Objective : The aim of this study was to clarify the clinical features and complications of central venous access port (CV port) implantation via the internal jugular vein under real-time ultrasound guidance.

Methods : A total of 173 patients underwent implantation of CV ports from 2009 to 2019 in our hospital. They were divided into the internal jugular venipuncture group under real-time ultrasound guidance and the subclavian venipuncture group with anatomical landmark technique, and the two groups were compared.

Results : The right implant side was significantly more common (P< 0.01), and operation time was significantly longer (P< 0.01) in the internal jugular venipuncture group than in the subclavian venipuncture group. There were no intraoperative complications in the internal jugular venipuncture group, and they were significantly less than in the subclavian group (P< 0.01). Although the duration of implantation was shorter (P< 0.01), postoperative complications were also significantly less in the internal jugular venipuncture group than in the subclavian venipuncture group (P= 0.026).

Conclusion : Implantation of CV ports via the internal jugular vein under real-time ultrasound guidance decreased intraoperative complications. It also appeared to have the potential to decrease postoperative complications.

The case involved a 74-year-old man who had a history of undergoing thoracoscopic esophageal subtotal resection and posterior mediastinal route subtotal gastric tube reconstruction as additional resection after ESD for esophageal cancer. Two years after the operation, he visited a neighboring hospital with cold symptoms. Chest X-ray revealed free air in the abdominal cavity under his diaphragm. He was introduced to our hospital and a CT scan showed right pneumothorax and intraperitoneal free gas. Gastrointestinal perforations could not be identified. Upper gastrointestinal endoscopy did not show upper gastrointestinal perforation. We considered to perform exploratory laparotomy, but he had not peritoneal irritation symptoms nor inflammation findings. Based on his history and CT findings, we diagnosed that right spontaneous pneumothorax had spread into the abdominal cavity via the esophageal hiatus, leading to intraperitoneal free gas. Consequently, we chose conservative treatment with fluid replacement. After emergency admission, there was no increase in pneumothorax or intraperitoneal free gas, and the patient was discharged on the 7th hospital day. Within the scope of the search, there were only two similar cases reported in Japan, and in both cases unnecessary surgical treatment could be avoided. We discuss this case herein.

The case involved a 67-year-old woman who had undergone extended thymectomy for an anterior mediastinal tumor in March 2017. Pathological findings revealed World Health Organization (WHO) classification type AB thymoma. A year after thymectomy, she developed pneumonia and was treated. From then, she had recurrent bouts of pulmonary infection and this could be explained by a fact that the absence of immunoglobulin was clarified by further examination. Thus, she was diagnosed with Good's syndrome when one and half years had elapsed after thymectomy. She began receiving intravenous immunoglobulin and long-term macrolide maintenance therapy. She followed an uneventful course after the treatment for 6 months. Good's syndrome is a comparatively rare entity associated with hypogammaglobulinemia and thymoma. However, the exact cause of this rare syndrome remains unknown and recurrent pulmonary infection carries poor prognosis. It also remains controversial that what therapy is effective including surgical resection of thymoma. Further accumulation of clinical cases would be mandatory.

A 64-year-old man presenting with continuous distention of the upper abdomen was referred to our hospital because an abdominal tumor was detected by an abdominal ultrasonography at another hospital. Esophagogastroduodenoscopy showed a submucosal tumor with multiple ulcers at the anterior wall under the cardia of the remnant stomach. A biopsy revealed the diagnosis of gastrointestinal stromal tumor (GIST) of the stomach. An abdominal CT scan showed a tumor with the longer diameter of 20 cm at the left upper quadrant of abdomen, where infiltration of the tumor into the surrounding organs was suspected. We planned to conduct neoadjuvant chemotherapy and imatinib regimen at a dose of 400 mg/day was started. The following CT scan on the 19^th day after the initiation of the regimen revealed necrosis of the tumor and its penetration into the gastric lumen. This situation appeared to entail a greater risk of causing threatened rupture of the tumor, and we performed an emergency operation. Intraoperative findings did not confirm the tumor rupture, but it so firmly adhered with left lobe of the liver, diaphragm, spleen and pancreatic tail that combined resection of them was needed. His postoperative course was uneventful and he was discharged from our hospital on the 11^th postoperative day.

