Pancreaticobiliary maljunction (PBM) is an anomaly in which the bile and pancreatic ducts join outside the area of action of the sphincter. PBM is typically accompanied by choledochal cysts (dilated PBM); however, cases of PBM without biliary dilatation (nondilated PBM) have also been reported. PBM manifests throughout life. The presentation remains unclear due to age-dependent differences in its pathophysiology. PBM symptoms may be attributed to biliary obstruction caused by substances that differ with age: calcium bilirubinate debris in neonates, protein plugs in children, and gallstones in adults. Each substance is associated with PBM types. Debris occurs in dilated PBM with a narrow segment. Plugs are produced by pancreatobiliary reflux in dilated PBM but rarely in nondilated PBM. Bile duct gallstones have been implicated in dilated PBM with a narrow segment, while gallbladder gallstones may be coincident. Pancreatobiliary reflux appears to induce carcinogenesis silently and cause symptoms in the elderly. A large number of adults with PBM are reported to be asymptomatic. In summary, PBM on its own appears to cause no symptoms. However, associated biliary stricture and pancreatobiliary regurgitation produce obstructive substances or cancers, which may lead to symptoms. The substances may vary with the patient's age and PBM types.

Low anterior resection syndrome (LARS) is a common complication of rectal resections. This study aimed to identify the symptoms that patients perceive as most bothersome, compare the symptom patterns between the early and late postoperative phases, and assess the limitations of existing scoring systems in reflecting patient distress. A cross-sectional study was conducted with 82 patients who underwent sphincter-preserving rectal resection at the Aichi Medical University Hospital (2016–2024). A questionnaire including the LARS score, Cleveland Clinic Florida Fecal Incontinence Score (CCFIS), and original questions on bothersome symptoms and subjective severity (0–10 scale) were administered. The patients were classified into the early (≤ 2 years, n = 28) and late (> 2 years, n = 54) postoperative groups. Clustering was the most frequently reported symptom in both the early (67.9

Laparoscopic percutaneous extraperitoneal closure (LPEC) is an established procedure for pediatric inguinal hernia repair. In adults, however, its application is technically more demanding because of a thicker abdominal wall, greater tissue resistance, and a deeper ligation plane. Based on our standardized pediatric LPEC technique, we describe technical refinements for adult indirect inguinal hernias and examine an important cautionary finding related to patient selection. Among adults with suspected indirect inguinal hernia treated between 2023 and 2025, 20 patients who underwent LPEC were evaluated. For adult cases, we incorporated several technical refinements, including double ligation, puncture-site enlargement, tension reduction during ligation, and needle-route straightening. The procedure was completed in selected adults, including those with a high body mass index and greater abdominal wall thickness. Recurrence occurred in two patients, both of whom had preoperative bowel protrusion. This finding suggests that bowel protrusion should be regarded as an important cautionary feature when considering the indication for adult LPEC. Standardized pediatric LPEC may be adapted for selected adults when appropriate technical refinements are applied. However, cases with preoperative bowel protrusion require particularly careful judgment when determining indication.

Caroli disease encompasses multiple distinct entities. We report two cases of localized cystic dilatation of the intrahepatic bile ducts exhibiting a unique morphology. Both patients were Japanese, diagnosed with a cyst in the liver prenatally (27 weeks’ gestation) and at 3 months of age. The dilatation was limited to the anterior section branch and its first upstream branches, and the cystically dilated bile ducts abruptly connected to normal-sized ducts on both the upstream and downstream sides. One case transiently had debris in the dilated duct during the neonatal period, but did not present any symptoms. The patients have remained asymptomatic for 10 years (case 1) and 9 years (case 2). This case report presents a distinct entity separate from other forms of Caroli disease, namely, localized cystic dilatation of the intrahepatic bile ducts. In total, 12 cases, along with 10 similar cases from literature, were assessed.

