JAPANESE JOURNAL OF GYNECOLOGIC AND OBSTETRIC ENDOSCOPY
Online ISSN : 1884-5746
Print ISSN : 1884-9938
Volume 26, Issue 2
Displaying 1-50 of 52 articles from this issue
Prepublication paper
Case report
  • Kazuko Takagi, Motofumi Yokoyama, Shinpei Tohjo, Norihito Yuge, Kenich ...
    2010 Volume 26 Issue 2 Pages 363-369
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Renal cell carcinoma during pregnancy has rarely been reported in the literature. We report a case of a 34 year-old pregnant woman who underwent a laparoscopic nephrectomy for renal cell carcinoma at 15 weeks of gestation. Clinical symptoms included lower abdominal pain at 12 weeks of gestation. The UST, MRI and CT scan findings revealed a 7.6-cm tumor originating from the left kidney that was highly suspicious for malignancy. Further examinations suggested neither invasion nor metastasis to other organs, including the left renal vein and bones. Following an explanation of the above results, the patient and her family wished to continue the pregnancy. After obtaining informed consent, a laparoscopic nephrectomy was performed at 15 weeks of gestation under CO2 pneumoperitoneum. The insufflated pressure was changed from 5mmHg to 12mmHg depending on the surgical process. The patient was lying in the right lateral position. The operation time was 5 hours and 15 minutes and the estimated blood loss was 50 ml. No operative complications were encountered during the procedure. The post-operative pathological diagnosis was clear cell carcinoma. During the operation, we examined the blood flow of the uterine arteries and the umbilical artery under pneumoperitoneum. The resistance index (RI) of the right uterine artery only correlated with the pressure of the pneumoperitoneum. A significant difference between the RIs of the both uterine arteries was observed. It was suggested that the difference of the RI resulted from the pressure of pneumoperitoneum and the body position during the operation. From our observations, we recommend that when performing laparoscopic surgery during pregnancy, the pressure of pneumoperitoneum should be kept under 12 mmHg and the body should be positioned to maintain adequate blood flow for both uterine arteries.
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  • Kazushige Adachi, Masahiro Watanabe, Tomoko Kanayama, Seiji Ogata, Kyo ...
    2010 Volume 26 Issue 2 Pages 370-373
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Growing teratoma syndrome (GTS) is defined as enlargement of a mature teratoma which arises during or after chemotherapy, caused by a malignant germ cell tumor. We managed a case of GTS in a 33-year-old woman who was successfully treated by laparoscopic surgery. She was diagnosed immature teratoma at the age of eighteen. Three and fifteen years after her initial surgery and chemotherapy, the mature teratoma recurred as pelvic masses without or with ovarian tumor. At the second recurrence, early recognition enabled us to perform laparoscopic surgery consisting of ovarian cystectomy and resection of a pelvic mass. Final histological evaluation documented only the mature teratoma. Her post-operative course was uneventful without recurrence for one year. Laparoscopic surgery was performed safely and considered to be an effective method in this case. Early recognition of GTS is important for its curative resection, especially to be completed by laparoscopic surgery. A long term follow-up is also essential because of the possibility of late recurrence.
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  • Naoko Yamamoto, Hisahiko Hiroi, Yutaka Osuga, Tetsuya Hirata, Akihisa ...
    2010 Volume 26 Issue 2 Pages 374-377
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Interstitial pregnancy is rare, accounting for 2%-4% of ectopic pregnancies. Massive intra-abdominal bleeding from uterine rupture may be fatal, so early detection and treatment are crucial. We report here a case of interstitial pregnancy detected early via laparoscopic surgical ultrasound probe.
      The patient, a 39-year-old female, presented at 5 weeks and 2 days of gestation, according to last menses. The initial serum human chorionic gonadotropin level of 2599 mIU/ml climbed to 4498.6 mIU/ml after two days. With a clinical diagnosis of ectopic pregnancy, emergency laparoscopic exploration was performed, disclosing a swollen left uterine cornu. Passage of an ultrasound probe enabled imaging of left cornual implantation and guided surgical extraction of the gestational sac. The limited uterine defect was easily repaired with negligible total blood loss. Laparoscopic diagnosis and treatment of this interstitial pregnancy was thus expedited through the use of an ultrasound probe.
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  • Tomoaki Takahashi, Daisuke Osumi, Shuhei Okamoto, Shinitsu Kitamura
    2010 Volume 26 Issue 2 Pages 378-382
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Herniations through 5-mm port sites are very rare after laparoscopic surgery. Most surgeons routinely close fascial defect in 10-mm or larger port sites to prevent herniation, but not in 5-mm port sites. Because 5-mm fascial defects are not the cause of hernia formation. Here, we report a 70-year-old female, diagnosed with a hernia through 5-mm port site in the early postoperative period after laparoscopic salpingooophorectomy. She complained of abdominal pain with a palpable mass. Abdominal CT revealed an incarcerated bowel hernia. The patient underwent segmental resection of the strangulated small bowel. Fascial defects should be closed not only in 10-mm or larger port sites but also in 5-mm port sites when they are dilated.
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  • Reiko Koushi, Masao Fukuhara, Yoshinobu Shintani, Akiko Miyawaki, Miek ...
    2010 Volume 26 Issue 2 Pages 383-387
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Case Report: A 35-year-old woman who had 3 years infertility period was referred to our hospital because of suspected ectopic pregnancy. A halo surrounded by a thin hyperechoic area, which was suspicious for ectopic pregnancy, was visualized by vaginal sonogram in the right adnexal region and laparoscopic surgery was performed. A 10 x 10 x 10 mm dark blood mass was observed on the left side of peritoneum of vesico-uterine pouch. There was no other findings suggesting ectopic pregnancy anywhere in pelvis. Neovascularity was minimally observed close to the mass and it was resected with adjacent peritoneum after the injection of a dilute vasopressin solution around the mass. The blood loss was little. Operative findings fulfilled Studdiford's criteria of primary peritoneal pregnancy. Villus, decidua and peritoneum were observed in the same specimen. The postoperative course was uneventful and serum hCG level was declined rapidly. It may be possible to manage abdominal pregnancy on laparoscopic surgery without suffering from profuse bleedings, if the diagnosis was established in early pregnancy.
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  • Tomomi Okawa, Naoyuki Yoshiki, Tomonori Ishikawa, Tatsuya Harada, Tosh ...
    2010 Volume 26 Issue 2 Pages 388-391
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Uterine myomas are extremely common in women, and distinct variants of these tumors do exist. We report here a rare ectopic (parasitic) myoma, with a ringlike calcification, discovered during laparoscopic surgery. The 35-year-old nulliparous female patient had multiple uterine myomas; but one in particular, situated in the pouch of Douglas, was entirely separate from the uterus, and it was calcific. Radiographs are helpful in such instances to detect opacities, delineate the lesion in vivo, and formulate a surgical strategy. Pertinent past medical history is also essential.
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  • Tomohiro Okuda, Takashi Yoshioka, Makoto Akiyama, Sadao Yamashita
    2010 Volume 26 Issue 2 Pages 392-396
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      A significant percentage of patients diagnosed pre-operatively with appendicitis are shown to be normal during laparotomy. Laparoscopic surgery is useful for both diagnosis and treatment of acute abdomens.
    Herein we report two cases diagnosed with pelvic inflammatory disease (PID) from Chlamydia during laparoscopic surgery for appendicitis.
    Cases: Case 1: An 18 year-old woman visited our hospital with abdominal pain. A CT and MRI revealed a large abdominal tumor and appendicitis. Laparoscopic surgery was performed.
    During laparoscopic cystectomy and appendectomy, we observed fibrous adhesions forming violin string-like sheets between the liver surface and the abdominal wall. Later, a cervical swab test for Chlamydia trachomatis by polymerase chain reaction (PCR) was positive and a serum test was positive for anti-Chlamydia IgA and IgG.
