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In this retrospective, non-randomized study, we compared the quality of life (QOL) of patients who underwent laparoscopic ventral and incisional hernia repair (LVIHR) with fascial defect closure or non-defect closure and examined the factors associated with the QOL after LVIHR. Between February 2013 and 2016, we conducted a single-center, follow-up study of 33 consecutive midline hernia patients who underwent LVIHR. Overall, 14 cases underwent intraperitoneal onlay mesh repair (IPOM), and 19 underwent IPOM with fascial defect closure (IPOM-plus). Patients were interviewed using the 36-item Short Form Health Survey (SF-36) to assess their pre- and postoperative QOL (at 1, 3, 6, and 12 months after surgery). The QOL, as assessed by the SF-36, was compared before and at 1 year after surgery, and the risk factors associated with the QOL were examined. Overall, scores for 5 of the 8 domains and 1 of the 3 components of SF-36 had improved by 1 year after surgery compared with before surgery. The scores for the SF-36 domains and components at 1 year post-surgery were comparable in patients undergoing IPOM or IPOM-plus. Obesity, operative time, hernia size, and mesh size were factors correlated with the QOL. LVIHR improved the QOL, regardless of defect closure.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is an extremely rare benign lesion. We herein report a case of asymptomatic SANT of the spleen in a middle-aged woman with early breast carcinoma and an undiagnosed splenic mass, which was successfully treated by laparoscopic splenectomy and diagnosed postoperatively. We also review the literature on SANT to help make knowledge more accessible when clinicians encounter a splenic tumor. The present case taught us the following lesson: the presence of a splenic lesion during follow-up for malignancy is not always indicative of metastasis. Therefore, SANT should be considered in the differential diagnosis.

Background Angiomyolipoma is a benign mesenchymal tumor that develops commonly in the kidney and rarely in other organs. The involvement of the spleen in angiomyolipoma is extremely rare, and only one such case has been reported in the English literature. Case presentation A 27-year-old man presented with adenoid hyperplasia and bilateral palatal tonsillar hyperplasia. During the treatment for adenoid hyperplasia, a 15-cm tumor was detected in the spleen using abdominal ultrasonography and enhanced computed tomography. Partial resection of the spleen was successfully performed. A giant tumor of approximately 13 cm with a smooth surface was observed in the upper left quadrant of the abdomen. The tumor was confirmed to be continuous with the upper spleen, and there was no invasion of the other organs. The postoperative course was good, and the patient was discharged on the 7th postoperative day. The excised specimen was a smooth, extremely soft tumor measuring 123 × 120 × 82 mm. The cleaved surface of the tumor was reddish brown, and a distressing yellow color was observed. Pathological examination revealed a proliferation of mature adipocytes and an increase in the number of blood vessels of various sizes. Furthermore, spindle-shaped cell proliferation foci were visible between the adipocytes and the surrounding blood vessels. Profuse leakage of erythrocytes from the blood vessels, hemosiderin deposition, and small round cell infiltration were also noted. Immunostaining disclosed that the spindle-shaped cells were weakly positive for smooth muscle antibody and were identified as smooth muscle cells. The adipocytes and spindle cells were negative for HMB 45, Melan A, MDM, and CDK4. However, some parts of the cells were positive for estrogen and progesterone receptors. Besides, vascular endothelial cells were positive for CD31 and CD34 and negative for CD8. Based on these findings, the patient was diagnosed to have primary angiomyolipoma of the spleen. Conclusions We have reported the surgical treatment for an extremely rare case of giant splenic angiomyolipoma in a young man. Globally, this is the second report on this condition. We believe that partial splenic resection is a feasible option for the management of giant tumors.

