Pelvic organ prolapse (POP) is a very common condition in elderly women in which pelvic organs descend or prolapse, impairing quality of life (QOL). In this article, I describe the concept of POP, and review papers published after the emergence of vault suspension procedures, with a focus on surgical treatments. There are differences in the context of POP operations between foreign countries and Japan, such as a ban of tension-free vaginal mesh (TVM) in western countries ; therefore, I picked papers written on subjects that seemed important in Japan. As for native tissue repair (NTR), procedures such as hysterectomy combined with vaginal vault suspension have been performed ; however, the relatively high recurrence rate has been a problem. As for TVM, mesh-related complications, such as mesh extrusion or chronic persistent pain, have been reported, resulting in many western countries banning TVM using a polypropylene mesh. In Japan, a PTFE mesh is now available for TVM, but there is still little evidence surrounding its use. There are two types of laparoscopic sacrocolpopexy (LSC), a US style and a French style, with the latter more popular in Japan. On the whole, a lack of evidence remains a key issue for the Japanese in POP surgery.

Objective and methods : Robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer has become a standard procedure, and the number of cases of this procedure has increased. Indirect inguinal hernia is a late complication of radical prostatectomy. We retrospectively evaluated 204 patients who underwent RALP at our hospital between April 2012 and December 2016. We examined the risk factors of and the preventive measures for inguinal hernia after RALP.

Results : The mean follow-up period after RALP was 645 days. Twenty-four patients with 27 lesions developed an inguinal hernia postoperatively. Twenty patients with 23 lesions who underwent hernioplasty developed an indirect inguinal hernia. As the internal inguinal ring was difficult to peel off owing to its strong adhesion due to the influence of RALP, the plug method was used in the reconstruction. In the case of an anatomical change in the internal inguinal ring, postoperative inguinal hernia developed in 17.8% of the patients, and in 12.8% patients, it developed even after isolation of the spermatic cord.

Conclusion : Inguinal hernia that develops after RALP is indirect hernia, for which the use of the plug method in reconstruction is reasonable. If intraoperative findings during RALP indicate an anatomical change in the internal inguinal ring, the possibility of postoperative inguinal hernia and prophylactic procedures should be considered. However, the preventive effect of isolation of the spermatic cord remains questionable.

A 20-year-old woman who had been aware of a left breast mass since she was 19 years old presented to our hospital for the purpose of close exploration and treatment because it tended to grow. An elastic soft tumor 9.5 cm in diameter was palpated in the left BD area. Ultrasonography revealed a well-circumscribed solid tumor with a uniform inner part. The tumor partly presented a slit-like appearance, and it seemingly showed findings suggestive of fibroadenoma or a phyllodes tumor. However, a fine needle aspiration biopsy revealed only atrophic mammary tissue. Magnetic resonance imaging (MRI) scan revealed a low-intensity tumor on T2-weighted images and the enhancement effect was mild and ununiform, which were different from the typical features of fibroadenoma or phyllodes tumor. Without gaining the definite diagnosis, we performed tumor extirpation for the diagnosis and treatment. Histopathology showed the tumor to be an almost uniform lesion composed of proliferation of dense stromal tissue with a slit-like space and of poorly atypical mammary tissue. The stromal cells were positive for CD34 and SMA and negative for Factor VIII and p63 on immunostaining. Pseudoangiomatous stromal hyperplasia was thus diagnosed. Our experience with the disease is presented here with some bibliographical comments.

A primary aortic intestinal fistula is a very rare condition, and its mortality is very high without surgical treatment. A patient with a primary aortoduodenal fistula with hematemesis is presented. The patient was a 78-year-old man with a chief complaint of hematemesis. Emergency gastroduodenal endoscopic examination showed a lesion protruding into the duodenum. However, the source of bleeding was unknown, and he was referred to our hospital. Although his vital signs were stable, he had progressive anemia, and computed tomography showed an abdominal aortic aneurysm measuring 65 mm in diameter adjacent to the duodenum. Therefore, emergent surgery was performed with a diagnosis of aortoduodenal fistula. Intraoperative examination confirmed the fistula between the aortic aneurysm and the third portion of the duodenum. Abdominal aortic replacement was performed anatomically with a rifampicin-soaked prosthetic graft. The duodenal fistula was directly closed, and the pedicled omentum was used to patch between the graft and the duodenum. The patient's postoperative course was uneventful, and he was discharged on the 15th postoperative day. The antibiotics were discontinued, and there was no recurrence of infection.