    Case 2; A 26-year-old woman with no surgical history visited our hospital for evaluation of lower abdominal pain. Marked tenderness in the hypochondriac region was noted. The white blood count and C-reactive protein level were elevated. CT image revealed an edematous appendix and right adnexa. Laparoscopic surgery was performed, and an edematous appendix and inflammatory changes in the right adnexa were noted. Subsequently, Chlamydia trachomatis was confirmed by PCR and serum test.
    Conclusion: Without an increase in costs, laparoscopic surgery provides clinical advantages. Initial laparoscopic surgery reduces the possibility of misdiagnosis. We recommend laparoscopic surgery as a first choice in the management of an acute abdomen.
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  • Miyuki Ito, Makoto Tokushige, Takuya Inoue, Yukiko Okada, Akiko Takash ...
    2010 Volume 26 Issue 2 Pages 397-400
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Deep endometriosis forms severe adhesion in the peritoneal cavity,which sometimes displaces the anatomical position of the ureter, and occasionally extends deeply into the retroperitoneal space, pressing and obstructing the ureter.
      Therefore, ureteral injury is an important complication that may occur during laparoscopic excision of endometriosis.
      We report a case of ureteral injury during laparoscopic deep endometriosis excision, which was repaired by laparoscopic ureteroureteral anastomosis using an indwelling D-J catheter as a ureteral stentguide.
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  • Hirokazu Arima, Juri Sugiyama, Mitsuko Takano, Masataka Furuya, Hirono ...
    2010 Volume 26 Issue 2 Pages 401-404
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      We present a case of a 19 year-old woman with endometriosis treated by laparoscopy 6 years after a liver transplant. This case had a high risk of visceral injury during trocar insertion. We used cine MRI for evaluation of intra-abdominal adhesions and color Doppler ultrasonography for detecting extrahepatic collateral routes.
      Previous major abdominal surgery has been considered a relative contraindication to laparoscopic surgery. Visceral injury during trocar insertion is comparatively frequent in laparoscopic surgery, especially for patients with a history of abdominal surgery. Functional cine MRI imaging has been reported to be a reliable noninvasive technique for detecting intra-abdominal adhesions. In this case, preoperative cine MRI findings showed no intra-abdominal adhesions between the small bowel and abdominal wall around the umbilicus.
      It is known that, after a liver transplant or its possible associated portal hypertension, there is a risk of recanalization by the umbilical and paraumbilical veins, which act as collaterals. We used cine MRI and Doppler ultrasound to evaluate this patient preoperatively for the presence of recanalization by these veins.
      We were able to perform laparoscopic surgery without complications with the use of preoperative cine MRI and Doppler ultrasound.
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  • Yusuke Matsuura, Chiho Hatae, Toshinori Kawagoe, Naoyuki Toki, Toru Ha ...
    2010 Volume 26 Issue 2 Pages 405-409
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Smooth muscle tumour of uncertain malignant potential (STUMP) is a rare neoplasia which is a variant of smooth muscle tumor. We report a case of "STUMP" occurring in a 44-year-old female. She was referred to our hospital with complaint of hypermenorrhea and dysmenorrhea. Magnetic resonance imaging (MRI) showed tumors about 6cm in diameter at the myometrium, and about 5cm in diameter at the uterine cavity which were suspected to be uterine myomas. She underwent a hysteroscopic resection for submucosal tumor. The resected tumor grew in interlacing bundles of smooth muscle cells displaying moderate cytologic atypia and a mitotic index of three to four mitotic figures per 10 high power fields (HPFs). Coagulative tumor cell necrosis or hemorrhage were not seen. The tumor cell showed positive staining for α-SMA, while staining for both CD10 and HMB45 was negative. Ki-67 was positive in occasional neoplastic cells. The final diagnosis was "STUMP", and she had a total abdominal hysterectomy.
      Although uterine leiomyoma is the most common benign neoplasm of the female genital tract, resected specimens should be submitted for pathological examination. Patients diagnosed with "STUMP" should receive long-term surveillance because of its "uncertain potential".
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  • Toyoharu Watanabe, Tomoko Fukunaga, Kenta Masuda, Hideyuki Akutagawa, ...
    2010 Volume 26 Issue 2 Pages 410-413
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: Report a relatively rare case of persistent hCG-negative tubal pregnancy.
    Case report: The patient, a 21-year-old female, underwent successful expectant therapy for ectopic pregnancy. Serum hCG was soon undetectable, BBT measurement became biphasic, and menstruation resumed after 3 months. Meanwhile, a 6.0 x 3.5 cm growth, resembling endometrioma, was identified in the pelvis. With laparoscopy, the mass was confirmed as the persistent tubal hematoma of an ectopic pregnancy. The products of conception were extracted, and ostomy of the salpinx was done.
    Conclusion: In the event of an hCG-negative endometrioma-like pelvic mass, especially with known prior pregnancy, the residual hematoma of ectopic implantation must be considered.
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  • Naoki Yoshino, Narihisa Takahashi, Jun-ichi Nishimura, Keiko Egawa, To ...
    2010 Volume 26 Issue 2 Pages 414-417
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Background: Inflammatory pseudotumor is a tumor-like mass of inflammatory origin. It is most commonly found in the lung or the orbit, but occurrences have been reported at nearly every site in the body. These tumors most commonly appear in young and middle-aged patients.
    Case: A 37-year-old female presented with vaginal bleeding and anemia. Ultrasound and MRI showed a myoma like mass of 56 mm in maximum diameter at the posterior wall of the uterine body. Preoperative hormone therapy failed to shrink the mass. Histological examination of the mass following laparoscopic enucleation revealed spindle shaped mesenchymal cells with infiltration by inflammatory cells, consistent with inflammatory pseudotumor. Smooth muscle cells were seen scantily in the margins of the resected mass.
    Conclusion: A rare inflammatory pseudotumor of the uterus is diagnosed after laparoscopic surgery.
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  • Keiko Mekaru, Kozue Asato, Chiaki Yagi, Yoichi Aoki
    2010 Volume 26 Issue 2 Pages 418-421
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: Numerous surgical and nonsurgical procedures aimed at creating a neovagina in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH syndrome) have been described. Surgery is required to create a neovagina with adequate size and physiological function for performance of normal sexual intercourse. We report a case of MRKH syndrome treated by the Davydov's laparoscopic procedure to evaluate the anatomic and functional performance of a neovagina.
    Case: We present the case of a 26-year-old nulliparous (46,XX) woman who was initially diagnosed with MRKH syndrome at 18 years of age. Magnetic resonance imaging showed absence of vagina and uterus, but both the ovaries were normal. She underwent the Davydov's modified laparoscopic technique. A vaginal dilator was used to maintain the neovagina postoperatively. She was able to successfully perform sexual intercourse 6 months after the surgery.
    Conclusion: Davydov's modified laparoscopic technique is a minimally invasive, safe, effective treatment option for creating a neovagina in patients with MRKH syndrome.
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  • Bao-Liang Lin, Yoshifumi Kasuga, Tomofumi Matsuoka, Takayuki Higuchi, ...
    2010 Volume 26 Issue 2 Pages 422-424
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      A thirty-five-year-old infertile woman underwent two trials of hysteroscopic resection of a large calcified submucous myoma. During the first surgery, a resectoscope and an orthopedic rongeru forceps were used. Fifty-one grams of myoma were removed. During the second operation, a pneumatic urological lithotriptor (Swiss LithoClast) was used. Only fourteen grams of myoma were removed. Because the remaining myoma was still large and there were no signs of improvement of menorrhagia, the patient went and received an abdominal myomectomy at another hospital. We conclude that a hysteroscopic surgery is unfit for treating a large calcified submucous myoma.
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  • Ikuhito Yamanaka, Kyoko Uchiyama, Miho Oeda, Hiroyuki Osogami, Miyabi ...
