Shigetoshi Yamada

Broad ligament hernia successfully treated by laparoscopy: Case report and review of literature.

We report a case of a 36‐year‐old woman with a history of caesarean section who presented with small bowel obstruction. Abdominal multi‐detector CT showed discontinuity of the small bowel near the broad ligament on the left. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated by the broad ligament. Multi‐detector CT may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.

Recurrence of pancreatic cancer presented as cervical lymphadenopathy

BackgroundWe report a case of recurrent pancreatic cancer that presented as cervical lymphadenopathy.Case presentationA 69-year-old woman with stage IIb pancreatic cancer underwent a curative Whipple’s procedure after neoadjuvant chemoradiation therapy. Despite adjuvant chemotherapy with S-1, postoperative recurrence was diagnosed as left cervical lymphadenopathy 11xa0months postoperatively. After she underwent chemoradiation therapy to the cervical area followed by systemic chemotherapy with S-1, the lymphadenopathy became unremarkable 17xa0months postoperatively. S-1 treatment was discontinued 23xa0months postoperatively at the patient’s request. She has remained free of disease since that time and has achieved an overall duration of survival of 48xa0months.ConclusionsTo the best of our knowledge, this is the first reported case of middle cervical lymph node metastasis of pancreatic cancer. Although rare, it should be considered as a site of recurrence. This case suggests concurrent radiation therapy can be a good option for patients who cannot tolerate an aggressive regimen.

Current surgical training: simultaneous training in open and laparoscopic surgery

Endoscopic surgery has been widely accepted in various surgical fields, and for some surgeries such as cholecystectomy, these procedures are performed primarily by laparoscopic technique [1]. Consequently, concerns about education for open surgery have appeared, with some educators cautioning that “if so many surgeries are done using laparoscopy, chances for open conventional surgery critically decreases.” n nAt the early stage of laparoscopic surgery, the prime concern was how to train experienced surgeons to be eligible for laparoscopic surgery [2]. Kimura and Suzuki [3] described training for laparoscopy as follows: The experienced and competent surgeons must learn anatomy specific to laparoscopic surgery for each organ, tactical sensation and hand–eye coordination under a two-dimensional monitor, and knowledge of instruments specific to laparoscopic surgery. Scott et al. reported that 67% of biliary injury in laparoscopic cholecystectomy (LC) was encountered during the first 25 cases of each surgeon’s experience [4]. According to the Southern Surgical Club, the incidence of biliary injury during LC in all member institutions of the club was 2.2%, although this included only 0.1% of the cases managed by surgeons whose experience involved more than 13 cases of surgery [5]. Deziel et al. [6] reported that the incidences of biliary injury at the institutions with experience involving fewer than 100 cases of LC were significantly higher than those at institutions whose experience included more than 100 cases. Their report emphasized the importance of training for experienced and established surgeons starting to perform endoscopic surgery. In the recent literature, Hobbs et al. [7] reported that after the introduction of LC in 1991, the prevalence of all complications doubled by 1994 and then stabilized, whereas that of bile duct injury declined after 1994. n nThe age has changed since the introduction of LC, and the great concern is how to educate both young surgical residents starting their careers as surgeons and surgeons with experience in open surgery. Currently, the main concern is how to give a well-balanced education to young surgical residents in both open and laparoscopic surgery [8]. n nThe rapid expansion of endoscopic surgery has led to concern about education for conventional open surgery. We conclude that there need be little concern about surgical education in this era of endoscopic surgery. By experiencing both open and endoscopic surgery, residents currently learn more meticulous anatomy than their senior surgeons learned in their younger days. During laparoscopic surgery, they can learn fine anatomy through magnified images on monitors. The anatomic relationship of the cystic duct and cystic artery seen behind the gallbladder neck can be visualized easily in laparoscopic surgery, a view not provided by open surgery. By experiencing both open and laparoscopic surgery, residents can learn more meticulous operative anatomy and technique, demonstrating a synergistic effect in surgical training (Fig.xa01). n n n nFig.xa01 n nHands on training by residents themselves n n n nSurgical residents at our institution are given sufficient experience in both open conventional surgery and laparoscopic surgery. They are educated by senior surgeons with enough experience in open and endoscopic surgery. The synergistic effect of simultaneous training in open and endoscopic surgery is realized (Fig.xa02). n n n nFig.xa02 n nSynergetic effect by simultaneous training n n n nAnother policy in our surgical training is early exposure of trainees as primary surgeons. Even the first-year surgical residents can experience LC and open gastrectomy. However, this type of system appears to be very difficult in many other institutions in Japan. Although the education and training system for surgery often appears as a discussion topic at the surgical congresses in Japan, very few references are available on the synergistic effect of teaching both open and laparoscopic surgery in parallel in contemporary practice in Japan and elsewhere (Tablesxa01, u200b,2,2, u200b,3,3, u200b,44). n n n nTablexa01 n nGuidelines for performing endoscopic surgery (JSES 2(I):7), proposed by Japan Society for Endoscopic Surgery, 29 August, 1992, 4 December 1996 (4th revision) n n n n n nTablexa02 n nCriteria for evaluating endoscopic surgical skill at the Kameda Medical Center n n n n n nTablexa03 n nProgress of surgical residents during 2xa0years of training (rated every 6xa0months in terms of levels) n n n n n nTablexa04 n nThree generations of surgeons currently classified by their educational background n n n nSome surgeons report that they have started requiring surgical residents to do surgeries as primary surgeons, but not until about the 10th year after graduation. Surgical residents progress more rapidly in the parallel open/laparascopic model, and this is a strong recruiting incentive for programs that offer it. n nHands-on training under two-dimensional vision is indispensable for the training of endoscopic surgery. Therefore, the training room in the dry lab at our institution, available anytime to anybody, is working well for educating beginners. The effectiveness of training using bench models has been documented [9, 10]. Recently, more effective training using virtual reality simulators is increasingly reported [11–13]. Vlaovic and McDougall [12] reported that surgical simulation may provide an opportunity to enhance residency experience and training and to optimize the postgraduate acquisition of new skills and maintenance of competency. Surgical simulation will be an important adjunct to the traditional methods of surgical skills training, allowing surgeons to maintain their proficiency in the technically challenging aspects of minimally invasive surgery. We currently are using Lap MentorTW technology. n nThe surgeon pioneers who contributed to the development of endoscopic surgery in its early stage established their prestige in the field of open surgery. They introduced and learned endoscopic surgery after they had mastered conventional open surgery. In contrast, young surgeons currently learn open and endoscopic surgery in parallel, or they learn laparoscopic surgery first and then learn open surgery (e.g., cholecystectomy). They may learn in an order opposite that of the conventional teaching system. Still another group of surgeons adhere only to open surgery and show little interest in learning endoscopic surgery. n nThe surgical world currently consists of these three generations. It will be increasingly difficult for the third generation to survive in the 21st century. Funch-Jensen [14] reported that surgery is increasingly reoriented into laparoscopic procedures, and classic open surgery will presumably, with few exceptions, cease to exist in the future. We do not think open surgery will disappear and therefore believe that its skills must be maintained for the future. n nSimultaneous training of conventional open surgery and endoscopic surgery provides a synergistic effect in the education of surgical residents. However, even with the rapid expansion of endoscopic surgery, education in open surgery will continue to be important in the training of young surgeons.

