Laparoscopic resection aided by preoperative 3‐D CT angiography for rectosigmoid colon cancer associated with a horseshoe kidney: A case report

We herein report a case of laparoscopic high anterior resection with D3 lymph node dissection for rectosigmoid colon cancer with a horseshoe kidney. A 65‐year‐old Japanese man referred to our hospital for rectosigmoid colon cancer was found to have a horseshoe kidney on a CT scan. On 3‐D CT angiography, an aberrant renal artery was visualized feeding the renal isthmus that arises from the aorta just below the root of the inferior mesenteric artery (IMA). Laparoscopic anterior rectal resection with D3 lymph node dissection was performed. During the operation, the IMA, left ureter, left gonadal vessels and hypogastric nerve plexus could be seen passing over the horseshoe kidney isthmus. With the aid of preoperative 3‐D CT angiography, the root of the IMA was identified on the temporal side of the isthmus and divided safely just above the hypogastric nerve. As a horseshoe kidney is often accompanied by aberrant renal arteries and/or abnormal running of the ureter, 3‐D CT angiography is useful for determining the location of these structures and avoiding intraoperative injury.     

Laparoscopic high anterior resection for triple colorectal cancers with persistent ascending and descending mesocolons: A case report

Persistent mesocolon is an embryological anomaly of the colon resulting from failure of the primitive dorsal mesocolon to fuse with the parietal peritoneum. We herein present a case of laparoscopic high anterior resection for triple colorectal cancers with persistent ascending and descending mesocolons and a right‐bound inferior mesenteric artery. Preoperative 3‐D CT demonstrated that the sigmoid colon had shifted to the right abdomen and was located under the ascending colon. Moreover, the inferior mesenteric artery and vein traveled toward the right abdomen accompanied by the mesentery of the descending colon. Adhesiolysis between the ascending and sigmoid colon was initially performed, and the sigmoid colon was placed in its normal position. The inferior mesenteric artery was then divided with lymph node dissection using a medial approach, and high anterior resection was completed. An understanding of the anatomical characteristics of persistent mesocolon is important to ensure safe laparoscopic surgery.     

Using indocyanine green fluorescent imaging to successfully resect metachronous regional lymph node recurrence of rectosigmoid cancer

A 39‐year‐old female patient underwent anterior resection with locoregional lymph node dissection for rectosigmoid cancer at another hospital. The procedure involved transection of the superior rectal artery just below the origin of the left colic artery. Postoperative diagnosis was stage III B. The patient received adjuvant chemotherapy with oxaliplatin plus capecitabine for 6 months. Sixteen months after the operation, PET‐CT scans revealed regional lymph node metastases around the root of the inferior mesenteric artery. The patient was referred to our hospital with a recurrence of rectosigmoid cancer. We performed laparoscopic lymph node dissection with real‐time indocyanine green fluorescent images superimposed on color images to prevent intraoperative vascular insufficiency. We were able to successfully observe the sufficient blood flow in the descending colon. Postoperative pathological findings showed lymph node recurrence after initial surgery. She was discharged 7 days after the operation. In the 8 months since the second operation, the patient has not had any indication of further recurrence.     

Laparoscopic surgery for sigmoid colon cancer with complicated communication between the superior and inferior mesenteric arteries

To perform complete mesocolic excision with central vessel ligation, it is important to recognize the vessel anomaly and the location of the tumor. For left-sided colon cancer, the variations in the course of the left colic artery and accessary middle colic artery must be recognized preoperatively. Here, we describe our experience with a 57-year-old man who was diagnosed with sigmoid colon cancer with complicated inter-mesenteric connections between the inferior mesenteric artery (IMA) and superior mesenteric artery (SMA), possibly due to median arcuate ligament syndrome. We performed laparoscopic sigmoidectomy with low ligation of the IMA to preserve the extremely enlarged left colic artery. The total operative time was 155 minutes, and the estimated total blood loss was 10 mL. The patient was discharged on postoperative day 9 without any postoperative complications. For patients with vascular anomalies in the left-sided mesocolon, preoperatively ruling out SMA stenosis by using angiography and 3-D CT might be important.     

Sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer

We report the first case of sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer. The patient is a 75‐year‐old man who presented with the sudden onset of severe abdominal pain. He had undergone laparoscopic sigmoidectomy for cancer 2 years before presentation. CT scan showed a distended sigmoid colon with a mesenteric twist, or “whirl sign.” Colonoscopy showed a mucosal spiral and luminal stenosis with dilated sigmoid colon distally and ischemic mucosa. The diagnosis of ischemic colonic necrosis due to sigmoid volvulus was established. Resection of the necrotic sigmoid colon was performed and a descending colon stoma was created. A long remnant sigmoid colon and chronic constipation may contribute to the development of sigmoid volvulus after laparoscopic sigmoidectomy. Prompt diagnosis is essential for adequate treatment, and colonoscopy aids in the diagnosis of ischemic changes in patients without definitive findings of a gangrenous colon.     

Laparoscopic subtotal proctocolectomy for synchronous triple colorectal cancers: a case report

A 42‐year‐old woman presented with abdominal pain. On the basis of CT results, we diagnosed her condition as bowel obstruction caused by advanced transverse colon cancer. Colonoscopy findings showed three lesions: (i) an advanced tumor in the transverse colon; (ii) a laterally spreading descending colon tumor; and (iii) a rectal polyp. The tumors and the polyp were all pathologically diagnosed as adenocarcinoma. After inserting a self‐expanding metallic stent into the main tumor of the transverse colon to decompress the bowel, we performed endoscopic submucosal dissection of the laterally spreading descending colon tumor. Pathological examination results showed submucosal invasion and a positive margin. Because we endoscopically identified that the rectal polyp was invading the submucosa, we performed laparoscopic subtotal proctocolectomy and ileorectal anastomosis with lymph node dissection along the surgical trunk; we also performed central vascular ligation of the ileocolic artery, right and left branches of the middle colic artery, and inferior mesenteric artery. The patient's postoperative course was uneventful. We present this case because there have been few reports on laparoscopic subtotal or total proctocolectomy for synchronous multiple colorectal cancers.     

Laparoscopic repair of an irreducible femoral hernia containing an epiploic appendage of the sigmoid colon

Here we present the first report of laparoscopic repair of an irreducible femoral hernia containing an epiploic appendage of the sigmoid colon. A 73‐year‐old woman presented with a 1‐week history of a left groin mass below the inguinal ligament with no abdominal symptoms. Abdominal CT demonstrated a 21 × 18‐mm oval‐shaped, fat‐dense structure in the left groin area. The hernia contents were considered potentially associated with the omentum; thus, a left irreducible femoral hernia was diagnosed. Elective laparoscopic surgery revealed an irreducible femoral hernia containing an epiploic appendage of the sigmoid colon, which was then reduced. The reduced epiploic appendage showed no ischemic changes, inflammation, torsion, or swelling, obviating the need for resection. The femoral hernia was laparoscopically repaired via a transabdominal preperitoneal approach with mesh. The patient's postoperative recovery was uneventful, and no recurrence of the femoral hernia was noted at the 6‐month follow‐up.     

Laparoscopic sigmoidectomy in a case of sigmoid colon cancer with situs inversus totalis

Situs inversus totalis (SIT) is a rare anatomic anomaly in which organs in the chest and abdomen exist in a mirror image reversal of their normal positions. SIT can complicate surgical procedures, and few reports have described laparoscopic surgery for colorectal cancer in patients with SIT. Here, we report a case of successful laparoscopic surgery in a patient with SIT and sigmoid colon cancer. Laparoscopic sigmoidectomy involved colonic mobilization with high ligation of the inferior mesenteric vessels and complete mesocolic excision. The operating surgeon stood on the patient's left side, opposite the normal location for sigmoidectomy. By placing a 12‐mm trocar in the left iliac fossa and using an automatic endoscopic linear stapler, the operating surgeon was able to perform left‐handed colon resection without having to change position or move the laparoscopic monitor mid‐procedure. An automatic endoscopic linear stapler is useful for laparoscopic left‐side colon surgery in a patient with SIT.     