Popliteal artery aneurysms may often rupture and are usually diagnosed based on imaging or other studies performed in patients with suspected or definitive evidence of thromboembolism. However, a ruptured popliteal artery aneurysm and concomitant thromboembolism that leads to spontaneous autoamputation of the digits are rare. Surgical repair is recommended in all patients with popliteal artery aneurysms ; however, guidelines are unclear regarding the exact surgical procedure. Therefore, individualized surgical treatment is necessary. A rare case of popliteal artery aneurysm is reported. The patient was an 87-year-old woman who was referred to our institute in a state of shock. The initial physical examination showed swelling of her right femur and autoamputation of the digits. Enhanced computed tomography showed a ruptured right popliteal aneurysm. A ruptured popliteal artery aneurysm causing thromboembolism was diagnosed. The patient underwent bypass surgery from the superficial femoral artery to the below-knee popliteal artery using a reversed great saphenous vein bypass graft by the medial approach. Subsequently, toe debridement was also performed. Her postoperative course was uneventful, and additional amputation was not required.

Video-assisted thoracoscopic surgery (VATS) has increasingly been performed in respiratory surgeries and may contribute to lighten the patient's load, however, there are some cases where patient's general condition disturbs VATS. We experienced two patients in a severe condition who were placed on one-lung ventilation during VATS. By combining with extracorporeal membrane oxygenation (ECMO), we could perform VATS in them.

Patient 1 was a 58-year-old man who suffered from bilateral pneumothorax with interstitial pneumonitis. Patient 2 was a 50-year-old woman with bilateral pneumothorax and lymphangiomyomatosis. Both patients underwent VATS with the assistance of ECMO and were taken off ECMO immediately after the surgery. Patient 1 and 2 underwent right bullectomy and bilateral pleural coverage, respectively. None of them experienced complications either during or after the surgical intervention. Although the patient 2 who was not administered anticoagulant agents had thrombosis in the jugular vein after the surgery, oral administration of edoxaban was effective, and the thrombosis disappeared immediately. The patient 1 was transferred to other hospital for rehabilitation and the patient 2 was discharged. These findings reveal that ECMO is useful for supporting patients with severe pulmonary involvement.

A 63-year-old woman was pointed out to have a middle mediastinal giant mass by a chest X-ray examination at a medical checkup. An upper GI endoscopy revealed a submucosal tumor with smooth surface in the middle thoracic esophagus. Boring biopsy taken from the tumor led to the diagnosis of neurogenic tumor. Chest computed tomography scan revealed a hypovascular mass lesion, 7cm in longer diameter, which had widely compressed the left pulmonary hilum and the descending aorta. Since a possibility of tumor invasion to the left pulmonary hilum and the descending aorta could not be ruled out, we initially performed left thoracotomy and confirmed that the tumor was able to be peeled from the left pulmonary hilum and the descending aorta. Subsequently, we changed the position of the patient and performed right thoracotomy. Subtotal esophagectomy with gastric conduit reconstruction was performed. The postoperative course was uneventful and the patient was discharged on the 12^th postoperative day. The histopathological diagnosis was esophageal schwannoma. We report the first case of esophageal schwannoma resected with a bilateral thoracic approach.

A 65-year-old woman was referred to our hospital for a gastric submucosal tumor which was detected by upper GI series at a medical checkup. Upper gastrointestinal endoscopy showed a tumor 15 mm in size located in the antrum of the stomach. Endoscopic ultrasound revealed a hypoechoic mass 13 mm in diameter arising from the fourth layer of the gastric wall. Contrast enhanced CT scan showed a 10-mm well-defined, enhancing mass at the anterior wall of the stomach antrum without lymph node invasion and distal metastasis. The preoperative diagnosis was gastrointestinal stromal tumor (GIST), and laparoscopic and endoscopic cooperative surgery (LECS) was performed. Pathological findings showed fibrosis of muscularis propria infiltrated by IgG4-positive plasma cells. The IgG4-positive cell/IgG-positive cell ratio was around 40%. IgG4-related sclerosing disease of the stomach was diagnosed. We herein report a rare case of IgG4-related sclerosing disease forming a submucosal tumor.