Xanthogranulomatosis of the spleen: a case report

BackgroundXanthogranulomatous inflammation is recognized as a subtype of cholecystitis; however, it can also occur in other organs. Xanthogranulomatosis of the kidney, bone, ovary, endometrium, vagina, prostate, lymph nodes and pancreas was reported. Herein, we report a case of laparoscopic splenectomy in a patient with xanthogranulomatosis of the spleen that was difficult to diagnose preoperatively.Case presentationA 63-year-old man with a past medical history of hyperlipidemia had gradually growing multiple splenic masses, which were revealed on abdominal ultrasonography. Preoperative imaging suggested hamartoma, extramedullary hematopoiesis, or an inflammatory pseudotumor. Although metastatic splenic tumors and malignant lymphoma are atypical, they were considered in the differential diagnosis. Thus, laparoscopic splenectomy was performed. Pathological results confirmed a diagnosis of splenic xanthogranulomatosis. An increase in the postoperative triglyceride levels indicated that hyperlipidemia was the cause of xanthogranulomatosis of the spleen.ConclusionsXanthogranulomatosis should be considered in the differential diagnosis of multiple splenic mass lesions in patients with splenomegaly. Additionally, fine-needle aspiration biopsy should be considered for the preoperative diagnosis.

Curative resection of carcinoma of the ampulla of Vater with lymph node metastases around the abdominal aorta after chemotherapy: A case report

Highlights • Curative resection of carcinoma with lymphnode metastasis around the aorta.• Conversion surgical strategy for unresectable case after chemotherapy.• Rare case of biliary tract cancer with distant metastasis.

Study of Cases with Intestinal Obstruction Caused by Peritoneal Metastasis of Gastric Cancer

開腹 手術 を行 った 胃癌症 例378例 につ い て開腹 播種 に よ るイ レウスの発 生頻 度,病 理 組織 学 的,臨 床 的検 討 を行 った。フォ ローア ップ期 間 は中央値37カ 月で あ った。この 間に イ レウ スの 診断 で入 院 を要 した症例 は42例105回 あ った。 イ レウスの 原 因は27例81回 が癒 着性 イレ ウスで あ り14例23回 が 腹膜播 種 に よ るイ レウスで あ った。 胃癌 手 術 後 の イレ ウス症 状 発現 までの期 間 は癒 着性 イ レウス例 と腹膜 播種 例 で有意 差 を認め なか った.腹 膜 播種 に よ る イ レウ ス14例 中6例 につ い ては外科 的 治療 を行 い8例 に つい ては保 存 的に加 療 した。イ レウ ス術 後 の平均 生存期 間は外 科 的治療例 で173±121日,保 存 的治療 例 で は123±56日 で有 意差 を認め なか った。しか し症例 に よって は外 科 的治 療 に よ り胃癌 の抜 去,経 口摂 取 の開始,在 宅 医療へ の移 行 な どが可能 とな りQOLが 大 き く改善 され る症例 もあ る こ とか ら症例 に応 じて治療 方法 を検 討す るこ とが 重要 と考 え られ た。