We report a case of a 51‒year‒old man who presented with right lower abdominal pain. On physical examination, a palpable, tender mass was detected in the right lower abdomen. Contrast‒enhanced computed tomography (CT) revealed a 15‒cm mass in the right lower abdominal wall, supplied by the right inferior epigastric artery, with internal hemorrhage and necrotic areas. Radiological findings were inconclusive for malignancy. As there was no evidence of distant metastasis or invasion into adjacent organs, the tumor was considered resectable, and surgical resection was performed. Histopathological examination confirmed the diagnosis of synovial sarcoma. Given the high risk of recurrence and metastasis associated with synovial sarcoma, adjuvant chemotherapy was administered postoperatively. The patient remains alive without recurrence 1 year after surgery.

当院で外科的治療を行った後腹膜脂肪肉腫25例(男性16例、女性9例、年齢中央値66歳)の手術成績と再発リスク因子について検討した。その結果、全症例の5年OSは59.8%で、根治度別ではR0:76.2%、R1:50.0%、R2:0%であった。初回手術後の5例と3回目切除後の1例の計6例が現在無再発生存中である。一方、局所再発リスク因子は分割切除と組織型であり、再発率は分割切除例で100%、WDLPS以外の組織型で91.7%と高率であった。また、組織型は独立した予後因子であり、WDLPSはそれ以外の組織型に比して予後良好であった。

A 59-year-old man presented with abdominal mass and weight loss. Computed tomography revealed a 20 cm mass in the vicinity of the left kidney. A tumor biopsy was performed and diagnosed with leiomyosarcoma. We performed tumor resection. The tumor invaded the surrounding tissues, and a lumpectomy with resection of the left kidney and left adrenal gland was performed. Pathologically, there was a slight suspicion of tumor exposure, so radiotherapy was administered to the dissected surface. There was no evidence of local recurrence or metastasis after 12 months.

PURPOSE: Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy. METHODS: A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM). RESULTS: After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174 min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0 ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9 days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394). CONCLUSION: Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

INTRODUCTION: Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. PRESENTATION OF CASE: A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein. DISCUSSION: There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely. CONCLUSION: Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis.

BACKGROUND: Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices. METHODS: We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017. RESULTS: Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis. CONCLUSIONS: Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon's skill. The appropriate indications must be established with more case registries because our experience is limited.

BACKGROUND: Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure. METHODS: We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients. RESULTS: Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7-14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10-16 days). CONCLUSION: The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

Mesenteric cysts are rare intra-abdominal masses. They do not show classic clinical findings and are detected incidentally during imaging because of their absent or nonspecific clinical presentation. We herein report 2 cases of mesenteric cysts that were successfully diagnosed and resected through a laparoscopic approach. In a 35-year-old man underwent a comprehensive medical checkup at another hospital, during which ultrasound incidentally revealed a cystic mass in his right retroperitoneum. The patient was referred to our hospital for surgical treatment. He was asymptomatic and his medical history was unremarkable. Physical examination revealed no palpable abdominal mass, and all laboratory test results were within normal ranges. Contrast-enhanced computed tomography showed a 7.2-cm-diameter smooth-surfaced, well-demarcated mass behind the right colon without a contrast effect (Fig. 1). We considered the cyst to be benign and localized in the mesentery of the ascending colon. In one patient, the cyst was located in the mesentery of the ascending colon and removed via a right hemicolectomy; in the other patient, the cyst was located in the sigmoid mesentery, which was completely resected through the operative wound under an open procedure after laparoscopic mobilization of the sigmoid mesentery. We chose the laparoscopic approach in both cases because the cysts were considered benign, noninfectious, and nonhemorrhagic. Histologic examination revealed cystic lymphangioma in both cases. For mesenteric cysts, laparoscopy could be a preferred approach in properly selected patients.

A 71-year-old woman, who had undergone radiation therapy, developed radiation-induced rectal adenocarcinoma and lower abdominal sarcoma. At the age of 51, the patient had undergone adjuvant radiation therapy of 50 Gy for uterine cervical cancer, directed at the pelvis. Her medical history included radiation proctitis and dermatitis of the lower abdominal wall. At the age of 65, she underwent high anterior resection for radiation-induced rectosigmoid cancer. At the age of 71, her chief complaint was itching and redness of the lower abdominal skin. Additional enhanced computed tomography examinations showed a 7-cm, hard, poorly-demarcated tumor in the lower abdominal wall. Histopathological diagnosis, using a needle biopsy specimen of the tumor, was consistent with poorly differentiated adenocarcinoma. Subsequently, systemic chemotherapy with mFOLFOX6 and CPT-11 was performed. However, as the tumor was progressive, the biopsy specimen was reexamined by immunohistochemical staining, which revealed that the tumor stained positively only with vimentin. Finally the lower abdominal tumor was diagnosed as undifferentiated sarcoma. The patient died within 16 months after the appearance of the first symptoms. During the follow-up of patients who have undergone radiation therapy, especially those with inflammatory change in the radiation field, the possible occurrence of radiation-induced neoplasms should be carefully considered.