We report a case of gastric adenocarcinoma with enteroblastic differentiation (GAED) that occurred with common adenocarcinoma. A 74-year-old man underwent an endoscopic examination for a small amount of hematemesis in a neighboring hospital. The examination showed a 0-IIa lesion in the posterior wall of the cardia (lesion 1), a Type II lesion in the lessor curvature of the corpus (lesion 2), and a 0-IIa lesion in the posterior wall of the corpus (lesion 3). The patient was referred to our department for surgical treatment. Adenocarcinoma was identified on pathological biopsy examinations of the lesion 1 and 2, and adenocarcinoma was suspected for the lesion 3. The patient was diagnosed with multiple gastric cancers, and laparoscopic total gastrectomy was performed. The pathological diagnosis was GAED for lesion 2 and 3 because they were positive for SALL4 and negative for AFP and glypican. GAED occurred with well-differentiated tubular adenocarcinoma (lesion 1). Moreover, lymphatic and vascular invasion and nodal metastases were found.

GAED is very rare, carries an extremely poor prognosis, and the preoperative diagnosis is difficult. When the gastric cancer shows significant lymphatic and vascular invasions and liver metastasis, detailed histopathological studies should be performed.

Pulmonary metastasis of gastric cancer usually occurs as a result of carcinomatous lymphangiosis or carcinomatous pleurisy, and solitary pulmonary metastasis after gastric cancer surgery is rare. Although resection of solitary pulmonary metastases is reportedly effective, the role of surgical treatment is unclear.

The study subjects were five patients who underwent surgical resection of a solitary pulmonary metastasis after gastric cancer surgery.

Median time to pulmonary metastasis recurrence was 22 months, and the time was ≥12 months in all cases. Median survival after pneumonectomy was 45 (8-96) months, and the 5-year survival rate was 40%. The two patients for whom the time to pulmonary metastasis recurrence after gastric cancer surgery was ≥30 months both survived recurrence-free for ≥5 years after pneumonectomy.

Some patients achieved a good outcome following pneumonectomy for a solitary pulmonary metastasis after gastric cancer surgery. The prognosis for patients in whom the time to recurrence after gastric cancer resection is ≥30 months may be particularly good, suggesting that surgery should therefore be considered if at all possible.

A 48-year-old woman had been diagnosed with anorexia nervosa, and had been suffering from appetite loss, abdominal distention, and constipation for 30 years. She had been receiving psychosomatic treatment. This time, she suddenly developed strangulation ileus and underwent emergency surgery. During the procedure, axis rotation from ileum to cecum was observed, with intestinal necrosis and perforation of terminal ileum. Intestinal malrotation and duodenal stenosis due to formation of Ladd's bands were also observed. In addition to ileocecal resection, the Ladd procedure was performed to correct the stenosis. At the 18-month follow-up post-surgery, her chronic complaints disappeared and her nutritional status had markedly improved. This case was valuable in that chronic appetite loss and abdominal distention that had been diagnosed as anorexia nervosa were caused by intestinal malrotation in actuality.

The patient, a 76-year-old man, had undergone laparoscopic left partial nephrectomy for renal cell carcinoma (RCC) 44 months earlier (the histopathological diagnosis was clear cell carcinoma, T1a, N0, M0), and was regularly followed-up at our department of urology. He had undergone retroperitoneal tumor resection for local recurrence of the RCC 15 months earlier. Abdominal CT at the present admission revealed an ileal mass. Lower gastro intestinal endoscopy revealed a type 1-like tumor at the terminal end of the ileum. Biopsy revealed features consistent with RCC. PET-CT showed abnormal uptake in the ileal mass and a mesenteric lymph node. We made the diagnosis of ileal metastasis from RCC and performed ileocecal resection and lymph node dissection. The patient has not exhibited disease recurrence until now, 6 months after the ileocecal resection. Small intestinal metastasis from RCC is often associated with multiple concomitant metastases. Isolated small intestinal metastasis from primary RCC in the absence of metastasis to the lung is rare, and only a few cases, including the present case, have been reported in Japan.

