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In hepatobiliary and pancreatic surgery, an understanding of hepatic artery anomalies is of great importance to surgeons. Cases of the proper hepatic artery originating from the superior mesenteric artery and the gastroduodenal artery originating from the celiac trunk are extremely rare. To our knowledge, there are no reports of these arterial variants being diagnosed before hepatobiliary and pancreatic surgery. A 73-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy and lymphadenectomy for duodenal carcinoma. Preoperative vascular construction with 3-dimensional computed tomography showed variants of the proper hepatic artery and gastroduodenal artery. The proper hepatic artery originated from the superior mesenteric artery, and the gastroduodenal artery originated from the celiac trunk. Intraoperative findings and preoperative vascular construction from 3-dimensional computed tomography were found to be matched exactly; both the proper hepatic artery and gastroduodenal artery were preserved. By diagnosing a rare arterial variant preoperatively, we were able to perform the surgery safely. In hepatobiliary and pancreatic surgery, understanding any potential variation of the hepatic artery before surgery is crucial to ensure the best patient outcomes.

Highlights • Colon MiNEN, in this case, adenocarcinoma and NET G1 is a rare tumor. • Preoperative diagnosis of MiNEN is difficult, and detailed observation of histopathology is important. • Prognosis depends on the more aggressive components of adenocarcinoma or NET., Introduction Neuroendocrine tumor (NET) that develops in the right-sided colon is relatively rare. Coexistence of adenocarcinoma and NET is extremely rare, and such cases are called mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN). Presentation of case Colonoscopy in an 85-year-old woman for an anemia examination indicated laterally spreading tumor-nongranular (LST-NG) in the transverse colon. Colonoscopy and endoscopic ultrasonography (EUS) showed that the depth of the tumor invasion was deep submucosal. The tumor localization was diagnosed as transverse colon close to the hepatic curvature by enema. Computed tomography (CT) showed no obvious lymph node or distant metastasis. Based on these findings, laparoscopic transverse colectomy with D2 lymphadenectomy was performed. Pathologically, most of the tumor was well-differentiated tubular adenocarcinoma, but some solid follicles of polygonal tumor cells with poor nuclear atypia were observed. Immunostaining was positive for synaptophysin and diagnosed as NET G1. This tumor consisted of adenocarcinoma and neuroendocrine tumor, so we diagnosed it as MiNEN and classified the tumor as fT1N0M0 fStage I (TNM Classification of Malignant Tumors, 8th Edition). Since it was an early stage cancer, postoperative adjuvant therapy was not performed. No recurrence has yet been noted. Discussion Although MiNEN is extremely rare, the detailed pathological specimen observation and diagnosis are important because long-term follow-up after surgery is needed, as is the adequate selection of postoperative adjuvant therapy. Conclusion It is important to elucidate the mechanisms involved in the coexistence of NET and adenocarcinoma and to apply these findings to future medical care.

Highlights • Inguinal bladder hernia (IBH) is a rare condition that is difficult to diagnose preoperatively. • 16% of IBHs are diagnosed postoperatively due to bladder injury and leakage. • Preoperative diagnosis of IBHs is important to lessen postoperative complications. • Transabdominal preperitoneal approach can significantly reduce the risk of bladder damage., Introduction Inguinal bladder hernia (IBH) is a rare condition that is difficult to diagnose preoperatively based only on physical examination; 16% of IBHs are diagnosed postoperatively due to complications. Presentation of case We report the case of a 56-year-old man who presented with left inguinal swelling and increased frequency of urination since eight years. Physical examination demonstrated a 6 × 4 cm non-reducible left inguinal bulge with mild tenderness on palpation. Computed tomography revealed a left inguinal hernia containing a portion of the urinary bladder. He was diagnosed with IBH and transabdominal preperitoneal (TAPP) repair was performed. We confirmed a left internal inguinal hernia and incised the peritoneum from the outside of the left inguinal ring. The preperitoneal space was dissected toward the Retzius space, and the prolapsed bladder was examined. The adhesion with the surroundings was carefully dissected and the bladder was reduced into the abdomen. Indigo carmine was injected through a urinary catheter, which confirmed that no bladder damage had occurred. After the mesh was positioned to cover the myopectineal orifice, it was fixed to the Cooper’s ligaments, interior side, lateral side, and ventral side. The postoperative course was uneventful, and the patient is now free of symptoms and recurrence two months after surgery. Conclusion TAPP repair is a useful treatment for IBH. Preoperative diagnosis of IBH is important to lessen postoperative complications.