Neoadjuvant chemotherapy for GISTs appears to be beneficial for its contribution to a complete resection, however, careful observation is needed because it can also cause serious complications.

A 51-year-old woman had first complained of fever and abdominal pain 19 years earlier. Investigations at that time showed a submucosal tumorous lesion with cyst formation and thickening of the wall of the gastric antrum, and she was treated conservatively for phlegmonous gastritis. She subsequently developed the same condition seven times, each time improving with conservative treatment. One month before presenting on the most recent occasion she had developed loss of appetite and abdominal pain, and upper gastrointestinal endoscopy showed enlargement of the submucosal tumorous lesion in the gastric antrum. Computed tomography also showed a mass in the greater omentum, and surgery for a suspected malignant tumor was performed. Intraoperative findings were indicative of gastric cancer with peritoneal dissemination, and distal gastrectomy was performed with the objective of avoiding pyloric stenosis. Postoperative histopathological testing confirmed that the submucosal tumorous gastric cancer was mucoid carcinoma, and the tumor contained vestiges of islets of Langerhans, suggesting that it may have been derived from ectopic pancreas. In this case, ectopic pancreas was the cause of the clinically repeated phlegmonous gastritis, and it developed into gastric cancer over the long term. It is often difficult to make a definitive diagnosis of gastric submucosal tumors, and even more careful follow-up may have been needed taking into account the possibility that they may turn cancerous over the long term.

A 78-year-old man presented with loss of appetite. Upper gastrointestinal endoscopy showed Type 1 gastric cancer in the anterior wall of the lower gastric corpus, which was diagnosed as poorly differentiated adenocarcinoma on biopsy. The preoperative white blood cell (WBC) count was elevated at 34,700/μL. Granulocyte colony-stimulating factor (G-CSF)-producing gastric cancer (cT4aN2M0, Stage III) was suspected, and distal gastrectomy was performed. Histopathological tests showed the presence of pT4aN3aM0, Stage IIIB multiple gastric cancers comprising Type 1 gastric cancer (por1>tub1, SE, N3a, M0, CY0) and Type 0-IIc gastric cancer (tub1, M, N0, M0). Immunohistological staining was positive for anti-G-CSF antibodies, and a diagnosis of G-CSF-producing multiple gastric cancers was made. Although the WBC count normalized rapidly postoperatively, it again rose to 50,100/μL on postoperative Day 76, and contrast-enhanced computed tomography showed local recurrence. The patient's condition rapidly deteriorated, and he died on postoperative Day 84. A case of G-CSF-producing multiple gastric cancers with a rapid course is reported, together with a discussion of the literature.

A 60-year-old man who was being followed for cytomegalovirus (CMV) enteritis was referred to our hospital with a chief complaint of anemia. Lower gastrointestinal endoscopy showed mucosal redness, edema, and ulceration in the ileocecal region. The results of biopsy showed no CMV antigen-positive cells, and deposition of unstructured basophilic material was observed in the lamina propria. The patient was taking calcium polystyrene sulfonate (CPS) at that time. Considering the possibility of a relapse of CMV enteritis, administration of antiviral drugs was resumed, and the CPS was discontinued. Thus, conservative treatment was started. However, his enteritis with hemorrhage did not improve, so a laparoscopic-assisted ileocecal resection was finally performed. The patient's postoperative condition was good, his anemia improved, and he was discharged on the 10th postoperative day. On histopathological examination, lesions and ulcers were seen in the ileum and cecum, and deposition of unstructured basophilic material was observed in the area from the mucosa into the muscle layer. No nuclear inclusions or CMV antigen-positive cells were found; thus, he was diagnosed with hemorrhagic enteritis caused by CPS associated with CMV enteritis.