Background. Terminal ileum diverticulitis is a rare clinical disease. It can frequently mimic other processes, such as acute appendicitis. Diagnosis and therapeutic decision making (surgical or conservative treatment) can be complex. We report four interesting cases of terminal ileum diverticulitis. Case Presentation. Case 1: a 55-year-old male presented to us with a 3-day history of severe right lower quadrant pain. Computed tomography (CT) showed penetration of terminal ileum diverticulitis. Following a 7-day conservative treatment, he underwent ileocecal resection. Pathology results revealed a false diverticulum and two in five points of perforated terminal ileum diverticulum. Case 2: a 77-year-old male presented to us with severe right lower quadrant pain and unconsciousness. CT showed penetration of terminal ileum diverticulitis and air in the mesentery. Ileocecal resection was performed 2 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 3: a 61-year-old male presented to us with a right lower quadrant pain for 10 days and fever for 6 days. CT showed penetration of terminal ileum diverticulitis and abscess of the psoas muscle. Puncture and drainage of abscess were performed. Laparoscopic ileocecal resection was performed 30 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 4: a 39-year-old female presented to us with right lower quadrant pain for 9 days, suspicious of appendicitis. CT showed abscess of pericecal area. Puncture and drainage were performed. A drainage tube was located into the cecum through the terminal ileum. Conservative therapy was effective, and she was discharged 23 days postadmission. Conclusions. All four cases had right lower quadrant pain. Three cases were diagnosed by CT, whereas one was diagnosed by abscess drainage. Two cases required surgical treatment within 3 days, one within about 1 month, and one case did not require surgery. The decision of whether to manage a patient surgically or conservatively is difficult. It is critical not to delay the decision of performing a surgical treatment until each patient reaches a stable general condition.

Purpose: Peripherally inserted central venous catheters are some of the most useful devices for vascular access used globally. Peripherally inserted central venous catheters have a low rate of fatal mechanical complications when compared to non-tunnel central venous catheters. However, as peripherally inserted central venous catheter access requires a smaller vein, there is a high risk of thrombosis. The axillary vein (confluence of the basilic and brachial veins) can serve as an access for cannulation. Moreover, as this vein is larger than the basilic or brachial vein, it might be a superior option for preventing thrombosis. The risk of catheter-related bloodstream infection should be considered when the puncture site is at the axillary fossa. The aim of this study was to present our new protocol involving peripherally inserted central venous catheters (non-tunneled/tunneled) and a tunneling technique and assess its feasibility and safety for improving cannulation and preventing thrombosis and infection. Methods: The study included 20 patients. The axillary vein in the upper arm was used for peripherally inserted central venous catheters in patients with a small-diameter basilic vein (Results: The observed catheter duration was 645 days (median ± standard deviation, 26 ± 22.22 days). Catheterization was successful in all cases, however, two accidental dislodgements were identified. No fatal or serious complications were observed after catheterization. Conclusion: Our new protocol for axillary peripherally inserted central venous catheters/tunneled axillary peripherally inserted central venous catheters use for a small-diameter basilic vein is safe and feasible.

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouviere's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Background Generally, surgeons’ perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. Methods A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200–499, 500–999, and ≥1000). Results The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the “critical view of safety” technique, identification of Rouviere's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Conclusions Even among experts, surgeons’ perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence. This article is protected by copyright. All rights reserved.

BACKGROUND: Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce.METHODS: Surgeons from Japan, Korea, Taiwan, and the U.S., etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5.RESULTS: Response rates for the first- and the second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: 1) Effective retraction of the gallbladder, 2) Always obtaining critical view of safety, and 3) Avoiding excessive use of electrocautery/clipping as vital procedures; and 4) Calot's triangle area and 5) Critical view of safety as important landmarks. For 6) Impacted gallstone and 7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated.CONCLUSIONS: A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI. This article is protected by copyright. All rights reserved.