肠系膜下血管的腔镜下解剖学观察

目的:阐明肠系膜下动脉(inferior mesenteric artery,IMA)和肠系膜下静脉(inferior mesenteric vein,IMV)的腔镜下解剖学特点,以指导腔镜下血管定位.方法:解剖和观察15具尸体;对126例接受腹腔镜左侧结肠癌和直肠癌手术的患者进行术中观察和术后录像复习.结果:IMA起自腹主动脉前壁,起点大部分平L3椎体或L3-4椎间盘,与主动脉分叉距离(42.08±6.26)mm;IMA分支有多种变异.腔镜下:系膜前,IMA表现为自主动脉前面向左下走行、乙状结肠系膜内隆起并搏动的条索;系膜后,IMA主干位于结肠系膜偏后部,IMA根部是左结肠后间隙内的固有障碍.在左髂总动脉水平,IMA位于左输尿管、左性腺血管内侧,三者位置关系恒定.IMA根部神经纤维分布少.IMV走行于IMA左侧的结肠系膜内,末段与动脉分离后,经十二指肠空肠襞左缘后方进入胰体后面.结论:正确的外科间隙(左结肠后间隙)、标志、外观和线索,是腹腔镜下IMA和IMV定位的解剖学基础.     

Laparoscopic surgery for sigmoid colon cancer after multiple operations including urinary diversion with Indiana pouch: A case report

A 73‐year‐old man with lower abdominal pain was diagnosed at our hospital with sigmoid colon cancer. He had previously undergone radical cystectomy with Indiana pouch construction and gastrectomy to treat bladder cancer and gastric cancer, respectively. We performed a laparoscopic Hartmann's operation with Japanese D3 lymph node dissection. We observed severe adhesion in the abdominal cavity; adhesions between the urostomy and sigmoid colon were particularly severe. The tumor had invaded to the distal rectum, which had adhered to the pubic bone and the previously reconstructed urinary pouch. By performing careful and persistent laparoscopic dissection, we completed the operation without damaging the urostomy and with no remnant tumor tissue (R0). The postoperative course was uneventful, and the patient was doing well with no evidence of cancer recurrence 1 year after surgery.     

Retrograde colon intussusception in an adult due to adenoma: Treatment by combined laparoscopic and endoscopic approach

This report describes the case of a young patient who underwent laparoscopic surgery to reduce for a retrograde intussusception of the sigmoid‐descending colon caused by adenoma of the sigmoid colon. A 36‐year‐old woman visited our hospital, complaining primarily of vomiting and abdominal pain. Abdominal CT scan showed the typical finding of intussusception. An emergency colonoscopy revealed that the invaginated colon with a polypoid mass was protruding into the descending colon. A gastrografin enema showed the invaginated bowel segment at the descending colon. We performed endoscopic polypectomy and then hand‐assisted laparoscopic reduction. The pathological finding showed tubular adenoma. Laparoscopy is a diagnostic or therapeutic tool for selected cases of adult intussusception. Benign tumor is one of the causes of intussusception in adults and a good indication for laparoscopic surgery.     

Laparoscopic surgery for rectal cancer with a coexisting Retzius shunt and inferior mesenteric arteriovenous malformation: A case report

A coexisting short-circuit from the inferior mesenteric vein (IMV) to the inferior vena cava, known as a Retzius shunt, and arteriovenous malformation (AVM) of the inferior mesentery are extremely rare conditions. We encountered a case of rectal cancer with coexisting Retzius shunt and inferior mesenteric AVM successfully treated with laparoscopic surgery. Contrast computed tomography (CT) in a 62-year-old man with rectal cancer showed multiple dilated veins at the mesenterium of the descending sigmoid colon. These dilated veins were connected between the IMV and the left renal vein. A diagnosis of Retzius shunt was made, and laparoscopic low anterior resection with lymph node dissection was performed. A pathological examination of the colonic mesenterium revealed AVM communicating with the dilated IMV and Retzius shunt. The preoperative evaluation of aberrant vessels by three-dimensional CT is particularly useful for patients with vascular malformations to ensure safe laparoscopic surgery.     