INTRODUCTION: Robot-assisted surgery has become an established approach for rectal cancer, offering favorable short-term outcomes and oncologic results comparable to conventional laparoscopic surgery. With recent technological advances, its use has expanded to more complex scenarios, including reoperative surgery with severe adhesions or distorted pelvic anatomy. Metastatic anal fistula carcinoma is uncommon, and its surgical management is challenging, particularly in patients with prior rectal surgery because of severe adhesions and distorted pelvic anatomy. We report a rare case of metastatic carcinoma associated with an anal fistula that developed after curative resection of rectosigmoid cancer and was treated with robot-assisted abdominoperineal resection (R-APR) and gluteal myocutaneous flap reconstruction. CASE PRESENTATION: A 61-year-old man who had previously undergone laparoscopic high anterior resection for Stage IIIB rectosigmoid cancer presented 13 months later with anal pain and swelling. Imaging revealed a mass connected to the rectum through a chronic fistulous tract, and biopsy confirmed adenocarcinoma. A primary carcinoma arising in an anal fistula or local recurrence of rectosigmoid cancer was considered. R-APR was performed using the da Vinci Xi system. Severe adhesions around the prior anastomosis were meticulously dissected, allowing safe total mesorectal excision and resection of the tumor and fistula tract. The large perineal defect was reconstructed with bilateral gluteal myocutaneous flaps. No intraoperative complications occurred. Histopathological examination showed an adenocarcinoma that was morphologically identical to the previously resected rectosigmoid cancer with no evidence of associated in situ lesions. In addition, both tumors demonstrated CK7 (-)/CK20 (+) staining on immunohistochemical examination, which is most consistent with metastatic anal fistula carcinoma. Surgical margins were negative, and no recurrence was observed during 12 months of follow-up. CONCLUSIONS: This case suggests that the robotic platform may facilitate safe dissection in complex reoperative pelvic procedures. Gluteal myocutaneous flap reconstruction provided effec-tive coverage for a large perineal defect in this patient.

Background The gubernaculum is essential for testicular descent, but its detailed surgical anatomy remains poorly understood. We have previously identified an unrecognized anatomy of the round ligament in female patients with sliding inguinal hernias. Objective This study investigated whether comparable anatomical features exist in the gubernaculum of male cryptorchidism patients, as compared to those identified in female sliding hernias. Materials and Methods We retrospectively analyzed undescended testes located in the inguinal canal that underwent open inguinal orchidopexy between 2016 and 2025. Laparoscopically managed nonpalpable testes and those with suprascrotal testes were excluded. To ensure consistent anatomical evaluation, a standardized surgical protocol supervised by the senior author was applied to all cases. Findings were verified using operative reports and video recordings. After dissecting the processus vaginalis along the internal spermatic fascia (transversalis fascia), the pars infravaginalis gubernaculi were exposed. The relationship between the plica gubernaculi and pars infravaginalis gubernaculi, as well as the site of distal gubernacular fixation, was assessed. Results A total of 64 undescended testes of 56 patients were included. Video recordings were available for 45 of these 64 testes (70%). A patent processus vaginalis was observed in 60 out of 64 testes (94%), while it was obliterated in two ascending testes and unknown in two. In all 64 testes (100%), the pars infravaginalis gubernaculi was not continuous with the plica gubernaculi, with the transversalis fascia interposed between them. This configuration closely resembled that described previously for sliding inguinal hernias in women. Distal gubernacular fixation was located lateral to the scrotum in 49 testes (77%), at the upper scrotal border in 14 testes (22%), and absent in one testis (1.6%). Discussion Cryptorchidism is associated with a previously unrecognized discontinuity of the gubernaculi and common abnormal distal gubernacular fixation. These findings challenge the conventional views on gubernacular invagination and suggest that abnormal distal fixation may contribute to failed testicular descent. The study was limited by its single-center, retrospective design, small sample size, and lack of a control group. Conclusion This study identified a previously unrecognized discontinuity of the gubernaculi in cryptorchidism. These findings deepen the understanding of the pathophysiology of testicular descent.