Background. Primary omental leiomyosarcoma is an extremely rare type of tumor. Leiomyosarcomas originating from the lesser omentum have not been reported since immunohistochemical staining for c-kit has been used for the diagnosis of mesenchymal abdominal tumors. They are yet to be reported since gastrointestinal stromal tumors were categorized. Here we reported a case of successful resection of a lesser omental leiomyosarcoma. Case Presentation. A 71-year-old man underwent ultrasonography at the outpatient clinic through which an upper abdominal tumor was identified. Following computed tomography and endoscopy, a 4.5 cm submucosal tumor in the lesser curvature of the stomach was highly suspected. A laparoscopic partial resection of the stomach was performed. Histopathological examination revealed the tumor to be a leiomyosarcoma arising from the lesser omentum that did not invade the stomach. Immunohistochemical staining showed that the tumor was negative for CD34, c-kit, and S-100 and positive for desmin and α-smooth muscle actin. No recurrence had been observed 1 year after surgery without adjuvant chemotherapy. Conclusions. Primary lesser omental leiomyosarcoma, which is difficult to diagnose before surgery given the location of the primary tumor in the lesser omentum, has rarely been reported. Considering the high possibility of malignancy, close observation is essential.

Background: Totally implantable venous access devices are valuable tools for total parenteral nutrition, chemotherapy, and long-term intravenous therapy. However, late catheter fracture is a well-known complication of totally implantable venous access device, particularly in Groshong silicone catheter. Recently, a specific type of totally implantable venous access device made with Groshong silicone has been introduced to facilitate power injection of contrast medium for enhanced computed tomography. Cases description: We reported three cases of catheter fracture in power-injectable Groshong silicone totally implantable venous access device. From May 2012 to August 2014, 66 patients underwent power-injectable Groshong silicone totally implantable venous access device implantation at our institution, with a median follow-up of 20.1 (range 0.2–58.1) months. The catheters in all patients were inserted into the internal jugular vein under ultrasound guidance and were connected to the port implanted in the upper chest through the subcutaneous tunnel. Chemotherapy was administered using these routes. Fractures of all three cases specifically showed a torn catheter section: smooth surface on one side, and a rough edge on the other side of the catheter, suggesting that long-term repeated stretch force may be related with the mechanism of fracture. Conclusion: Totally implantable venous access devices with Groshong silicone catheters, if inserted via the internal jugular vein, have a potential risk for late catheter fracture.

Background/Purpose Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. Methods A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. Results The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. Conclusions Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Background We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. Methods Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0–6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level. Results Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. ‘Diffuse scarring in the Calot's triangle area’ in the ‘Factors related to inflammation of the gallbladder’ category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. Conclusions A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

Here, we describe a case of a retroperitoneal liposarcoma successfully managed by laparoscopic surgery. A 72-year-old man underwent abnormal hypertension screening using computed tomography (CT), which revealed a low-density mass measuring 7 cm in diameter in the retroperitoneal space. We diagnosed the mass as a liposarcoma before the operation. The mass was resected laparoscopically. No perioperative complications were encountered, and the patient was discharged on the fourth postoperative day. The pathologic diagnosis was well-differentiated liposarcoma, indicating complete surgical resection. Thus, we conclude that a laparoscopic approach for the patients with retroperitoneal tumors, including liposarcomas, is safe, feasible, and minimally invasive, even if there is a possibility of the tumor being malignant.

消化管ストーマ造設の標準化を進める上で，適切な分類法に基づいたストーマ合併症の評価が重要である．発症時期別分類としては早期と晩期に分けるのが一般的であるが，早期の定義に関して，過去の報告はストーマ造設術後30日（1カ月）以内とするものと術直後の入院期間中とするものに大別される．術後の入院期間が短縮しつつある昨今，退院直後にストーマ合併症が問題となる症例もみられるので，入院中に限らず術後30日以内を早期と定義するのが良いと考えられる．またストーマ合併症には処置不要なものから緊急手術を要するものまで様々な重症度があるが，重症度別の検討を行った論文は少ない．重症度分類としては有害事象共通用語基準（CTCAE）のストーマ合併症に関するGrade分類が利用可能と考えられるが，用語がストーマケアの現場で使いにくいという問題がある．そこで本稿では用語の修正と追加を行い，ストーマ合併症の重症度分類案として使用可能か検討を行った．

