Prognosis and recurrence of spontaneously ruptured hepatocellular carcinoma treated after hepatectomy: A single institution experience.

Spontaneously ruptured hepatocellular carcinoma (srHCC) is a life-threatening disease. The prognosis of patients with srHCC after hepatectomy remains unclear. This study aimed to investigate the prognosis and recurrence after hepatectomy in patients with srHCC. From 2015 to 2020, a retrospective analysis of patients with srHCC who underwent hepatectomy was performed, and compared with patients with unruptured HCC. Among the 86 patients with HCC who underwent hepatectomy, 11 had srHCC. The median tumor size in the ruptured group was significantly larger than that in the unruptured group (P = .001). The incidence rate of vascular invasion and Glisson capsule invasion in the ruptured group was significantly higher than that in the unruptured group. (P = .012 and P < .001, respectively). The American Joint Committee on Cancer was significantly higher in the ruptured group than in the unruptured group (P < .001). In total, 8 (73%) patients in the ruptured group experienced recurrence, whereas the median recurrence-free survival (RFS) and overall survival (OS) periods in the ruptured group were 15 (11-32) and 23 (17-38) months, respectively. In the unruptured group, 34 (45%) patients experienced recurrence, and the median RFS and OS periods were 20 (8-37, P = .099) and 33 (12-51, P = .394) months, respectively. Patients who developed peritoneal metastases were included in the ruptured group (n = 3). Ruptured HCCs exhibit worse oncological outcomes have poorer survival and higher recurrence rates than unruptured HCCs.

Clinical impact of surgical treatment for the spontaneously ruptured resectable hepatocellular carcinoma: A single institution experience.

Spontaneously ruptured hepatocellular carcinoma (srHCC) is a fatal complication of hepatocellular carcinoma (HCC). In addition, emergency treatment is frequently fraught with difficulties. This study aimed to investigate the prognosis and recurrence pattern in patients undergoing hepatectomy for the srHCC. This retrospective study included 11 patients with srHCC treated using either emergency hepatectomy or emergency transarterial embolization (TAE) followed by staged hepatectomy between January 2015 and December 2019. The patients visited the emergency room because of a sudden rupture of HCC without being diagnosed with HCC. We analyzed the prognosis, recurrence rate, and survival in these patients after hepatectomy. Four of the 11 patients in this study were classified as Child-Pugh class A and 7 as Child-Pugh class B. Nine patients visited for sudden onset of abdominal pain, and 2 for sudden onset of shock. The median hemoglobin level at the time of the visit was 11.5 g/dL (interquartile range: 9.8-12.7). Five patients underwent one-stage hepatectomy and 6 underwent emergency TAE hemostasis followed by staged hepatectomy. Median overall survival and recurrence-free survivals were 23 and 15 months, respectively. Recurrence occurred in 7 patients (4 in the one-stage group and 3 in the staged group). Among patients with recurrence, 6 had intrahepatic recurrence and 3 peritoneal metastases. Patients with srHCC who undergo staged hepatectomy can achieve a relatively good prognosis. The most common sites of recurrence after hepatectomy are intrahepatic and peritoneal. Peritoneal metastases are more likely to occur after one-stage hepatectomy.

Ampullary gangliocytic paraganglioma with lymph node metastasis: A case report with literature review.

RATIONALE: Gangliocytic paraganglioma (GP) is a rare tumor that mostly develops in the duodenum and is composed of the following 3 cell types: epithelioid endocrine, spindle-like, and ganglion-like cells. It manifests as symptoms such as abdominal pain, gastrointestinal bleeding, and weight loss; however, occasionally, it is incidentally detected on endoscopic or radiologic examinations. Although GP is usually benign, it can metastasize to the lymph nodes, and distant metastases have been reported in some cases. PATIENT CONCERNS: A 46-year-old woman presented with anemia on health surveillance examination. She had no other specific symptoms, and her physical examination did not reveal any abnormal finding. DIAGNOSIS: Endoscopic ultrasound-guided fine-needle aspiration biopsy was performed, and the endoscopist obtained samples from the inner side of the ampullary mass. Pathological examination suggested GP or a neuroendocrine tumor. INTERVENTIONS: Initially, we planned transduodenal ampullectomy with lymph node excision. However, there was severe fibrosis around the duodenum, and an examination of a frozen biopsy sample from the periduodenal lymph node showed atypical cells in the lymph node. Therefore, we performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection. OUTCOMES: The final pathological diagnosis was GP located in the ampulla of Vater. The GP showed lymphovascular and perineural invasion and invaded the duodenal wall. Furthermore, 4 out of 18 harvested lymph nodes showed metastasis. LESSONS: We described a case of GP confined to the ampulla with regional lymph node metastasis and reviewed published literature on ampullary GP with lymph node metastasis.

