"Hook and roll technique" using an articulating hook cautery to provide a critical view during single-incision laparoscopic cholecystectomy.

We describe a new simple and easy technique called the "Hook and roll technique" (HRT) that uses an articulating hook cautery to provide a critical view during single incision laparoscopic cholecystectomy (SILC). A 2-cm incision is made at the umbilicus to insert three 5-mm trocars or a multichannel port. After dissection of the serosa of the dorsal and ventral sides of the gall bladder, including Calot's triangle, the angled tip of the hook cautery is inserted between the cystic artery and duct with its tip placed dorsally. The tip is then rotated in a clockwise manner to avoid bile duct injury, allowing the connective tissue between them to be hooked, coagulated and cut. This procedure is repeated several times, followed by dissection between the cystic artery and the liver bed to achieve a critical view. From December 2008 to May 2011, 121 patients underwent SILC using HRT in our hospital without any serious complications. This technique is suitable for SILC, as it is consists of simple procedures that can be performed safely and easily, even by left hand in a cross-over approach, and it allows complete dissection of Calot's triangle to achieve a critical view without using any dissector under dangerous in-line viewing.

[Intramuscular myxoma of intercostal muscle; report of a case].

A 72-year-old woman was reffered to our hospital for further examination of a tumor shadow in the left upper lung field which was detected in a mass screening chest X-ray. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a chest wall tumor located in the left 4th intercostal space. The lesion was suspected to be neurogenic tumor and CT-guided needle biopsy was performed. The tumor was consisted of spindle-shaped cells, but immunohistochemistry demonstrated no evidence of neurogenic tumor. As a possibility of malignant tumor could not denied, we performed tumor resection under video-assisted surgery. The lesion was not originated from nerves, but adhered to the intercostal muscle. Histologically, the tumor was consisted of spidle-shaped cells without atypia which sparsely proliferate in the myxoid stroma adjacent to intercostal muscle. In immunohistochemistry, tumor cells were positive for vimentin, and negative for desmin, S-100 protein, smooth muscle actin, CD34 and factor VIII. It was diagnosed as intramuscular myxoma. This histology in the intercostal muscle is extremely rare.

[Epithelial-myoepithelial carcinoma of the lung].

A 42-year-old woman was admitted to our hospital because of an abnormal shadow on chest X-ray. Chest computed tomography scan revealed a tumor 4.0 cm in diameter in the right segment S8. We resected the right lower lobe because of the possibility of lung cancer. Historical finding of the resected specimen revealed epithelial-myoepithelial carcinoma of the lung. The patient has remained disease-free for a year and 3 months postoperatively.

Laparoscopic tailored Nissen fundoplication.

BACKGROUND: It is difficult sometimes to determine the suture points for proper Nissen fundoplication under laparoscopy. We introduce a new procedure to define the suture points in Laparoscopic Nissen fundoplication (LNF). SURGICAL TECHNIQUE: After dissection of the hiatus and mobilization of the fundus, the circumference of the esophagus c is measured at a point 2-cm cranial from the esophagogastric junction over the 52-Fr bougie. The inner diameter of the fundoplication is calculated based on the esophageal diameter. To create a 2-cm fundoplication in which the greater curvature of the gastric fundus is moved straight toward the cranial side without any twist, we located points a and b, which correspond to the top of the left and right suture positions on fundoplication, respectively. Approximately 2 cm of floppy Nissen is constructed by suturing caudally with intervals of ~1 cm. METHODS: A total of 20 patients (3 men, 17 women, mean age, 64.5 years) with gastroesophageal reflux disease and/or hiatal hernia underwent LNF using this procedure. RESULTS: LNF was successful in all 20 patients. There were no complications except for mild dysphagia in two patients, which disappeared within 3 weeks. Improvement of the symptom scores for heartburn, regurgitation, and dysphagia was observed in all patients. The evaluation of the fundoplication by the morphologic scores was quite satisfactory. During a median follow-up period of 30 months, 19 patients exhibited no recurrence, and 1 patient had a mild recurrence but was controlled by PPI on demand. CONCLUSIONS: Our new procedure is very safe and effective to create a proper Nissen fundoplication. In addition, our preliminary findings highlight the feasibility of precise localization of suture points without the need to measure the circumference of the esophagus and that LNF could be performed without a bougie.