    2010 Volume 26 Issue 2 Pages 425-428
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Laparoscopic surgery is increasingly recommended for the treatment of benign uterine pathologies. We report a case of endometrial cancer diagnosed after laparoscopically-assisted vaginal hysterectomy for uterine fibroids. The patient was 70 years-of-age, gravida 2, para 2. She was referred to our department for evaluation of a pelvic mass. Magnetic resonance imaging revealed numerous intramural leiomyomas ranging from 1 to 9 cm. Pap smears of endometrial scrapings showed no atypical cells. She was diagnosed with uterine fibroids preoperatively, and underwent laparoscopically-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The pathologic findings revealed serous adenocarcinoma of the uterine corpus without deep myometrial invasion. She received six courses of adjuvant chemotherapy with paclitaxel and carboplatin. There was no evidence of recurrent and metastatic tumor one year after the laparoscopic intervention. As use of laparoscopic hysterectomy increases, we need to be aware of the possibility of adenocarcinoma in elderly women with multiple leiomyomas, even when endometrial cytology is negative.
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  • Tomohiro Okuda, Takashi Yoshioka, Makoto Akiyama, Sadao Yamashita
    2010 Volume 26 Issue 2 Pages 429-434
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Laparoscopic surgery is a valuable tool in the definitive diagnosis and treatment of benign uterine tumors. Here we report two cases diagnosed as benign uterine tumors by laparoscopic surgery: the first is an adenomatoid tumor that was suspected preoperatively as a uterine leiomyoma; the second is a uterine leiomyoma that was suspected preoperatively as an adenomatoid tumor.
    Cases:
      Case 1: A 63 year-old woman presented to our hospital complaining of lumbago. Uterine myoma was suspected and ultrasound and MRI were performed. A cystic uterine tumor suggesting benign uterine leiomyoma was discovered. However, malignancy could not be ruled out, therefore, the patient consented to LAVH (laparoscopic assisted vaginal hysterectomy). Upon removal of the patient's uterus, macroscopic examination of the tumor was strongly suggestive of uterine leiomyoma. The specimen was sent to pathology; microscopic examination and immunohistological testing provided the definitive diagnosis of benign adenomatoid tumor.
      Case 2: A 44 year-old woman presented to our hospital for periodic examination of a uterine myoma that she had been diagnosed with several years ago. MRI was performed and myoma nodule was found. To rule out malignancy, a diagnostic and therapeutic laparoscopic assisted myomectomy (LAM) was recommended. LAM was chosen because the tumor surface appeared as a usual myoma nodule. Final pathology findings on immunohistochemical study of the surgical specimen confirmed the diagnosis of uterine leiomyoma.
    Conclusion:
      Laparoscopic surgery provides many advantages in clinical gynecological practice. We stress the importance of laparoscopic surgery in preventing misdiagnosis, and in providing definitive diagnosis and treatment in cases of benign gynecologic tumors, including the rare uterine adenomatoid tumor presented herein. We recommend laparoscopic surgical intervention particularly in cases where various imaging studies including MRI, CT, and sonogram, are incompatible with or unable to confirm benign tumor origin.
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  • Hidenori Umeki, Rei Ishii, Asami Hirata, Maiko Kitano, Mikiko Tsugata, ...
    2010 Volume 26 Issue 2 Pages 435-438
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: We report a case of laparoscopic implantation of a subcutaneous peritoneal catheter port performed for advanced ovarian carcinoma.
    Patient: A 51-year-old female patient was admitted because of an abnormality of the cytology. Magnetic resonance imaging showed solid tumors of both ovaries. Massive ascites and disseminations showed peritonitis carcinomatosa. Primary debulking surgery was performed, but optimal surgery was impossible. Histopathological examination revealed that the surgical specimen was serous cystadonocarcinoma. Partial response was observed after six courses of paclitaxel-carboplatin-based systemic chemotherapy following the operation. Dissemination still remained although ascites had disappeared. As such intraperitoneal injection was chosen as the second line chemotherapy. Laparoscopic implantation of a subcutaneous peritoneal catheter port was selected as the operation method in order to resume the chemotherapy immediately after the operation. The catheter was inserted to avoid the disseminated parts under the laparoscopic observation, and the catheter tip was fixed under the right diaphragm. The postoperative course was fair, and the second line of chemotherapy was administered soon, thereafter.
    Conclusion: Laparoscopic implantation of a subcutaneous peritoneal catheter port was useful as a method in the case where it was not performed at the time of the first operation.
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  • Mieko Jikumaru, Rika Egami, Yoshitsugu Watanabe, Masao Fukuhara, Akiko ...
    2010 Volume 26 Issue 2 Pages 439-443
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      A unicornuate uterus with a non-communicating rudimentary horn is a rare Müllerian anomaly that has been associated with various comorbidities including hematometra, endometriosis and obstetric complications. Laparoscopy has proven to be an effective and minimally invasive surgical approach to the management of uterine anomalies. We present the case of a 23-year-old nulligravida woman with dysmenorrhea and vaginal spotting. Hysterosalpingogram and magnetic resonance imaging revealed a right unicornuate uterus, left rudimentary horn and ipsilateral ovarian endometrioma. In addition, computed tomography (CT) demonstrated absence of the left kidney and ureter. The course of the patient's uterine artery was examined with CT angiography. At laparoscopy the rudimentary horn was not identified initially because of the large endometrioma and dense adhesion. After adehesiolysis, laparoscopic removal of the rudimentary horn and ipsilateral salpingo-oophorectomy was performed without complications. The CT angiography was useful for the safe performance of laparoscopic management of this case.
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  • Yuko Kosako, Tomoyoshi Sakurai, Yoko Sano, Hirosuke Sasaki, Sinichiro ...
    2010 Volume 26 Issue 2 Pages 444-447
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    We experienced The breakage of resectoscopic cutting loop tip while we were performing the transcervical resection . And the broken pieces were all retrieved without causing any trouble. It is very rare to break a loop tip, but a cutting loop should be maintained in a good condition at anytime. And it is mandatory to check it whether if there is any crack or worn-out before starting the operation to prevent this kind of complication. Also, we learned the importance of knowing how to immediately manage sudden break of the resectoscopic cutting loop.
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  • Kentaro Nakayama, Haruhiko Kanasaki, Aki Oride, Takeshi Yoshizako, Koh ...
    2010 Volume 26 Issue 2 Pages 448-452
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      We report here a case of retroperitoneal schwannoma histopathologically diagnosed after laparoscopic surgery. This surgery was initially performed for suspected gossypiboma based on preoperative diagnostic imaging (MRI and CT). The patient was a 62-year-old female with gravida 2 and para 2. When she was 32 years old, she underwent extirpation of a right ovarian tumor via laparotomy. In August 2008, she presented to her primary physician with a chief complaint of constipation and gastric discomfort. Abdominal ultrasound showed a tumor of φ 2.9 x 3.5 cm in the left lower quadrant. The patient was referred to our department with a suspicion of left ovarian tumor. CT and MRI revealed a mass of φ 3.0 x 2.0 x 2.0 cm in the left iliac fossa. The mass had a regular margin. In both CT and MRI T1-weighted images, its central region had areas with low signal intensity and without dense enhancement. In MRI T2-weighted images, the mass showed high intensity. The mass was located in an unusual site for an ovarian tumor, and gossypiboma was suspected because the patient had a history of laparotomy with right ovarian resection. Laparoscopic surgery was selected to minimize as much as possible physical stress on the patient. Laparoscopy revealed a reddish brown protrusion (diameter: 3 cm) near the left iliopsoas muscle. The retroperitoneum was incised and then opened bluntly with grasping forceps. A grayish white mass with a smooth surface which was connected to cord-like tissue was found. Intraoperative rapid histological diagnosis was retroperitoneal schwannoma. Postoperatively, the patient complained of decreased sensation of the lateral left thigh (femoral nerve territory) but there was no decrease in motor function. In this patient, gossypiboma was initially suspected from diagnostic imaging and because of the patient's surgical history. However, this case indicates that when a tumor occurs in an unusual site, it is necessary to consider retroperitoneal schwannoma in the preoperative differential diagnosis.