腹腔鏡下鼠径ヘルニア修復術の経腹腔的アプローチ（TAPP）は，前方アプローチのメッシュ手術より利点が多い．しかし，新たな手技習得が必要でラーニングカーブが長いため本邦では必ずしも普及していない．筆者らは，TAPPの手技的難点を軽減する目的に，経皮的に鼠径部腹膜前腔にロピバカインとエピネフリンの膨潤麻酔剤希釈液約150ml注入することを先行する膨潤TAPPを考案し22例を経験した．対象は，男21例，女性1例で平均年齢は58.2歳，24病変，間接ヘルニア19病変，直接ヘルニア5病変であった．手技的に，従来TAPPと比べて，腹膜前腔の膨化によって層確認が容易となり剥離しやすく，出血も少なく，比較的確実な手術が可能となった．合併症は，血腫，水腫各1例でいずれも軽微で，術後疼痛も少ないと考えられた．今後，さらなる症例集積と従来TAPPとの比較試験による検証が必要であるが，膨潤TAPPは従来TAPPを手技的，臨床的に改善すると推察された．

MRIにて術前診断しえた右大腿ヘルニア内虫垂嵌頓の1例を経験したので報告する．症例は83歳女性で，右鼠径部膨隆を主訴に来院した．右鼠径靱帯尾側に弾性軟の腫瘤を触知した．血液検査ではCRP 0.38mg/dl以外異常所見はなかった．MRIにて大腿ヘルニア内虫垂嵌頓と診断され，緊急手術を施行した．術中所見では右大腿ヘルニア内に虫垂が嵌頓し，その先端部は暗赤色に陥っていた．同一創より虫垂切除術，大腿ヘルニア修復術（McVay法）を施行した．術後経過良好にて10病日に退院した．今回，自験例を含めた本邦報告18例に文献的考察を加えて報告する．

A 75-year old woman was admitted to our hospital with right upper quadrant pain, vomiting, and jaundice. Laboratory findings showed elevated total bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, and C-reactive protein levels. Abdominal ultrasonography (US) and drip infusion cholangiographic computed tomography (DIC-CT) showed not only cholecystocholedocholithiasis, but a gallbladder located left of the round ligament and close to the lateral segments of the liver. We performed laparoscopic cholecystectomy (LC) with choledocholithotomy for suspected cholecystocholedocholithiasis with a left-sided gallbladder. Routine ports were inserted in the American configuration for LC. The gallbladder was normogradely separated from the gallbladder fossa, and the fundus of the gallbladder was lifted ventrally and toward to the patient's right shoulder. These procedures provided the usual view for laparoscopic choledochotomy. The patient recovered uneventfully and was discharged on postoperative day 10. To our knowledge, this is the first report of laparoscopic common bile exploration in a patient with a left-sided gallbladder.

The splenic flexure (SF) anatomy is complex due to multiple vessels, surrounding organs, layers, and irregular adhesions [1–3]. Our laparoscopic approach involves a lateral-to-medial approach to the left-sided transverse mesocolon (TM), a medial-to-lateral approach to the left mesocolon (LM), and take-down of the remnant SF. First, the omental bursa is opened and its posterior wall and the anterior layer of the TM are dissected along the pancreas, where a gauze is placed. The TM is spread cephalad. A window in the TM is opened in the gauze seen through the TM. If necessary, the middle colic vessels are divided with lymph node (LN) dissection. Then the left colic artery is divided with LN dissection using a medial approach. The LM is widely dissected from the retroperitoneum to reach the TM window. While observing the pancreas through the window, the LM and TM are divided from the pancreas close to the SF. The descending colon is mobilized from its lateral attachment. Finally, the SF is taken down from the spleen by separating remnant structures, including adhesions. Subsequently, functional end-to-end anastomosis was performed extracorporeally. During March 2012–December 2016, 39 patients with left-sided transverse or descending colon cancer underwent this treatment. The mean operative time, blood loss, number of harvested LNs, and hospital stay duration were 283 min, 45 ml, 15, and 9 days, respectively. No patient needed conversion to open surgery or had organ injury, anastomotic leakage, or Clavien–Dindo III–V complications. There were 7/13/18/1 patients with Stage I/II/III/IV colon cancer, respectively. Nineteen cases had positive LNs. All patients were alive with one local and two distant recurrences at a mean 24-month follow-up. This is a safe and effective surgical strategy for treating colon cancer of the SF, strategically designed to resect the SF after dissecting the surrounding structures.

