Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Acute appendicitis(AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy(LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Nonoperative management of AA may be tolerated only in children. Postoperative complications increase according to the patient's factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon's skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner(i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

Protocol for laparoscopic cholecystectomy: Is it rocket science?

Laparoscopic cholecystectomy(LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety(CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations.Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC:(1) consideration that a high level of experience alone is not enough;(2) recognition of the plateau involving the common hepatic duct and hepatic hilum;(3) blunt dissection until CVS exposure;(4) Calot's triangle clearance in the overhead view;(5) Calot's triangle clearance in the view from underneath;(6) dissection of the posterior right side of Calot's triangle;(7) removal of the gallbladder body; and(8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.

Investigation of Shoreline and Topographic Change on the West Side of the Imagire-Guchi Inlet, Japan

Near the Imagire-guchi inlet, which is the target area in this study, the shoreline on the west side of a jetty retreats because of a decrease in sediment supply from the east side upstream. This study attempts to analyze the shoreline and topographic changes around the inlet through analysis of GPS （global position system） measurements and digitized shoreline from aerial photographs. In addition, the DoC （depth of closure） is determined by examining datasets of cross-shore profiles and by calculations using the Hallermeier equation （1981） based on the offshore wave height and period. The results obtained by GPS indicate coastal erosion caused by waves generated by typhoons. The gradual recovery of the shoreline position after the typhoons struck was also captured by the GPS survey. However, analysis of the aerial photographs reveals that the shoreline on the west side of the jetty fluctuated widely. The cross-shore profile datasets reveal that closure depth far from the inlet was deeper than that near the inlet.