Cotyledonoid dissecting leiomyoma treated by laparoscopic surgery: A case report

A cotyledonoid dissecting leiomyoma is categorized as a leiomyoma with an unusual growth pattern, which is characterized by remarkable extrauterine bulbous growth in continuity with a dissecting myometrial component. A 36‐year‐old patient was preoperatively diagnosed with a mature cystic teratoma of the left ovary, and according to MRI, the tumor protruded from the uterus into the right broad ligament and was 10 cm in diameter. She underwent laparoscopic surgery to resect ovarian teratoma and the tumor under the right broad ligament. The tumor was almost completely resected and diagnosed as a cotyledonoid dissecting leiomyoma based on intraoperative and pathological findings. Recurrence was not seen for 26 months postoperatively in our case. Gross specimens are often mistaken for malignant lesions, but this was a benign disease. Even if some remnants of the leiomyoma remained postoperatively, recurrence has never been reported. When a cotyledonoid dissecting leiomyoma is resected laparoscopically, intrapelvic structures around it, such as the ureter, uterine artery, bladder, rectum and external iliac vessels, must be given careful attention.     

Laparoscopic resection of retroperitoneal ectopic thyroid tissue

A 43‐year‐old otherwise healthy woman was found to have a retroperitoneal mass during a routine medical examination and was referred for further evaluation. Abdominal CT scan showed a well‐delineated, low‐density area that exhibited heterogeneous contrast enhancement. The area measured about 20 mm in size and was to the left of the aorta at the level of the inferior mesenteric artery. MRI showed a mass with heterogeneous hypointensity on T₁‐weighted images and heterogeneous hyperintensity on T₂‐weighted images. PET‐CT scan showed slightly increased ¹⁸F‐fluorodeoxyglucose accumulation within the mass. Laparoscopic resection was performed. A smooth, brownish mass was seen in the retroperitoneum and was resected with minimal blood loss. Histopathological examination showed a nodular mass measuring 40 × 26 × 20 mm that was composed solely of ectopic thyroid tissue. This case shows the exceptional development of ectopic thyroid in the infradiaphragmatic retroperitoneum and demonstrates the usefulness of laparoscopy for resecting such masses.     

Thymic metastasis of breast cancer 22 years after surgery: A case report

We report a rare case of thymic metastasis of breast cancer. A 68‐year‐old woman, who had undergone surgery for cancer in her right breast and had been free of recurrence for 22 years, was noted to have an abnormal shadow on a chest X‐ray at a regular medical checkup. Further workup, including chest CT, revealed a 22 × 18‐mm mass in the anterior mediastinum. Fluorine‐18‐fluorodeoxyglucose‐PET showed increased fluorine‐18‐fluorodeoxyglucose uptake that was highly suggestive of thymoma. Thoracoscopic thymothymectomy was performed. The tumor had invaded the pericardium, which was also resected. A small nodule was found in the right lung, and it was also resected. The intraoperative frozen‐section diagnosis was breast cancer metastasis to the thymus and lung. The pathological diagnosis was luminal A solid tubular carcinoma (strongly estrogen receptor and progesterone receptor positive, HER2 negative) with an MIB‐1 index of less than 5%. After surgery, the patient was treated with an aromatase inhibitor. As of August 2013, she has been free of recurrence for more than 36 months. It is extremely rare for breast cancer to metastasize to the thymus more than 20 years after surgery.     

Usefulness of indocyanine green fluorescence imaging: A case of laparoscopic distal gastrectomy after distal pancreatectomy with splenectomy

Safe preservation of the remnant stomach during distal gastrectomy in patients who have undergone distal pancreatectomy is important. During distal pancreatectomy, the splenic artery that supplies arterial blood to the cardiac part of stomach is resected. Previous reports suggested that blood flow to the remnant stomach may be insufficient when supplied by only the left inferior phrenic artery. In the present case, a 79‐year‐old woman who underwent distal pancreatectomy with splenectomy 20 years before she was diagnosed with gastric cancer and referred to our hospital. We performed laparoscopic distal gastrectomy and Roux‐en‐Y reconstruction because preoperative CT scan indicated a developed left inferior phrenic artery. To evaluate the blood supply, we employed indocyanine green fluorescence and were able to safely preserve the remnant stomach. Our experience suggests that indocyanine green fluorescence is potentially useful for evaluating blood flow to the remnant stomach.     