Although surgery is commonly used to treat parastomal hernia, it is very difficult and has shown poor results. Recently, repair with prosthetic materials has been thought to be a more promising method.The Sugarbaker technique with e-PTFE mesh (DualmeshThe median operative time was 211 min (range 147-256). The median hernia size was 28 cmThe surgical results were satisfactory with minimal morbidity and no recurrences. The Sugarbaker technique for parastomal repair using e-PTFE mesh may be suitable as a standard method for treating parastomal hernia.

We describe the case of a patient with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was successfully treated by laparoscopic surgery. A 62-year-old man with a long history of hepatitis C-induced liver cirrhosis was admitted to our institution because of recurrent postprandial periumbilical pain. Eight years earlier, he had undergone radiofrequency ablation for hepatocellular carcinoma at hepatic segment VIII. Computed tomography, gastrografin enema examination revealed transverse colon obstruction because of a diaphragmatic hernia. We diagnosed diaphragmatic hernia associated with the prior radiofrequency ablation treatment. The patient underwent laparoscopic repair of the diaphragmatic hernia. Though the patient experienced the recurrence once, relaparoscopic treatment has improved the patient's conditions. Thus, diaphragmatic hernia can develop as a complication of radiofrequency ablation treatment. A laparoscopic approach is safe, feasible, and minimally invasive, even in patients with cirrhosis who develop iatrogenic diaphragmatic hernia as a complication of radiofrequency ablation treatment.

今回われわれは比較的稀とされている骨盤腔の後腹膜に原発した血管内皮腫を経験したので報告する. 症例は34歳女性で,子宮癌検診時に子宮筋腫と骨盤腔の後腹膜に腫瘤を指摘されたが無症状のため経過観察されていた.3年後に腹痛を訴えて来院.骨盤腔の後腹膜腫瘤の増大が認められ精査加療のため入院した.画像診断上腫瘤は左内外腸骨動脈分岐部付近に発生した血流豊富な充実性腫瘍であった.全身麻酔下に腫瘤を摘出した.腫瘍は軟かく,軽い圧迫で縮小し,血管腫を思わせた.術中迅速組織診では血管腫であったが,ホルマリン固定後の標本の検索では第VIII因子関連抗原, CD-34, Ki-67陽性であったことより低悪性度の血管内皮腫と診断された.

我々の経験した9例の胃粘膜下腫瘍に対する腹腔鏡下手術について, その手技と手術成績を検討したので報告する.9例の内訳は男性4例, 女性5例, 年齢は46歳から79歳であった.発育形式は胃内型6例, 胃外型2例, 胃内外型1例で, 腫瘍径は22～40mmであった.7例に腹腔鏡下胃局所切除, 2例に胃内手術を施行した.平均手術時間は103分, 平均術後在院期間は10日であった.合併症は認めなかった.組織診断は胃平滑筋肉腫が8例, 神経鞘腫が1例であった.一般に悪性の胃粘膜下腫瘍は平滑筋肉腫がほとんどで, そのリンパ節転移はまれである.したがって, 胃局所切除は胃粘膜下腫瘍に対する十分な術式と考えられる.胃粘膜下腫瘍に対する腹腔鏡下胃手術は, 低侵襲性, 美容的外観など利点が多く得られる.腫瘍径, 局在, 発育形式によって胃局所切除あるいは胃内手術を選択し, 積極的に適応すべき手技と考えられた.

The objective of this study was to clarify the etiology of acute cholecystitis and the role of bacteria in the bile in this condition. We evaluated 52 patients with acute cholecystitis; 46 had cholesterol stones and 6 had no claculi. In the presence of cystic duct obstruction, circulatory disturbance occurs gradually, but circulatory disturbance alone cannot cause severe inflammation unless a bacterial infection is present. If there is no obstruction, rapid circulatory disturbance produces necrotic changes of the gallbladder wall, which are implicated in a fulminant course. In both instances, bacterial infection may play an important role in fulminant cholecystitis. Bacteria implicated in acute cholecystitis are usually present in the bile before the onset of this disease.

