A case of uterine cystic adenomyoma managed by laparoscopic surgery is reported. A 27-year-old unmarried woman complained of severe right lower abdominal pain and lumbago. Transvaginal ultrasonographic and magnetic resonance imaging examination showed the 3-cm well-defined mass with a cystic cavity. On hysterosalpingography, the uterine cavity was normal in shape, and the bilateral tubes were attached at the cornual end of the both uterine horn. These findings suggested that she had an isolated uterine adenomyoma rather than non-communicating rudimentary uterine horn. Therefore, laparoscopic resection of the lesion was performed. On histologic examination of the excised tissue, the diagnosis of cystic adenomyoma was confirmed. Her post-operative course was uneventful. Postoperatively, she did not experience abdominal pain and lumbago.

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Case Report :Management of Pregnancy and Delivery After Total Laparoscopic Radical Trachelectomy
Background: The recent increase of cervical carcinoma in younger women has led us to introduce a total laparoscopic radical trachelectomy (TLRT) Our procedure has wider parametrial resection than the vaginal radical trachelectomy (VRT). We applied our TLRT to patients with both adenocarcinoma and squamous cell carcinoma with a diameter less than 20mm and could obtain a 15mm surgical margin.
Cases: Between 2002 and 2008 we performed 38 cases of TLRT. Nine patients became pregnant. Two cases resulted in miscarriage. Two cases were missed abortions. Two cases are currently 23 weeks and 26 weeks. Three cases reached the 3rd-trimester and delivered. Two patients had PROM at 26 and 34 weeks. One had a poor biological profiling score at 36 weeks. All underwent emergency cesarean sections. Unexpectedly, we didn't experience any trouble during the cesarian sections of patients at 34 and 36 weeks but observed the enlargement of the lower uterus despite having removed the isthmus.
Conclusion: RT has long been accepted as the standard fertility-sparing procedure. Although we had concerns about the uterus function disorder because of the wider resectioning of the parametrium in our procedure, 3 patients became pregnant and have infants. Our TLRT meets the fertility-sparing parameters while extending the radicality, making it an effective treatment for patients who require more extensive resection.

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Objective: Ovarian carcinoid is categorized as a borderline tumor in the ovarian neoplasm classification system. However, the treatment of this disease remains controversial, especially in patients wishing to become pregnant.
Case: The patient was a 27-year-old woman. She was diagnosed with a benign ovarian cystic tumor (less than 6cm in diameter) preoperatively, and underwent total laparoscopic cystectomy of right ovary. Pathological examination revealed right ovarian strumal carcinoid with mature cystic teratoma.
Conclusion: There have been no recurrence or reported cases of death associated with ovarian strumal carcinoid with mature cystic teratoma. However, we have to pay attention to this borderline disease even in ovarian tumors less than 6cm in diameter.

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We performed laparoscopic surgery for two women after repeated failure of in vitro fertilization with intent to increase the possibility of pregnancy. First case was a 32-year-old woman with functional infertility. She underwent diagnostic laparoscopy and mild endometriosis was detected. She became pregnant with her second IVF-ET trial after the surgery, but miscarried. She failed to become pregnant with following 5 trials of IVF-ET although good quality embryos were transferred in all trials. We performed laparoscopic surgery and treated her for mild endometriosis. She became pregnant with the next IVF-ET 2 months after the surgery. The other case was a 34-year-old woman with functional infertility. She underwent embryo transfer 4 times including 2 frozen-embryo-thawed transfers. She could not become pregnant even though good quality embryos were transferred in all trials. We performed laparoscopic surgery and treated her for mild endometriosis. She finally became pregnant with the next frozen-thawed-embryo transfer 2 months after the surgery. IVF-ET is regarded as the final treatment for infertility. But even after repeated failure of IVF-ET, laparoscopic surgery will able to be an effective treatment for some patients with functional infertility.

