Vagal-mediated cardiovascular responses can occur following carbon dioxide pneumoperitoneum during laparoscopic surgery. In rare cases, an exaggerated vagal reflex may result in profound bradycardia or asystole. We report the case of a 44-year-old woman (American Society of Anesthesiologists physical status II) who developed abrupt bradycardia progressing to asystolic cardiac arrest immediately after abdominal insufflation during an elective minimally invasive gynecologic procedure. The planned operation included hysteroscopy with MyoSure (Hologic, Inc., Marlborough, MA, US) resection, NovaSure (Hologic) endometrial ablation, Acessa (Hologic) radiofrequency fibroid ablation, diagnostic laparoscopy, and salpingectomy for symptomatic uterine fibroids refractory to conservative management. Her past medical history was notable only for uterine fibroids and recently diagnosed hypertension. Preoperative laboratory testing and vital signs were within normal limits, and electrocardiography demonstrated normal sinus rhythm without clinically significant rhythm abnormalities. Immediately following the bradycardia, one milligram of atropine was administered intravenously. The patient then became asystolic, pneumoperitoneum was evacuated, and cardiopulmonary resuscitation was initiated. Return of spontaneous circulation was achieved after a single round of compressions, with restoration of normal sinus rhythm. The intra-abdominal portion of the procedure was subsequently aborted, and the patient remained hemodynamically stable postoperatively. At cardiology follow-up nine days postoperatively, the patient reported prior vasovagal-type episodes, including syncope following influenza vaccination and near-syncope during magnetic resonance imaging with intravenous contrast. This case highlights the importance of rapid recognition and management of vagally mediated cardiac events in the operating room. It also raises the question of whether targeted preoperative assessment for prior syncope or vasovagal episodes may help identify patients at increased risk for exaggerated vagal responses during procedures involving pneumoperitoneum, a potential area for future investigation.

To present the 2025 revision of the Japan Society of Gynecologic Oncology Clinical Practice Guidelines for the treatment of ovarian, fallopian tube, and primary peritoneal cancers, which incorporates recent advances in surgical strategies, molecular diagnostics, and maintenance therapies within the context of the Japanese healthcare system. Clinical questions (CQs) were formulated using the PICO framework. Systematic literature searches were conducted in PubMed, the Japan Medical Abstract Society, and the Cochrane Library (January 2019-December 2023), along with additional manual searches for emerging evidence. Three new systematic reviews addressing minimally invasive surgery, secondary cytoreductive surgery, and lymphadenectomy for malignant germ cell tumors were performed. Evidence levels and recommendation strengths were determined according to the Minds 2020 methodology adapted to the Japanese clinical and insurance environment. Recommendations were formulated using a modified GRADE approach. Final recommendations were established through multidisciplinary consensus voting, with a predefined agreement threshold of 75%. The sixth edition comprises 6 chapters and 49 CQs. Major updates include expanded guidance on homologous recombination deficiency testing and genomic profiling, refined indications for maintenance therapy with poly(ADP-ribose) polymerase (PARP) inhibitors and bevacizumab, clarified recommendations for secondary cytoreductive surgery, updated management of PARP inhibitor-exposed recurrence, and strengthened sections on onco-fertility and palliative care. Transparency was enhanced by disclosing key discussion points and consensus rates for each recommendation. These guidelines define evidence-based standards tailored to Japanese clinical practice while maintaining international relevance. They aim to reduce inter-institutional disparities, optimize patient outcomes, and provide a transparent framework for future therapeutic integration.