INTRODUCTION:We have developed a stapler repair technique as an endoscopic retromuscular strategy for ventral hernia repair. Because transversus abdominis release before stapled fascial closure is technically difficult in this technique, preoperative reduction of fascial tension may be valuable even in moderate-sized hernias. Botulinum toxin A may address this limitation, but its necessity and appropriate dosing in Asian patients remain unclear. METHODS:This prospective, single-center study included 10 patients with midline ventral hernias ≥ 5 cm in width. Ultrasound-guided botulinum toxin A was injected into the bilateral lateral abdominal wall muscles using a weight-adjusted dose of 200 units of Botox Vista for patients weighing ≥ 50 kg and 100 units for those weighing < 50 kg. Surgery was scheduled 4 weeks later, and endoscopic retromuscular repair using the stapler repair technique was the preferred approach. CT-based changes in defect width and muscle length, surgical outcomes, and treatment-related adverse events were evaluated. RESULTS:Eight patients underwent endoscopic repair, one open repair, and one intraperitoneal onlay mesh plus repair. Median defect width decreased from 5.7 to 4.5 cm (p = 0.004), and lateral abdominal wall muscles significantly elongated bilaterally. No treatment-related adverse events occurred. Primary fascial closure was achieved in all patients, with no recurrence during a median follow-up of 12 months. CONCLUSION:Weight-adjusted preoperative botulinum toxin A was safe and produced favorable CT-based morphological changes. These changes may reduce fascial tension before stapled closure and help expand the applicability of the stapler repair technique to selected patients with moderate-sized ventral hernias.

Chronic postoperative inguinal pain (CPIP) is a major complication after hernia repairs in adults. However, little is known about CPIP in children. Charts of 855 children with an average age of 3.7 years (range, 0–18 years) who underwent laparoscopic percutaneous extraperitoneal closure (LPEC) between April 2016 and December 2023 were reviewed. Pain after one postoperative month (PIP: postoperative inguinal pain) was the primary outcome measure. Of these, pain lasting more than three months was extracted as CPIP. Nine children (1.1

Video-based learning, a form of nonsynchronous imitation, is widely used in robotic surgical training. However, the effectiveness of synchronous imitation, in which trainees replicate expert movements in real time, remains unclear. This study aimed to evaluate the effect of synchronous imitation on robotic surgical skill acquisition. A randomized-controlled trial was conducted with 20 novices in robotic surgery, between April 2023 and March 2024. Participants were stratified by suturing experience and randomly assigned to either the synchronous or nonsynchronous group. The training task was “Thread the Rings” on the da Vinci Skills Simulator. Before each of the 10 trials, participants in the synchronous group watched a recorded expert demonstration and attempted to mimic instrument movements in real time. In contrast, the nonsynchronous group viewed the same video passively without simultaneous imitation. Proficiency scores (0–100) were calculated automatically for each trial. Both groups demonstrated improvement over time; however, mixed-effects regression models showed no significant difference in the rate of score improvement between the two groups (P = 0.88). Synchronous imitation did not lead to superior skill acquisition compared with video-based observations alone. Further research with a larger sample size is warranted to validate these findings.

ABSTRACT Aim We successfully established the stapler repair technique (SRT), a straightforward laparoscopic Rives‐Stoppa approach utilizing a linear stapler. This study retrospectively evaluated its short‐term outcomes to determine its safety and efficacy. Methods The surgical outcomes of 87 patients who underwent laparoscopic median incisional hernia repair at our hospital were reviewed between August 2017 and May 2024. Patients were treated with intraperitoneal onlay mesh (IPOM), laparoscopic trans‐abdominal retromuscular (TARM), or SRT. Results Among these patients, 37 were treated with IPOM, 16 with TARM, and 34 with SRT, with no significant differences in patient characteristics. The median surgical time (range) was 96 min (50–211) for IPOM, 256 min (196–300) for TARM, and 112 min (60–289) for SRT, respectively. The median mesh areas (ranges) were 210 cm 2 (80–500) for IPOM, 500 cm 2 (270–780) for TARM, and 379 cm 2 (176–864) for SRT, respectively. The SRT group had significantly shorter operative times ( p < 0.001) and smaller mesh areas ( p = 0.005) than the TARM group. Compared to the IPOM group, there was no significant difference in operative time in the SRT group ( p = 0.444), but the mesh area was significantly larger ( p < 0.001). The SRT group had no significant intraoperative complications or conversions to open surgery. Conclusion SRT offers a comparable operative time to IPOM and a significantly shorter time than TARM. Additionally, SRT can be performed extraperitoneally with no significant intraoperative complications or conversion to open surgery. These findings suggest that SRT is a safe and effective minimally invasive approach in median laparoscopic incisional hernia repair.