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Original
  • Hironori Kenjo, Keiko Kataoka, Nari Yamamoto, Masahide Miyazaki, Akiko ...
    2010 Volume 26 Issue 2 Pages 453-456
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Hydrosalpinx is a predisposing factor of isolated tubal torsion. However, the incidence of hydrosalpinx with tubal torsion in pre-menarcheal girls is very rare, and the pre-operative diagnosis is difficult to establish. We report a case of a pre-menarcheal 11-year-old girl. Hydrosalpinx was diagnosed pre-operatively by MRI, and because of repeated left lower abdominal pain, we diagnosed a tubal torsion. Emergent laparoscopy was performed, and torsion of the left hydrosalpinx was confirmed and resected. It is our recommendation that in the differential diagnosis of repeat acute lower abdominal pain in girls, isolated torsion of the fallopian tubes should be considered.
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  • Takafumi Ujihira, Noriko Abe, Hidehiro Konno, Eriko Yamamoto, Soushi K ...
    2010 Volume 26 Issue 2 Pages 457-461
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: Recently, the diagnosis of the ectopic pregnancy [EP] have advanced by serum human chorionic gonadotoropin [hCG] levels and a high-resolutional transvaginal ultrasonography. Therefore, the recent strategies for EP make it possible to diagnose EP in the early stage and it seems that the operation of the asymptomatic cases increase. However there are some cases that are hard to discriminate EP and intrauterine pregnancy [IUP], especially in their early stage. We report about five cases which turned out that they were not EP after laparoscopic surgery.
    Design: Retrospective analysis.
    Methods: We identified 5 cases with misdiagnosis as EP between April, 2005 and March, 2008. And we assessed for the data on patient characteristics, clinical presentations , and surgical findings.
    Results: Misdiagnosis rate was 4.1% (5/121). All cases had regular menstrual cycles and were spontaneous pregnancies. 4 cases were introducted for EP doubt, one had lower abdominal pain. In three cases, serum β-hCG were above 1500mIU/ml (1643-2892mIU/ml). Transvaginal ultrasonography findings showed GS like echo near the adnexal lesion in 3 cases, one had hematoma in the adnexal lesion, another had ascites image in douglas pouch that seemed bleeding in the peritoneal cavity. All 5 cases were finally diagnosed spontaneous abortion and GS like echo appeared corpus luteum in 2 cases, ascites image appeared ovarian bleeding in one case.
    Conclusions: All of misdiagnosed 5 cases were intrauterine nonviable pregnancy. In order to avoid misdiagnosis, it is important to evaluate their general status closely and dilatation and curettage as gradual strategy is previously performed when the diagnosis is suspicious.
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  • Chiharu Tomonaga, Hirohide Inagaki, Eiji Shibata, Satoshi Aramaki, Ken ...
    2010 Volume 26 Issue 2 Pages 462-465
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: We compared Laparoscopic Myomectomies (LM) with Abdominal Myomectomy (AM) for the operating time and the blood loss because of an assessment of the indications and limits of LM.
    METHODS: We studied a retrospective analysis of 19 cases of LM and of 20 cases of AM in our hospital.
    RESULT: When the maximum length of myomas were under 8cm, LM was equivalent to AM for the operating time and the blood loss. Furthermore, when the number of removed myomas were within 3, LM was also equivalent to AM for the blood loss.
    CONCLUSION: When the maximum length of the myomas are under 8cm and the number of them to remove are within 3, we consider that it is possible to operate safely by LM as well as AM.
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  • Takeshi Nakayama, Kazunori Tanaka
    2010 Volume 26 Issue 2 Pages 466-472
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To assess current trends in laparoscopic surgery, involving trocar insertion and wound closure.
    Design: Postquestionnaire survey.
    Setting: A consortium of 64 hospitals belonging to the Japanese Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE).
    Patient(s): None
    Intervention(s): None.
    Main outcome, Measure(s): Common clinical practices.
    Result(s): To assess procedural safety, the author issued a multicenter questionnaire directed at expert gynecologic laparoscopists authorized by the JSGOE. We received 64 completed surveys (a 59% response). Acknowledged differences in trochar insertion and wound closure, as in previous reports, were associated with rare intraoperative complications, such as rupture of larger blood vessels and intestines, trocar site bleeding/infection, and port-site hernia. The questionnaire also revealed strategies for prevention, formulated by those having experienced these complications.
    Conclusion(s): Laparoscopic surgical complications are largely attributable to trocar insertion. The body of preventive measures contributed by respondents to our questionnaire is therefore worthy of note, in order to increase the relative safety of this procedure.
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  • Akitoshi Hasegawa, Yasuhiro Konishi, Osamu Inoue, Kenta Masuda, Yuko K ...
    2010 Volume 26 Issue 2 Pages 473-476
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      We report a case of rivet damage to a claw-forceps used with an electric morcellator during a laparoscopic myomectomy.
      The claw-forceps was purchased on 30 March 2007. We noticed the dropout of a rivet's head of a claw-forceps during a laparoscopic surgery study meeting in the operating room on 25 October 2007. The claw-forceps was used from the time of purchase to awareness of the defect after 14 laparoscopic myomectomies. When we reviewed the operative videos all 14 cases, the rivet's head possibly dropped out in one of seven cases. We looked for the rivet's head with abdominal X-rays for the seven cases. However, it turned out that there were no foreign objects in the abdomens of any of the patients.
      The period of use for reusable claw-forceps is 1 year or 30 cases, but our instrument did not reach the period of use. Thus, confirmation of medical equipment in proper working order is very important before and after surgery. Of course, confirmation intra-operatively is also important. The durability of reusable medical equipment changes with the method used and the duration of use. It is important to study the durability of reusable medical equipment. It is also more important that we are aware that delicate medical equipment is breakable.
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  • Takehiko Tsuchiya, Ichiro Uchiide, Masahito Nakakuma, Takao Toyoizumi, ...
    2010 Volume 26 Issue 2 Pages 477-481
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Recently, surgical treatments for gynecologic benign diseases have become minimally invasive. Thus, in our department, we perform laparoscopic surgery for all cases in which benign tumors are diagnosed, with the exception of cases that are too difficult to treat laparoscopically, such as size or suspected malignancy. We have reported before the efficacy of local infusion of vasopressin for endometrial and dermoid cysts. However, the use of vasopressin for vasocontraction is not indicated and has the possibility for severe complications. Herein we reviewed the cases in which laparoscopic ovarian cystectomies were performed for ovarian dermoid cysts, into non-drug, vasopressin, and epinephrine groups, and examined retrospectively about the age, diameter of tumors, haemorrhage, and operative time. We examined the cases in which laparoscopic ovarian cystectomies were performed for ovarian dermoid cysts in our hospital between January 2005 and March 2009.
      We performed ovarian cystectomies by using 100X diluted vasopressin or 1,000,000X diluted epinephrine, locally infused into a crevice of walls of ovarian cysts and normal ovarian tissues. There were no significant differences between the three groups in age, diameter of tumors, and operative times. Significant differences were shown with respect to haemorrhage (36.2 ±38.4 ml for the non-drug group, 3.4±6.3 ml for the vasopressin group, and 12.5±23.1 ml for the epinephrine group). More research will be necessary to reduce the haemorrhage equivalent to the use of vasopressin, by modifying the concentration of epinephrine. In the future, we will change the level of epinephrine administration, and it is thought that it is necessary to review whether or not there is an equal reduction in the hemorrhage effect with vasopressin.
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  • Takenori Nishi, Eiji Boshi
    2010 Volume 26 Issue 2 Pages 482-485
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To assess the usefulness of laparoscopic uterine artery ligation (LUAL) for laparoscopic myomectomy.
    Materials and Methods: Twenty-six patients with intramural and subserosal myomas underwent the LUAL procedure in cases of laparoscopic myomectomy. After the identification of the course of uterine arteries, and the size and location of uterine myomas by using ultrasonography, MRI, CT, and/or 3D-CT, the unilateral or bilateral uterine arteries were ligated laparoscopically before the myomectomy. The decision whether the unilateral or bilateral uterine arteries were ligated was made based on the following factors: the main feeding artery of the dominant nodule being evident or not, the number and location of nodules, patient's age as well as the patient's wish to preserve fertility, and so on.