An 86-year-old man was admitted to our hospital with abdominal pain and bloody stool. He was diagnosed as having ischemic colitis (IC) in the transverse colon and treated conservatively for 9 days. However, 6 days after discharge, he visited our emergency department complaining of severe abdominal pain. His abdomen was moderately distended with tenderness throughout the abdomen, with no muscle guarding. Abdominal contrast-enhanced computed tomography showed intestinal dilatation, attenuated enhancement of the small intestinal wall, hepatic portal venous gas, and pneumatosis cystoides intestinalis without definite superior mesenteric artery occlusion. Non-occlusive mesenteric ischemia (NOMI) was suspected, and emergency surgery was performed. During surgery, segmental necrosis of the small intestine, 150 cm in length, 270 cm from the ligament of Treitz, was observed. Therefore, the necrotic small intestine was resected, and a functional end-to-end anastomosis was performed. The transverse colon that might have been involved in ischemic colitis seemed intact. The patient's postoperative course was uneventful, and he was transferred to another institute on postoperative day 23.

A patient with isolated right colon ischemia is likely to have a worse prognosis than one with left colon ischemia. When a patient presents with ischemic colitis affecting the right colon, careful diagnosis, intensive care, and follow-up are needed.

The patient was a 74-year-old woman who visited our hospital with a chief complaint of sudden sharp abdominal pain. She was diagnosed with superior mesenteric artery occlusion, and emergency surgery was performed. Extensive ischemia was noted, but there was no intestinal necrosis, so only thrombectomy was performed. In a second-look operation on the following day there was no intestinal necrosis, and the intestine was preserved. Intermittent abdominal pain and diarrhea recurred after surgery, and hypoalbuminemia and systemic edema progressed. After 3 months of conservative treatment, there was no improvement. Edema of the upper jejunum and irregular enhancement were noted on contrast-enhanced abdominal CT, with accumulation in the corresponding region on protein leakage scintigraphy. Protein-losing gastroenteropathy was diagnosed, and reoperation was performed. Staging laparoscopy showed thickening of the small intestinal wall for 20 cm from the ligament of Treitz and a color change to dark red. Laparoscopic observation through the resected stump showed more extensive ulcer and stenosis than on the serosal surface of the intestine. After additional resection, a total of 60 cm of intestine were resected. No abdominal symptoms developed after surgery, and her serum albumin increased. This case shows the value of intraoperative laparoscopy for determining an appropriate intestinal resection range.

Three patients visited our hospital because of abdominal pain with or without nausea. Enhanced computed tomography showed a whirl sign and edematous mesentery proper in all cases. Emergency surgery was performed in all cases with the diagnosis of strangulated ileus ; cases 1 and 2 underwent laparotomy, and case 3 underwent laparoscopic surgery. In all cases, mesenteroaxic torsion without intestinal necrosis was seen. Small bowel volvulus was finally diagnosed intraoperatively ; cases 1 and 2 were primary, and case 3 was secondary. In cases 1 and 2, only the torsion was reset, whereas adhesiolysis was also performed in case 3. Intestinal resection was not necessary in all cases. Small bowel volvulus is reported to be rare, and immediate treatment is needed because intestinal necrosis may occur.

A 64-year-old man with a history of diabetes, hypertension, and previous myocardial infarction presented at our hospital in September 2017 with epigastric pain, vomiting, and watery stool. Abdominal contrast-enhanced computed tomography (CT) showed only mild dilatation of the small intestine. Since the clinical course suggested infectious enteritis, he was admitted for observation. On Day 3, the abdominal pain worsened, and blood tests showed an elevated inflammatory reaction with CRP of 50.6 mg/dl. Abdominal contrast-enhanced CT showed localized necrosis of the small intestine, and generalized peritonitis associated with small bowel necrosis was diagnosed. Emergency laparotomy was performed, and a 15-cm section of the ileum located 20 cm on the oral side of the distal end of the ileum was found to be necrotic. The necrotic portion was excised, and the operation was concluded by reconstructing the intestine with a functional end-to-end anastomosis. Aeromonas hydrophila (A.H.) was subsequently detected from stool culture, and infectious enteritis due to A.H. was diagnosed. The patient's postoperative course was uneventful, and he was discharged on postoperative Day 15. There have been not a few reported cases of A.H. infection that have been serious. A case of small bowel necrosis that developed from infectious enteritis caused by A.H. in which the patient's life was saved by surgery is reported.

