Trans-perineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer.

BACKGROUND: Laparoscopic abdominoperineal resection (APR) for low rectal cancer (LRC) is performed worldwide. However, APR involves technical difficulties and often causes intractable perineal complications. Therefore, a novel and secure technique during APR is required to overcome these critical issues. Although the usefulness of the endoscopic trans-anal approach has been documented, no series of the endoscopic trans-perineal approach during laparoscopic APR for LRC has been reported. METHODS: Trans-perineal minimally invasive surgery (TpMIS) has been used during laparoscopic APR in our institution since April 2014. TpMIS is defined as an endoscopic trans-perineal approach using a single-port device and laparoscopic instruments. In this study, we retrospectively evaluated 50 consecutive patients with LRC who underwent laparoscopic APR at our institution from February 2011 to June 2017 and compared the outcomes of the patients who underwent TpMIS [trans-perineal APR (TpAPR) group, n = 21] versus the conventional trans-perineal approach (conventional group, n = 29). We investigated our experiences with TpMIS in detail and evaluated the safety and utility of TpMIS for patients with LRC. Moreover, major features and difficulties of TpMIS were examined from a surgical viewpoint. RESULTS: Intraoperative blood loss (median (range) 55 (10-600) vs. 120 (20-1650) ml) and severe perineal wound infection (Clavien-Dindo grade 3, 0 vs. 5 cases) were significantly lower in the TpAPR than conventional group. TpMIS led to a shortened hospital stay (median (range), 14 (10-74) vs. 23 (10-84) days), and neither mortality nor conversion to open surgery occurred in the TpAPR group. CONCLUSIONS: Magnified visualization via endoscopy provided more accurate dissection and less blood loss during surgery. Minimal skin incisions enabled a reduction in postoperative perineal complications, and consequently shortened the hospital stay. TpMIS during laparoscopic APR is safe and beneficial for patients with LRC.

Feasibility of Extended Dissection of Lateral Pelvic Lymph Nodes During Laparoscopic Total Mesorectal Excision in Patients with Locally Advanced Lower Rectal Cancer: A Single-Center Pilot Study After Neoadjuvant Chemotherapy.

BACKGROUND The feasibility of additional dissection of the lateral pelvic lymph nodes (LPLNs) in patients undergoing total mesorectal excision (TME) combined with neoadjuvant chemotherapy (NAC) for locally advanced rectal cancer (LARC) is controversial. The use of laparoscopic surgery is also debated. In the present study, we evaluated the utility of laparoscopic dissection of LPLNs during TME for patients with LARC and metastatic LPLNs after NAC, based on our experience with 19 cases. MATERIAL AND METHODS Twenty-five patients with LARC with swollen LPLNs who underwent laparoscopic TME and LPLN dissection were enrolled in this pilot study. The patients were divided into 2 groups: those patients with NAC (n=19) and without NAC (n=6). Our NAC regimen involved 4 to 6 courses of FOLFOX plus panitumumab, cetuximab, or bevacizumab. RESULTS The operative duration was significantly longer in the NAC group than in the non-NAC group (648 vs. 558 minutes, respectively; P=0.022). The rate of major complications, defined as grade ≥3 according to the Clavien-Dindo classification, was similar between the 2 groups (15.8% vs. 33.3%, respectively; P=0.4016). No conversion to conventional laparotomy occurred in either group. In the NAC group, a histopathological complete response was obtained in 2 patients (10.5%), and a nearly complete response (Tis N0 M0) was observed in one patient (5.3%). Although the operation time was prolonged in the NAC group, the other perioperative factors showed no differences between the 2 groups. CONCLUSIONS Laparoscopic LPLN dissection is feasible in patients with LARC and clinically swollen LPLNs, even after NAC.

[A case of stage IV rectal cancer successfully resected after chemotherapy (mFOLFOX6 plus panitumumab)].