During laparoscopic inguinal hernia repair, the inferior epigastric vessels (IEVs), vas deferens, and spermatic vessels are often used as landmarks for horizon adjustment during camera navigation. The present study investigated the visual angle of landmarks around the internal inguinal ring using recorded video clips. The angle of the IEVs, vas deferens, spermatic vessels, and the degree of lateral tilt of the scope were measured using a video clip. The angle of the median line of the vas deferens and spermatic vessels (MVS) was also calculated. Between 2018 and 2022, 70 inguinal hernia lesions underwent robot-assisted inguinal hernia repair. Under adjustment according to lateral tilt of the scope, the mean angles of the IEVs and MVS were 14.1° laterally (SD = 15.9°) and −1.5° medially (SD = 15.8°), respectively. The IEVs and MVS do not always adopt an absolutely vertical course, and some structures run obliquely. The angles of the IEVs and MVS should, therefore, be confirmed at the beginning of the operation to guide horizon adjustment.

BACKGROUND:Although pancreaticobiliary maljunction (PBM) is associated with a high incidence of biliary cancer, it often goes undiagnosed. This means that the true prevalence of PBM and the incidence of biliary cancer are unknown. High confluence of the pancreaticobiliary ducts (HCPBD) may be an intermediate PBM variant, though reports are scarce. In this study, we aimed to determine the true prevalence of PBM and HCPBD and the actual incidence of biliary cancer. METHODS:We retrospectively analyzed data from adults who underwent cholecystectomy for benign gallbladder disease and compared them to those with gallbladder and bile duct cancers. The common channel (CC) and narrow distal segment (NDS) were measured using magnetic resonance cholangiopancreatography to diagnose PBM and HCPBD. RESULTS:PBM and HCPBD were identified in 0.44% and 0.88% of 2046 benign cholecystectomies, 16% and 4.2% of gallbladder cancers, and 1.3% and 3.8% of bile duct cancers, respectively (p < 0.01). CONCLUSIONS:The overall prevalence was 0.44%. Combined with national data, the gallbladder cancer incidence in PBM was estimated to be 2.4% over one decade, which is 38-fold higher than that in the general population. Approximately 1% of the population have HCPBD, which may be a risk factor for biliary cancer.

Background Liposarcomas represent similar to 9.8-16% of soft tissue sarcomas, with the extremities and retroperitoneum being the primary sites of occurrence. While liposarcoma in the inguinal region is uncommon, few reported cases originate from the retroperitoneum and protrude into the scrotum through the inguinal canal. Here, we present a case of a retroperitoneal liposarcoma with prolapse from the left inguinal canal into the scrotum following hernia repair with a mesh plug. Case presentation A 55-year-old male patient underwent a CT scan for a suspected recurrent inguinal hernia, which revealed a sizeable adipose-dense tumor by the left kidney extruded through the left inguinal canal surrounding the scrotum. The patient had undergone mesh plug repair for a left inguinal hernia at another hospital one year ago and noticed ipsilateral inguinal swelling after the hernia repair. The patient was referred to our hospital. The tumor resection was completed with combined resection of potentially involved organs: left side colon, left kidney, and left adrenal gland. Also, complete excision of the tumor was accomplished through surgical resection of the posterior wall of the inguinal canal, the mesh plug, and the tumor extending into the scrotum. Given the nearly complete absence of the inguinal canal's posterior wall and the anterior wall's torn state, sutures were employed to close the external obturator tenosynovitis. Additionally, the inguinal ligament was closed using a tension-free incision technique. Only a mesh was subsequently placed. The resected tumor measured 47 x 30 x 15 cm and 7.5 kg in weight. After surgical resection, a retroperitoneal liposarcoma diagnosis was established. After 2 years and 6 months following the surgical resection, no recurrence has been observed for either liposarcoma or inguinal hernia. Conclusion The previous inguinal hernia in this case must be a prolapse of retroperitoneal liposarcoma. Thus, it is recommended to conduct a preoperative examination, which should include a CT scan, since the presence of a fatty mass within the hernia may indicate the presence of a retroperitoneal liposarcoma. Even if a preoperative diagnosis cannot be made, a long-term prognosis can be expected if the retroperitoneal liposarcoma can be completely resected at reoperation.