Laparoscopic excision for multiple intra-abdominal juvenile fibrosarcoma: A case report.

INTRODUCTION AND IMPORTANCE: Fibrosarcoma is a rare malignant tumor comprising spindle-shaped fibroblasts exhibiting variable collagen production. Adult-type fibrosarcoma (AFS) mainly occurs in people aged between 30 and 80 years, primarily in the deep soft tissues of the trunk, neck, and extremities, especially in areas surrounding bones. Juvenile fibrosarcoma(JFS) is a type of AFS that occurs in adolescents and rarely develops in the abdominal cavity. CASE PRESENTATION: A 13-year-old girl presented with right upper quadrant pain for 5 days. Abdomen and pelvis computed tomography showed a 12 × 6-cm, ill-defined, lobulated, solid, cystic mass in the abdominal cavity. On laparoscopy, there were two masses in the abdominal cavity. One abutted the stomach and severely adhered to the gallbladder. The second mass was located between the transverse colon and duodenum, and it was surrounded by the omentum. The tissues surrounding the masses were finely dissected, and the two masses were excised completely. The patient was discharged without complications on post-operative day 7. CLINICAL DISCUSSION: JFS, AFS in adolescents, is a rare malignant tumor. And there have been no reported cases of multiple JFS in abdominal cavity. Surgical excision is the gold standard of treatment for localized AFS, and the laparoscopic approach for minimal tumor handling is beneficial. CONCLUSION: We describe a rare case of multiple intra-abdominal juvenile fibrosarcoma, managed through laparoscopic surgery.

Spontaneous heterotopic mesenteric ossification around the pancreas causing duodenal stenosis: A case report with literature review.

INTRODUCTION AND IMPORTANCE: Heterotopic mesenteric ossification (HMO) is a rare condition that can be hereditary or nonhereditary. It can lead to small bowel obstruction, which may require corrective surgery. Most affected patients have a history of abdominal surgery or trauma. Spontaneously occurring HMO is even rarer, with only 7 cases reported till date. There has been no previous report of spontaneous peripancreatic HMO. CASE PRESENTATION: A 60-year-old man presented with complaints of recurrent nausea and vomiting for 2 months. Esophagogastroduodenoscopy revealed luminal stenosis and edematous changes involving the second and third parts of the duodenum but not its complete obstruction. Abdominopelvic computed tomography showed faintly enhanced thickening of the involved duodenal walls along with mild dilatation of the common bile duct. Considering the possibility of periampullary cancer, we performed a pylorus-preserving pancreaticoduodenectomy. Histopathological examination confirmed the diagnosis of HMO with extensive fibrosis involving the peripancreatic soft tissue. CLINICAL DISCUSSION: The peripancreatic HMO with severe fibrosis can occur duodenal stenosis, and it is mimicking periampullary cancer. However, the preoperative diagnosis of spontaneous HMO is difficult, and a diagnosis confirmed after surgery. CONCLUSION: Herein, we described our experience of managing a rare case of duodenal stenosis due to spontaneous HMO involving peripancreatic tissue.

Laparoscopic management for stump appendicitis: A case series with literature review.

