UNASSIGNED: Lateral lymph node dissection (LLND) for recurrent lateral pelvic lymph node metastasis could be the only surgical treatment to improve its prognosis, but is difficult and challenging technically.
UNASSIGNED: A 75-year-old Japanese man who underwent a radical laparoscopic intersphincteric resection to treat double lower rectal cancer. Computed tomography and MRI showed lower rectal wall thickening and bilateral lateral lymph node swelling. The authors scheduled and performed the LLND for recurrent lateral pelvic lymph nodes after ISR by the totally extraperitoneal (TEP) approach. The bottom of the obturators lymph node (#263D) were positive for metastasis histologically.
UNASSIGNED: The TEP approach is an especially effective option for the treatment of bilateral LLND.
UNASSIGNED: Herein, the authors introduce our surgical technique: successful challenging treatment of the LLND by the TEP approach after intersphincteric resection of the lower rectum.

Inguinal hernia repair is a common surgical procedure with an acceptably low complication rate. However, complications with potentially life-threating consequences may occur in rare cases. These complications might be very challenging to manage, even more in laparo-endoscopic interventions compared to open repair. One of these challenges can be the treatment of an intraoperative injury to the iliac vein. To the best of our knowledge, a lesion of the iliac vein during TEP (totally endoscopic preperitoneal) for inguinal hernia repair, and a safe technique for its management have not been reported yet. We report the case of a 75-year-old male patient with previous abdominal surgery scheduled for TEP repair of an inguinal hernia. During surgery, the iliac vein was damaged. If we had performed a laparotomy in this situation, the potentially life-threatening condition of the patient could have deteriorated further. Instead, to avoid a potential CO2 associated embolism, the preperitoneal pressure was gradually reduced, and the positive end expiratory pressure (PEEP) was increased in the manner that a balance between excessive bleeding and potential development of a CO2 embolism was achieved. The injured vein was sutured endoscopically, and in addition a hemostatic patch was applied. We then continued with the planned surgical procedure. Thrombosis of the sutured vein was prevented by prophylactic administration of low molecular weight heparin until the 14th postoperative day. We conclude that in case of major vein injury during TEP, which might happen irrespective of prior abdominal surgery, the preperitoneal pressure and PEEP adjustment can be used to handle the complication.

Foreign body aspiration (FBA) is a rare, but potentially fatal condition frequently seen in the emergency department. Bronchoscopy plays a major role in its diagnosis and treatment. In patients with laryngectomy, the strategies for airway maintenance and foreign body retrieval are limited. We describe management of a patient with laryngectomy presenting with aspiration of a tracheoesophageal voice prosthesis (TEP). The TEP was not initially seen in chest radiography; however, computed tomography showed it within the right lower bronchus. Successful extraction of the TEP was achieved through bronchoscopy with forceps and retrieval basket. Otolaryngology placed a larger TEP and secured it with sutures. TEP migration is rare, but represents a risk for FBA. Initial imaging in the emergency department can be misleading, requiring a high degree of suspicion, as the TEP device may not be seen in standard chest radiography. Flexible bronchoscopy under moderate sedation in conjunction with forceps and retrieval basket may be appropriate for treatment of FBA in patients with laryngectomy and can be performed in the emergency department, preventing hospital admission.

A 74-year-old man presented for surgical treatment to alleviate chronic post-herniorrhaphy inguinal pain. Physical and imaging examinations suggested that his pain was due to his ilioinguinal nerve being entrapped by a meshoma composed of bilayer mesh and plug mesh. The patient strongly desired mesh removal, although it appeared challenging because of adhesion of the meshes from the previous herniorrhaphies. Anticipating technical difficulty, we performed laparoscopic totally extraperitoneal repair followed by open mesh removal. Thus, the risk of damaging the peritoneum and visceral organs during open mesh removal was eliminated because the peritoneum had already been separated from the pathogenic mesh during the laparoscopic repair. The patient\'s chronic pain was drastically relieved. Combination surgery may therefore be a safe and useful technique in select patients with chronic postoperative inguinal pain. This approach could also prevent hernia recurrence.

Robot-assisted surgery has advanced rapidly since the 1980s. However, new equipment is still needed to overcome problems in conventional endoscopic surgery, including unique risks, such as camera shake and communication difficulties between the operator and the scopist. EMARO, an endoscope manipulator robot, is the world\'s first pneumatically driven endoscope-holder robot that can operate flexibly and smoothly with the use of air pressure. We herein report the surgical experience of using EMARO in totally extraperitoneal inguinal hernia repair. A 77-year-old Japanese man presented with bulging in the right groin area. After we diagnosed a right inguinal hernia, endoscopic inguinal hernia repair was performed. We selected the totally extraperitoneal approach with EMARO. The endoscopic procedure time was 100 minutes, and no intraoperative complications occurred. EMARO brings together features of smooth motion and good manipulation performance. This operation was performed safely and was comparable to a conventional operation completed with human assistants. Solo surgery with EMARO was beneficial in this inguinal hernia patient.