Background As laparoscopic surgery becomes more prevalent worldwide, Meckel’s diverticula are increasingly being discovered incidentally during surgery. There is no consensus on whether to follow up or resect such diverticula, which are usually asymptomatic. In cases of transabdominal preperitoneal inguinal hernia repair, resection of such a diverticulum might add the risk of mesh infection. Thus, it is unclear whether simultaneous intestinal resection is advisable. Case presentation A 64-year-old man diagnosed with a left indirect inguinal hernia underwent laparoscopic inguinal hernia repair, during which a 2-cm Meckel’s diverticulum located contralateral to the mesentery of the ileum approximately 30 cm from Bauhin’s valve was detected incidentally. Because of the potential risk of future complications such as hemorrhage, diverticulitis, or tumor development, wedge resection of the ileum was performed extracorporeally through an extended umbilical port site after completion of the hernia repair. Pathological examination revealed a neuroendocrine tumor (G1) in Meckel’s diverticulum, which was successfully resected without any mesh infection or postoperative complications. Discussion Our patient’s clinical course raises two important issues. First, a Meckel’s diverticulum detected incidentally during laparoscopic surgery should be resected promptly because malignant tumors within such diverticula have frequently been reported. Second, simultaneous resection with hernia repair using mesh seems to be as safe as other clean-contaminated surgery. Conclusions Management of incidental Meckel’s diverticula should be selected by appropriate assessment for the risk of malignancy and complications.

Background Accurate assessment of acute appendicitis severity is important for planning treatment. This study aimed to evaluate the utility of ultrasound (US) grading classification in assessing acute appendicitis severity in children. Methods We retrospectively studied pediatric patients diagnosed with acute appendicitis using US. US findings were classified into four grades based on the internal structure, and the clinical findings were compared among them. We also compared the frequency of complicated appendicitis (CA) among US grades in patients who underwent early appendectomy (EA). Results In total, 124 pediatric patients with acute appendicitis were enrolled. The mean age was 11.7 years, and 74 patients were male. Fifty-seven patients were classified as Grade Ⅰ-Ⅱ, and 67 patients were classified as Grade Ⅲ-Ⅳ. Grade III-IV patients were significantly younger, had lower body weights, and longer duration of symptoms than Grade I-II patients. Grade III-IV patients also had significantly higher body temperatures, pediatric appendicitis scores, white blood cell counts, and C-reactive protein levels on admission. In the EA cases, most CA cases were Grade III-IV (90.3%). Conclusions US grading classification may be useful for assessing the severity of acute appendicitis in children and assisting in making treatment decisions.