A 68-year-old man on oral antihypertensive therapy was brought to our hospital as an emergency on a very hot day in July after developing excessive sweating, inability to stand, hypotension, and bradycardia after having been working outdoors. His vital signs on arrival were indicative of shock, with a Japan Coma Scale score of I-3, heart rate of 42 bpm, blood pressure of 72/44 mmHg, and SpO₂ that was not measurable. Heatstroke was diagnosed on the basis of his medical history and physical signs, and when lactated Ringer's solution was administered, his vital signs rapidly stabilized, and his symptoms started to improve. Blood tests showed moderate renal impairment (BUN 36.0 mg/dL, creatinine 2.32 mg/dL), and abdominal computed tomography (CT) showed gas in the hepatic portal vein. On the basis of these findings, Grade III heatstroke and hepatic portal venous gas were diagnosed, and the patient was admitted. Although his renal function improved the following day, abdominal pain intensified, and another CT scan showed localized intestinal pneumatosis in the left transverse colon, hyperdensity of the surrounding adipose tissue, and accumulation of ascites. Intestinal necrosis was diagnosed, and partial transverse colectomy was performed the same day. It is comparatively rare for gangrenous ischemic colitis, requiring colectomy to develop as a result of heat stroke, and the present case is reported along with a short discussion of the literature.

The patient was a 23-year-old man who had been diagnosed as having tracheomalacia, dilated cardiomyopathy and Duchenne muscular dystrophy. He had developed cardiopulmonary arrest as a result of airway obstruction caused by thick sputum 6 years earlier ; although he had been revived, he developed anoxic encephalopathy as a sequela, which made communication with him difficult.

The patient had undergone both gastrostomy and tracheotomy, and had become ventilator-dependent. During the course, he developed abdominal distension, which, we diagnosed following thorough investigation, was caused by neoplastic ileus secondary to transverse colon cancer.

As we obtained successful intestinal decompression with an intestinal tube and colonic stent placement, in consideration of the patient's age and wishes of the family, we planned palliative surgery.

We performed right hemicolectomy (D2 dissection). Careful attention needs to be paid during surgery in patients with muscular dystrophy, as the muscle relaxant drugs administered for may need time to take effect. There were no significant postoperative complications, and the patient was discharged on the 11^th day after surgery. We report this case, as it is very rare for surgery to be performed for transverse colon cancer in patients with muscular dystrophy.

An 81-year-old female patient who was prescribed sodium polystyrene sulfonate (SPS : Quixarate^®) for hyperkalemia had the abrupt onset of abdominal pain 23 days after oral administration of SPS. She was introduced to our department with a diagnosis of acute abdomen. In abdominal findings, strong tenderness and muscular defense were observed throughout the lower abdomen, and general pan-peritonitis was suspected. An abdominal CT scan showed multiple diverticula in the sigmoid and ascending colon and a free gas image in the peritoneal cavity. No storage of ascites was allowed. Contrast enema with amidotrizoic acid revealed leakage of the medium from the sigmoid colon to the outside of the intestinal tract. Perforation of sigmoid colon diverticulum was suspected and an emergency operation was performed on the same day. Intraoperative findings showed two sites of perforation in the sigmoid colon. Postoperative pathological findings showed deposition of SPS crystals in wall of the perforated diverticulum. In this case, it is suggested that taking SPS may be involved in the development of sigmoid diverticular perforation.

A 58-year-old man underwent colectomy due to sigmoid colon cancer. The pathological examination revealed that it was type 2 endocrine cell carcinoma, 11.0 × 8.5 cm in size, with subserosal invasion and no lymph node metastasis, corresponding to T3N0M0 stage II A on the 8^th edition UICC. Nine months later axillary lymph node metastasis appeared solitarily, and it was resected under local anesthesia. Subsequently oral chemotherapy was performed for five years. No further metastasis has appeared for thirteen years after the resection of the metastasis. We consider this is a rare case of endocrine cell carcinoma, in which the resection of the solitary unusual axillary lymph node metastasis resulted in a long-time survival. So far we have not encountered such a case report like ours.