症例は75歳の女性. 腹部手術の既往はない-腹痛と嘔吐が突然出現し, 腸閉塞の診断で近医入院. 保存的治療後, 当院に転院した. イレウスチューブにより症状改善したため経口摂取開始したが, 右股関節痛そして発熱, 右大腿の発赤腫脹が出現. 皮下膿瘍をみたため, 右大腿部の切開排膿を行った. しかし, 切開口より便臭を伴う膿の排出が続き, 周辺は皮膚から筋膜まで壊死に陥った. 瘻孔造影にて小腸内腔に造影剤の流入が認められた. 右大腿ヘルニアの小腸嵌頓による腸閉塞および小腸壊死による大腿管からの小腸瘻と診断し, 手術を施行した. 回腸壁の一部が, 大腿管に嵌頓し, 穿孔を起こしており, 回腸部分切除術を行った. 右大腿部は壊死性筋膜炎の状態でデブリードマンを行った. 以上, 大腿ヘルニアのRichterヘルニアは局所所見が乏しいため診断が遅れやすく, 腹部手術既往のない腸閉塞には考慮すべき疾患と考えられた.

We describe a patient with liver scarring associated with congenital absence of the right lobe of the liver. Computed tomography demonstrated a low density zone at the periphery of the liver that appeared hyperintense on T2-weighted MRI and markedly enhanced on contrast-enhanced T1-weighted imaging. Computed tomography during both arteriography and arterial portography demonstrated a differential blood supply to the low density zone, suggesting the diagnosis of liver scarring. Histological examination of a biopsy from this region disclosed periportal fibrosis and sinusoidal dilatation, confirming the diagnosis of liver scarring.

症例は18歳の男性. 大腸クローン病で上行結腸に高度の狭窄を来したため, 腹腔鏡下右半結腸切除術を施行した. 手術はすべて体内操作で行い, 回腸横行結腸吻合は自動吻合器を用い, 側側吻合いわゆるfunctional end to end ananstomosisを施行した. 摘出標本では, 上行結腸に広範に敷石状外観と縦走潰瘍がみられたが, 両側断端には病変の遺残はなかった. 術後経過は良好で, 早期に排ガス, 排便や完全な歩行が得られ, 開腹例に比べ回復が早いと思われた. 術後透視で吻合口は大きく保たれ, 9か月続過した現在, 再発の徴なく健常である. 以上から, 早期回復や腹腔内癒着の軽減が期待される腹腔鏡下腸手術は, その手技に熟練すれば, クローン病などの炎症性腸疾患にも, 積極的に施行されるべきと考えられた. しかし, 腹腔鏡下右半結腸切除術は手技が煩雑で簡単でなく, トロッカーの位置を含め手技の定型化や簡便化が今後の問題と思われた.

近位側胃切除後の逆流性食道炎を防止するため, 逆流防止弁形成食道胃吻合術を考案し, 施行後長期経過例における遠隔成績を中心に検討した.対象とした34例を3年以上を経過したA群 (16例), 経過3年未満のB群 (18例) の2群に分けて検討した.長期経過後強い胸やけを訴えていたのは2例のみで, ともに3年未満経過のB群の症例であった.3年以上経過した症例では愁訴は軽度であった.体重の回復, 食事回数などでは経過年数の長いA群で良好であった.内視鏡所見から食道炎と思われた症例は2例であったが, これらではいずれも防止弁が吻合口から離れて位置していた.胃透視上防止弁の大きさを測定すると, 3～4年でも術直後の80～85%程度であり, 長期間を経過しても弁の萎縮は起こらず, 有効に機能しているものと思われた.本術式は, 逆流性食道炎という近位側胃切除術のもっとも困難な合併症を防止する簡便かつ有用な術式と考えられた.

