The increasing number of inguinal hernia patients on oral antithrombotic medications creates a challenging balance between bleeding risk during surgery and thromboembolism risk upon discontinuation. This study investigated the safety of the inguinal incision technique for inguinal hernia repair in patients continuing antithrombotic medications at our hospital. Between August 2015 and December 2021, we retrospectively analyzed data from 1,192 patients who underwent inguinal hernia surgery. We compared 225 patients who continued antithrombotic therapy (oral group) and 967 who did not (non-oral group). The oral group was significantly older and had a higher prevalence of ASA III classification. Compared to the non-oral group, the oral group had significantly longer operative times, increased blood loss, extended postoperative hospital stays, and a higher rate of postoperative hematoma. However, no significant difference was observed in the incidence of Clavien-Dindo Class III bleeding, indicating potentially manageable levels of postoperative bleeding. We believe that inguinal hernia repair by inguinal incision technique under continued antithrombotic medications can be performed safely without increasing complications such as postoperative bleeding that requires treatment.

The demand for fertility preservation among cancer patients has increased due to improved prognosis and delayed marriages. The number of breast cancer patients in their 30s is increasing. Of all cases, 80% undergo pre- or postoperative pharmacotherapy as standard treatment. However, chemical menopause represents a critical problem.

At our hospital, 3,445 breast cancer surgeries were performed over the past 33 years. In this study, we examined 14 of the aforementioned previous patients who were able to give birth after surgery. At the time of surgery, the mean age was 32.4 years and 10 patients were married. At the time of delivery, the mean age was 37.6 years. The average number of births was 1.29. In 2018, the average age of women at the time of birth of their first child in Japan was 30.9 years and the overall fertility rate was 1.30.

The age of the patients at the birth of their first child was 6.7 years greater than the national average, underpinning the various problems encountered in the course of breast cancer treatment and fertility preservation. This study aimed to report on the fertility-preserving treatment approach at our hospital.

We report a case of breast pseudoangiomatous stromal hyperplasia (PASH) with local recurrence. The patient was a 42-year-old woman. In 2022, she noticed a 50 mm mass in the A area of her right breast and sought medical attention at our hospital. A core needle biopsy (CNB) confirmed the diagnosis of PASH, after which she underwent a tumorectomy. The histopathological examination confirmed PASH, with positive surgical margins. After discussion with the patient, we opted for a follow-up approach. Six months post-surgery, ultrasonography revealed hypoechoic masses measuring 52 mm and 23 mm at the previous surgical site. CNB demonstrated the growth of vascular-like spaces lined with spindle cells in the fibrous stroma, with the spindle cells testing positive for CD34. Consequently, she received a diagnosis of PASH and underwent tumorectomy. Immunohistochemically, the stromal spindle cells were positive for CD34, α-SMA, and Bcl-2 and negative for ER, PgR, Desmin, D2-40, CD31, and Factor VIII. Approximately six months after the second surgery, there were no signs of recurrence. We present this case along with a literature review.

We report the case of a 77-year-old female patient whose main affliction upon presenting at our hospital was a tumor in the right breast. She was diagnosed with cT4bN0M0 Stage IIIB, triple-negative, cancer of the right breast. She was initiated on neoadjuvant therapy consisting of a pembrolizumab + paclitaxel + carboplatin regimen. During the 4^th cycle of treatment, the patient complained of fever, fatigue, and exertional dyspnea. After blood tests and a contrast-enhanced computed tomography scan, she was diagnosed with a pulmonary embolism, drug-induced lung injury, and pituitary inflammation, suggesting an immune-related adverse event (irAE) caused by pembrolizumab. After the administration of an anticoagulant and a steroid pulse, the symptoms improved. The patient was discharged on the 17^th day of hospitalization. The neoadjuvant therapy was discontinued, and two months after the onset of the irAE, a right breast total mastectomy and sentinel lymph node biopsy were performed. Pathological examination revealed no viable tumor cells.

Because pembrolizumab combination therapy is the standard care for triple negative breast cancer, irAEs should be considered. In this case, the neoadjuvant therapy was discontinued due to irAE, but pCR was nonetheless achieved. The treatment strategy should be determined based on the severity of the irAE and the therapeutic effect of the adjuvant therapy.

We report a rare case of obstructive jaundice due to solitary para-aortic lymph node metastasis after breast cancer surgery. The patient was a 45-year-old woman. She was diagnosed with left breast cancer cT1N1M0 cStage IIA triple negative type and was treated with neoadjuvant chemotherapy. She underwent left breast partial mastectomy and axillary lymph node dissection, and achieved a pathologic complete response (pCR). Fourteen months after the surgery, the patient presented to our hospital with fatigue. Blood biochemistry tests showed elevated levels of hepatobiliary enzymes, and a CT scan of the abdomen showed soft shadows from the hilar region to the para-aortic region, which led us to suspect pancreatic cancer. However, endoscopic ultrasonography revealed no obvious tumor in the pancreas, which was thought to be enlarged para-aortic lymph nodes. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of the same site revealed that the primary site was difficult to identify because the results were consistent with both mammary and pancreatic sites. However, we considered it to be a primary mammary gland tumor based on comprehensive consideration of the patient's medical history, imaging studies, and histopathological examinations. Weekly paclitaxel + bevacizmab (wPTX + Bev) therapy was effective, and she is currently maintaining a complete clinical response (cCR).