A 6 6-year-old woman with hematochezia was admitted to our hospital. A colonoscopy detected KRAS wild-type rectal cancer. An abdominal computed tomography (CT) scan revealed a liver metastasis, and invasion to the uterus was suspected. The patient underwent a laparotomy, and intraoperative cytology and peritoneal dissemination proved positive. The tumor had invaded the uterus. We administered chemotherapy consisting of 5-fluorouracil, Leucovorin, and oxaliplatin(mFOL FOX6)plus panitumumab. A CT scan and colonoscopy performed after 10 courses of chemotherapy indicated remarkable tumor regression. An abdominal CT scan did not detect any liver metastases, and we performed a laparoscopic low anterior resection. In the second operation, peritoneal dissemination and washing cytology were negative. The pathological diagnosis of the surgically resected specimen was ypStageII. The patient is recurrence-free 7 months after surgery.

[A case of resection for a huge pancreatic acinar cell carcinoma with tumor thrombus in the portal vein].

A 6 3-year-old man with a huge pancreatic tumor was referred to our hospital. Abdominal computed tomography revealed a heterogeneously enhanced encapsulated mass, 14 cm in diameter, in the pancreas head. The tumor thrombus extended to the bifurcation of the portal vein. The tumor, which had invaded the descending duodenum, was diagnosed as a probable case of acinar cell carcinoma, based on the biopsy results. Prior to resection, we prepared an ileocecal vein-umbilical vein bypass. Initially, we planned to perform a pancreatoduodenectomy, however, a total pancreatectomy had to be performed due to the atrophy of the residual pancreas tail. Since the tumor thrombus was visible, floating up from the portal vein wall at the upper level of pancreas, we dissected the portal vein at this level. The thrombus was extracted after securing the main tract and both (right and left) branches of the portal vein with vessel tape. About 5 cm of portal vein was resected and reconstructed. Since patients who undergo resection of acinar cell carcinoma have a better prognosis and long-term survival is often reported for cases of resected tumor thrombus of the portal vein, it is advisable to resect acinar cell carcinomas even in cases as advanced as reported here.

[A case of advanced gastric cancer successfully treated with trastuzumab, capecitabine, and Cisplatin therapy followed by curative resection].

We report a case of human epidermal growth factor receptor 2(HER2)-positive advanced gastric cancer successfully treated with combination therapy of trastuzumab, capecitabine, and cisplatin, followed by a curative resection. A 23-year-old woman was diagnosed with advanced type 3 gastric cancer, and the clinical findings were T3N0M0, StageIIA. A laparoscopic exploration revealed that it was a CY1 unresectable StageIV cancer. Initially, docetaxel, cisplatin, and S-1 therapy was chosen. However, the patient's HER2 status proved to be positive (IHC 3+), and so trastuzumab, capecitabine and cisplatin therapy was administered. After four cycles, the tumor significantly decreased in size, suggesting a partial response(PR). A further laparoscopic exam showed no apparent dissemination or metastatic cancer cells. We performed a curative resection consisting of a laparoscopic distal gastrectomy and D2 lymphadenectomy. The patient's postoperative course has been uneventful. She has been alive for 4 months and is receiving adjuvant chemotherapy comprising trastuzumab and S-1.

Laparoscopic surgery for median arcuate ligament syndrome using real-time stereotactic navigation.

INTRODUCTION: In median arcuate ligament syndrome (MALS), a hyperplastic MAL causes compression and stenosis of the celiac artery (CA). The treatment involves releasing the external pressure on this artery by dissecting the ligament. However, it is difficult to identify the artery because of its deep anatomical location. Stereotactic navigation provides real-time information regarding the surgical instrument's location on computed tomography (CT) images. We utilized this system to overcome the difficulty of anatomical identification. MATERIALS AND SURGICAL TECHNIQUE: We present a case of aneurysm rupture caused by MALS, which was treated with laparoscopic MAL dissection with real-time stereotactic navigation. Surgery was performed in a hybrid operating room with three-dimensional C-arm CT (Artis Zeego, Siemens) and an installed Curve navigation system (BrainLab). Preoperative CT images were aligned with intraoperative C-arm CT-like images and the surgical instrument position was projected onto preoperative CT images. After the left gastric artery isolation, the fibrous tissue surrounding the left gastric artery was dissected toward the CA while confirming the location of the CA and aortic wall using the navigation system. The CA's diameter was dilated from 1.8 to 2.6 mm with intraoperative angiography. DISCUSSION: This is the first report of laparoscopic MAL dissection using real-time stereotactic navigation. Although navigation setting was time-intensive, this system helped us understand the anatomical structures and in safely and precisely dissecting the MAL.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults.