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We report a case of ovarian hemorrhage at 4 weeks of pregnancy that was managed with laparoscopic surgery with intraoperative autologous blood transfusion (IABT) and not homologous blood transfusion. We suspected ectopic pregnancy in a 37-year-old woman (para 2; postmenstrual day 32) because ultrasonography revealed massive hemoperitoneum and no gestational sac in the uterus, in spite of increased serum human chorionic gonadotropin (HCG) (4084 mIU/ml), and an emergency laparoscopic surgery was performed. Continuous bleeding from the surface of the left ovary was apparent. Corpus luteum and not chorion was detected; partial resection and coagulated hemostasis of the left ovary was performed. We aspirated 1350 ml of blood and reinfused 650 ml with IABT. Homologous blood transfusion was not required. Four days post-surgery (5 weeks of pregnancy), the gestational sac was detected in the uterus. Pathological examination revealed normal ovarian tissue with hemorrhage. The course of pregnancy was uneventful, and she delivered at 38 weeks of pregnancy. Although corpus luteum hemorrhage is commonly observed and safely followed without treatment, surgery is required for life-threatening hemorrhage. It is difficult to distinguish the findings of a ruptured corpus luteum without a detectable gestational sac at early pregnancy from ectopic pregnancy, and surgery is required for accurate diagnosis and hemostasis. Laparoscopic surgery with IABT avoids or reduces the need for homologous blood transfusion and is a safe and minimally invasive treatment for massive hemoperitoneum.

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Background; MR images are considered to be highly effective to examine ovarian tumors. However, in some case, it is difficult to differentiate malignant ovarian tumors from benign ones.
Methods; Five hundred eighty-nine cases of ovarian tumors were managed by laparoscopic surgery during a period of six years. Of these cases, 15 cases were diagnosed as borderline ovarian tumors after surgery, and MR images of these cases were retrospectively reviewed.
Results; The mean age was 35 years old and the mean follow-up period was 36 months. Pathological results revealed ten cases of mucinous borderline tumors (67%), three cases of serous borderline tumors (20%), and the other two cases. In reviewing preoperative MR images, six cases showed solid parts within the tumor walls enhanced by contrast agents or huge tumor size (over 20 cm in diameter). Of ten cases of pathologically proven mucinous borderline tumors, five cases were interpreted as endometrial cysts before surgery.
Conclusion; For the gynecologic laparoscopists, it is necessary to thoroughly understand the characteristic features of MR images for ovarian tumors. If MR images show any possibility of malignancy, proper strategies such as frozen section diagnosis should be considered.

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At Yotsuya Medical Cube, during LAM, we have experienced three damages of forceps during surgery. All broken parts were successfully corrected immediately and no obvious invasion was observed during and after the surgery. However, such an interruption as damage of surgical instruments in a confined abdominal area always accompany risks like an extension of surgery and a possible shift to laparotomy. Moreover, interruptions during laparoscopic surgery give doctors a tremendous stress during procedure. In order to prevent such damage of surgical instruments, close attention of operating forceps as well as appropriate check and maintenance of all instruments for laparoscopic surgery are indispensable. At our hospital, we worked on establishing the maintenance management system of surgical instruments for laparoscopic surgery through cooperation with our clinical engineers. As a result, safer laparoscopic surgery has become possible, as no interruptions by damage of instruments has occurred and stress during procedures has been reduced. I think any medical facility requires to maintain quality control and establish its own management system of medical instruments. In this paper three cases of damage of forceps during LAM that we experienced will be reported and the maintenance management system of surgical instruments for laparoscopic surgery through cooperation with our clinical engineers will be introduced.

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We report a case of laparoscopic surgery in a patient considered to be at high risk for latex allergy.
A 42-year-old nulligravida sought evaluation at our hospital for infertility. A magnetic resonance image (MRI) showed myoma uteri. The preoperative history was significant for pruritus, swelling, and erythema of the labia after eating some fruits, e.g., melons and watermelons. Because she was considered at high risk for latex allergy, a laparoscopically-assisted myomectomy was performed without using medical instruments containing latex components in order to prevent an allergic latex reaction. No anaphylactic reactions were observed.
It is important to be familiar with latex allergies and to ask patients detailed questions about allergic symptoms and to determine if daily-used operative and anesthetic instruments contain latex components.