    Results: The unilateral and/or bilateral LUAL procedures were successfully performed on all patients. One conversion to a laparotomy occurred because of a technical difficulty in enucleating a large cervical nodule. The remaining 25 patients were completed a laparoscopic myomectomy after the LUAL procedure. The estimated blood loss was less than 30ml in 22 patients, and the others were 150ml, 200ml, and 300ml in the completed cases, respectively. Two women conceived spontaneously. One woman delivered a baby, and the other experienced a miscarriage. No intraoperative and postoperative complications were observed.
    Conclusion: The LUAL procedure, especially the unilateral procedure, prior to myomectomy is an effective and feasible way to reduce operative blood loss and thermal tissue damage by hemostasis procedure.
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  • Satomi Kikawa, Eiji Nomura, Kenrokuro Mitube, Maki Ishimoto, Makiko Na ...
    2010 Volume 26 Issue 2 Pages 486-492
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: This study was conducted to assess the validity of laparoscopic lymphadenectomy for gynecologic malignancies at our hospital.
    Methods: Twenty-five patients undergoing laparoscopic (LS) paraaortic and pelvic lymphadenectomy for endometrial carcinoma were compared with 21 control subjects similarly treated via laparotomy (LT). Only surgeries involving systematic lymphadenectomy were included. Extracted lymph nodes were classified using The General Rules for Clinical and Pathological Management of Uterine Cervical Cancer1). For the two groups, the count of nodes retrieved was analyzed by region.
    Result: PAN and PLN lymph node totals were similar with either technique. However, comparatively fewer lymph nodes were obtained from left common iliac regions of the LS group.
    Conclusion: These data suggest that complete removal of nodes from the left common iliac region may be difficult with a laparoscopic retroperitoneal approach. This potential pitfall must be recognized and care taken for thorough dissection in this area.
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  • Yuki Hyodo, Keiichi Matsubara, Toru Fujioka, Yuko Matsubara, Shinji Hy ...
    2010 Volume 26 Issue 2 Pages 493-496
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Laparoscopic surgery is often performed to remove ovarian cysts in pregnant women to minimize pain and the length of recovery after surgery. These surgeries are typically performed after 12 weeks of gestation to avoid the risks of anesthesia and surgery on the fetus. Since the uterus is enlarged, the surgical field is smaller. Often, the ovarian cyst is not clearly visible, and it can be difficult to move it from Douglas' pouch to the surgical field if the cyst is impacted behind the uterus. In this case, a left ovarian cyst measuring 6 cm in diameter was detected by ultrasonography in a 25-year-old primipara on the 6th gestational week. The ovarian cyst did not decrease in size, so during the 13th gestational week, a laparoscopic ovarian cystectomy was performed. A Diamond-Flex retractor was used to move the ovarian cyst from Douglas' pouch to the surgical field during the procedure. The laparoscopic ovarian cystectomy was performed successfully, with no complications.
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  • Atsushi Kuno, Ai Saeki, Hisato Oku, Rihoko Kuramori, Yoshiko Hashimoto ...
    2010 Volume 26 Issue 2 Pages 497-502
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      In management of the lower uterine ligament during total laparoscopic hysterectomy (TLH), it is necessary to ensure maintenance of hemostasis and prevent hemorrhage from the cardinal ligament as well as to avoid accidental injury of the ureter.
      Various methods are available for management of the lower uterine ligament that differ with regard to the facilities, operator skill, and equipment required. We divided these methods of managing the uterine artery and cardinal ligament when performing TLH into four groups, and the advantages and disadvantages of each method were examined.
      The results indicated a tendency to ligate the uterine artery and cardinal ligament in cases where the uterine weight is heavy and intrapelvic adhesion is advanced. However, the frequency of cardinal ligament ligation was decreased after introducing the vessel sealing system in our hospital.
      In management of the cardinal ligament and uterine artery when performing TLH, it is important to use the most appropriate method for management of the lower uterine ligament for each individual case, and it is also very important to introduce effective surgical equipment for these procedures. This may lead to improvements in the safety of surgery, reduce operation times, and improve education for young doctors.
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  • Azumi Nakamura, Yutaka Hirota, Eiji Nishio, Masako Miyata, Haruki Nish ...
    2010 Volume 26 Issue 2 Pages 503-506
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: We conducted postoperative follow-up of patients with bilateral ovarian chocolate cysts, focusing on rates of recurrence, potential to conceive, and degree of ovarian reserve.
    Methods: A total of 128 patients diagnosed with bilateral ovarian chocolate cysts were studied during a 9-year period. Any patient seen postoperatively for six months or more was included in the study. Of this cohort, 21 underwent bilateral cystectomy, while bilateral fenestration and coagulation was performed for the remainder (n=107).
    Results: The recurrence rate was 4.7% (6/128), with all instances of recurrence limited to the bilateral fenestration and coagulation technique The mean period from surgery to recurrence was 12.5 months (range, 10-31 months). The recurrence rate by surgical procedure was 0% (0/21) for bilateral cystectomy and 5.6% (6/107) for bilateral fenestration and coagulation. Seventeen of 40 (42.5%) patients became pregnant in the study time frame (12 spontaneous cycles, 3 clomiphene cycles, and 2 IVF-ET cycles). We also selectively examined subjects under the age of 40 years (115/128) whose menstrual cycles had been normal prior to surgery. The rate of postoperative menstrual disorders was 22.2% (4/18 cases) for bilateral cystectomy and 4.1% (4/97 cases) for bilateral fenestration and coagulation (p=0.0055).
    Discussion: Laparoscopic fenestration and coagulation, rather than cystectomy, may be a preferable treatment for bilateral chocolate ovarian cysts in terms of preserving fertility and ovarian reserve.
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  • Keiichi Matsubara, Toru Fujioka, Shinji Hyodo, Koji Koizumi, Yuko Mats ...
    2010 Volume 26 Issue 2 Pages 507-510
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objectives: Laparoscopic surgery is widely used as a therapy for gynecologic diseases. However, there are few reports with respect to the hydration status of patients during laparoscopic surgery. It is suspected that insensible water loss is reduced during laparoscopic surgery because a laparotomy is not performed. However, further studies are required to confirm this notion and ensure that fluid balance is regulated appropriately during laparoscopic surgery. The aim of the current study was to determine the fluid balance of patients undergoing total laparoscopic hysterectomy (TLH) in comparison with vaginal hysterectomy (VH) and total abdominal hysterectomy (TAH).
    Methods: All surgical procedures were performed under general anesthesia. We analyzed the volume of intra-operative bleeding, urine, and transfusion, and calculated the third space losses in 37 patients who underwent VH, TAH, or TLH in the Ehime University Hospital between December 2007 and April 2009. Statistical analysis was performed by ANOVA. The differences were statistically significant at a p<0.05, and the results were recorded as the mean average ± standard error of the mean.
    Results: The amount of bleeding, urine output, and transfusion per hour was significantly increased in patients undergoing TAHs. Third space loss was significantly increased in patients undergoing TLHs (7.7±0.7 mL/kg/h; p<0.05) and VHs (5.7±0.6 mL/kg/h; p<0.05).
    Conclusions: Third space loss was significantly increased during TLH, suggesting that the loss was caused by evaporation into the carbon dioxide aeroperitoneum and as a result of electrocoagulation. Given these results, we should reconsider the issue of third space loss during laparoscopic surgery and manage fluid balance accordingly during TLH.
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  • Chiaki Izumiya, Kayo Taniguchi, Nagamasa Maeda, Takao Fukaya
    2010 Volume 26 Issue 2 Pages 511-515
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To evaluate the efficacy of laparoscopic surgery for endometriosis-associated infertility.
    Design: Retrospective study.
    Setting: Department of Obstetrics and Gynecology, Kochi Medical School.