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

Safety and feasibility of laparoscopic gastrectomy accompanied by D1+ lymph node dissection for early gastric cancer in elderly patients.

INTRODUCTION: The age of patients with gastric cancer has increased worldwide. The aim of this study was to investigate the safety and feasibility of laparoscopic gastrectomy (LG) for early gastric cancer in elderly patients. METHODS: We retrospectively investigated 221 consecutive patients who underwent LG for early gastric cancer during a 5-year period (January 2010 to December 2014). We divided the patients into two groups: elderly patients (≥75 years old) and younger patients (<75 years old). We compared these two groups with respect to clinical characteristics, histopathological findings, intraoperative factors, and postoperative outcomes. RESULTS: The preoperative characteristics were similar in both groups. Except for the number of harvested lymph nodes (42.0 vs 34.9; P = 0.0016), the short-term operative outcomes, including postoperative complications and histopathological findings, were comparable between the two groups. Although significantly fewer lymph nodes were harvested in the elderly group, the overall survival and relapse-free survival rates did not significantly differ between the groups. Postoperative complications, such as acute cholecystitis and internal hernia, occurred during the long-term postoperative period after LG, and these unexpected complications were more frequently observed in elderly patients. All elderly patients required additional emergent surgeries for delayed complications. CONCLUSION: The outcomes of LG for early gastric cancer in elderly patients seem to be reasonable. Aggressive lymph node dissection may be omissible in elderly patients with acceptable results. LG can be a safe and feasible procedure in elderly patients. However, the higher rate of delayed but urgent complications during the long-term postoperative period must be considered.

Aggressive Graphic/Surgical R0 Resection and Jejunal Interposition with Preservation of Mesojejunal Autonomic Nerves in Patients with Stage IV Esophagogastric Junction Adenocarcinoma: A Report of 3 Cases.

BACKGROUND Three patients with stage IV esophagogastric junction cancer (EGJC) underwent extended resection to achieve a graphic/surgical R0 status (no visible remnant of viable tumor in imaging/surgical findings) and adjuvant chemotherapy from the early postoperative period. We also introduced use of our digestive reconstruction technique in these patients. CASE REPORT We used jejunal interposition for digestive reconstruction, which involved end-to-end jejunojejunostomy with a biofragmentable anastomosis ring. The mesojejunal autonomic nerves of the lifted jejunum were preserved. The first adenocarcinoma involved the perilesional lymph nodes (LNs). Graphic/surgical R0 resection was completed by para-aortic LN dissection. The diagnosis (Japanese Classification of Gastric Carcinoma) was stage IV [pM1(LYM)]. Adjuvant chemotherapy began on postoperative day (POD) 11. The second adenocarcinoma was accompanied by a solitary lung metastasis. Intraoperative cytology of ascitic fluid was positive, and cisplatin was intraperitoneally administered. Adjuvant chemotherapy began on POD 10. The solitary lung metastasis was then resected, and graphic/surgical R0 resection was achieved. The diagnosis was stage IV [pM1(PUL) and CY1]. The third adenocarcinoma was accompanied by multiple liver metastases and metastatic regional LNs. The diagnosis was stage IV [H1]. Systemic chemotherapy was repeated. Only a solitary liver metastasis remained and was treated by radiofrequency ablation. Conversion surgery was conducted, achieving graphic/surgical R0 resection. Systemic chemotherapy was continued from POD 10. CONCLUSIONS For patients with stage IV EGJC, extended resection to achieve a graphic/surgical R0 status is still controversial, and systemic chemotherapy is important. The results of the present study suggest that our physiological reconstruction technique does not affect the efficacy of other therapies, such as adjuvant chemotherapy.

Brachial plexus paralysis after thoracoscopic esophagectomy for esophageal cancer in the prone position: A thought-provoking case report of an unexpected complication.