INTRODUCTION: Appendectomy is one of the most common emergency surgical operations. Stump appendicitis is a rare complication after appendectomy and is caused by acute inflammation of the remnant part of the appendix. Because of the low index of suspicion owing to a previous history of appendectomy, the diagnosis of stump appendicitis is often delayed. METHODS: Between January 2008 and December 2017, 6 patients were diagnosed with stump appendicitis with or without perforation at a single institution. They had undergone operative management with laparoscopic approach. The clinical data of these patients were retrospectively analyzed by reviewing the medical records and pathologic reports. RESULTS: Five patients were male, with a mean age of 42.4 years (range 11-77 years). The time interval after initial appendectomy ranged from 2 weeks to 30 years. Three patients underwent laparoscopic completion appendectomy, and the others underwent laparoscopic ileocecectomy. The mean hospital stay was 9 days (range 5-13 days). There were no cases of open conversion. CONCLUSIONS: Stump appendicitis is a rare complication after appendectomy. A laparoscopic procedure can be performed for management of stump appendicitis with or without perforation.

Urinary Cell-Free DNA IQGAP3/BMP4 Ratio as a Prognostic Marker for Non-Muscle-Invasive Bladder Cancer.

BACKGROUND: Disease monitoring in non-muscle-invasive bladder cancer (NMIBC) patients is crucial for early identification of disease recurrence and progression. High IQGAP3/BMP4 and IQGAP3/FAM107A ratios in urinary cell-free DNA (ucfDNA) are a diagnostic biomarker for bladder cancer. We aimed to investigate whether the levels of these biomarkers in ucfDNA can be used to monitor disease recurrence or progression in patients with NMIBC. PATIENTS AND METHODS: A total of 103 patients with NMIBC (pTa-pT1) were enrolled. The IQGAP3/BMP4 and IQGAP3/FAM107A ratios in ucfDNA were measured by real-time PCR, and the results were compared with clinical outcome by Kaplan-Meier curves and Cox regression analyses. RESULTS: Overall, 55 patients (53.4%) experienced recurrence and 29 (28.2%) experienced disease progression during a median follow-up of 42.7 months (range, 6.1-172.2 months). Kaplan-Meier analysis revealed that NMIBC patients with a high IQGAP3/BMP4 ratio had worse recurrence-free survival and progression-free survival (PFS) (P = .001 and < .001, respectively), and those with a high IQGAP3/FAM107A ratio had worse PFS (P = .006). Multivariate Cox regression analysis revealed that the IQGAP3/BMP4 ratio was independently associated with recurrence-free survival (hazard ratio, 2.462; P = .003) and PFS (hazard ratio = 3.871; P = .004), whereas the IQGAP3/FAM107A ratio was not an independent factor for PFS (P = .079). CONCLUSION: The IQGAP3/BMP4 ratio in ucfDNA might be a valuable novel biomarker for predicting disease recurrence and progression in patients with NMIBC.

Intrahepatic Glissonian Approach to the Ventral Aspect of the Arantius Ligament in Laparoscopic Left Hemihepatectomy.

BACKGROUND: Laparoscopic left hemihepatectomy using the Glissonian approach is technically challenging secondary to a thick Glissonian pedicle and limited maneuverability of laparoscopic instruments. This procedure demands extreme caution owing to the high risk of bile leakage associated with left hemihepatectomy. We describe the technical details and surgical outcomes of the intrahepatic Glissonian approach to the ventral aspect of the Arantius ligament in laparoscopic left hemihepatectomy. METHODS: After detachment of the left side of hilar plate, the meticulous dissection was performed in the liver capsule above the left Glissonian pedicle. Dissection of the ventral aspect of the Arantius ligament creates the space between the liver parenchyma and the left Glissonian pedicle. The left Glissonian pedicle was isolated and encircled using the long curved laparoscopic instrument. During the parenchymal transection, the left Glissonian pedicle was transected using lateral to the Arantius ligament. RESULTS: Between February 2013 and July 2018, 13 consecutive patients underwent pure laparoscopic left hemihepatectomy. The median operation time was 230 min (range 180-300 min), and the median estimated blood loss was 300 mL (range 100-600 mL). Two patients (15%) required transfusion. The median tumor size was 40 mm (range 10-105 mm). All patients showed negative resection margins. The median postoperative hospital stay was 8 days (range 6-15 days). Major postoperative complications occurred in 1 patient (7.7%). No perioperative deaths occurred. CONCLUSION: An intrahepatic Glissonian approach to the ventral aspect of the Arantius ligament is a feasible and effective technique in laparoscopic left hemihepatectomy.