A 56-year-old man who had undergone total colectomy and ileostomy for familial adenomatous polyposis (FAP) was diagnosed as having ileal cancer at the ileostomy site. Radical surgery with abdominal wall resection was performed because tumor infiltrated to the abdominal wall. The resected specimen showed that there were many adenomatous polyps in the ileal pouch. Pathological findings showed an ileal cancer developing at the ileostomy. Fifteen months after the second operation, recurrent lesions were seen in the abdominal wall and right inguinal lymph nodes.

Although he underwent a chemotherapy regimen for colorectal cancer, he finally died of metastasis in the mesencephalon.

This is an important case suggesting the need for postoperative surveillance in FAP patients with ileal cancer, even after total colectomy.

According to the Clinical Practice Guidelines for Gastroenteropancreatic Neuroendocrine Neoplasms 2019, ileocecal excision is recommended for tumors with more than 2 cm in diameter or with risk factors such as vascular invasion. However, few studies have been reported on pediatric patients and no clear notion has been established.

We present a case of a neuroendocrine tumor (NET) of the appendix in a child presented with appendicitis. A 12-year-old girl presented to the emergency department with the chief complaint of pain in the right lower quadrant of abdomen. An abdominal contrast-enhanced CT scan revealed findings consistent with early acute appendicitis. She underwent laparoscopic appendectomy with a diagnosis of acute appendicitis. No tumorous lesion was detected macroscopically in the surgical specimen. The histopathological examination, however, showed tumorous cells spreading from the proper mucosal layer to the proper muscular layer at the base of the appendix, and the resection margin was positive for neoplasm. Immunohistochemical staining was positive for synaptophysin and chromogranin A, and the Ki67 index was less than 0.5% ; no mitotic figures were observed. We diagnosed the case as NET G1 of the appendix. Because of the positive surgical margin, we performed additional laparoscopic ileocecal resection with D3 lymphadenectomy 54 days after the appendectomy. Pathologically, tumorous cell metastasis was found in one of the dissected pericecal lymph nodes. The patient was followed up for 20 months with no recurrence.

We encountered a 44-year-old male patient who accidentally swallowed a dental instrument (Peeso Reamer) while undergoing dental treatment five days prior. He had no abdominal pain. Abdominal X-ray showed a 4 cm foreign body in the lower right abdomen. Plain abdominal computed tomography (CT) examination revealed a foreign body in the ascending colon. There were no perforations or abdominal abscess on abdominal CT. On X-ray, the foreign body appeared fixed in the right lower abdomen on hospital day 2. Therefore, we performed laparoscopic surgery using an X-ray imaging scope. We confirmed the presence of a foreign body in the ascending colon. We cut the ascending colon and removed the dental instrument laparoscopically. We then repaired the hole using a suture ligament and an auto-suture device. The patient's postoperative course was uneventful and he was discharged five days later.

A submucosal tumor of the ascending colon, approximately 4.0-cm in size, was discovered on colonoscopy of a 77-year-old woman. Histological examination of a biopsy specimen showed suspected mucosa-associated lymphoid tissue (MALT) lymphoma. Since there was no evidence of distant metastases on PET-CT, laparoscopy-assisted right colectomy was performed for diagnostic and therapeutic purposes. The histopathological findings of the removed tumor showed small and medium atypical lymphocytes with plasma cell differentiation and nuclear inclusions.

Immunohistochemically, the tumor cells were positive for CD79a, but negative for CD3, CD5, CD10, and cyclinD1. The tumor was diagnosed as a limited-stage MALT lymphoma of the ascending colon.

Since tumor metastasis was found in one of the near lymph nodes, Helicobacter pylori eradication therapy was performed in addition to the surgery. There was no sign of recurrence over 40 months of observation. Therefore, we consider that laparoscopy-assisted colectomy is both a radical and minimally invasive surgical method of treatment for colonic MALT lymphoma.

