately, multiple hepatic metastases recurred a year after the hepatectomy. Considering tumor hypervascularity, transcatheter arterial embolization (TAE) was performed and achieved complete remission except for persistence of a single lesion, which was later resected (partial hepatectomy). The patient is doing well at the time of writing this report, 5 years and 5 months after surgery. She continues to receive mitotane for stable multiple lung metastases. TAE is effective for hepatic metastasis of adrenocortical carcinoma ; however, previous reports have noted that tumor regrowth invariably occurs following TAE. In our view, hepatectomy with concomitant TAE can effectively control hepatic metastases of adrenocortical carcinoma.

The patient was a 66-year-old woman who had undergone thoracoscopic medial-basal segment segmentectomy for a tumor arisen in the visceral pleura of the right lower lobe 3 years previously. The histopathological diagnosis was solitary fibrous tumor (SFT). Thereafter she had been followed up by yearly CT scan. Recently she presented with back pain and an abdominal ultrasonography revealed a 91 × 30 mm tumor situating from the neck to the body of the gallbladder. On contrast-enhanced CT scan, the tumor was not apparently enhanced. MRI showed a homogeneous low-signal-intensity tumor on T1-weighted images and an heterogeneous high-signal-intensity tumor on T2-weighted images, no decreased diffusion being observed on diffusion-weighted images. Open cholecystectomy was performed with the diagnosis of gallbladder tumor. Gross findings of the resected specimen included the gallbladder of which inside was filled with a dark-red and jelly-like tumor and a pedunculated tumor which continued from body and bed of the gallbladder. The tumor had arisen from the inside of the gallbladder wall and protruded to the mucosal side. The most part of the tumor had degenerated and necrotized. Histopathological findings revealed a fascicular and dense growth of spindle-shaped cells from the deep part of the gallbladder wall to form a tumor. Immunostaining showed Stat6 (+). Consequently, SFT was diagnosed. As this case of SFT arising in the gallbladder is the first case report in Japan, we present the case together with some bibliographical comments.

A 49-year-old man was examined in another hospital for sudden upper abdominal pain, and computed tomography showed a hypodense mass, 2 cm in diameter, in the pancreatic head, the central part of which was enhanced during the arterial phase. On ultrasound endoscopy, this was visualized as a 20-mm hypoechoic mass with a 6-mm anechoic region inside it, and on Doppler ultrasound, a pulse wave could be seen between the anechoic area and the superior mesenteric vein adjacent to the lesion. Angiography showed mesh-like vascular proliferation in the area of the anterior superior pancreaticoduodenal artery and a shunt to the superior mesenteric vein, with an aneurysm in the area of the inferior pancreaticoduodenal artery. A pancreatic arteriovenous malformation with associated aneurysm was therefore diagnosed, and the patient was transferred to our hospital for surgery. Because the aneurysm was becoming larger, semi-emergency pancreaticoduodenectomy was performed. A pancreatic arteriovenous malformation associated with a pseudoaneurysm due to the breakdown of the abnormal vessels was diagnosed on the basis of histopathological examination. A pancreatic arteriovenous malformation is a comparatively rare condition, accounting for 0.9% of gastrointestinal arteriovenous malformations. A case of pancreatic arteriovenous malformation with an associated pseudoaneurysm is reported, together with a discussion of the literature.

A 77-year-old woman was referred to our hospital because of descending colon cancer detected on total colonoscopy. Multiple splenic tumors, growing and increasing in number for 3 years, were detected on preoperative contrast-enhanced computed tomography. We suspected that the multiple splenic tumors were malignant lymphomas because fluorodeoxyglucose positron emission tomography showed abnormal uptake in the spleen. Thus, we simultaneously performed laparoscopic partial descending colectomy and splenectomy. The pathological diagnosis of the multiple splenic tumors was sarcoidosis. The patient has not shown recurrence for 4 years.