    Patient(s): Sixty-five women with endometriosis-associated infertility.
    Intervention(s): Laparoscopic evaluation and treatment of endometriosis.
    Main outcome Measure(s): Background of 65 women with endometriosis-associated infertility. Clinical pregnancy rate (PR) of 57 women, who were followed > 6 months after laparoscopic surgery for endometriosis.
    Result: Of 57 women who underwent laparoscopic surgery, 34 conceived (clinical PR, 59.6%), including 28 non-ART pregnancies and 6 ART pregnancies. Eighty percent of non-ART pregnancies conceived within 1 year after laparoscopic surgery. In women with minimal and mild endometriosis, the clinical PR of non-ART after laparoscopic surgery was 61.1%, and in women with moderate and severe endometriosis the clinical PR of non-ART was 43.8%. The clinical PR of non-ART in women < 35 years of age (67.6%) was significantly higher than in older women (27.2%).
    Conclusion: Women with endometriosis-associated infertility can be expected to conceive spontaneously within 1 year after laparoscopic surgery. When patients fail to conceive 1 year after laparoscopic surgery, ART should be considered.
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  • Misugi Matsuoka, Yutaka Hirota, Haruki Nishizawa, Takahiro Sako, Akira ...
    2010 Volume 26 Issue 2 Pages 516-520
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      In recent years, improvements in diagnostic technology have enabled the early detection of ectopic pregnancy, and the opportunities for preserving the oviduct have increased, particularly as laparoscopic surgery has become the first-line choice for treatment of ectopic pregnancy in an increasing number of institutions. At our institution we use laparoscopic techniques to attempt oviduct preservation in patients with ectopic pregnancy who wish to become pregnant again. In this report, we examined the rates of persistent ectopic pregnancy and repeat ectopic pregnancy over a ten year period in patients who were treated laparoscopically with oviduct preservation. When compared with other treatments, we found a lower rate of persistent and recurrent ectopic pregnancy in women who were treated with oviduct-persevering laparoscopy. We conclude that laparoscopic surgery with oviduct preservation should be the therapy of choice for ectopic pregnancy when the patient still desires to get pregnant. However, a thoroughly informed consent detailing the risks of persistent and recurrent ectopic pregnancies must be a priority because of the high emotional toll of these complications.
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  • Setsuko Yamamoto, Michiko Umeki, Tomoko Maeda
    2010 Volume 26 Issue 2 Pages 521-525
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To determine the efficacy of laparoscopic surgery for managing infertile patients with endometriosis.
    Design: Retrospective study.
    Setting: Assisted Reproductive technology (ART) Center, Fukuda Hospital, Kumamoto, Japan.
    Patient(s): Consecutive total of 209 infertile patients who had undergone laparoscopic surgery for endometriosis as a first-line therapy were enrolled.
    Intervention(s): Eighty-three women were also involved in ART programs.
    Main Outcome Measure(s): Age, infertile period, revised American Fertility Society (re-AFS) score, peritubal and periovarian adhesions were compared between pregnant and nonpregnant patients. We also evaluated the pregnancy rate and infertile period, adhesion score and re-AFS score. We compared cumulative pregnancy rates in patients with no (Group CF, n = 142), unilateral (Group U, n = 41) and bilateral endometriomas (Group B, n = 26).
    Result(s): An infertile period > 3 years and a mean adhesion score > 21 points were negatively correlated with pregnancy rates. There were no significant differences in pregnancy rates after surgery and after ART across the four disease stages. The cumulative pregnancy rate of Group B (53.8%) was significantly lower than Groups CF (76.1%) (p<0.01) and U (80.5%) (p<0.05).
    Conclusion(s): Women with no or unilateral endometriomas and a duration of infertility > 2 years should be encouraged to undergo laparoscopic surgery. However, encouraging such women with bilateral endometriomas to move directly to ART might improve their ability to achieve a pregnancy. Further prospective studies are necessary to test this hypothesis.
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  • Tetsuya Ishikawa, Takao Mikoshiba, Takashi Mimura, Yusei Noguchi
    2010 Volume 26 Issue 2 Pages 526-529
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objectives: AESOP3000 is a computer-driven robot capable of holding and positioning a laparoscope under the direct voice control of a surgeon. This device could be especially helpful when surgeon availability is low. Because we have occasionally experienced voice misrecognition in test situations, we conducted a study to determine whether or not voice training is an effective corrective measure for this problem.
    Methods: At voice card recording, we modified pronunciation and accent for a number of commands (AESOP, Back, Up, In, Down, Right, Left) in English-speaking mode, and carried out 26 of 63 laparoscopic maneuvers. Conventional voice cards were also used in the same series of operations for comparison.
    Results: With the stated modifications, voice misrecognition rates for most commands were significantly reduced as follows: AESOP: 17.5% to 9.2% (p<0.001), Back: 23.9% to 8.3% (p<0.001), Up: 18.5% to 6.7% (p<0.001), In: 9.4% to 8.0%, Down: 8.7% to 4.2% (p<0.05), Right: 4.3% to 3.4%, Left: 25.1% to 13.1% (p<0.001).
    Conclusions: While not 100% effective, pronunciation training is a valid means of reducing AESOP3000 voice misrecognition.
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  • Tatsuya Harada, Tomonori Ishikawa, Tomomi Okawa, Naoyuki Yoshiki, Tosh ...
    2010 Volume 26 Issue 2 Pages 530-534
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: The purpose of this study is to investigate the significance of early second-look laparoscopy (ESLL) and to evaluate post-operative adhesion formation after myomectomy by laparotomy.
    Patients: 57 women who wanted to conceive in the future underwent early second-look laparoscopy (ESLL) after myomectomy by laparotomy.
    Interventions: ESLL was performed to evaluate and to lyse post-operative adhesions at 7 to 14 days after myomectomy by laparotomy.
    Results: Post-operative adhesions were found in 39 patients and could be removed in 34 of them. Therefore, the efficacy rate of ESLL is about 0.6. Adhesions were found on sutured uterine muscles in 24 patients (42.1%), and new adnexal adhesions were identified in 23 patients (40.4%). The frequency of post-operative adnexal adhesions was similar between patients with and without simultaneous adenexal operations (41.2% vs. 40.0%), and the seriousness of those adhesions was also similar. The rate of post-operative adhesions in patients with endometriosis was significantly higher than that in patients without endometriosis (85.0% vs. 59.5%, p<0.05).
    Conclusions: Because the rate and the seriousness of post-operative adenexal adhesions were high after myomectomy by laparotomy, we need to make more provisions against adhesions. Because the frequency of adhesions after laparotomy was higher in patients with endometriosis, great care in preventing adhesions should be taken in all other gynecological operations as well.
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  • Aiko Sakamoto, Tadayuki Kanai, Ayako Tanaka, Izumi Suzuki, Masato Fuka ...
    2010 Volume 26 Issue 2 Pages 535-540
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Study Objective: To analyze the progression of patients after incomplete TCR (transcervical resection), including natural regression, pregnancy and repeated surgery.
    Setting: Numazu City Hospital, Shizuoka, Japan
    Patients: From 2005 to 2008, hysteroscopic myomectomy was performed on 21 patients with sessile type submucous myoma. Thirteen of these cases underwent an incomplete resection, and the follow up period after which post TCR occurred in these cases was between 5 to 26 months. Of 13 cases, 9 patients had a single myoma, and 4 had multiple myomas.
    Results: Of 9 cases of a single myoma, 2 regressed spontaneously within 4 months postoperatively. Four cases remained stable. Three cases required another surgery, including TCR. The sizes of the persistent myomas were 13 to 19.5 mm, 13 to 18 mm, and 20 to 38 mm, respectively. Based on our results between stable and repeated surgery groups, the border size of a myoma was 20 mm. Both a patient with a regressed myoma and 1 with a stable myoma became spontaneously pregnant. Of 4 cases with multiple myomas, 2 cases remained stable and another 2 cases likely needed another surgery. The number of myomas in stable cases was 2, while the number of myomas that required another intervention was 7 and innumerable. Therefore, the border number of a myomas was 2.