The patient was a 70-year-old male who underwent lower gastrointestinal endoscopy prior to surgery for gastric cancer. During the procedure, a tumor was incidentally found in the rectum and biopsied. The tumor appeared to be a mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) ; thus, we performed an endoscopic submucosal dissection. Pathological findings indicated that the tumor was positive for perpendicular stumps, with a depth of sm1,050 μm or more. The final diagnosis was MiNEN with a mixed adenocarcinoma and G2 neuroendocrine neoplasm (NEN). No residual tumors or lymph node metastases were found during a subsequent radical surgery. MiNEN-previously referred to as mixed adeno-neuroendocrine carcinoma (MANEC)-is associated with poor prognosis. The condition includes a mix of a high-grade neuroendocrine tumor (NET), equivalent to G3, and adenocarcinoma. In Japan in 2019, NET was renamed NEN and MANEC was renamed MiNEN. Here we report our experience of MiNEN mixed with low-grade (G2) NEN.

The case of a 66-year-old man in whom colonoscopy showed a 20-mm 0-IIa + IIc lesion on the left wall of the rectum (Rb) is presented. When observed under normal light, the folds were concentrated, and under narrow-band imaging (NBI), the surface structure disappeared, and the microvascular structure was irregular. Endoscopic ultrasonography showed massive infiltration of the three layers by tumor, which led to a diagnosis of deep submucosal (SM) invasion. Pelvic MRI showed swelling of a lymph node with a major axis of 10 mm in the left obturator area and a high signal intensity on diffusion-weighted imaging. A diagnosis of T1bN3M0 cStage IIIb was made, and a laparoscopic intersphincteric rectal resection, left lymph node dissection, and ileostomy were performed. The patient was discharged on the 16th postoperative day. Pathological results were pT1b (1750 μm), ly0, v0, sprouting (-), N3 [(# 251 (1/4), # 283 (2/4)], pStage IIIb. CapeOX therapy was started as adjuvant chemotherapy, and the patient continues to be followed.

The patient was a 72-year-old woman who had undergone direct acting antivirals (DAA) therapy for chronic hepatitis due to HCV in the Department of Gastroenterology in our hospital. After the DAA therapy, the patient acquired sustained virological response (SVR). Ten months later, a follow-up CT scan revealed a 35-mm liver tumor in the right liver lobe. CT and MRI findings showed the tumor to be hepatocellular carcinoma or cholangiocellular carcinoma. Two months later, the patient was referred to our department for surgery when the tumor rapidly enlarged to 65 mm in diameter. The patient underwent laparoscopic liver S5 and S6 subsegmentectomy. Resected specimen showed that the tumor was yellowish white and 70 mm in diameter. The patient was discharged on the 7^th postoperative day. Pathology showed diffuse growth of atypical round lymphocytes, and the tumor cells were CD3 negative and CD 20 positive. Finally diffuse large B-cell lymphoma was diagnosed. This case serves as an important reminder to consider malignant lymphoma in the investigation of all possible causes of a liver tumor after DAA treatment.

We have performed laparoscopic subtotal cholecystectomy for chronic cholecystitis with Corlette classification type II where a barbed suture (V-Loc^TM Covidien & Co.) was used to close the gallbladder head. After the barbed sutures, the patient had not experienced bile leak nor bile duct obstruction or stricture. In performing laparoscopic subtotal cholecystectomy for acute or chronic cholecystitis, the treatment of the gallbladder neck by sutures using a barbed suture appears to be an available technique according to conditions. It is advantageous that the technique has not a harmful effect caused by making ligation in the body cavity that is inevitable with conventional laparoscopic techniques, however, careful consideration would be necessary for the indication. Because the suture itself demands training and we cannot remake by using a barbed suture so that we have great difficulties in repairing if local injuries or erroneous manipulation against the surrounding bile duct or vascular vessels might occur. In addition, short-term problems might be absent, however, further accumulation of clinical cases and observation would be mandatory in terms of the long-term suitability.

We experienced a case of a 77-year-old man who suffered from gallbladder necrosis developed a month after the emergent surgery for acute Stanford type A aortic dissection. An abdominal CT scan showed pericholecystic fluid and unclear gallbladder wall, revealing acalculous necrotizing cholecystitis. We performed open cholecystectomy and abdominal cavity drainage. No gallstones were observed. Two days later, bile discharge was seen from the abdominal drain and an ENBD tube was placed. Cholangiography demonstrated bile leakage occurred from the intrapancreatic bile duct, and bile duct necrosis was diagnosed. The ENBD tube was replaced with an ERBD tube. On 8^th POD, the drain discharge got bloody and a dynamic CT scan revealed rupture of a pseudoaneurysm around the bile duct. TAE was performed in the PSPDA with coils. Bile discharge was persistent and finally, the drain tube could be removed 2 months after cholecystectomy. Further two months later, fever due to ERBD tube obstruction occurred and the ERBD tube was replaced. Bile duct stenosis was found around the embolization coils and cholangitis with bile duct stones occurred repeatedly. Eventually, choledochojejunostomy was performed. Although terminal organ ischemia occurs in about 30% of acute aortic dissection patients, gallbladder necrosis is very rare. In a review of the literature, all cases of acute gallbladder necrosis with or after acute aortic dissection were of Stanford type B.