A 64-year-old man was referred to our hospital for further investigation of a growing hepatic tumor of 1.5 cm in diameter that was located in segment 7. It was difficult to make a definite diagnosis of a dysplastic nodule or an early-stage hepatocellular carcinoma by abdominal sonography and enhanced computed tomography. A Gd-EOB-DTPA-enhanced MRI scan showed poor uptake of contrast agent in the hepatobiliary phase, but no signal change at a chemical phase shift. Nevertheless, hepatectomy of the posterior segment was performed because a malignant tumor could not be ruled out. The tumor was an unclear nodule without a coating and was histologically composed of a palisade structure with no atypical or high-density cells. A low-grade dysplastic nodule was diagnosed. Because a patient's liver with alcoholic change tends to have dysplastic nodules, it is very difficult to diagnose them. We think there is some possibility that a fat-containing evaluation such as a chemical phase shift is useful. It is also necessary to perform a comprehensive evaluation based on the diameter of the tumor, the clinical course, and multiple imaging modalities to make a diagnosis.

A 70-year-old man presented to our hospital complaining of back pain. CT revealed an intra-abdominal tumor under the left diaphragm, located next to the spleen and lateral segment of the liver. The tumor showed a remarkably high fat density, with a peripheral enhancement effect. MRI also showed the fat-rich character of the tumor. Based on the findings, the tumor was suspected as a hepatocellular carcinoma (HCC) or angiomyolipoma. Laparoscopic partial resection of the liver was performed.

The resected specimen showed a yellow tumor, 5.0 cm in diameter. Histopathologically, the tumor was diagnosed as moderately differentiated HCC with marked fatty change.

This case serves as an important reminder to consider hepatocellular carcinoma in the investigation of possible causes of liver tumor with marked fatty change.

A 60-year-old man who had been followed for chronic hepatitis C was admitted to our hospital for hepatocellular carcinoma (HCC). An abdominal contrast-enhanced CT scan showed a tumor, 10 mm in diameter, in the S4 segment of the liver. Intraabdominal severe adhesion was expected from his history of tuberculous peritonitis. However, total laparoscopic partial hepatectomy was performed because the tumor was solitarily located at the surface of the liver at the segment S4. Although adhesions from the liver to the abdominal wall were showed, laparoscopic hepatectomy could be performed by minimum division of adhesions. The postoperative course was uneventful, and he was discharged 7 days after the operation. Eight months later, a new 12-mm HCC occurred in the S7 segment and laparoscopic partial hepatectomy (S7) was performed because the tumor was located at the liver surface as before and away from the former surgical site. The postoperative course was uneventful, and he was discharged 9 days after the second operation. The patient is now doing well and cancer-free at 1 year 9 months after the initial surgery. Laparoscopic hepatectomy may be difficult to perform in this case because adhesions caused by tuberculous peritonitis might restrict vision and manipulation of forceps. We could safely perform laparoscopic hepatectomy twice for recurrent as well as primary HCC with adhesions due to tuberculous peritonitis.

An 82-year-old man was admitted to our hospital due to gross hematochezia. Colonoscopy showed a circumferential type 3 tumor in the sigmoid colon. Computed tomography (CT) showed multiple hepatocellular carcinomas (HCCs) with maximum diameters of 10 cm in S4/5/8 and 5 cm in S7, for which right hepatic trisegmentectomy was indicated because the predicted future liver remnant (FLR) was 43%. Laparoscopic portal vein ligation (PVL) was performed following laparoscopic sigmoidectomy. Four weeks postoperatively, the FLR reached 63% with ICG-K 0.072, and the patient underwent right hepatic trisegmentectomy. The patient had an uneventful postoperative course and underwent adjuvant chemotherapy for colonic cancer. Laparoscopic portal ligation is feasible in some patients with liver cancer concomitant with other gastroinstestinal disease. This method may be a superior choice for selected patients with HCC because it decreases potential morbidity associated with percutaneous transhepatic portal vein embolization.