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Objectives: Uterine myomas are frequently occurring benign tumors that are characterized by symptoms such as anemia and dysmenorrhea, and may lead to infertility. In this study, we examined the efficacy of laparoscopic myomectomy, as well as pregnancy and obstetric outcome after the surgery in patients with uterine myomas who were infertile or wished to conceive.
Methods: Of 300 patients who underwent laparoscopic myomectomy in our hospital, 78 who wished to conceive before or after surgery, and whose factors contributing to infertility were identified, were selected as subjects. The factors measured during/after the surgery included uterine weight, number of myomas, maximum diameter of myomas, blood loss, and operative time. The pregnancy rate and obstetric outcome after the surgery were also examined.
Results: The pregnancy rate after the surgery was 53.8%; the pregnancy rate was as high as 73.0% in women who had no other factors contributing to infertility except uterine myomas. Spontaneous pregnancies occurred in 85.7% of the patients and 14.3% required assisted reproductive technology (ART). Forty-four pregnancies were confirmed in 42 patients after surgery. Of these 44 pregnancies, 20.4% resulted in spontaneous abortions and 79.5% culminated in a successful delivery. Nine gravidas (25.7%) were delivered vaginally and 26 gravidas (74.3%) had caesarean sections. The only complication noted was a case of serious bleeding after expulsion of the placenta during a caesarean section.
Conclusion: In patients who wish to conceive and have no other obvious factors contributing to infertility except uterine myomas, laparoscopic myomectomy improves the pregnancy rate. It is necessary to establish strict indications for laparoscopic myomectomy, taking complications during pregnancy and delivery into consideration, and to improve the surgeon's skills.

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Two cases with ovarian sex cord stromal tumors and successful pregnancy outcomes after laparoscopic surgery for infertility are described. Case 1 was a 33-year-old primipara with a history of ovulation induction for the first pregnancy. The evaluation for secondary amenorrhea after the birth demonstrated an elevated level of estradiol (161 pg/ml) and a decreased level of FSH and LH. A solid tumor of the left ovary, 2.5 cm in a diameter, was detected by trans-vaginal ultrasonography and MRI. A left salpingo-oophorectomy was performed laparoscopically. The histology of the tumor was a sex cord tumor with annular tubules. The patient conceived 9 months after the surgery and delivered a second baby. There has been no tumor recurrence for 4 years. Case 2 was a 33-year-old nullipara. She had a 4 year history of infertility and 2 years of amenorrhea. The testosterone level was elevated (297 ng/dl), but no adrenal massed were detected on CT scan. A solid tumor of the right ovary, 3 cm in a diameter, was detected by trans-vaginal ultrasonography and MRI, and removed laparoscopically. The histology of the tumor was a stromal Leydig cell tumor. She conceived spontaneously 3 months post-operatively and delivered a baby uneventfully. These tumors were both small; however, the MRI finding ( a solid mass surrounded by small follicles) was very helpful in establishing an accurate diagnosis, and laparoscopic surgery was quite useful for prompt recovery of fertility.

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Two cases of sex chromosomal mosaicism treated by laparoscopic gonadectomy are described. Case 1 was a 23-year-old phenotypic female with primary amenorrhea. She had a history of a right inguinal herniorrhaphy at the age of 1 year and 3 months. Her external genitalia and vagina were normal, but chromosomal analysis showed mosaicism of 45X/46XY which comfirmed the diagnosis of mixed gonadal dysgenesis. A MRI demonstrated a small uterus and two high-intensity nodules near the orifice of both inguinal canals consistent with ectopic gonads. A laparoscopic bilateral gonadectomy was performed to avoid the risk of gonadoblastoma or dysgerminoma. The histopathologic study showed ovarian stromal cells lacking follicles and epithelial cells in the right gonad and a dysgenetic testis in the left nodule. Neither gonad contained neoplastic components. Case 2 was 28 years of age. She was diagnosed with Turner syndrome at the age of 2 years. Chromosomal analysis revealed a mosaic karyotype [45X/46X, idic(Y)]. Typical features of Turner syndrome, such as short statue, webbed neck, and a cubitus valgus deformity were observed. A MRI demonstrated a small uterus, but did not detect the location of the gonads. A laparoscopy was performed and streak gonads were identified adjacent to the oviducts bilaterally. Both gonads and oviducts were removed laparoscopically for prevention of neoplasm. The histopathologic examination revealed ovarian stromal cells without follicles and epithelial cells. Laparoscopy is helpful, not only to detect the location of gonads in patients with chromosomal abnormalities, but also to remove the structures with minimum invasion.

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