Gallbladder torsion is a rare disease but requires emergent cholecystectomy. Radiologic findings of gallbladder torsion mimic those of acute cholecystitis, making a differential diagnosis between them very difficult. From 2012 to 2019, we have experienced four cases of gallbladder torsion in our hospital. Case 1 : An 88-year-old woman presenting with chest and back pain was diagnosed with gallbladder torsion and underwent laparoscopic cholecystectomy (LC) on the same day as she was first seen. Case 2 : A 90-year-old woman presenting with right lower quadrant pain of abdomen underwent LC with a diagnosis of gallbladder torsion on the same day. Case 3 : An 83-year-old woman presenting with abdominal pain underwent LC on the same day with a preoperative diagnosis of acute cholecystitis. Based on intraoperative findings, gallbladder torsion was diagnosed. Case 4 : A 47-year-old man presenting with epigastralgia underwent LC with the diagnosis of gallbladder torsion on the same day. A review of these four cases together with the previous 216 cases reported during recent 10 years (2010 - 2019) revealed that the rate of gallbladder torsion treated with LC was 57.7%. The preoperative diagnosis of gallbladder torsion was correctly made in 70%. CT scan possibly helps us make the correct preoperative diagnosis.

Eight years ago, we treated a 41-year-old male patient with pancreatic divisum using an endoscopic minor papillotomy. The patient developed severe pancreatitis in March 2018 and was hospitalized repeatedly between March and October of 2018. The pancreatitis caused biliary stenosis and an infected pseudocyst. He required multiple endoscopic therapies. Pancreatoduodenectomy was attempted for repeated episodes of severe pancreatitis caused by pancreatic divisum. After surgery, he patient developed mild acute pancreatitis which was treated with medical therapy. Pancreatoduodenectomy may the preferred therapy for patients who experience repeated bouts of pancreatitis with pancreatic divisum.

A 69-year-old man who had been treated for diabetes elsewhere was found to have dilatation of the bile ducts and was referred to our institute. He was diagnosed with distal cholangiocarcinoma (cT1aN0M0, Stage IA) and surgical treatment was planned. Preoperative CT imaging detected the type I portal annular pancreas (PAP), in which the main pancreatic duct (MPD) ran at dorsal side of the portal vein (PV) and the accessory PD ran at the ventral side of the PV. Pylorus-preserving pancreaticoduodenectomy was performed for the distal cholangiocarcinoma. During the operation, the pancreatic parenchyma on the ventral side of the PV was initially dissected in order to separate the pancreatic head from the PV. Then, the pancreatic bed was mobilized toward the tail side and pancreatic transection was finally performed at the pancreatic body to remove the aberrant parenchyma of the PAP and create a single pancreatic stump containing the MPD. The distal pancreas was reconstructed by pancreatojejunostomy applying a type of Blumgart method as a regular procedure in our institute. Intraoperative findings were identical to the type I PAP which had been detected by the preoperative CT imaging. Postoperatively, there were no complications including pancreatic fistula and the patient survived without recurrences and worsened control of the diabetes for 9 months after surgery.

