Combined choriocarcinoma, neuroendocrine cell carcinoma and tubular adenocarcinoma in the stomach

We described a patient with adenocarcinoma of the stomach combined with choriocarcinoma and neuroendocrine cell carcinoma. An 85-year-old man visited our hospital because of appetite loss. Gastric fiberscopy revealed a large tumor occupying the cardial region and anterior wall of the gastric body. The patient underwent total gastrectomy with lymphnode dissection and partial resection of the liver. Choriocarcinoma, small cell carcinoma and tubular adenocarcinoma existed in the gastric tumor. The choriocarcinomatous foci contained cells positive for beta-subunit of human chorionic gonadotropin (B-hCG) and human placental lactogen mainly in syncytiotrophoblastic cells. The small cell carcinomatous foci contained cells positive for synaptophysin, neuron-specific enolase (NSE), and chromogranin A. The prognosis for gastric adenocarcinoma with choriocarcinoma and neuroendocrine cell carcinoma is exceedingly poor. This patient died about 2 mo after the first complaint from hepatic failure. This is the first reported case of gastric cancer with these three pathological features.

Single-Incision Robotic Surgery

Introduction: Single Incision Laparoscopic Surgery (SILSTM) has been developed as a less invasive laparoscopic surgery. On the other hand, robotically assisted surgical technology has offered new options for minimally invasive surgery. In this study, we report a new surgical technology to perform SILS using the da Vinci S surgical system (Intuitive Surgical Inc., Sunnyvale, CA). Materials and Surgical Technique: A porcine liver with gallbladder was placed on an endoscopic surgery trainer, and a 25 mm incision was made for one robotic camera and two instruments at the umbilicus position. Both instruments were crossed while preventing them from colliding with each other, and Robot-assisted single-incision cholecyctectomy was perfumed. Discussion: This technique is expected to contribute to the development of a number of procedures in the future.

Laparoscopic Observations in Acquired Inguinal Hernia before and after Robotic-Assisted Laparoscopic Prostatectomy

Background: The mechanism of the development of acquired inguinal hernia, especially indirect inguinal hernia, is not well known. Although anatomical studies have been performed to explain development of inguinal hernia, they have mainly involved autopsy or temporal findings at the time of hernioplasty. To elucidate the pattern of development of acquired inguinal hernia, we studied the occurrence of inguinal hernia after robotic-assisted laparoscopic prostatectomy (RALP). Methods: From March 2009 to November 2011, RALP for prostatic cancer was performed on 60 patients in our institute. The RALP was performed by one urologist using the da Vinci Surgical System. The postsurgical development of inguinal hernia was diagnosed based on patients’ symptoms. Seven patients were treated with laparoscopic hernioplasty, and one underwent mesh-plug repair. Using video recordings, the laparoscopic findings during RALP and laparoscopic hernioplasty were compared among all patients. Results: Seven of 59 patients (11.9%) developed an inguinal hernia. One patient had a pre-existing pantaloon inguinal hernia at the time of RALP. Eleven inguinal lesions in the seven patients who underwent laparoscopic hernioplasty were reviewed, and all were indirect inguinal hernias. Conclusion: A main factor in the development of inguinal hernia after RALP could be a combination of outer-side intact layers and inner-side hard scar of the inguinal ring, which seems like “out swing door”.

Umbilical Endometriosis without Pelvic Surgery

We report a recently observed case of primary umbilical endometriosis without previous pelvic surgery. A 41-year-old Japanese woman complained of umbilical nodular tumor. Histopathology revealed endometriosis of an approximate 10 mm resected mass. The stromal cells in endometriosis were immunohistochemically positive for CD10. Two months later the first umbilical surgery, she underwent a left salpingo-oophorectomy and release of adhesion around the left adnexa under a laparoscope. She was treated with dienogest (2 mg/day) for six months after four injections of GnRH analogue for four months. After three years of the follow-up, there were no signs of local relapse and no clinical and ultrasonographic abnormalities due to endometriosis.

The da Vinci Surgical System versus the Radius Surgical System

Objective: Kanazawa University introduced the da Vinci surgical system and the Radius surgical system. In this study, we compared the advantages and disadvantages of each system. Methods: The da Vinci system is a master-slave tele-manipulation system, which provides hi-resolution 3D images. The Radius system is pair of hand-guided surgical manipulators. In this study we focus on the operability of both instruments rather than their 3D optical systems. Results: The Radius was originally developed specifically focused on ligation and suturing with suture sizes bigger than 4-0, it is more effective, less expensive compared with the da Vinci. Although the da Vinci system is bulky, it allows surgeons to perform endoscopic surgeries only if ports are properly placed to prevent each arm from colliding with the other arms. A crucial difference between the Radius and the da Vinci is not limited to anastomose small vessels but is extended to multidirectional dissection. Currently, the cost including initial investment is the biggest issue;however, the da Vinci is absolutely necessary to implement delicate cardiac surgeries endoscopically and less-invasively. Early approval of robotic surgery by the government is urgently required in Japan. Conclusions: Although both the da Vinci and the Radius have endoscopic instruments with a multi-degree of freedom, applications need to be differentiated depending on the procedures and indications. Therefore, it can be clearly said that these unique innovative systems will never compete against each other.

Laparoscopic Hernioplasty Using Omega-3 Coating Mesh

Background: Laparoscopic hernioplasty has gained popularity with significant advances in prostheses. Omega-3 coating mesh (C-Qur) is a prosthesis that can be used in the abdominal cavity, and the coating prevents adhesion of the mesh to the viscera. We planned a prospective observational study of laparoscopic hernioplasty using C-Qur. Methods: C-Qur was used in laparoscopic hernioplasty over the course of 1 year. We considered laparoscopic approaches as our primary treatment method for abdominal wall hernias. Although only a single incision was made for the majority of the laparoscopic hernioplasties, additional incisions were made when severe adhesions were encountered. For incisional or ventral hernias, a lateral lower incision was made. For inguinal hernias, an umbilical incision was made. Sex, age, diagnosis, number of incisions, additional incisions, morbidity, and follow-up period were evaluated. Results: Twenty-four patients who underwent surgery between May 2010 and April 2011 were included in this study. The median follow-up period was 14 months. The most common early complications included wound pain and edema;however, there were no persistent complications.

Open Distal Gastrectomy versus Laparoscopic Distal Gastrectomy: As Influenced by Facility Background Factors in the Real World

The purpose of our study was to retrospectively evaluate the clinical efficacy and safety of laparoscopy assisted distal gastrectomy (LADG) performed by one operating and advising surgeon in patients with gastric cancer over a period of 10 years. We examined the choice of anastomosis techniques, and compared the duration of surgery, blood loss, number of dissected lymph nodes and intraoperative complications for LADG and open distal gastrectomy (ODG). We studied 254 patients who underwent laparoscopic gastrectomy and 36 patients who underwent ODG. 169 of 254 patients received LADG. Duration of surgery was significantly longer for LADG than that for ODG, blood loss was significantly smaller, and numbers of dissected lymph nodes were similar. With LADG, there was anastomotic leakage in 2 patients and postoperative obstruction in 2 patients. No recurrence of disease and no deaths have been reported to date. Though previous clinical trials have shown that LADG is less invasive, our study of LADG in the real world did not show superiority, but rather equivalence to ODG in terms of other outcomes. This study could be advantageous to evaluate the clinical efficacy and safety of LADG without having to take into account multiple surgeons’ technical levels and the background differences between the facilities.