The patient was a 76-year-old man. He underwent right upper lobectomy 13 years and segmentectomy of the left upper major division 5 years previously for lung adenocarcinoma and was taking methotrexate (MTX) and anticoagulants for rheumatoid arthritis and deep vein thrombosis. He had been followed up for lung masses that were enlarging and shrinking for 4 months after lung surgery and was referred to our department due to wobbliness and hypercoagulability. Blood tests showed high Ca level and marked prolongation of coagulability, and a computed tomography (CT) showed enlarged lung masses and multiple liver masses, which led us to suspect recurrence. After emergency hospitalization and improvement of coagulability, a biopsy was performed by upper esophagogastroduodenoscopy on a depressed lesion in the duodenum, and a pulmonary needle biopsy was also performed on the lung lesion. Immunostaining of the pathology showed strong positivity in diffusely proliferated lymphocytes for both LCA and L26 in the lung and duodenum biopsy specimens, and high levels of soluble IL-2 receptors in the blood, leading to the diagnosis of diffuse large B-cell lymphoma (DLBCL), which developed in an iatrogenic immunodeficient state while taking MTX for a long time. Immunodeficiency-associated lymphoproliferative disease should also be differentiated in RA patients receiving MTX, when multiple lung masses appear, suggesting recurrence after lung cancer surgery.

A 53-year-old woman was referred to our department with a mediastinal tumor measuring 70×50 mm incidentally identified on a chest computed tomography. The mass primarily consisted of fluid and contrast enhancement was observed in part of its wall, which was consistent with a thymoma or a teratoma. We planned to resect it. A tense cystic mass was arising from the right lobe of the thymus. Only a small portion of the adhered right mediastinal pleura was concomitantly resected, resulting in complete tumor resection. On incision of the capsule, dark brown components were discharged, and necrotic tissue was deposited at the bottom. Pathological examination revealed that the cyst contents consisted mainly of necrotic tissue. In solid white areas in the cyst wall, we identified AE1/AE3-positive epithelial components and terminal deoxynucleotidyl transferase-positive lymphocytes. Therefore, it was diagnosed as Type AB (WHO classification), T1N0M0-Stage I (UICC-TNM classification), and Stage I (Masaoka classification) thymoma. Thymomas present with various pathologic pictures such as cystic changes and necrosis. We report a relatively rare case of asymptomatic cystic thymoma even with extensive necrosis.

A 77-year-old man with a history of neurofibromatosis type 1 underwent resection of a tumor on the posterior part of his right ear at another hospital three years earlier, which was diagnosed as a malignant peripheral nerve sheath tumor (MPNST). This time, he presented to our hospital complaining of lower back pain. Computed tomography (CT) showed not only vertebral destruction caused by a paraspinal tumor, but also intestinal obstruction due to a small bowel tumor. After intestinal decompression using an ileus tube, laparoscopic partial small bowel resection was performed. On pathological examination, proliferation of spindle cells without structural differentiation was seen, and MPNST of the small intestine was diagnosed based on the pathological findings combined with the results of immunostaining. Since his postoperative course was good, he was transferred to the orthopedics department on the 15th day after surgery. However, he refused treatment for the spinal tumor and died four months after surgery in a recuperation hospital. MPNSTs most commonly occur in the trunk and extremities, and those occurring in the digestive tract are extremely rare. A rare MPNST of the small intestine associated with neurofibromatosis type 1 is reported along with a review of the literature.

A case of abscess-forming appendicitis caused by a fish bone that was treated with interval appendectomy (IA) is presented. The patient, an 80-year-old man, was referred to our hospital with suspected acute appendicitis due to abdominal pain, which had lasted for 2 days, and difficulty swallowing. The right lower abdomen was tender, abdominal computed tomography (CT) showed linear radiopaque images within the abscess, and a diagnosis of abscess-forming appendicitis due to a fishbone was made. The patient was treated conservatively with antibiotics, and laparoscopic IA was performed approximately 6 months later. The appendix was not enlarged, and the tip was only mildly adherent to the retroperitoneum. The patient had an uncomplicated postoperative course and was discharged three days after surgery. Two needle-like substances inside the appendix, which were thought to be fish bones, and an ulcerated scar at the tip of the appendix were discovered. Since there are reports that acute appendicitis due to a fishbone is associated with a high risk of perforation, prompt appendectomy has been considered necessary in cases with no perforation or abscess at the time of diagnosis. However, IA could be a possible treatment strategy in cases where abscess formation is already present.