A 72-year-old man was referred to our hospital because of impaired hepatic function. A contrast-enhanced CT scan revealed a 15 × 10 mm irregular-shaped avascular tumor with the dilated main pancreatic duct and common bile duct at the pancreatic head. It was diagnosed as pancreatic head cancer. Imaging evaluation performed preoperatively revealed that the common hepatic artery and the replaced right hepatic artery had branched from the superior mesenteric artery independently, and the common trunk of the first jejunal artery and the inferior pancreaticoduodenal artery had branched from the replaced right hepatic artery. We considered this malignancy to be pancratic head cancer associated with an aberrant hepatic artery. We treated the inferior pancreaticoduodenal artery which had branched from the replaced right hepatic artery and performed subtotal stomach-preserving pancreaticoduodenectomy without disturbing the hepatic arterial blood flow. A contrast-enhanced CT scan conducted 3 months after the operation revealed that the blood flow in the replaced right hepatic artery which was preserved had been kept intact.

We could perform pancreaticoduodenectomy for pancreatic head cancer associated with an aberrant hepatic artery safely and without disturbing the organ blood flow by understanding the branching pattern with a preoperative use of multi detector row CT (MDCT). The aberrant hepatic artery in this case is so rare that the international classifications including the Adachi's and the Michels's classification have never mentioned. We present this case together with a review of the literature.

A 79-year-old woman was admitted to our hospital because of anorexia and general fatigue. Enhanced abdominal computed tomography showed a 26-mm ill-defined splenic mass with heterogeneous contrasting effect. Positron emission tomography/ CT could not conclude that the tumor was malignant due to poor FDG uptake, so we observed the clinical course because the patient did not hope for an operation. After that, the tumor increased in size and FDG uptake in PET-CT also increased. We performed operation with a suspicion of a splenic malignant tumor. The tumor was solid and elastic-soft, and had no invasion into the surroundings. Splenic resection was thus performed. No neoplasms nor epithelial cells were observed pathologically, and the tumor contained mostly necrotic fibrous tissue with old hemorrhage. We diagnosed the tumor as chronic expanding hematoma (CEH) originating from the spleen. CEH is proposed to define the hematoma which increases chronically, and CEH of the spleen is very rare.

We present our experience with a case of multiple, giant incisional hernias in a patient. Repair necessitated use of an anterior and posterior component separation technique (CST) combined with mesh placement in the sublay space. The patient was a 45-year-old-female with a surgical history of Hartmann's operation for peritonitis. After closure of the colostomy, huge incisional hernias (20 × 15 cm and 10 × 8 cm in size) were recognized at the median incision and the stoma closure site. A computed tomography (CT) scan revealed prolapse of the small intestine and the urinary bladder. We performed a simultaneous hernia repair with hysterectomy for uterine myoma. First, the posterior rectus sheath was incised near the medial border, after separation of the rectus muscle. The transversus abdominis was released at the same line. Next, polypropylene mesh was placed and fixed within the layer above the posterior rectus sheath, following closure of the posterior rectus sheath. After division of the external oblique fascia lateral to the linea semilunaris, the plane between the external oblique and internal oblique muscles was developed. The patient did not experience any complications or recurrences during the six months after follow-up. The anterior and posterior CST, combined with reinforcement using sublay mesh placement, was a useful technique for reducing recurrence of multiple, giant incisional hernias.

A 53-year-old man who underwent renal transplantation for chronic renal failure at the age of 38 years was referred to our hospital complaining of a right inguinal bulge with pain of 10 months' duration. He was diagnosed as having a right inguinal hernia. Since abdominal CT showed the implanted ureter running dorsally close to the right inguinal canal, the Lichtenstein operation was performed. He was discharged from hospital on the 5^th day after surgery without any postoperative complications. The Lichtenstein operation is considered to be a suitable procedure to avoid inadvertent injury to the implanted ureter for a transplant-side inguinal hernia.

The patient was a 67-year-old male who presented with a 2-year history of a left inguinal bulge accompanied by intermittent pain. In addition to the left inguinal bulge, another bulge was noted in the left lower abdomen. Abdominal computed tomography revealed a left internal inguinal hernia and a dilated internal inguinal ring. The hernia sac protruded through the internal inguinal ring into the muscle layer on the cranial side. The hernia was classified as type IV interparietal hernia, as per Japanese Hernia Society classification guidelines. Laparoscopic hernia repair was selected as the surgical treatment. The hernia sac was removed, and transabdominal preperitoneal repair was performed in the usual manner. An interparietal hernia is a rare subtype of inguinal hernia ; however, in this case, laparoscopic surgery allowed for accurate assessment and treatment.