Introduction Erythropoietic protoporphyria (EPP) is a rare disorder caused by reduced ferrochelatase activity and shows incomplete autosomal dominant inheritance. Meticulous perioperative management can avoid characteristic complications. This report describes a case of a bleeding jejunal tumor in a patient with EPP. Presentation of case A 49-year-old man with a history of EPP was admitted to our department with abdominal distention and severe anemia. Contrast-enhanced computed tomography revealed an abdominal tumor measuring 5 cm, originating from the small bowel wall or mesentery. Tumor resection was planned after correction of anemia. Red blood cell transfusion restored his hemoglobin to acceptable levels; however, his liver function worsened. Institution of liver support therapy achieved gradual reduction in his elevated liver enzymes; however, hyperbilirubinemia persisted. He underwent tumor resection on the 12th day of hospitalization. Yellow filters were used to avoid operating room light-induced tissue injury. The tumor was located in the jejunum 30 cm from the Treitz ligament toward the anal aspect. The histopathological diagnosis was desmoid-type fibromatosis of the jejunum. Postoperatively, his hemoglobin levels were stabilized; however, his serum bilirubin level remained high. His serum bilirubin level gradually decreased following hemin injections (150 mg/day). Discussion Reducing heme synthesis and minimizing protoporphyrin generation are important perioperatively. Additionally, preventing operating room light-induced tissue burns and selecting appropriate anesthestic agents are important during surgery. Conclusion The institution of appropriate treatment and adequate intra- and perioperative measures can ensure safe surgery in patients with EPP even under emergency conditions.

Highlights • Accompanying support by full use of procedure of general or cardiovascular surgeons for urological surgery in malignancies provide curability. • Cardiovascular intervention should be necessary to remove long extension of tumor thrombus into the vena cava or right atrium. • Hepatic or pancreatic mobilization or combined resection is required for invasive or metastatic urological malignancies. • Operative safety is also required by precise preoperative planning and arrangement of procedure during operation by the good combination in each., Introduction The present case reports demonstrated the accompanying surgical support from hepato-biliary-pancreas (HBP) surgeons for urological surgery to secure operative safety because HBP surgeons are well experienced in dissecting techniques for mobilization of the liver or pancreas. We experienced 9 consecutive patients who underwent nephrectomy, adrenectomy or resection of retroperitoneal tumors by urological surgeons. Cardiovascular intervention was also required in cases of long tumor thrombus into the vena cava. Cases All patients had no severe co-existing diseases except the main tumor. Reverse T-shape incision was performed in 7 cases and thoracolaparotomy in two. Dissection and mobilization at the site of severe compression by the urinary tumors were performed in three cases. Partial liver resection was performed for testicular liver metastases in two, and right hepatectomy for right renal cancer was performed in one. Encircling the vena cava and preparation of transection for tumor thrombi were performed in three, and among these, cardiovascular intervention was necessary in two because of extension into the right atrium. During admission, all patient outcomes were uneventful without severe complications. We herein showed the representative two cases of combined surgery. Discussion and conclusion The point of this case report is the coordination between each surgeon and anesthesiologist under precise perioperative planning or management. The role of HBP surgeons is to provide information as a specialist on the operative field for urological or cardiovascular surgery to achieve operative safety.

Extranodal Rosai-Dorfman disease (RDD) of the kidney is rare, with unknown etiology. We present a case of extranodal RDD of the kidney. Imaging revealed a nodular lesion in the right renal pelvis, with accompanying pelvic dilation and parenchymal atrophy, reminiscent of immunoglobulin G4 (IgG4)-related disease. With the clinical diagnosis of suspected renal pelvic cancer, laparoscopic right nephrectomy was performed. Macroscopic findings showed a mass with a white-tan cut surface. Histological examination revealed histiocytes with emperipolesis and patchy infiltration of plasma cells, lymphocytes and foamy macrophages in a fibrocollagenous stroma. Immunohistochemically, the histiocytes were positive for S100, CD68 and CD163, but negative for CD1a, p80/ALK and phospho-p44/42 MARK (Thr202/Tyr204). IgG4-positive plasma cells were not evident.These findings indicated that the lesion represented extranodal RDD of the kidney. No mutations of the K- and N-RAS genes could be identified in this case. Although rare, extranodal RDD should be included in the differential diagnosis of a renal pelvic mass. Keywords: Rosai-Dorfman disease, Sinus histiocytosis with massive lymphadenopathy, Kidney

A 55-year-old Japanese woman had a large retroperitoneal tumor involving the inferior vena cava (IVC) in the right infrahepatic space. We performed en bloc tumor resection with the right kidney and ipsilateral adrenal gland. Because of the large tumor size, we used a retroperitoneal laparoscopic approach for the posterior dissection and performed renal artery ligation. Following open conversion by a thoracoabdominal anterior approach, the tumor was completely removed without major reconstruction. Pathological examination confirmed a leiomyosarcoma arising from the IVC. Retroperitoneal laparoscopic dissection of the posterior side enabled easy and safe surgery even for a large tumor involving the IVC. Keywords: Inferior vena cava, Leiomyosarcoma, Retroperitoneal laparoscopic posterior approach