A 75-year-old man underwent left hepatectomy for portal tumor embolism. A biliary disconnection fistula was diagnosed after hepatectomy, because the drainage from the drain placed at the cut surface changed to bile on postoperative day 5, and infusion of contrast agent to the drain showed the bile duct of the caudate lobe. Infusion of contrast agent to the drain showed the drain fistula connected to the duodenal cap. Upper gastrointestinal endoscopy showed a duodenal ulcer (A1 Stage). Proton pump-inhibitor treatment cured the duodenal ulcer, but the drain fistula connected to the duodenal cap remained. Histoacryl^® 0.4 ml + lipiodol 1 ml were infused from the duodenal ulcer on postoperative day 55. The next day, the connection between the drain fistula and the duodenal cap was closed. Infusion of contrast agent into the drain did not show the bile duct of the caudate lobe. The drain was pulled out because the drainage from the drain was decreasing. Infusion of histoacryl to the disconnected bile duct was minimally invasive, and it may be effective therapy for biliary disconnection fistulae after hepatectomy.

We report a rare case of “so-called” carcinosarcoma of the distal bile duct. Carcinosarcoma is described as a malignant tumor with an admixture of both epithelial and mesenchymal components. Carcinosarcoma lesions are most frequently reported in the female genital system, esophagus, lungs, kidneys, bladder and breast. However, distal common bile duct carcinosarcoma is very rare. A 78-year-old man was referred to our hospital due to jaundice. Dynamic CT and ERCP revealed an 18-mm-long circumferential stenosis in the middle portion of the bile duct. Endoscopic retrograde forceps biopsy revealed well to moderately differentiated adenocarcinoma. He was diagnosed as having distal bile duct adenocarcinoma (cT2N1M0c Stage IIB) and treated by subtotal stomach-sparing pancreatoduodenectomy. Postoperative histopathological examination revealed spindle-shaped atypical cells with irregular nuclei infiltrating the bile duct wall, with fibrosis. Immunohistochemistry showed positive staining of the spindle cells for pancytokeratin (AE1/AE3). The final pathological diagnosis was “so-called” carcinosarcoma of the distal common bile duct. The patient remains alive and without recurrence now, 6 months after the surgery (with no adjuvant therapy).

Solid-pseudopapillary neoplasm (SPN) of the pancreas is common in young women and rare in young men. It is frequently diagnosed in asymptomatic patients. Here, we report our experience of a young male SPN patient presenting with hemoperitoneum after suffering a blunt abdominal trauma, set in the context of the literature. A 16-year-old man was referred to our hospital with abdominal pain after suffering a blunt abdominal trauma. An abdominal contrast-enhanced CT scan showed a 50-mm mass at the head of the pancreas and retroperitoneal hemorrhage. The hemorrhage was conservatively treated. Another abdominal contrast-enhanced CT scan taken 3 months after the trauma showed the mass to be still present at the pancreatic head. Pancreaticoduodenectomy was performed. The operation took 604 minutes and the patient lost 405 ml of blood. The patient was discharged 35 days after the procedure. The tumor was pathologically diagnosed as SPN. In cases where the main pancreatic duct is narrow or the texture of the pancreas is soft, we always perform a 2-stage pancreatojejunostomy. We performed pancreatojejunostomy 3 months after pancreaticoduodenectomy. Two years following the pancreaticoduodenectomy, the patient is doing well with no evidence of recurrence and malnutrition.

A 61 year-old man with a 6-month history of epigastric pain visited our hospital for close exploration and treatment. A computed tomography (CT) showed a 50×30 mm low density area at the pancreatic tail which was suggestive of pancreatic cancer. It also revealed the dilatation of the main pancreatic duct (MPD) at the pancreatic head, and intraductal tumors were detected in the main pancreatic duct at the pancreatic head by endoscopic ultrasonography. Fine needle aspiration for the pancreatic tail tumor exhibited atypical cells showing both phenotypes of the acinar and of the neuroendocrine. Since the cytological examination for the tumor in the main pancreatic duct at the pancreatic head obtained similar cells, total pancreatectomy was performed. Pathological diagnosis of the pancreatic tail tumor was mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) accompanied with intraductal polypoid growth (IPG) reached to the main pancreatic duct at the pancreatic head, and the main tumor showed higher activity with the Ki-67 score of 50%. Unfortunately, he was detected having multiple liver metastases 4 months after the surgery, and administration of everolimus was started. The recurrent disease progressed even after starting the treatment, and he died a year after the surgery. We report here an extremely rare case of MiNEN accompanied with IPG.

