Distal stent graft-induced new entry is not rare after frozen elephant trunk implantation. We report a case of covered frozen elephant trunk placement for prevention of distal stent graft-induced new entry. Coverage of the rigid distal stent edge using a graft reduces mechanical stress on the intima and radial force of the distal stent; therefore, this technique can potentially prevent distal stent graft-induced new entry.

In this report, we highlighted the clinical manifestations of obturator hernia and focused on laparoscopic views. Given its rarity and vague symptoms, the early diagnosis of obturator hernia presents a challenge. Although delays in diagnosis cause high rates of morbidity and mortality, CT with multi-planar reformations provides an excellent means of preoperative diagnosis. Despite current progress of laparoscopic surgery, its indication is believed to be limited only in elective obturator hernia repairs because of technical difficulties associated with bowel strangulation followed by a resection anastomosis. However, in selected cases, laparoscopic techniques can provide a minimally invasive option for obturator hernia repairs. These laparoscopic views, together with CT imaging, allow a better understanding of spatial anatomy and abnormality surrounding an obturator hernia.

Spontaneous bile duct rupture is a rare condition in adults, with only 70 cases reported. Increased bile duct wall pressure may lead to rupture and biliary peritonitis. In this patient, the bile duct ruptured in the hepatic left triangular ligament. A 91-year-old man underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and endoscopic retrograde biliary drainage (ERBD) placement. One week later, removal of the ERBD and common bile duct stones and an endoscopic sphincterotomy (EST) were performed. Four days later, the patient had abdominal pain, increased inflammatory reaction, and jaundice. Abdominal computed tomography showed ascites, bile duct dilatation and fluid collection under the liver (10 cm in diameter). Emergency surgery was performed to drain the fluid. On laparotomy, encapsulated biliary ascites was seen. To search for the site of the leak, after cholecystectomy, a tube (C-tube) was inserted into the common bile duct via cystic duct stump. Because of uncontrollable bleeding, after packing with surgical gauze, the operation was temporarily stopped. The next day, reoperation was performed. Intraoperative cholangiography with contrast dye revealed the perforation site in the left triangular ligament and a partial resection was performed. Bile excretion from the C-tube was subsequently observed, but the patient’s jaundice did not improve. Although endoscopic retrograde cholangiopancreatography revealed that the EST site was normal, ERBD was placed again, and the jaundice gradually improved. Although EST was performed in this case, biliary peritonitis resulting from spontaneous bile duct rupture occurred. This case was very informative because biliary perforation may occur even after EST.

In total arch replacement, using frozen elephant trunk (FET) or elephant trunk techniques ensures proximalization of the distal anastomosis. However, in some cases, the left subclavian artery (LSCA) is deeply located and difficult to visualize. Therefore, surgeons face technical challenges during the LSCA reconstruction. We report an end-to-side anastomosis technique that enables safer and easier anatomical reconstruction of the LSCA.

No abstract