We use transumbilical laparoscopic-assisted appendectomy (TULAA) with a lifting retractor as the surgical technique of first choice for acute appendicitis. Although this technique provides excellent cosmetic results and contributes to reducing medical costs, it is less advantageous in difficult-to-complete cases that require conversion to pneumoperitoneum or additional ports. We retrospectively reviewed the records of 76 patients who underwent laparoscopic appendectomy between June 2020 and March 2023 (43 in a TULAA group and 33 in a pneumoperitoneal conversion group) to identify preoperative factors associated with pneumoperitoneal conversion. Univariate analysis showed significant differences for preoperative C-reactive protein (CRP) level, age, and body mass index. Logistic regression analysis identified preoperative CRP level and age as significant risk factors for pneumoperitoneal conversion. The pneumoperitoneal conversion rate was 12.5%, 48.2%, and 68% for patients with 0, 1, and 2 preoperative risk factors, respectively, indicating patients with 2 risk factors were more likely to undergo pneumoperitoneal conversion. These data may inform the selection of the surgical technique and the decision to convert to pneumoperitoneum.

We treated a total of 67 patients for mamushi viper (Gloydius blomhoffii) bite during a 10-year period between 2007 and 2016. The mean age of the patients was 68 years, with those aged ≥ 60 years accounting for about 80％ of all patients. Most injuries occurred between July and September in rice fields and other cropland, or in the patients’ homes. Except for 1 severe case who developed a marked thrombocytopenia immediately after the incident, the remaining 66 patients were included in the analysis. All patients received inpatient care, with a mean hospital stay of 6.8 days. There was a significant positive correlation between the size of the swelling at the bite site and the length of hospital stay. Kidney dysfunction occurred in 3 patients, 1 of whom died. The mean time to the largest swelling was 21.8 h while the mean time to the highest creatine phosphokinase level was 2.6 days. The more severe cases were more likely to be have been treated with mamushi antitoxin while 2 of the 3 patients with kidney dysfunction, including the 1 fatality, were not, suggesting that the use of mamushi antitoxin is essential in severe cases. We also report a very rare case of mamushi viper bite complicated by thrombocytopenia.

A 59-year-old man was admitted to our hospital with severe mitral incompetence. Mitral valve repair, tricuspid annuloplasty and the Maze procedure were performed. After weaning from cardiopulmonary bypass, his systolic blood pressure (SBP) dropped to 40 mmHg. Immediate administration of catecholamines markedly increased SBP but his continuing low blood pressure required additional treatment with vasopressin and hydrocortisone. On postoperative day 12 in the general ward, he suddenly lapsed into an intractable hypoglycemic coma. Endocrine function tests revealed adrenocorticotropic hormone deficiency. Since the time of writing has been doing well with 20 mg of hydrocortisone.

Laparoscopy is useful for minimally invasive detailed examination of patients with suspected gastrointestinal perforation. Here we report a case of gastrointestinal perforation of unknown cause that was diagnosed laparoscopically as perforation of the sigmoid colon by a toothpick. The patient was a 41-year-old woman. She presented with a chief complaint of left lower abdominal pain and CT showed a small amount of free air in the peritoneal cavity, so emergency surgery was performed. Laparoscopy revealed a foreign body penetrating the sigmoid colon. After mobilization of the sigmoid colon, the surgical technique was switched to minilaparotomy and partial sigmoid colectomy was performed. The foreign body that had penetrated the intestine was identified as a toothpick. We later learned that the patient had become intoxicated while eating at a yakiniku barbecue restaurant 7 days prior to the operation, and she guessed that she had accidentally consumed a toothpick stuck in an onion. Gastrointestinal perforation by a toothpick is rare and is difficult to diagnose preoperatively because toothpicks appear transparent on X-ray imaging. In this case, laparoscopy was useful for identifying the site and cause of perforation as well as the extent of leakage into the peritoneal cavity.

We recorded a case of a 58-year-old man who presented with swelling of the right neck after sudden chest pain. He was diagnosed with Stanford type A aortic dissection. Computed tomography revealed an aneurysm in the innominate artery surrounded by a hematoma. We therefore suspected a rupture of the innominate artery. In addition, the right common carotid artery was almost completely obstructed due to dissection. An emergency partial arch replacement was performed. Cardiopulmonary bypass (CPB) was established with two blood supplies : the right axillary and left common femoral arteries. When CPB was started, the innominate artery ruptured and could no longer be used for cerebral perfusion or as an anastomotic site. The right side of the neck was opened, and a synthetic graft was anastomosed to the right common carotid artery for cerebral perfusion. Finally, the graft was anastomosed with a branch of the main trunk. The right subclavian artery was also reconstructed using a graft that was anastomosed to the axillary artery for blood supply. The postoperative course was favorable, and no cerebral complications were observed.

A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy ; therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient's activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.

We have conducted a nationwide survey on faculty development for simulation-based medical education in Japan. The response rate was 90%. Forty-seven (68%) schools have implemented faculty development programs for simulation-based education. The most commonly implemented contents were standardized patient development, task trainer, high fidelity manikin operation, and student evaluation, which were related to objective structured clinical examination objective clinical skill assessment. Only 15 percent of medical schools implemented topics on reflective practice, and scientific writing. A constraint on faculty time was the most commonly perceived barrier to simulation use (mentioned by 62 schools; 90%).

The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device (VAD) was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement (AVR) with a bioprosthetic valve (CEP Magna Ease 21 mm) at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography (TEE) revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR (CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.