We performed distal pancreatectomy with preservation of the pancreatic body for carcinoma of the remnant pancreas which was diagnosed 4 years and 8 months after pancreatoduodenectomy for bile duct carcinoma. The patient was a 75-year-old man undergone pancreatoduodenectomy for carcinoma of the inferior bile duct which was pathologically diagnosed as well-differentiated tubular adenocarcinoma Stage II. Four years and 8 months later, an increase in the CA19-9 level was noted. An abdominal CT scan showed a 2-cm poorly enhanced irregular-shaped tumor at the remnant pancreatic tail. The main pancreatic duct had dilated, and a granular shadow which seemed to be a pancreatic stone was confirmed in the main pancreatic duct in the vicinity of the pancreatojejunostomy. Pancreatic carcinoma in the remnant pancreas and chronic pancreatitis due to the pancreatic stone were diagnosed, and we performed distal pancreatectomy with preservation of the pancreatic body, splenectomy and lymph node dissection. At surgery, the jejunum was dissected and lifted at the distal aspect of the gastrojejunostomy, and jejunal anastomosis was made at the distal pancreatic stump as a drainage of the pancreatic duct for recurrent pancreatitis. The histopathological diagnosis was tubular adenocarcinoma Stage IB. After the operation, his blood-sugar level has been kept stable without using insulin. As metachronous remnant pancreatic carcinoma after resection of bile duct carcinoma is extremely rare, we present this case with some bibliographical comments.

A 41-year-old woman was admitted to our hospital for examination and treatment of leukemia. Her left abdominal pain worsened and anemia progressed. Computed tomography revealed an atraumatic splenic rupture with active bleeding. Thus, transcatheter embolization of the splenic artery was performed. As the bleeding from the spleen was uncontrolled, splenectomy was performed. A pathological diagnosis of hairy cell leukemia was made. The patient was discharged on postoperative day 9. As her leukemia showed no progression, she underwent observation for 30 months after the surgery.

A 40-year-old man was found to have a splenic tumor on the ultrasonography performed at an annual medical checkup. He had no symptoms, but his serum C-reactive protein level was elevated in the blood test. Abdominal contrast-enhanced computed tomography (CT) revealed an 8-cm splenic tumor. On dynamic study, most of the interiors of the tumor were found to be hypointense, but a part of it, from the periphery to the center, was enhanced. The tumor was hypointense on T1- and fat suppression T2-weighted imaging, and had avidity for fluorodeoxyglucose on positron emission tomography-CT. We performed a laparoscopic splenectomy for both diagnosis and treatment as obtaining a definitive diagnosis of the tumor using an imaging modality was difficult. The cut surface of the specimen showed a solitary and well-circumscribed lesion. On photomicrography, typical angiomatoid nodules and fibrosis were observed. The pathological diagnosis based on the immunohistochemical staining for CD31, CD34, and CD8 was sclerosing angiomatoid nodular transformation (SANT). Twenty-seven cases of SANT have been reported in Japan. We report the clinical characteristics of 28 cases, including the present case.

A 67-year-old woman underwent computed tomography before an operation for bladder cancer, and was found to have a 21-mm cystic lesion under the left diaphragm. We additionally performed magnetic resonance imaging and positron emission tomography examination, but still had difficulty making a preoperative diagnosis. Thus, laparoscopic surgery was performed for therapeutic diagnosis.

The tumor was 22×17×5 mm in size. Pathological findings revealed a ciliated epithelium, smooth muscle, colleterial gland, and cartilage. As a result, we made a diagnosis of a bronchogenic cyst.

The bronchogenic cyst is a congenital cyst occurring for a lesion derived from foregut of the developing in the bronchus formative period. Most cases occur in the lungs and posterior mediastinum, and cases occurring in the retroperitoneum are rare. We report a rare case with bibliographic considerations.

A right retroperitoneal liposarcoma and the right kidney of a 64-year-old female were surgically resected at another hospital 22 years ago. She did not experience any recurrence until she underwent abdominal computed tomography (CT) for the evaluation of sustained fever and a severe inflammatory reaction. The CT scan revealed an 8-cm right retroperitoneal mass. Non-neoplastic causes of fever were ruled out, and the patient underwent excision of the retroperitoneal mass, right hemicolectomy, and partial hepatectomy. The pathological diagnosis was dedifferentiated liposarcoma. The fever and inflammatory reaction was promptly resolved, and the patient was discharged 13 days after surgery. There was no recurrence in the 2 years after surgery. A retroperitoneal tumor is difficult to diagnose and may present with compressive symptoms due to tumor growth. However, diagnosis was conducted due to the occurrence of a tumor-related fever.