INTRODUCTION: During prone esophagectomy, placement of a port in the third intercostal space for upper mediastinal dissection requires adequate axillary expansion. To facilitate this, the right arm is elevated cranially and simultaneously turned outward. Brachial plexus paralysis associated with esophagectomy in the prone position has not been documented. PRESENTATION OF CASE: A 58-year-old man diagnosed with middle intrathoracic esophageal cancer was referred to our department. Thoracoscopic esophagectomy in the prone position was performed following neoadjuvant chemotherapy. After surgery, he complained of difficulty moving his right arm. Physical examination revealed perceptual dysfunction and movement disorder in the territory of cervical spinal nerve 6. Magnetic resonance imaging indicated the injury in the right posterior cord of the brachial plexus at the costoclavicular space. Therefore, we diagnosed the patient with right brachial plexus injury caused by the intraoperative position. The postoperative course was uneventful other than the brachial plexus paralysis, and he was discharged on postoperative day 23. He underwent continuous rehabilitation as an outpatient, and the right brachial plexus paralysis had completely disappeared by 2 months after surgery. DISCUSSION: This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. In prone esophagectomy, managing the patient's position, especially the head and arm positions, is so important to avoid brachial plexus injury due to intraoperative positioning. CONCLUSION: The clinicians should consider managing the patient's position with anatomical familiarity to avoid brachial plexus injury due to intraoperative positioning.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports.

BACKGROUND: Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula. CASE SUMMARY: The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL. CONCLUSION: CLL has therapeutic potential for postoperative pancreatic fistula.

Overlap Anastomosis for Digestive Reconstruction during Laparoscopic Distal Gastrectomy with Intensive Regional Lymph Node Dissection: Physiological Impact of Preserving the Mesenteric Autonomic Nerves in the Lifted Jejunal Limb.

Laparoscopic gastrectomy is a treatment for gastric cancer, and isoperistaltic side-to-side reconstruction is called "overlap anastomosis." The physiological advantages of preserving the autonomic nerves in the jejunal limb for digestive reconstruction are well known. Here, we focused on overlap anastomosis with autonomic nerve-preserved mesojejunum of the lifted jejunal limb for laparoscopic distal gastrectomy with intentional lymph node dissection. Our surgical techniques and technical pitfalls were described in detail. The jejunum was partially sacrificed to preserve the autonomic nerves in the lifted jejunal limb. The length of the staple line was 35 - 40 mm. The endostapler entry was carefully closed to avoid even subtle stenosis. Twelve patients were retrospectively evaluated with a follow-up of 5.0 ± 0.6 years. Histological findings according to the Japanese classification were stage IA or IB. Dietary intake and postoperative ambulation occurred at 3.3 ± 1.0 and 1.3 ± 0.5 days after surgery, respectively. Postoperative complications according to Clavien-Dindo classification were one each of grade I and grade II. Postoperative hospital stay was 6.7 ± 1.6 days. Five patients were medication-free at final follow-up, with no recurrence in any patient. Overlap anastomosis with autonomic nerve-preserved jejunal limb was safe and feasible for laparoscopic distal gastrectomy with lymph node dissection.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits.

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Successful Laparoscopic Cholecystectomy in Moderate to Severe Acute Cholecystitis: Visual Explanation with Video File.

BACKGROUND Experience alone is insufficient to ensure successful laparoscopic cholecystectomy (LC), although LC has become widespread worldwide. Iatrogenic biliary injuries occur beyond the learning curve. CASE REPORT Biliary injury during laparoscopic cholecystectomy results from anatomical misidentification. The use of a critical view of safety has been established, to identify the cystic artery and the cystic duct, as the cystic duct can be hidden by inflammation (infundibular cystic duct). Seven patients who underwent emergency laparoscopic cholecystectomy due to acute cholecystitis are presented who underwent a critical view of safety protocol during surgery. Five men and two women (mean age, 63.0±13.0 years) included five cases of acute severe cholecystitis and two cases of acute moderate cholecystitis. The mean operative time to complete the critical view of safety exposure was 54.0±17.4 minutes. No cases underwent conversion to open surgery. The mean postoperative duration to ambulation and normal diet was 0.7±0.5 days and 1.0±0.6 days, respectively. The mean time to postoperative patient discharge was 3.9±0.9 days. In all seven cases, the postoperative course was uneventful. The protocol for this surgical procedure is presented, with schematic figures and videos. CONCLUSIONS A case series of seven patients who presented with moderate-to-severe acute cholecystitis and who underwent laparoscopic cholecystectomy, showed good postoperative outcome without surgical complications, using a using a critical view of safety protocol.