BACKGROUND: Obturator hernias account for less than 0.073% of all hernias and less than 1.6% of all cases of mechanical bowel obstructions.
METHODS: We present a case of a 79 year-old elderly female with two recurrent bowel obstructions that have resolved with conservative management. On the third presentation we performed a totally extraperitoneal repair (TEP) with conscious sedation and a L3/4 spinal block. An obturator defect was patched with a self gripping mesh (progrip). The patient was discharged day 2 post operatively.
CONCLUSIONS: Laparoscopic surgery can be safely performed in high risk patients with careful monitoring. Laparoscopic surgery is usually associated with a shorter post-operative length of stay.
CONCLUSIONS: This case demonstrates the successful but unconventional repair of an obturator hernia in a patient who had a high risk of significant morbidity and mortality with a more conventional anaesthesia and surgery.

BACKGROUND: An Amyand\'s hernia is defined by the presence of a vermiform appendix within an inguinal hernia sac. Most of these cases are not diagnosed preoperatively and the surgical approach is dependent on the type present and associated intraoperative findings. We present a case of a preoperatively diagnosed Amyand\'s hernia in a man who underwent treatment by simultaneous laparoscopic totally extraperitoneal repair and laparoscopic appendectomy.
METHODS: We encountered the case of a 76-year-old Japanese man with a right inguinal pain. Ultrasound and computed tomography confirmed his vermiform appendix herniated into the right inguinal canal. We managed a simultaneous laparoscopic total extraperitoneal inguinal hernia repair with mesh and laparoscopic appendectomy. He was discharged without any postoperative morbidity.
CONCLUSIONS: We recommend laparoscopic appendectomy and totally extraperitoneal hernia repair with mesh after laparoscopic reduction for Amyand\'s hernia.

BACKGROUND: Currently, laparoscopic surgery (LS) is a widely accepted surgical treatment for inguinal hernias, and it has major advantages, especially for recurrent cases.
METHODS: We diagnosed the recurrent inguinal hernia after wound infection and performed the laparosocopic approach. We would like to introduce our method. We distinguished between the presence and absence of bilateral inguinal hernia with an intra-abdominal scope using the transabdominal preperitoneal inguinal hernia repair (TAPP) technique, which we call laparoscopic examination. Thus, we can distinguish between the types of inguinal hernias and whether they are bilateral or not. TEP) part> We dissected the Retzius space on the inside of an epigastric arteriovenous fistula as part of TEP part A, and dissection was performed without a balloon. We separated and dissected the Retzius space. We also performed lateral dissection of the preperitoneal space. We made an incision in the peritoneum at the inner groin ring (hernia sac). We isolated the cord structures (parietalization) using TAPP. We finally checked this operation from the abdominal space (TAPP filed) and determined whether the repair was satisfactorily completed or not.
CONCLUSIONS: Our hybrid method is not special but the conventional laparoscopic approach adapted each merits both TAPP and TEP.
CONCLUSIONS: Our method is effective for difficult recurrent inguinal hernias.

Laparoscopic repair of inguinal hernias is an increasingly popular method of herniorrhaphy, providing advantages, including lower wound infection rates, faster recovery times and less postoperative pain compared with open procedures. The perioperative incidence of venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, in laparoscopic inguinal hernia repair is low, but VTE is still one of the most common causes of postoperative mortality. Moreover, the VTE risk assessment and prophylaxis in inguinal hernia patients is not well defined.
We present an unusual case of sudden death owing to acute pulmonary embolism after undergoing total extraperitoneal inguinal hernia repair. Medline and PubMed databases were searched using the keywords mentioned below, and the literature on VTE risk assessment and prophylaxis in laparoscopic inguinal hernia repair is reviewed.
Laparoscopic inguinal hernia repair, which is regarded as a low risk procedure for VTE, has potential risks for VTE development in the perioperative period. The risks come from both surgical procedures and intrinsic patient characteristics.
Clinicians should consider both the strength of individual risk factors and the cumulative weight of all risk factors prior to surgery. A full VTE risk assessment is essential with proper prophylaxis measures especially in quality-of-life procedures.

For some common conditions, pre-operative clinic visits are often of little value to the patient or surgeon with transfer to the waiting list being predictable. In response to local patient feedback, we introduced a single hospital visit laparoscopic hernia surgery pathway with focus on informed consent, patient-reported outcomes and post-operative interaction with primary care services.
A single hospital visit service for elective hernia repairs was created. Patients were not excluded on age, BMI or co-morbidity. Following referral, patients were telephoned by a surgeon. If considered appropriate, a symptom assessment tool, procedure information and consent form were sent. All patients were operated without attending clinic or pre-operative assessment. Surgeon-led telephone follow-up was made at either 2 or 7 days post-operatively and patient satisfaction assessed at 3 months.
A total of 517 patients were referred for single-stop surgery between 2012 and 2015. Median age was 58 (range 20-92), 91 % were male, and mean BMI was 25.6 (17.4-52.0). No patient refused the single-visit pathway. Single-stop patients had higher knowledge questionnaire scores (mean 16 vs. 10, p = 0.01) than patients who had attended clinic. Nine (1.7 %) were requested to attend clinic to confirm diagnosis, and three (0.8 %) were cancelled by their surgeon on the operative day. A total of 393 hernia repairs (331 TEP, 63 open) were performed under general anaesthetic. 92 % were discharged on day zero. Telephone follow-up day two rather than seven decreased attendance to primary care services (25 % vs. 57 %, p = 0.001). At 3 months, 95 % were satisfied and symptom scores were reduced (median 5-0, p < 0.0001).
Single-visit surgery appears to extend the patient benefits of laparoscopy by reducing hospital visits without compromising safety. Single hospital visit hernia surgery for unselected primary care referrals is possible and acceptable to patients.