A giant lipoma of the parietal peritoneum: Laparoscopic excision with the parietal peritoneum preserving procedure - a case report with literature review.

BACKGROUND: Lipomas are very common benign tumors of mature fatty tissue that can occur in any part of the body. However, lipomas of the parietal peritoneum are extremely rare. CASE PRESENTATION: A 36-year-old man presented with urinary frequency for 6 months. On computerized tomography of the abdomen and pelvis, a well-defined fatty mass measuring 20 × 11 × 6.5 cm in size, was found in the lower abdominal cavity. We performed a laparoscopic parietal-peritoneum-preserving excision of the mass. The patient was discharged without complications on post-operative day 6. CONCLUSIONS: To our knowledge, a laparoscopic excision with preservation of the parietal peritoneum for a giant parietal peritoneal lipoma has never been reported. Herein, we report a case of a giant lipoma of the parietal peritoneum successfully managed by laparoscopy.

Primary hepatic peripheral T-cell lymphoma mimicking hepatocellular carcinoma: a case report.

Peripheral T-cell lymphomas (PTCLs) are aggressive neoplasms which may involve the liver. The imaging manifestations of hepatic lymphoma are highly variable and show overlapping appearances of numerous other hepatic diseases. As the management and prognosis of lymphoma differ markedly from those of other malignant diseases, prompt diagnosis and early effective treatment are very important. Here, we report an atypical case of primary PTCL not otherwise specified involving the liver that exhibited a solitary hepatic mass mimicking hepatocellular carcinoma (HCC) on CT. Liver biopsy is not commonly recommended in highly suspicious cases of HCC. However, in a patient without risk factors for HCC, consideration of other diagnostic possibilities is required and needle biopsy may be a more rational choice. An imaging approach, based on a careful review of clinical and laboratory findings is essential to prevent false-positive diagnosis of HCC and subsequent invasive treatment.

Two Cases of Plug or Stone in Remnant Intrapancreatic Choledochal Cysts Treated with Endoscopic Retrograde Cholangiopancreatography.

Incomplete resection of choledochal cysts (CCs) that extend deep into the pancreas can lead to protein plug or stone formation, pancreatitis, and cholangiocarcinoma. We encountered two cases of choledocholithiasis in remnant intrapancreatic CCs, in which the patients exhibited symptoms after 3 and 21 years of cyst excision. A 21-year-old woman who had undergone excision of a CC, as a neonate, presented with epigastric pain. Abdominal computed tomography (CT) revealed stones inside the remnant pancreatic cyst, which were removed by endoscopic retrograde cholangiopancreatography (ERCP), and her symptoms improved. A 33-year-old woman, who underwent cyst excision 3 years ago, presented with pancreatitis. Abdominal CT showed a radiolucent plug inside the remnant pancreatic cyst. The soft, whitish plug was removed by ERCP, and the pancreatitis improved. These cases indicate that plugs and stones in CCs have the same pathogenetic mechanism, and their form depends on the time since the incomplete excision surgery.

A Modified Liver Hanging Maneuver in Pure Laparoscopic Left Hemihepatectomy with Preservation of the Middle Hepatic Vein: Video and Technique.

BACKGROUND: The liver hanging maneuver is a novel and useful technique that is widely used in open liver resections. The present study describes the surgical technique and outcomes of a modified liver hanging maneuver for pure laparoscopic left hemihepatectomy. METHOD: The clinical data of patients who underwent laparoscopic left hemihepatectomy using a modified hanging technique were retrospectively reviewed. The upper end of the hanging tape was placed on the lateral side of the left hepatic vein. The pathway of the tape was situated along the ligamentum venosum. RESULTS: Sixteen patients underwent pure laparoscopic left hemihepatectomy with the modified hanging technique. The median operation time was 225 min (range 180-300 min), with a median blood loss of 265 ml (range 140-600 ml). Postoperative major complications occurred in one patient (6.3%). The median postoperative hospital stay was 8 days (range 5-15 days). There was no postoperative liver failure or mortality. CONCLUSION: This modified liver hanging maneuver is a simple, safe, and reproducible approach as dissection of between the middle and left hepatic vein is not required. This technique may be useful in laparoscopic left hemihepatectomy.