    Conclusion: Our results indicate that patients with persistent myomas that are single in number and smaller than 2 cm in size may be able to become pregnant and that these myomas may spontaneously regress. This study also showed that additional surgical intervention might be necessary for the persistent single myoma that is bigger than 2 cm or multiple myomas of more than 3 in number.
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  • Shoji Kaku, Yoshihiko Shimizu, Shiro Wakinoue, Akie Takebayashi, Akiko ...
    2010 Volume 26 Issue 2 Pages 541-544
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      It has been reported that the incidence of ureteral injury during laparoscopic surgery is higher than during laparotomy. Accordingly, we investigated the usefulness and safety of ureteral illuminating catheters during gynecological surgery. Two patients underwent laparoscopic assisted vaginal hysterectomy and laparoscopic hysterectomy with the use of ureteral illuminating catheters. After introduction of the laparoscope, the catheters were clearly seen within the ureters through the pelvic peritoneum, facilitating dissection of the ureters and control of periureteric bleeding. Regarding the complications of ureteral illuminating catheters, lumbar backache was noted postoperatively in one patient, but it resolved after one day. No other complications were found. This method can be applied for training in laparoscopy at teaching hospitals, as well as in technically challenging cases where identification of the ureters is likely to be difficult, e.g. patients with severe pelvic adhesions, severe endometriosis, and malignant tumours. To assess the safety of ureteral illuminating catheters, we will investigate more cases in the future.
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  • Takuya Inoue, Miyuki Ito, Kentaro Sekiyama, Makoto Tokushige, Shingo F ...
    2010 Volume 26 Issue 2 Pages 545-549
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objectives: We examined the cases of transcervical resection (TCR) due to uterine submucosal myoma performed in our institution from June 2007 to May 2010.
    Materials and Methods: TCR was performed in 23 women during this period. Women with uteine submucosal myoma, complaining hypermenorrhea or infertility, were treated by TCR. The excision using forceps extraction took precedence over the resection using loop electrodes of the resectscope. Before the operations, cervical canals were sufficiently dilated using the Laminaria cervical dilators. During forceps extraction, the guides by transabdominal USG were always used simultaneously.
    Results: In 22 cases among 23 cases, submucous myomas were completely removed. Submucous myomas were removed by forceps extraction alone in 16 cases, by both forceps and loop electrodes in 5 cases, by loop electrodes alone in 2 cases. In one case, a balloon occlusion was needed to be used to stop bleeding during operation. No other complications such as uterine perforation were occurred.
    Conclusions: TCR with forceps extraction as well as loop electrodes seems to be an useful method.
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  • Narihisa Takahashi, Naoki Yoshino, Masashi Moriyama, Osamu Iwanari
    2010 Volume 26 Issue 2 Pages 550-555
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      The placental polyp has been defined as an intrauterine polypoid or even pedunculated mass of retained placental tissue from an abortion or term pregnancy.
      Most of the chorionic villi forming the placental polyp were necrotic or sclerotic and hyalinized.
      A blind intrauterine operation was performed once, leading to hemorrhaging and hysterectomy.
      We report three cases of placental polyp successfully treated by transcervical resection (TCR) after uerine artery embolization (UAE) or iliac artery occlusion.
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  • Tomoko Yoshimoto-Kakoi, Shigeki Uehara, Haruka Suzuki-Kakisaka, Kouji ...
    2010 Volume 26 Issue 2 Pages 556-559
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Purpose: To evaluate the incidence, character, and prognosis of ovarian tumors diagnosed as benign before laparoscopic surgery but identified as malignant or of borderline malignancy by postoperative histopathology.
    Subjects: Of 1,066 laparoscopic ovarian tumor resections at Tohoku Kosai Hospital from April 2001 to May 2010, a total of 22 patients were postoperatively confirmed as having overt or borderline malignancies.
    Methods: For this patient subset, the following factors were analyzed: postsurgical histopathology, patient age, tumor size, solid tumor component, CA125 and CA19-9 markers, laparoscopic technique, tumor capsule status, adjunctive therapy, and prognosis.
    Results: The rate of preoperative diagnostic error was 2.2% (22/1,066). Of the 22 misinterpreted tumors, five were clearly malignant, and 17 were of borderline malignant potential. Although no specific tendencies were evident, based on analysis of preoperative features, malignant lesions were more likely in older patients or in those with large sized cysts. For two of the five patients with malignancies, definitive cancer surgery was performed, followed by chemotherapy, while the other three received chemotherapy alone. Three of the 17 patients with borderline malignancy also opted for surgery. Endometrial carcinoma was found in one patient with malignancy, and recurrent mucinous cysts occurred in two patients with borderline tumors, but the long-term prognosis for these patients in close follow-up was fairly good.
    Conclusion: Preoperative misdiagnosis of ovarian malignancies may be unavoidable, despite thorough assessment. However, even with laparoscopic resection, the prognosis of such tumors is not poor, given adequate adjunctive therapy and/or careful clinical follow-up.
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  • Yosuke Konno, Masataka Kudo, Daisuke Akashi, Satomi Kikawa, Shinya Nis ...
    2010 Volume 26 Issue 2 Pages 560-564
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: Considered to be a cause of unexplained chronic pelvic pain, appendiceal endometriosis is relatively rare, accounting for only 3% of all pathologic lesions of this disorder. In this study, we analyzed the clinicopathologic findings of resected appendices with an abnormal appearance discovered during laparoscopic surgery for endometriosis.
    Patients and Methods: We performed laparoscopic surgery on 309 patients with endometriosis between January 2006 and December 2008 in Hokkaido University Hospital and its affiliated hospitals. Nineteen patients underwent laparoscopic appendectomy after careful pathologic inspection of their appendices.
    Results: An abnormal appendiceal appearance was found in 17 of 19 patients; the remaining 2 patients possessed no superficial appendiceal abnormalities but had chronic pelvic pein. Of 17 cases with abnormal appendiceal appearance, 16 (94.1%) had pathological abnormalities: appendiceal endometriosis was found in 12 cases and appendicitis in 4 cases. Two patients affected by chronic pelvic pain with normal appendiceal appearances had appendices with no pathological abnormalities. The prevalence of appendiceal endometriosis in this study was 3.9% (12/309). All patients with appendiceal endometriosis had endometriomas. Neither conversion to open surgery nor treatment for surgical complication was necessary.
    Conclusion: Laparoscopic appendectomy is an appropriate procedure for patients with endometriosis if they have abnormal appendiceal appearances. During laparoscopic surgery for endometriosis, especially in the case of endometrioma, close observation of the appendix may allow surgeons to remove endometriotic lesions more thoroughly.
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  • Suguru Igarashi, Midori Tamura, Megumi Ishiyama, Haruhiro Kondo, Nao S ...
    2010 Volume 26 Issue 2 Pages 565-569
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective
      It has been reported that an ovarian tumor is diagnosed during pregnancy in 0.21-1.24% of cases. Patients with ovarian tumor who underwent surgery in pregnancy from 2004 to 2008 were reviewed.
    Design
      During these 5-years, there were 3,837 deliveries in our hospital, and 16 of which underwent surgery due to an ovarian tumor. A retrospective analysis of these cases was performed.
    Results
      Laparoscopic surgery was performed in 9 patients, while the remaining 7 patients underwent open abdominal surgery. The tumor was determined to be malignant in 2 patients. The mean patient age at the time of surgery was 31.4 years, and the median number of gestational age at surgery was 16 weeks. The median value for the maximal tumor diameter was 9 cm. Overall, among the patients with ovarian tumors complicating their pregnancy, the pathological diagnosis was a mature cystic teratoma in 9 patients, which was the predominant type, followed by an endometriotic cyst in 3 patients and a malignant tumor in 2 patients. These malignant tumors consisted of an immature teratoma (G2) and a yolk sac tumor, and these patients are currently undergoing chemotherapy.