A 38-year-old woman presented at a local clinic with a five-day history of lower abdominal pain. There was a slightly tender, palpable, 5-cm mass in the right lower quadrant. Blood tests showed mild elevation of the inflammatory response, and contrast-enhanced abdominal computed tomography showed that the appendix was enlarged, with an internally homogenous hypodense region suggestive of an abscess. Perforated appendicitis was suspected, and antibiotic treatment was initiated, but the differential diagnosis also included other conditions such as appendiceal mucocele. After the patient was transferred to our hospital, surgical resection was performed for diagnostic and therapeutic purposes. Intraoperatively, the tip of the appendix was covered by the greater omentum, but there was no sign of abscess formation, and only the appendiceal root was enlarged. Laparoscopic appendectomy was completed. There were no postoperative complications, and the patient was discharged improved on postoperative day 5. The resected specimen contained a pale yellowish area of appendiceal mucosa and surrounding fat, and pathological examination showed invasion by a large number of foamy histiocytes, leading to a diagnosis of xanthogranulomatous appendicitis, a rare disease. In most cases, a malignant tumor is suspected preoperatively, and extended surgery is performed. This case is reported along with a discussion of the literature.

We here in report a rare case of a patient with left spermatic cord metastasis from rectal cancer. A 75-year-old man had Robot-assisted low anterior resection (Robot-LAR) for rectal cancer (pT4aN0M0 pStage IIb) and received adjuvant chemotherapy when he was 73 years old. Nine months after the operation, the patient underwent a laparoscopic inguinal hernia repair for a left external inguinal hernia, and 22 months after the operation did laparoscopic partial hepatic resection of S4 for a liver metastasis. Twenty-seven months after the operation, his CT and PET/CT scans showed an enhanced tumor in the left inguinal region. He was diagnosed with spermatic cord metastasis of rectal cancer and received left orchiectomy. Histopathology showed adenocarcinoma compatible with metastasis from the rectal cancer. Due to the rarity of spermatic cord metastasis from gastrointestinal cancer, especially from rectal cancer, we here present the case.

A 66-year-old man was admitted to our hospital for treatment of cholelithiasis. He had been diagnosed with complete situs inversus in childhood. Abdominal ultrasound and contrast-enhanced computed tomography (CT) showed an atrophied gallbladder, gallstones, and complete situs inversus. Laparoscopic cholecystectomy was performed double-handed using four trocars. The operator stood on the right side of the patient, and the trocars were inserted symmetrically as for conventional laparoscopic cholecystectomy. However, the operator's right-hand trocar position was shifted approximately 7 cm to the foot side to maintain the distance from the gallbladder. Thus, all operative procedures, including dissection at Calot's triangle, could be easily performed with the right hand. The operation lasted 44 minutes without complications, and the patient was discharged on postoperative day 4. This case demonstrated that our modified trocar position can be useful in laparoscopic cholecystectomy with complete situs inversus.

Undifferentiated pleomorphic sarcoma (UPS) is a highly aggressive malignancy, and intra-abdominal rupture of UPS is extremely rare. We report an adult patient with ruptured UPS who survived more than five years after repeated resections. A 42-year-old man was brought to the emergency department because of a one-month history of abdominal bloating followed by abdominal pain. Contrast CT revealed a huge mass on the right side of the abdomen, and MRI findings suggested intra-tumoral hemorrhage. Because progressive anemia was also observed, resection of the tumor was performed urgently. The patient was then temporarily discharged. Pathological examination diagnosed the patient with UPS. Four months later, an outpatient examination revealed a recurrence of UPS, and resection of the recurrent tumor was performed. UPS subsequently recurred twice, and each time resection was performed. Five years after the initial surgery, the patient is currently alive. Intra-abdominal rupture of UPS is uncommon and can cause early recurrence, but multiple resections and intensive follow-up can contribute to long-term survival.

A 72-year-old woman attended the emergency department for left lower abdominal and left buttock pain. Computed tomography (CT) revealed the small bowel protruding from the pelvis through the left greater sciatic foramen, and a left sciatic hernia was diagnosed. There was no evidence of incarceration, and her blood tests were unremarkable. After examination, the pain resolved spontaneously, but as there was a possibility that the incarceration would recur in the future, laparoscopic surgery was scheduled. An approximately 3 cm hernia orifice in the left greater sciatic foramen was observed laparoscopically in the pelvic cavity. In addition to the left sciatic hernia, bilateral femoral and obturator hernias were observed, thus we decided to repair all of them. The peritoneum was incised and dissected, and the left sciatic hernia was repaired by filling the hernia hole with a plug. The femoral and obturated hernias were repaired by covering them with mesh sheets. The patient had a good postoperative course and was discharged on the 7^th day after surgery. To date, there have been no recurrences of any hernias. The laparoscopic approach was considered useful in the repair of sciatic hernias.