Necrotizing pancreatitis is a severe complication of acute pancreatitis that may not become radiographically evident until several days after symptom onset. Although progression from gallstone pancreatitis is well recognized, concurrent postoperative complications and Clostridioides difficile infection can obscure the clinical picture and delay diagnosis. This case adds to the literature by demonstrating how overlapping postoperative findings and concurrent infection masked the evolution of necrotizing pancreatitis despite initial clinical improvement and illustrating treatment approaches in such situations. A 61-year-old man presented with worsening right upper quadrant abdominal pain radiating to the back and was diagnosed with gallstone pancreatitis secondary to choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction followed by delayed laparoscopic cholecystectomy. After initial improvement and discharge, he returned with severe abdominal pain, nausea, vomiting, and systemic inflammatory findings. Exploratory laparotomy revealed chemical peritonitis of pancreatic origin without biliary leak or enteric perforation. During hospitalization, he developed Clostridioides difficile colitis, further complicating interpretation of persistent abdominal pain, leukocytosis, and inflammatory markers. Interval MRI ultimately demonstrated sterile peripancreatic necrosis and fluid collections consistent with necrotizing pancreatitis. The patient was managed with bowel rest, total parenteral nutrition, drainage of peripancreatic fluid, treatment of Clostridioides difficile infection, serial imaging, and multidisciplinary care involving surgery, gastroenterology, infectious disease, critical care, and internal medicine. His symptoms gradually improved, and he was discharged with outpatient surgical follow-up. This case highlights the unpredictable progression of gallstone pancreatitis to necrotizing pancreatitis despite early intervention and apparent clinical recovery. Persistent or worsening postoperative abdominal pain should prompt continued reassessment, as concurrent infections such as Clostridioides difficile may obscure an evolving pancreatic process. Serial laboratory evaluation, interval imaging, and multidisciplinary collaboration are essential for timely diagnosis and improved patient outcomes in complex cases.

Encapsulating peritonitis (EP), also known as abdominal cocoon syndrome, and internal hernia are uncommon yet important causes of small bowel obstruction (SBO). Their true coexistence is exceedingly rare and presents a unique diagnostic challenge. Despite their distinct pathogenesis, both entities can rarely share considerable clinical and radiological overlap. We report the case of a 29-year-old man who presented with acute abdominal pain and multiple episodes of non-projectile, non-bilious, non-blood-stained vomiting. Contrast-enhanced computed tomography demonstrated clustered dilated small bowel loops enclosed within an enhancing fibro-collagenous membrane, consistent with EP. In addition, mesenteric vascular convergence and a focal transition point within the transverse mesocolon raised suspicion for a concomitant internal hernia. Emergency exploratory laparotomy confirmed a dense fibro-collagenous membrane encasing the small bowel, together with a transmesocolic internal hernia through a defect in the transverse mesocolon. Complete excision of the encapsulating membrane, meticulous adhesiolysis, reduction of the herniated bowel, and closure of the mesocolic defect resulted in complete resolution of the obstruction and an uneventful postoperative recovery. This case highlights the exceptionally rare coexistence of EP and a transmesocolic internal hernia, two entities that have traditionally been described as radiological mimics rather than concurrent pathologies. Previous case reports have primarily described EP and internal hernia as independent causes of SBO, rarely also highlighting one entity as a radiological mimic of the other; however, their concurrent occurrence in the same patient is extremely rare. This case highlights the importance of a systematic computed tomography evaluation, as recognition of one diagnosis should not preclude careful assessment for the other, with direct implications for surgical planning and optimal patient management.

We aimed to demonstrate the intraoperative effectiveness of different doses of preoperative endoscopic tattooing in patients undergoing laparoscopic surgical treatment for colorectal cancer or tumors. According to the tattooing dose administered before laparoscopic surgery, patients were divided into 3 groups: Group 1, tattooing dose ≥ 1.0 cc (n = 35); Group 2, 0.5-<1.0 cc (n = 33); Group 3, <0.5 cc (n = 48). The groups were statistically compared in terms of clinical characteristics, surgical parameters, histopathological features, and ease of identification. A total of 116 patients were included in the study; the mean age was 63.8 (10.5) years, and most were male (68.1%). The rate of easy intraoperative identification during laparoscopic colorectal surgery was 88.7% (103/116). There were no statistically significant differences between the groups in terms of age, sex, body mass index, anesthesia score, tumor localization, operative time, tumor diameter, malignancy rate, neoadjuvant therapy, TNM and T stage, or number of resected lymph nodes (P > .05). Additionally, there were no statistically significant differences among the 3 groups regarding ease of identification and spillage of the dye into the peritoneum (P = .706 and P = .207, respectively). In laparoscopic colorectal tumor surgery, low-dose endoscopic tattooing provides similar outcomes in terms of ease of identification compared to high-dose tattooing. Low-dose tattooing is associated with lower cost and reduced risk of spillage into the peritoneum.