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Five cases of surgically confirmed focal fatty infiltration of the liver were detected by CT and sonography.In all five cases, the abnormality was located at the anterolateral edge of the medial segment of the liver. It was seen as a small area of low attenuation . However, when it has the appearance of a small nodule, it can be confused with various focal hepatic diseases [7-9]. We describe five surgically confirmed cases of this abnormality that were detected adjacent to the falciform ligament by CT and sonography. Materials and MethodsBetween June 1985 and December 1986, we encountered five patients in whom focal fatty change of the liver adjacent to the falciform ligament was discovered incidentally on CT and sonographic examinations performed to detect cholelithiasis or liver metastasis. CT scans and sonograms were analyzed, and the patients' clinical records were reviewed. All of the patients were women (average age, 64 years; range, 47-57 years) and had cholelithiasis (three cases) or sigmoid colon cancer (one case) or both (one case). Their liver function tests were normal except for one patient whose alkaline phosphatase level was slightly elevated. One had diabetes. None had a history of alcoholism. CT studies were performed with a Somatom DR2 scanner with a section thickness of 8 mm (three cases) or with a GE CT/ T9800 scanner with a section thickness of 1 0 mm (two cases). All CT scans were obtained with and without IV contrast material. Sonography was performed in all cases with a 3.5-or 5-MHz transducer of Aloka SSD-270 or Toshiba SAL 77A. Angiography was done in two cases. Dynamic CT was carried out during injection of contrast medium (65% meglumine amidotrizoate) in one case. The medium was injected via a catheter in the superior mesenteric artery at an estimated rate of 1 mI/sec, with a total dose of 10 ml [1 0 . In all patients, the lesion was resected during surgery performed for unrelated reasons, and the diagnosis of focal fatty infiltration of the liver was established histologically. ResultsCT scans showed a small area of low attenuation in the anterolateral part of the medial segment of the liver adjacent to the falciform ligament (Fig. 1). In all but one case, the lesions were shown on both plain and enhanced CT scans. In this case,

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Background:The aim of this study was to assess the outcome of robot-assisted minimally invasive direct coronary artery bypass grafting (MIDCAB), which is also termed "ThoraCAB". Methods and Results:From 2005 to 2013, 35 consecutive patients underwent MIDCAB via a small thoracotomy on a beating heart. Before performing MIDCAB, the internal thoracic arteries (ITAs) were endoscopically harvested through 3 ports using the da Vinci Surgical System in a completely skeletonized fashion. Distal anastomosis was hand-sewn using a vacuum stabilizer, and a coronary artery active perfusion system was used to prevent myocardial ischemia during anastomosis. Successful robot-assisted ITA harvesting was achieved in all patients. There was an average of 1.7±0.8 grafts (range, 1-3 grafts) per patient. No patient needed mechanical ventilation for more than 24 h. There were no deaths, strokes or myocardial infarctions, and none of the patients required conversion to median sternotomy.Conclusions: Robot-assisted ITA harvesting is safe and feasible. ThoraCAB is a relatively simple procedure and allows multivessel bypass grafting after a small thoracotomy. Therefore, it is expected that ThoraCAB will become the standard procedure for minimally invasive coronary revascularization and will be used in totally endoscopic CABG in the future. (Circ J 2014; 78: 399 -402)

INTRODUCTIONMost gastroenterological surgeries, even pancreatic surgery, can now be performed laparoscopically. However, the management of concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy is controversial. The performance of endovascular repair (EVAR) for AAA has been increasing; however, there is no report of laparoscopic pancreaticoduodenectomy after EVAR.PRESENTATION OF CASEA pancreatic tumor was detected during follow-up after EVAR for AAA. The enlarging tumor was diagnosed as an intraductal papillary mucinous tumor with a nodule. Laparoscopic pancreaticoduodenectomy was safely performed. After laparoscopic dissection around the pancreas head, an additional incision was made in the upper abdomen, and pancreatic reconstruction was performed through the incision. In spite of grade B pancreatic fistulae, the patient recovered with medical therapy. The pathological diagnosis was intraductal papillary mucinous adenoma with small foci of carcinoma in situ. The patient has been well with neither recurrence of the tumor nor any cardiovascular events for 18 months.DISCUSSIONThe management of concomitant malignancy and AAA is challenging, especially in patients with a pancreatic tumor. The reasons for the rarity of treatment include prognosis, anatomical vicinity, and postoperative complications. EVAR reduces retroperitoneal adhesions. A laparoscopic approach provides a small operative field and decreases mutual interference with AAA. Moreover, reconstruction is performed through an upper abdominal incision apart from the AAA. Hand-sewing provides more reliable stability of the anastomosis.CONCLUSIONThe increasing frequency of performance of EVAR for AAA and subsequent computed tomography may help to detect malignancy. Laparoscopic surgery appears to be a valid approach to malignancy after EVAR.