総胆管コレステローシスの2例を経験した.症例1は53歳の男性で, 内視鏡的逆行性胆道膵管造影で胆嚢結石と総胆管末端部付近の小陰影欠損像がみられ総胆管径は10mmであった.術中胆道鏡で多数の黄白色, 小球形の病変が乳頭部直上粘膜に付着していた.胆嚢には純コレステロール結石1個とコレステローシスが存在した.症例2は73歳の女性で胆嚢結石の診断で手術を行ったがウルソの4か月間の内服で結石は溶解消失していた.胆嚢にびまん性のコレステローシスがみられた.総胆管は径17mmと拡張あり胆道鏡で乳頭部直上に症例1と同様の病変がみられた.組織学的に粘膜上皮下にfoamcellの集族が認められた.2例とも総胆管コレステローシスに対し胆管匙で摘除するにとどめT字管ドレナージを行った.文献的に本症は胆嚢にコレステロール石やコレステローシスを随伴することが多く, その好発部位も乳頭部直上であった.

This report demonstrates a case of undifferentiated carcinoma of the duodenal ampulla. A 74-year male experienced jaundice lasting for 3 weeks. An upper gastrointestinal series demonstrated a polypoid, ovoid filling defect in the second portion of the duodenum, and duodenoscopy disclosed a protruding mass involving the orifice of the papilla of Vater. Cholangiography demonstrated obstruction due to compression in the terminal common bile duct. Pylorus-preserving pancreatoduodenectomy was performed on the diagnosis of ampullary carcinoma. The gross specimen showed a polypoid mass, measuring 3.5 cm in diameter, in the ampulla, located mainly in the duodenal submucosal layer and invading the terminal common bile duct. Histologically, the tumor was small cell type, undifferentiated carcinoma, arising from the duodenal epithelium adjacent to the ampulla.

The purpose of this study was to review our experience with laparoscopic common bile duct (CBD) exploration by the transcystic approach and choledochotomy. We selected the transcystic approach for patients whose CBD stones were less than five in number and smaller than 9 mm in diameter, and whose CBD was less than 15 mm in diameter on cholangiograms. Among 217 patients with CBD stones treated laparoscopically, the transcystic approach was performed successfully in 91 of 104 patients in whom it was attempted (87.5%). The other 126 patients underwent laparoscopic choledochotomy, followed by ductal closure with transcystic drainage in 59, T-tube drainage in 46, primary ductal closure in 19, and choledochoduodenostomy in 1. Choledochotomy was converted to open surgery in only 1 patient. The transcystic approach was associated with shorter hospital stay and less morbidity than choledochotomy. However, choledochotomy also had an acceptably low rate of complications. Bile leaks occurred more frequently in those with primary ductal closure than in those with transcystic drainage or T-tube drainage. Residual stones were found in 2 patients with the transcystic approach and in 10 with choledochotomy. The residual stones were removed through the T-tube tract by choledochoscopy in 7 of these 10 patients. From these results we conclude that laparoscopic management of CBD stones is feasible for almost all patients with CBD stones. It is considered to be safe and effective and has the advantage of being a single-stage procedure.

Purpose Laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) is technically difficult and not infrequently followed by postoperative complications and pain, especially when performed by inexperienced surgeons. To simplify TAPP and reduce postoperative pain, we devised a novel procedure whereby TAPP is carried out after the inguinal preperitoneal infiltration of diluted lidocaine and epinephrine saline solution and carbon dioxide gas (tumescent TAPP). This report introduces the concept of tumescent TAPP and summarizes its operative results. Methods About 120 ml of diluted lidocaine and epinephrine solution and 60 ml of CO2 gas were infiltrated into the inguinal preperitoneal space through a transabdominal needle before TAPP. Tumescent TAPP was performed for 400 patients (355 men, 45 women; mean age, 63.2 years). Results Using tumescent TAPP, we found it easier to confirm the inguinal anatomy and dissect the preperitoneal layer and inguinal floor, with less bleeding. The mean operation time was 101.9 min and there were few perioperative complications and minimal pain. Conclusions Tumescent TAPP makes conventional TAPP easier and safer; however, this procedure should be verified by a comparative study with conventional TAPP.