Imanaga's First Method for Reconstruction with Preservation of Mesojejunal Autonomic Nerves During Pylorus-Preserving Pancreatoduodenectomy.

BACKGROUND Pancreatic surgeries have undergone substantial development. Pancreaticoduodenectomy and pylorus-preserving pancreatoduodenectomy inherently require reconstruction. In 1960, Professor Imanaga introduced a reconstructive technique performed in the order of the gastric remnant, pancreatic duct, and biliary tree from the viewpoint of physiologic function after pancreaticoduodenectomy. We herein report our experience with Imanaga's first method during pylorus-preserving pancreatoduodenectomy and retrospectively evaluate the short- and long-term outcomes. Technicalities and pitfalls are also discussed. CASE REPORT Eight patients were evaluated (mean follow-up period, 16.7 ± 1.0 years). Mesojejunal autonomic nerves were preserved without tension to the greatest extent possible for reconstruction. Intentional dissection of regional lymph nodes and nerves was performed in five and two patients, respectively. During the short-term postoperative period, one patient developed pancreatic leakage resulting in an intraperitoneal abscess, and endoscopic transgastric drainage was required. Two patients developed delayed gastric emptying. In three patients, passage from the duodenojejunostomy to pancreaticojejunostomy was mechanically disturbed, and endoscopic dilations with a balloon bougie were repeated. Repeated cholangitis was observed in three patients. During the long-term postoperative period, neither cachexia nor sarcopenia was observed, although two patients had diabetes. Two patients were free from all medications. Three patients who did not undergo intentional dissection of lymph nodes and nerves showed acceptable short- and long-term outcomes, although one each developed repeated cholangitis and adhesive ileus during the short-term period. CONCLUSIONS Imanaga's first reconstruction may have potential benefits, especially for diseases that do not require intentional dissection. Adequate mobilization of the pancreatic remnant is important for successful reconstruction.

Internal Hernia Associated with Colostomy After Laparoscopic Surgery for Rectal Malignancy: A Report of 3 Thought-Provoking Cases.

BACKGROUND Colostomy creation via intraperitoneal route is often performed during laparoscopic Hartmann's operation or abdominoperineal resection (APR). Herein, we report 3 rare cases of internal hernia associated with colostomy (IHAC). CASE REPORT The first case involved a 70-year-old man with IHAC after laparoscopic APR. Laparoscopy revealed the small intestine passed through a defect between the lifted sigmoid colon and left lateral abdominal wall in a cranial-to-caudal direction. The dislocated bowel with ischemic change was restored to its normal position and the lateral defect was covered with lateral peritoneum and greater omentum. The second case involved a 75-year-old man with IHAC after laparoscopic APR. Intraperitoneal findings were similar to those in the first case, except for the size of the lateral defect. This defect was too large for primary closure or patching; therefore, no surgical repair was performed. Unfortunately, this led to IHAC recurrence and creation of a new colostomy via extraperitoneal route. The third case involved an 85-year-old man with acute peritonitis resulting from IHAC after laparoscopic Hartmann's operation. Surgery revealed incarcerated bowels forming a closed loop and a perforation in the lifted sigmoid colon. The perforated colon was compressed by the dilated herniated bowel. The resected sigmoid colon showed perforation at the ulcer, which was shown on pathology to be caused by ischemia. CONCLUSIONS IHAC can lead not only to ischemia of strangulated bowel, but also to secondary damage to the lifted colon. During laparoscopic Hartmann's operation or APR, the colostomy should be created via extraperitoneal route to avoid IHAC.

Robot-assisted distal gastrectomy with lymph node dissection for gastric cancer in a patient with situs inversus partialis: a case report with video file.