A 55-year-old man was admitted to a local hospital with a fracture in his right 9^th rib following a 3-month history of episodic chronic coughing. He received conservative treatment with analgesics ; however, he developed right-sided thoracoabdominal wall bulging during the course of treatment and was referred to our department. Abdominal computed tomography revealed an opening at the 9^th intercostal space with ileal and hepatic herniation through the defect, and he was diagnosed with an intercostal hernia. He underwent laparoscopic repair with intercostal hernia orifice closure using an appropriate mesh. The patient's postoperative course was uneventful without recurrence at his 8-month follow-up. Intercostal hernia is rare ; therefore, a standard operative approach has not been established for its management. Laparoscopic repair with mesh placement might be useful for this condition with regard to safety and recurrence prevention.

A 63-year-old man underwent anterior iliopubic tract repair of an incarcerated right inguinal hernia. From the day after surgery, the patient complained of pain in the region supplied by the genital branch of the genitofemoral nerve, and a policy of watchful waiting with analgesic use was adopted. However, the symptoms not only failed to improve, but became sufficiently severe to interfere with walking, and triple neurectomy by hybrid surgery was therefore performed 1 year 4 months after the initial surgery. The iliohypogastric and ilioinguinal nerves were first identified and resected via an inguinal incision. The genitofemoral nerve was then identified and resected laparoscopically. The inguinal floor was also reinforced with mesh. The pain improved postoperatively, and the patient was discharged on postoperative Day 2. Today, 1 year 11 months after the second surgery, there has been no flare-up of pain or hernia recurrence, and outpatient follow-up is ongoing.

An 85-year-old man presented to our hospital with painless swelling of the right inguinal region. He had undergone femorofemoral (F-F) bypass for atherosclerosis obliterans (ASO). An ultrasonographic study showed a hernia sac including small bowel under the vascular graft. A right inguinal hernia was diagnosed, and transabdominal preperitoneal hernia repair (TAPP) was performed. Before operation, the skin just above the graft was marked, and care was taken to ensure sufficient distance between the port sites and the vascular graft. The patient's post-operative course was satisfactory without complications. TAPP for inguinal hernia after F-F bypass surgery is one of the safe and useful strategies.

The orifice of a direct inguinal hernia is located internal to the inferior epigastric artery. A direct hernia protrudes directly through the weakened posterior wall of the inguinal canal. On the other hand, an indirect inguinal hernia has an external orifice and descends through the inguinal canal. A case of direct inguinal hernia with an external orifice successfully treated by the transabdominal preperitoneal approach (TAPP) is reported.

A 75-year-old man was referred to our hospital with left lower quadrant abdominal pain. Enhanced CT showed a left inguinal hernia with intestinal incarceration, and emergent surgery was performed. In the abdomen, there was an inguinal hernia with an external orifice, and the intestine was incarcerated in the hernia. After the intestine was pulled out, another indirect hernia was found, and the strangulated intestine protruded directly through the posterior inguinal wall. Both inguinal hernias were repaired with a polypropylene mesh. A rare case of inguinal hernia that was classified as a type V (unclassified) hernia according to the Japan Hernia Society Classification for groin hernia was reported.

A 41-year-old female met with a traffic accident and was taken to our hospital, Miyazaki Prefectural Nichinan Hospital. She was bruised on the chest and the abdomen, and complained of severe abdominal pain. Although computed tomography (CT) examination revealed no internal organ damage in the peritoneal cavity, the abdomen had a platelike hardness, and traumatic peritonitis was strongly suspected. While we planned the exploratory laparotomy, we found she had a history of familial Mediterranean fever (FMF). We diagnosed the abdominal pain as being caused by FMF. She was treated conservatively and the abdominal pain eased quickly. FMF is a disease that is characterized by periodic fever and serositis (pleuritis / peritonitis), developing paroxysmally due to factors such as stress. In this case, we could distingnish FMF from traumatic peritonitis accurately, and unnecessary exploratory laparotomy was avoided.