LAMP-3 (Lysosome-Associated Membrane Protein 3) Promotes the Intracellular Proliferation of Salmonella typhimurium.

Lysosomes are cellular organelles containing diverse classes of catabolic enzymes that are implicated in diverse cellular processes including phagocytosis, autophagy, lipid transport, and aging. Lysosome-associated membrane proteins (LAMP-1 and LAMP-2) are major glycoproteins important for maintaining lysosomal integrity, pH, and catabolism. LAMP-1 and LAMP-2 are constitutively expressed in Salmonella-infected cells and are recruited to Salmonella-containing vacuoles (SCVs) as well as Salmonella-induced filaments (Sifs) that promote the survival and proliferation of the Salmonella. LAMP-3, also known as DC-LAMP/CD208, is a member of the LAMP family of proteins, but its role during Salmonella infection remains unclear. DNA microarray analysis identified LAMP-3 as one of the genes responding to LPS stimulation in THP-1 macrophage cells. Subsequent analyses reveal that LPS and Salmonella induced the expression of LAMP-3 at both the transcriptional and translational levels. Confocal Super resolution N-SIM imaging revealed that LAMP-3, like LAMP-2, shifts its localization from the cell surface to alongside Salmonella. Knockdown of LAMP-3 by specific siRNAs decreased the number of Salmonella recovered from the infected cells. Therefore, we conclude that LAMP-3 is induced by Salmonella infection and recruited to the Salmonella pathogen for intracellular proliferation.

Lateral approach liver hanging maneuver in laparoscopic anatomical liver resections.

BACKGROUND: The liver hanging maneuver is a novel technique that is widely used in open liver resection. The hanging technique has been rarely applied during laparoscopic liver resection because a blind dissection between the anterior surface of the inferior vena cava and the liver is required. Dissection between the right and middle hepatic vein is necessary in right hepatectomy, as is dissection between the middle and left hepatic vein in left hepatectomy. The aim of this study was to introduce the lateral approach liver hanging maneuver in laparoscopic anatomical liver resections. METHOD: For this technique, the upper end of the hanging tape was placed on the lateral side of the right or left hepatic vein and the lower end of the hanging tape between three Glisson's pedicles. The pathway of the tape was situated along the lateral side of the inferior vena cava in right-sided hepatectomy or the ligamentum venosum in left-sided hepatectomy. RESULTS: From February 2013 to October 2014, this technique was performed in 35 patients. Of these patients, ten patients underwent a right hepatectomy, 5 patients underwent a right posterior sectionectomy, 12 patients underwent a left hepatectomy, and 8 patients underwent a left lateral sectionectomy. The median operative time was 240 min (range 90-390 min), and median blood loss was 350 ml (range 60-700 ml). Blood transfusion was required in six patients (17.1 %). In two patients (5.7 %), postoperative complications were observed due to intra-abdominal fluid collection and pneumonia, respectively. No postoperative mortality was encountered. CONCLUSION: The lateral approach liver hanging maneuver is a simple, safe, and reproducible approach as dissection of the anterior surface of the inferior vena cava and between the three major hepatic veins is not required. This technique may be useful in laparoscopic anatomical liver resections.

Lymphoepithelial cyst of the pancreas mimicking malignant cystic tumor: report of a case.

Lymphoepithelial cysts of the pancreas are a type of true cyst that can mimic pseudocysts and cystic neoplasms. They are very rare, non-malignant lesions that are unilocular or multilocular cystic lesions lined predominantly by mature squamous epithelium and surrounded by non-neoplastic lymphoid elements. We, herein, present a patient with a cystic pancreas tumor mimicking a malignant cystic neoplasm. The patient was admitted with upper abdominal discomfort. Computed tomography showed a 64×39 mm cystic mass in the pancreas tail. She underwent distal pancreatectomy and splenectomy. In the fluid analysis of the pancreas cystic mass, the CEA and CA19-9 were 618 ng/ml and 3.9 U/ml, respectively. The resected pancreas specimen showed a 6.5 cm-sized cyst the pancreas tail. The cyst was well circumscribed and multilocular. The final pathology report of the resected pancreas specimen noted that the cyst was multilocular, and the cyst lining was showing stratified squamous epithelium covering the lymphoid tissue (containing lymphoid follicles), which was consistent with a lymphoepithelial cyst. The patient recovered uneventfully from surgery and has been doing well for the past 3 months. A differential diagnosis of cystic pancreatic lesions is important. We suggest that lymphoepithelial cysts, although very rare, may be included in the differential diagnosis of cystic pancreatic tumors.