A 63-year-old woman was examined in our hospital with right lower abdominal pain, reddening of the skin on the protrusion of an abdominal incisional hernia, and fever. There was a massive abdominal incisional hernia in the midline of the lower abdomen, with reddening of the skin and tenderness at its lower end. Abdominal contrast-enhanced computed tomography showed that the intestine from the terminal ileum to the transverse colon had escaped into the hernia sac, and an abscess with a maximum diameter of 7 cm had formed in the lower abdominal wall where it was in contract with the ileocecal region. This abscess was drained under local anesthesia, and the symptoms improved, but an enterocutaneous fistula appeared, and small amounts of intestinal fluid continued to leak from the drain. Fistulectomy with partial resection of the ileum and abdominal incisional hernia repair by the component separation (CS) method were performed in two stages. The results of the pathological examination suggested that an abdominal wall abscess due to ileal diverticulum penetration had formed in addition to the abdominal incisional hernia. The CS method is useful for hernia repair when the surgical site is infected, because of the risk of postoperative infection when mesh and other artificial substances are used.

An 80-year-old man attended an outpatient clinic complaining of vomiting and left inguinal pain. There was a large, tender protrusion extending from the left inguinal region to the scrotum. Computed tomography showed that the sigmoid colon was incarcerated in the left scrotum, which contained free gas and feces. There was no sign of free gas or ascites in the peritoneum. A left incarcerated inguinal hernia causing sigmoid colon perforation in the hernia sac was diagnosed, and emergency surgery was performed. When the abdomen was opened, the sigmoid colon was found to be incarcerated in the left lateral inguinal hernia sac, and when it was reduced, a perforation was visible in the mesenteric attachment of the part of the sigmoid colon that had been in the hernia sac. There were no signs indicating either a tumor or a diverticulum at the perforation site or of ischemic necrosis. Hartmann's operation and hernia sac resection and suturing were performed. Postoperatively, the patient developed congestive heart failure and ileus, but these improved with conservative therapy, and he was discharged on postoperative Day 40. We considered that vomiting while the sigmoid colon was incarcerated had caused a sudden increase in intra-abdominal pressure, generating a pressure difference between the hernia sac and the peritoneal cavity that may have caused the perforation. A rare case of sigmoid colon perforation inside an inguinal hernia sac is reported.

Case 1 : A 75-year-old man underwent laparoscopic inguinal hernia repair (TAPP) bilaterally. One year and ten months after surgery, the patient returned to hospital with pain in his right inguinal region and fever. An abscess was noted in the right inguinal region on abdominal computed tomography (CT), and postoperative late-onset mesh infection was diagnosed. The infected mesh was removed entirely following an anterior approach. Because of persistence two Tucker during an operation, a refractory postoperative persistent abscess was detected, which improved with conservative management within two months after surgery. Case 2 : A 55-year-old man underwent inguinal hernia repair on the right side during his childhood. He visited our hospital with pain in his right inguinal region and nausea. Abdominal CT showed a recurrence of the inguinal hernia and an intestinal incarcerated hernia. We judged that there was no problem with the intestinal blood flow, and the intestinal hernia may reposition on its own. Therefore, we subsequently performed TAPP. Two months after surgery, the patient returned to hospital with high fever. There was an abscess in the right inguinal region on abdominal CT, and postoperative mesh infection was diagnosed. The mesh was surgically removed following an anterior approach. Postoperatively, no recurrence of hernia or infection was noted in either case. Complete removal of the prosthesis may be required in case of mesh infection with abscess formation.

A 69-year-old man, who had undergone hernioplasty for a right inguinal hernia at the ages of 57 and 64 years, presented to our hospital with a 6-month history of a right inguinal bulge. Abdominal computed tomography (CT) showed a soft-density mass in the right groin that contained part of the urinary bladder. Thus, a right inguinal hernia with bladder herniation was diagnosed, and transabdominal preperitoneal repair (TAPP) was performed. The patient's postoperative course was uneventful, and he was discharged from our hospital on postoperative day 2. There have been no signs of recurrence. There have been 17 reports of the TAPP method for bladder hernia repair in Japan. CT is considered a useful diagnostic method for a bladder hernia. A preoperative diagnosis of bladder hernia is important to prevent intraoperative bladder injury. A re-recurrent case of inguinal bladder hernia that was treated by transabdominal preperitoneal repair is presented.