[A long-term survival case of bilateral ovarian metastasis of progressive gastric cancer treated by chemotherapy].

We report a long-term survival case treated by chemotherapy with new anticancer drugs such as S-1, CPT-11 and docetaxel after bilateral overiectomy for bilateral ovarian metastases of progressive gastric cancer. A 68-year-old female, who had undergone total gastrectomy with D2 lymphadenectomy for scirrhous gastric cancer of Stage IIIA, was admitted because of ovarian metastasis. Laparoscopic bilateral ovariectomy was performed for ovarian metastases of the gastric cancer (Krukenberg tumor) 6 months after gastrectomy. Seven months after gastrectomy, 11-course of S-1 treatment (80 mg/m2) for bilateral ovarian metastases of the gastric cancer was administered. CT scan revealed mediastinal lymphadenopathy 2 years and 5 months after gastrectomy. Then, the drug was changed to docetaxel (60 mg/m2). After 9-course of docetaxel treatment, the mediastinal lymphadenopathy disappeared. For a treatment of grade 3 neuropathy, a 12-course CPT-11 was started after gastrectomy 3 years and 6 months ago. CT scan and PET-CT showed no new metastasis in 4 years and 10 months after gastrectomy.

[A case of duodenal gastrointestinal stromal tumor treated by pancreas-sparing partial duodenectomy].

An 79-year-old man admitted our hospital for abdominal mass. Computed tomography showed a tumor measuring about 10 cm in diameter without any metastasis lesion and any sings of local infiltration. Gastroduodenal endoscopy revealed the presence of a submucosal tumor in the third portion of the duodenum, and biopsy revealed tumor cells stained positive for c-kit. These findings were consistent with a GIST and we performed a partial resection of the duodenum sparing the pancreas. Gastrointestinal stromal tumors (GIST) were mainly located in the stomach and the small intestine. Duodenal localization is rare. Surgical approach for GISTs should basically be a partial resection. However, for GISTs located in the duodenum, the partial resection was sometimes difficult and pancreaticoduodenectomy (PD) may be needed, depending on the tumor size and the location of the tumor close to the papilla Vater. Since GIST grew expansively, rarely involving lymph nodes, PD may be an excessive procedure to treat the disease. For this reason pancreas-sparing partial duodenectomy has been introduced for the treatment of duodenal GIST.

[A case of gastric cancer with peritoneal dissemination which has been alive more than three years responding to intraperitoneal chemotherapy].

A 59-year-old man was admitted to our hospital for abdominal mass and found to have a gastric cancer with peritoneal dissemination. Three courses of neoadjuvant chemotherapy combined with S-1 and CDDP were performed. This chemotherapy showed a substantial reduction of the size of primary tumor and peritoneal dissemination by CT examination. Surgical resection consisted of distal gasterectomy and D2 lymph node dissection was performed, and an ip catheter was placed through the douglas pouch, and the catheter was attached to the subcutaneous portal delivery system for ip chemotherapy. Operative cytology of ascites proved positive and remnant neoplasm cells were identified in the peritoneum. The pathological stage was determined as T3 N2 H0 P1 CY1 M0, pStage IV. Following surgery, we selected the ip administration of paclitaxel at a dose of 100 mg per body. Finally, the peritoneal dissemination was re-grown. However, we continued the ip chemotherapy for twenty-five times on ambulant basis. Most gastric cancer patients with peritoneal dissemination die within a few months, and there is no standard treatment for peritoneal dissemination from gastric cancer. In conclusion, a condition of no progression has been achieved and maintained for more than three years by intraperitoneal administration of paclitaxel for patient with peritoneal dissemination due to advanced gastric cancer.

CT-guided placement of a drainage catheter within a pelvic abscess using a transsacral approach.

A 66-year-old man underwent CT-guided drainage catheter placement within a pelvic abscess with a diameter of 46 mm. We performed the drainage by a transsacral approach because it was considered the safest and most feasible approach. An 8G bone marrow biopsy needle was used to penetrate the sacrum to create a path for subsequent drainage catheter insertion. After withdrawal of the biopsy needle, a 6 Fr catheter was advanced into the abscess cavity through the path using the Seldinger technique. Except for bearable pain, no procedure-related complications occurred. Twenty-nine days after the placement, the catheter was withdrawn safely and the abscess cavity had shrunk remarkably.