BACKGROUND: Situs inversus is a rare congenital condition that is currently classified into two types: complete situs inversus (situs inversus totalis, SIT) and partial situs inversus (situs inversus partialis, SIP). In SIP patients, some organs are inverted and others are in their expected position, and individual patient variation in organ position increases surgical difficulty. Several surgeons have performed laparoscopic or robotic surgeries in situs inversus patients, but almost all were SIT patients. We report the first case, to our knowledge, of an SIP patient with gastric cancer who was successfully treated by robot-assisted distal gastrectomy (RADG) with lymph node dissection. CASE PRESENTATION: A 64-year-old woman diagnosed with early gastric cancer on the posterior midbody of the stomach was referred to our hospital for treatment. Computed tomography showed levocardia and inverted abdominal organs without enlarged lymph nodes or distant metastases. Polysplenia syndrome, intestinal malrotation, and left-sided gallbladder were also detected. RADG with D1+ lymph node dissection and Billroth I reconstruction (delta-shaped anastomosis) were performed using robotics. Hepatopathy caused by a liver retractor and pancreatic fistula were identified during the postoperative course, and the latter was classified as grade II based on Clavien-Dindo classification. The patient was discharged 18 days after the operation. CONCLUSIONS: Preoperative three-dimensional imaging is beneficial, and anatomical organ identification should be routinely performed, especially in SIP patients. We consider RADG a therapeutic option in SIP patients.

Which Therapeutic Option Is Optimal for Surgery-Related Perineal Hernia After Abdominoperineal Excision in Patients with Advanced Rectal Cancer? A Report of 3 Thought-Provoking Cases.

BACKGROUND Although perineal hernia (PH) is considered a surgery-related complication after abdominoperineal excision, the optimal therapeutic option for PH remains controversial. CASE REPORT The first case involved a 72-year-old man in whom PH was diagnosed 6 months after surgery. Laparoscopic findings revealed moderate adhesion at the pelvic floor, and a perineal approach was added. The pelvic floor defect was repaired by composite mesh. Combined laparoscopic surgery with a perineal approach was effective. The second case involved a 71-year-old man in whom PH was diagnosed 7 months after surgery. Laparoscopic findings revealed severe adhesion of the pelvis, and a perineal approach was added. The pelvic floor defect was repaired by composite mesh. The seromuscular layers of the small intestine were injured, and the damaged small intestine was resected and anastomosed. Composite mesh did not cause postoperative infection even with simultaneous bowel resection. The third case involved a 76-year-old man in whom PH was observed 12 years after surgery. Combined laparoscopic surgery with a perineal approach was performed from the beginning of surgery. Laparoscopic findings clearly demonstrated an intractable adhesion. Unexpected injury of the small intestine caused intra-abdominal contamination; therefore, the pelvic floor defect was primarily closed by absorbable sutures. Combined laparoscopic surgery with a perineal approach was effective even in this patient with a huge PH and intractable adhesion. CONCLUSIONS The combination of laparoscopic surgery with a perineal approach is an adequate option for PH treatment, and the perineal approach should be added without hesitation if needed.

Acute appendicitis caused by metastatic adenocarcinoma from the lung: a case report.

BACKGROUND: Appendiceal metastasis from lung cancer is rare. However, it often causes acute appendicitis that requires emergency surgery. We herein report a thought-provoking case of appendiceal metastasis from lung cancer. CASE PRESENTATION: A 71-year-old man was diagnosed with advanced lung cancer with multiple metastases and underwent chemotherapy. One month later, he developed acute appendicitis, and laparoscopic appendectomy was promptly performed. A swollen appendix and pus collection were observed during surgery. Histological analysis revealed an invasive adenocarcinoma in the appendix that infiltrated the mucosal, submucosal, and muscular layers. Positive immunostaining of thyroid transcription factor 1 indicated appendiceal metastasis of pulmonary adenocarcinoma, not a primary appendiceal malignancy. The postoperative course was uneventful, and the patient's pulmonary internist resumed continuous chemotherapy after surgery. CONCLUSIONS: Although appendiceal metastasis from pulmonary adenocarcinoma is rare, it often results in acute appendicitis. Optimal therapy including emergency surgery should be performed without hesitation so that chemotherapy can be resumed as soon as possible.