Objectives:This study evaluates the safety and efficacy of laparoscopic ventral rectopexy (LVR) in nonagenarian patients with external rectal prolapse (ERP) compared to Delorme's procedure.Methods:We conducted a retrospective analysis of prospectively collected data, including nonagenarian patients who underwent either LVR or Delorme's procedure, comparing outcomes such as morbidity, length of hospital stay (LOS), and recurrence rates.Results:Between September 2009 and August 2023, 22 patients (median age 91, range 90-94 years) underwent LVR, while 12 patients (median age 91, range 90-96 years) received Delorme's procedure. Baseline characteristics, including sex ratio, parity, American Society of Anesthesiology grade, and Body Mass Index, did not significantly differ between the groups. LVR had a significantly longer operating time but lower blood loss than Delorme's procedure. Postoperative LOS was significantly shorter for LVR patients (median 1, range 1-3 days) compared to Delorme's procedure patients (median 2.5, range 1-13 days; P = 0.001). Notably, no significant morbidity occurred in the LVR group, while one case of delirium and another of solitary rectal ulcer syndrome were observed in the Delorme's procedure group. Recurrence rates were lower in the LVR group, with no recurrences during a median follow-up of 23 months (range 1-65 months), compared to one recurrence at 2 months during a median follow-up of 34 months (range 1-96 months) in the Delorme's procedure group.Conclusions:LVR is a safe and effective surgical option for nonagenarian ERP patients, showing favorable outcomes in terms of morbidity, LOS, and recurrence rates compared to Delorme's procedure.

Peritoneal dialysis (PD) is a risk factor for inguinal hernia, and herniorrhaphy on PD might be complicated by PD fluid.Although sac resection should contribute to preventing indirect hernia recurrence, the safety on PD has not beendescribed. This case series describes the detailed surgical procedures and long-term outcomes of 16 cases ofinguinal herniorrhaphy on PD. Results are shown as median (range). The age was 67.5 (53-83) years. Beginning atthe 6th case, we omitted interim hemodialysis and performed the Lichtenstein procedure. We performed sac excisionin the 14 patients. No complication related to PD was found. The follow-up period was 41.5 (4-124) months. Norecurrence occurred. They could continue PD for 21.5 (4-103) months after surgery. The total PD duration was 38.5(18-152) months. In conclusion, inguinal herniorrhaphy with sac resection may not compromise safety even forpatients on PD and achieve the expected PD duration without recurrence.

Laparoscopic ventral rectopexy (LVR) has become the preferred treatment for patients with external rectal prolapse (ERP). However, its efficacy in male patients has raised concerns due to a higher recurrence rate. We evaluated the outcome of modifications to the LVR technique in men with ERP. Four male patients who underwent a combination of perineal and LVR procedures for ERP were included. The perineal procedure involved cauterization of the mucosa on the posterior surface of the prolapsed rectum using a saline-cooled radiofrequency coagulation device. Subsequently, longitudinal sutures were applied to plicate the rectal muscular wall along with the cauterized mucosa, ensuring the apposition of intact mucosa. The median follow-up duration was 24 months (range: 19 − 26 months), during which no postoperative complications were observed. Clinical examinations and postoperative defecography revealed no cases of recurrent ERP. The combined perineal and LVR treatment approach for ERP in male patients appears to effectively prevent recurrence for up to 2 years.

Mastitis and breast abscesses are most common in lactating women but can also be observed in non-lactating women, adolescent girls, and neonates. However, breast abscesses are extremely rare in young boys. Herein, we report the case of a three-year-old boy with a swollen and painful right nipple, later diagnosed with a breast abscess. In this case, we suspected that the patient's inverted nipple was the possible site of the infection. To our best knowledge, this is the first case report of breast abscess in a young boy after the neonatal period. Although Staphylococcus aureus is the most common pathogen, our patient showed three rare bacteria, namely, Peptoniphilus harei, Actinotignum sanguinis, and Porphyromonas somerae, in the culture of the aspirated pus. Furthermore, this case study is the first report of a breast abscess caused by Porphyromonas somerae.