Laparoscopic distal gastrectomy for gastric cancer with simultaneous resection of para‐aortic schwannoma

An asymptomatic 74‐year‐old man was diagnosed with early gastric cancer during screening. Preoperative CT revealed a 25‐mm tumor surrounded by the abdominal aorta, inferior vena cava, and left renal vein. Based on the primary tumor stage, para‐aortic lymph node metastasis was considered to be unlikely but could not be ruled out. For this reason, we planned a concurrent diagnostic and therapeutic laparoscopic resection with gastrectomy. The gastric cancer and para‐aortic tumor were successfully resected laparoscopically. The tumor was diagnosed as a schwannoma. With care and skill, we were able to resect the para‐aortic schwannoma and gastric cancer simultaneously and safely by using laparoscopic techniques.     

Laparoscopic excision of a retroperitoneal schwannoma: A case report

Schwannomas are tumors originating from the Schwann cells of the peripheral nerve sheath. Only 1%–3% of schwannomas reportedly occur in the pelvis. In a 67‐year‐old man, a pelvic mass that was 52 mm in diameter was incidentally diagnosed during a preoperative CT evaluation for prostate cancer. Preoperative 3‐D reconstruction CT showed that the feeding artery to the tumor originated from the internal iliac artery and the drainage vein from the internal iliac vein. Each vessel could be isolated, clipped, and cut with minimal bleeding. The tumor was easily dissected from adjacent structures and was completely resected via laparoscopic surgery. Histopathology and immunohistochemistry of the excised specimen revealed a benign schwannoma. Using 3‐D reconstruction to recognize a tumor's positional relation with the supplying vessels is important for avoiding complications during laparoscopic resection in the narrow pelvis. Laparoscopic resection is safe, feasible, and effective for retroperitoneal schwannoma.     

Laparoscopic reduced port surgery for schwannoma of the sigmoid colon: A case report

A 74‐year‐old woman who developed schwannoma of the sigmoid colon was referred to our hospital for colonography to determine the cause of her stool occult blood. Colonoscopy revealed a submucosal tumor, which measured 3 cm in diameter, in the sigmoid colon. Endoscopic ultrasonography revealed a low echoic, homogeneous and demarcated submucosal tumor that continued into the fourth layer of the colonic wall. Gastrointestinal stromal, myogenic or neurogenic tumor was suspected, and thus, laparoscopic sigmoidectomy was carried out. We used two ports during the operation, a SILS Port in the umbilical region and a 12‐mm port in the right lower abdominal wall, and performed sigmoidectomy with D2 lymph node dissection. Histological findings revealed spindle‐like tumor cells with multiform nuclei. The tumor was diagnosed by immunostaining as benign schwannoma of the sigmoid colon. The conventional surgical treatment for schwannoma of the digestive tract is partial resection, but if preoperative diagnosis is unknown, radical resection with lymphadenectomy is acceptable for submucosal tumors in the digestive tract. In this case, laparoscopic reduced port surgery using only one or two ports may be more feasible and beneficial with regard to cosmesis and reduced postoperative pain than conventional laparoscopic colectomy.     

Single‐incision laparoscopic totally extraperitoneal repair for bilateral inguinal hernias after femoral‐femoral artery bypass in a patient on antiplatelet therapy: A case report

A 77‐year‐old man visited our hospital due to bilateral painful inguinal swellings. He had a history of femoral‐femoral artery bypass surgery for peripheral artery disease and took ethyl icosapentate. Additionally, he had a previous history of open left colectomy for descending colon cancer and had a median incision reaching the lower abdomen. With a diagnosis of bilateral direct inguinal hernias after femoral‐femoral artery bypass surgery, he underwent single‐incision laparoscopic surgery for totally extraperitoneal repair, continuing on ethyl icosapentate. During surgery, the preperitoneal space was safely and easily dissected, avoiding a subcutaneous vascular graft. No perioperative complications or hernia recurrence have been observed at 3 months follow‐up.