Abstract Purpose The use of robotic surgery has increased exponentially worldwide, as robots have versatile functions that can amplify the surgeon's skill. At the same time, reports of robotic approach for bariatric surgery are increasing. However, a common problem with the introduction of novel surgeries is a prolonged operation time. Therefore, an innovative approach should be developed prior to the introduction of a novel surgery to ensure patient safety. Method This article describes robotic sleeve gastrectomy using the stapling-first technique in accordance with our newly revised task protocol, and evaluates the preliminary clinical results of robotic sleeve gastrectomy performed by a single surgeon between June 2021 and December 2022. Results The cohort comprised 10 patients with a median body mass index of 40.3 (range, 38.1–45.8) kg/m2. The median operation time was 230 (range, 178–281) minutes and median console operation time was 164 (range, 119–204) minutes. The median time for each surgical phase was 72 (range, 39–86) minutes for stomach stapling, 46 (range, 34–66) minutes for suturing the staple line, and 36 (range, 24–48) minutes for stomach dissection. The median blood loss was 15 (range, 5–78) g. Our task protocol was accomplished in all patients and only case 1 was converted to laparoscopic sleeve gastrectomy. No patients experienced postoperative complications or gastroesophageal reflux. Conclusion Robotic sleeve gastrectomy using the stapling-first technique was safely performed in the introductory phase by following the task protocol.

Background Biliary atresia (BA) is a rare cause of persistent jaundice in infants that can result in vitamin K malabsorption and vitamin K deficiency bleeding (VKDB). We present an infant with BA who developed a rapidly growing intramuscular hematoma in her upper arm after a vaccination which caused a radial nerve palsy. Case presentation An 82-day-old girl was referred to our hospital because of a rapidly growing left upper arm mass. She had received three doses of oral vitamin K before age 1 month. At age 66 days, she received a pneumococcal vaccination in her left upper arm. On presentation, she showed no left wrist or finger extension. Blood examination revealed direct hyperbilirubinemia, liver dysfunction, and coagulation abnormalities, indicating obstructive jaundice. Magnetic resonance imaging showed a hematoma in the left triceps brachii. Abdominal ultrasonography revealed an atrophic gallbladder and the triangular cord sign anterior to the portal vein bifurcation. BA was confirmed on cholangiography. VKDB resulting from BA in conjunction with vaccination in the left upper arm were considered the cause of the hematoma. The hematoma was considered the cause of her radial nerve palsy. Although she underwent Kasai hepatic portoenterostomy at age 82 days, the obstructive jaundice did not sufficiently improve. She then underwent living-related liver transplantation at age 8 months. The wrist drop was still present at age 1 year despite hematoma resolution. Conclusions Delayed detection of BA and inadequate prevention of VKDB can result in permanent peripheral neuropathy.

BackgroundThe Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis.MethodsThis study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2 years [early period group (EG)], whereas FFLC was predominantly used for the last 2 years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed.ResultsThe difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4 days, p < 0.001).ConclusionAfter the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay.

Background: The criteria for deciding upon non-operative management for nonocclusive mesenteric ischemia (NOMI) are poorly defined. The aim of this study is to determine the prognostic factors for survival in conservative treatment of NOMI. Methods: Patients with bowel ischemia were identified by searching for “ICD-10 code K550” in the Diagnosis Procedure Combination database between June 2015 and May 2020. A total of 457 patients were extracted and their medical records, including the clinical factors, imaging findings and outcomes, were analyzed retrospectively. Diagnosis of NOMI was confirmed by the presence of specific findings in contrast-enhanced multidetector-row CT. Twenty six patients with conservative therapy for NOMI, including four cases of explorative laparotomy or laparoscopy, were enrolled. Results: Among the 26 cases without surgical intervention, eight patients (31%) survived to discharge. The level of albumin was significantly higher and the levels of lactate dehydrogenase, total bilirubin, C-reactive protein, and lactate were significantly lower in the survivors than the non-survivors. Sepsis-related Organ Failure Assessment (SOFA) score was significantly lower in the survivors than the non-survivors. The most reliable predictor of survival for NOMI was SOFA score (cutoff value =<3 points), which had the highest AUC value (0.899) with odds ratio of 0.075 (CI: 0.0096-0.58). Conclusions: The SOFA score and several biological markers are promising predictors to determine a treatment plan for NOMI and to avoid unnecessary laparotomy.