Purpose This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). Methods Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the Constipation Scoring System (CSS) and Fecal Incontinence Severity Index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. Results Constipation was substantially improved in 40–70% of the LVR patients and 70–90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60–90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20–59] mm preoperatively vs. 11 [0–44] mm postoperatively, P < 0.0001) and TAR patients (33 [20–55] mm preoperatively vs. 8 [0–27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3–100] % vs. 79 [45–100] %, P = 0.047). Conclusion Thereduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

Objectives: This study aimed to evaluate factors that contribute to the recurrence of external rectal prolapse (ERP) following laparoscopic ventral rectopexy (LVR). Methods: All patients who underwent LVR using synthetic meshes between 2011 and 2018 were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index (FISI) and Constipation Scoring System (CSS) was administered preoperatively and postoperatively. Defecography was performed 6 months postoperatively. Univariate and backward stepwise multivariate Cox analysis was performed to determine the prognostic factors of recurrence. Results: In total, 132 patients with a median follow-up of 46 months were included. The overall recurrence rate was 6.8% (n = 9), as confirmed by defecography at 6 months in six of the patients. None of the patients developed mesh erosion. FISI and CSS scores were significantly reduced at 3 months and remained significantly reduced for 3 years. Multivariate analyses revealed that the predictors of recurrence included male sex (hazards ratio, 11.3; 95% confidence interval, 3.0-43.0) and age >80 years (hazards ratio, 10.7; 95% confidence interval, 1.3-86.3). Eight patients with recurrence underwent surgery via Delorme's procedure (n = 7) and posterior rectopexy (n = 1). Two patients with new-onset rectoanal intussusception and one with uncorrected sigmoidocoele underwent repeat LVR. Conclusions: LVR is effective in treating ERP with low morbidity and low recurrence. Male patients and patients older than 80 years are at increased risk of recurrence. Hence, the LVR technique should be modified or coupled with other perineal procedures when treating ERP, especially in male patients.

Introduction Although long‐term crude outcomes of laparoscopic ventral rectopexy for external rectal prolapse (ERP) have been documented, repetitive functional and quality of life (QOL) assessments are scarce. This study assessed midterm annual functional results and QOL after laparoscopic ventral rectopexy for ERP. Methods This study consisted of 58 patients and was a retrospective analysis of prospectively collected data. The Fecal Incontinence Severity Index, the Constipation Scoring System, and QOL instruments (ie 36‐item Short‐Form Health Survey and Fecal Incontinence Quality of Life scale) were administered before and after operation. Results There was no mortality or major morbidity. After a median follow‐up of 49 months (6‐92 months), recurrence of ERP was noted in one patient (2%). There were no mesh‐related complications. The median Fecal Incontinence Severity Index score was significantly reduced at 3 months (34 [10‐61] vs 12 [0‐50], P < 0.0001) and remained significantly reduced for 5 years. The median Constipation Scoring System score was significantly reduced at 3 months (14 [9‐20] vs 7 [0‐16], P < 0.0001) and remained significantly reduced for 4 years. No patients developed new‐onset constipation. All of the Fecal Incontinence Quality of Life scales significantly improved overtime for 4 years. All of the 36‐item Short‐Form Health Survey scales were significantly improved at 3 and 6 months, but none of the scales significantly improved after 2 years. Conclusion Laparoscopic ventral rectopexy for ERP was associated with low morbidity, low recurrence, and a midterm improvement in function and fecal incontinence‐specific QOL.

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.” At 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. The 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]. The 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. 1). Fig. 1 Hands on training by residents themselves Surgical 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. 2). Fig. 2 Synergetic effect by simultaneous training Another 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 (Tables 1, ​,2,2, ​,3,3, ​,44). Table 1 Guidelines for performing endoscopic surgery (JSES 2(I):7), proposed by Japan Society for Endoscopic Surgery, 29 August, 1992, 4 December 1996 (4th revision) Table 2 Criteria for evaluating endoscopic surgical skill at the Kameda Medical Center Table 3 Progress of surgical residents during 2 years of training (rated every 6 months in terms of levels) Table 4 Three generations of surgeons currently classified by their educational background Some 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. Hands-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. The 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. The 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. Simultaneous 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.

We report a case of adult intussusception due to inverted Meckelʼs diverticulum with lipoma, accompanied by idiopathic intussusception. A 34-year-old man with intermittent abdominal pain was found in enhanced abdominal CT to have multiple concentric ring signs of the intestines, diagnosed as ileoileal intussusception, ne-cessitating emergency surgery. After confirming the presence of two separate intussusceptions laparoscopically, we made a minimal 5cm incision at an appropriate site. The anal one shrank completely. The oral one, in-cluding the tumor, was resected after it had been shrunk as much as possible. Subserosal lipoma was located at the base of the inverted Meckelʼs diverticulum. Two such simultaneous intussusceptions are extremely rare.