    Conclusion
      Patients should be examined for the possible presence of an ovarian tumor early in gestation. Once a tumor is present and indication of operation is judged to be appropriate, it is necessary to carefully determine the best time and method for the surgery in each individual patient.
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  • Naohiro Ashizawa, Tetsuro Yahhata, Nobumichi Nishikawa, Katsunori Kash ...
    2010 Volume 26 Issue 2 Pages 570-574
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Recent advances in ultrasound diagnostic capability have enabled earlier detection of ectopic pregnancy, increasing the number of cases suitable for less invasive methotrexate (MTX) or laparoscopic intervention. We report here a case of interstitial pregnancy ultimately resolved through laparoscopic access after attempted MTX treatment.
      A diagnosis of right interstitial pregnancy was made at seven weeks, when a placental sac and viable embryo (with heartbeat) were detected near the right fallopian tubal horn. Findings were confirmed by MRI, so systemic MTX (1 mg/kg intramuscularly) was given. Although urinary hCG thereafter declined from 45,048 IU/L to 24,151 IU/L, heart tones persisted, and both embryonic crown-rump length and placental sac showed continued growth. At Week 9 of pregnancy, a laparoscopically facilitated right interstitial incision was made, exposing the implantation site. The extremely attenuated tubal wall was then incised linearly, allowing extraction of the intact sac and villi. Once discharged from the hospital, the patient's urinary hCG levels decreased steadily.
      It has been reported that even with detectable embryonic heartbeat or very elevated hCG, the success rate of conservative MTX therapy with interstitial pregnancy is high. However, if the placental sac expands without loss of heartbeat, surgical intervention at an early stage should be considered.
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  • Akitoshi Hasegawa, Toyoharu Watanabe, Akira Iida, Tomoko Hukunaga, Ken ...
    2010 Volume 26 Issue 2 Pages 575-579
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To describe a well-differentiated papillary mesothelioma (WDPM) detected incidentally at laparoscopic myomectomy.
    Design: Case series
    Patient: A 36-year-old asymptomatic female with uterine myomas and WDPM of the peritoneum, but no history of asbestos exposure.
    Intervention: Laparoscopic diagnosis, excision, and treatment of WDPM and uterine myomas.
    Result: During laparoscopic surgery for uterine myomas, we discovered a scattering of papillary nodules, 2.0 cm or less in size, studding the abdominal cavity serosa. The ovary was of normal size. Laparoscopic myomectomy and cytoreduction were executed to the extent possible. Histopathology confirmed our gross diagnosis of leiomyoma and WDPM. WDPM is rare subtype of peritoneal mesothelioma, marked by indolent behavior and a potential for malignant transformation. We thus referred the patient for specialty evaluation.
    Conclusion: Presurgical radiography of this WDPM was not helpful. Its presence was an unexpected finding during laparoscopic surgery, for which immediate cytoreduction was performed. Because WDPM usually carries a favorable prognosis after cytoreduction, without need of adjuvant therapy, distinguishing it from malignant peritoneal mesothelioma is critical.
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  • Hirofumi Henmi, Atsushi Azumaguchi, Manabu Saito, Eiko Itabashi, Syuji ...
    2010 Volume 26 Issue 2 Pages 580-584
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Single-port surgery utilizing a solitary incision at the umbilicus, but with multichannel access, improves cosmetic results. Initially, we grasp the lower umbilicus and edge of fascial defect together, using an Endopath XCEL 5.0 mm extra long (150.0 mm) sleeve as we optically puncture the fascia. The trocar tip is positioned 1.0 cm from the abdominal wall. A 30-degree 5.0 mm scope is then inserted through the central long trocar. Use of a clear central long trocar enables visualization of the two additional lateral trocars and Babcocks forceps that are subsequently inserted into the abdomen.
      The second and third punctures, each via Endopath XCEL 5.0 mm with long (100.0 mm) and short (75.0 mm) sleeves, are placed symmetrically 20.0 mm from the point at 5.0 mm closer to the focus from the camera port.
      We next insert Babcock forceps (5.0 mm diameter), without use of trochars, into the direct abdominal puncture along the inner detached opening. Insertion should be 10.0 mm from the camera port, oriented towards 12 o'clock. These forceps help maintain sufficient field of view.
      By implementing the above port arrangement, complete with direct puncture forceps, the need for trochars is reduced, thus promoting a safe single-port procedure.
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  • Yumiko Goto, Takahiro Suzuki, Atsuya Narita, Sungsil Kim, Eri Nakamura ...
    2010 Volume 26 Issue 2 Pages 585-588
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To report a case of TOA from bilateral ovarian endometriomas and discuss how fertility may be preserved.
    Case: A 37-year-old gravida 1/para 0 female underwent treatment for infertility for seven years. Her initial laparoscopy, at age 31, disclosed bilateral ovarian endometriomas (stage IV endometriosis according to the revised classification of the American Society for Reproductive Medicine [r-ASRM]). Ultrasound-guided transvaginal endometrioma aspirations were done on four occasions, and more than 10 attempts at intrauterine insemination (IUI) failed. At age 35, she also developed pelvic inflammatory disease (PID) two days following an IUI procedure. Antibiotics were given and the infected ovarian cysts aspirated. However, the condition became episodic, so laparoscopic intervention with transvaginal ultra-sound guided aspiration was elected to withdraw pus. Once recovered, 10 poststimulatory eggs were harvested. She subsequently conceived with in vitro fertilization (IVF), and a healthy baby was finally delivered vaginally.
    Conclusions: Up to 25% of infertility patients have ovarian endometriomas. If PID develops, antibiotics are clearly indicated; but surgical drainage of pus may still be needed. We routinely give preservation of fertility high priority, using minimally invasive laparoscopy and transvaginal, ultrasound-guided aspiration. Ovarian function was thus retained for this patient, despite TOA and repeated endometrioma infections.
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  • Akiko Takashima, Kiwamu Otaka, Mayumi Saito, Hiroaki Ishida, Yutaka Ya ...
    2010 Volume 26 Issue 2 Pages 589-594
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
    Objective: To identify factors associated with endometrioma recurrence after laparoscopic cystectomy.
    Design: Prospective observational study.
    Setting: Toho University Medical Center, Sakura Hospital
    Patient: Patients (N=153) undergoing laparoscopic cystectomy for ovarian endometrioma, followed postoperatively for two to five years.
    Intervention: Subjects were grouped by recurrent and nonrecurrent status.
    Main outcome: Evaluated parameters included endometrioma recurrence, patient age, prior surgery, previous medical treatment, cyst diameter, endometriosis stage and score, percentage of bilateral cysts, presence of multiple cysts, controlled ovarian hyperstimulation, and postoperative pregnancy.
    Result: Endometrioma recurred postoperatively at a rate of 22.9%. With fertility intact, prior surgery, bilateral cysts, and the presence of multiple cysts were associated with endometrioma recurrence. For infertile patients, older age, the presence of multiple cysts, and controlled ovarian hyperstimulation were identified as risk factors.
    Conclusion: The ability to effect complete surgical excision of endometrioma may significantly impact the risk of recurrence.
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  • Goichiro Kasai, Atsushi Fukui, Hachidai Hirakawa, Kazuhiro Abe, Akiko ...
    2010 Volume 26 Issue 2 Pages 595-599
    Published: 2010
    Released on J-STAGE: June 02, 2011
    JOURNAL FREE ACCESS
      Single port access laparoscopic surgery is a new, minimally-invasive, and elegant surgical technique. However, it is a costly investment, requiring bending forceps, a vessel-sealing system, and a special port for trocar installation. As a cost-effective alternative, a wound retractor and surgical glove may be used. However, this so-called "glove method" has not found wide acceptance, because it lacks the stability that laparoscopic forceps demand. We therefore developed a modified glove method, whereby trocars are fixed with a foley catheter. With this approach, manipulations with laparoscopic forceps are stable, and surgical duration is shortened. We thus believe this cost-conscious option has merit.
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