CEACAM6 as detected by the AP11 antibody is a marker notable for mucin-producing adenocarcinomas.

A new monoclonal antibody recognizing CEACAM6, which we named AP11, was generated by immunizing BALB/c mice with phytohemagglutinin-activated human peripheral blood mononuclear cells. This study aims to evaluate whether CEACAM6 can serve as a tumor marker using AP11. We examined the expression of CEACAM6 with AP11 in 11 human carcinoma cell lines by flow cytometry and 439 human tissues including 282 tumor tissues and 157 normal tissues by immunohistochemistry. CEACAM6 epitope recognized by AP11 was well preserved in formalin-fixed and paraffin-embedded tissues. Adenocarcinomas of the stomach (86%), colorectum (95%), pancreas (100%), and lung (83%), urinary bladder (100%), and mucinous ovarian tumors (88%) had a high rate of CEACAM6 immunoreactivity. We observed a variable expression of CEACAM6 in hepatocellular carcinomas (35%), squamous cell carcinomas of the lung (60%), renal cell carcinomas (14%), urothelial carcinomas (13%), serous carcinomas of the ovary (17%), and breast carcinomas (11%). Small-cell carcinomas of the lung, prostatic adenocarcinomas, papillary thyroid carcinomas, malignant melanomas, giant cell tumors, and osteosarcomas were negative for CEACAM6. All normal tissues of various organs were negative for CEACAM6. In conclusion, CEACAM6 as detected by AP11, may serve as a marker for mucin-producing adenocarcinomas of the gastrointestinal tract and ovary as well as non-small cell lung cancer. Thus, AP11 represents a valuable diagnostic tool for detecting CEACMA6-positive cancers.

Polyarteritis nodosa presented as a dilatation of the intrahepatic bile duct.

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of small- and medium-sized arteries in multiorgan systems. PAN may affect the gastrointestinal tract in 14%-65% of patients, but rarely involves the biliary tract and liver. We describe a patient without underlying disease who was diagnosed with PAN during resection of the gallbladder and liver.

Fate of dyspeptic or colonic symptoms after laparoscopic cholecystectomy.

BACKGROUND/AIMS: Gallbladder diseases can give rise to dyspeptic or colonic symptoms in addition to biliary pain. Although most biliary pain shows improvement after cholecystectomy, the fates of dyspeptic or colonic symptoms still remain controversial. This study as-sessed whether nonspecific gastrointestinal symptoms improved after laparoscopic cholecystectomy (LC) and identified the char-acteristics of patients who experienced continuing or exacerbated symptoms following surgery. METHODS: Sixty-five patients who underwent LC for uncomplicated gallbladder stones or gallbladder polyps were enrolled. The patients were surveyed on their dyspeptic or colonic symptoms before surgery and again at 3 and 6 months after surgery. Patients' mental sanity was also assessed using a psychological symptom score with the Symptom Checklist-90-Revised questionnaire. RESULTS: Forty-four (67.7%) patients showed one or more dyspeptic or colonic symptoms before surgery. Among these, 31 (47.7%) and 36 (55.4%) patients showed improvement at 3 and 6 months after surgery, respectively. However, 18.5% of patients showed continuing or exacerbated symptoms at 6 months after surgery. These patients did not differ with respect to gallstone or gall-bladder polyps, but differed in frequency of gastritis. These patients reported lower postoperative satisfaction. Patients with ab-dominal symptoms showed higher psychological symptom scores than others. However, poor mental sanity was not related to the symptom exacerbation. CONCLUSIONS: Elective LC improves dyspeptic or colonic symptoms. Approximately 19% of patients reported continuing or exacerbated symp-toms following LC. Detailed history-taking regarding gastritis before surgery can be helpful in predicting patients' outcome after LC.

The experience of transumbilical endoscopic appendectomies.

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 ± 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 ± 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.