Port site herniation (PSH) is a rare complication after laparoscopic surgery, usually at 10-mm and larger port sites. According to the past reports, only a few cases of PSH through 5-mm trocar sites have been reported. Here we describe a case with omental herniation through 5-mm port site after laparoscopic myomectomy. The patient was 40 years old, having laparoscopic myomectomy for 11-cm subserosal myoma with a peritoneal drain left at the lateral 5-mm port site. She was found to have omental herniation through a laterally placed 5-mm port site four days after the operation. The omentum was returned to the abdominal cavity in the emergent surgery. PSH can occur even through the 5-mm port site, especially after the inserted trocar moved repetitively through abdominal wall and drain was placed at the identical port site.

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[Objective] An air-fluid level (niveau) on abdominal X-ray is usually an important sign of ileus. We experienced two cases of ileus without air-fluid level following gynecologic surgery. Both patients underwent double-balloon enteroscopy for diagnosis, followed by laparoscopic adhesiolysis.
[Case 1] The patient underwent total abdominal hysterectomy and right salpingo-oophrectomy for myoma uteri and right ovarian tumor. Five months later, she was readmitted with abdominal pain and constipation, but there was no air-fluid level on abdominal x-ray. Adhesion of the small bowel was diagnosed by enteroscopy. Laparoscopic adhesiolysis was performed. There was a 20 cm adhesion of the small bowel to the scar from the previous operation, but there was no stenosis or obstruction. Usually, a post-operative ileus is a mechanical ileus, but this case it was not only a mechanical ileus, but also a functional ileus because there was peristalsis abnormality.
[Case 2] A patient who was being treated for depression underwent right adnexectomy for torsion of a right ovarian tumor. 16 months later, she was readmitted with lower abdominal pain and constipation without air-fluid levels. We initially suspected functional ileus because the patient was on antidepressants, but conservative therapy was not effective. Diagnostic enteroscopy revealed adhesion of the small bowel. Because of the enteroscopy results, laparoscopic surgery was selected and laparoscopic adhesiolysis between the ileum and retroperitoneum was performed.
[Conclusion] When abdominal pain and constipation without air-fluid level are persistent, we must consider the possibility of ileus. Enteroscopy and laparoscopic adhesiolysis may be options in these cases.

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  Recently, as laparoscopic myomectomy (LM) has become increasingly common, reports of intraoperative or postoperative complications have arisen. We experienced a case of massive hemorrhage resulting from a ruptured uterine arteriovenous fistula after LM.
  A 24-year-old woman, nulligravid, presented with hypermenorrhea. She was diagnosed with an 8-cm intramyometrial leiomyoma of the posterior uterus with endometrial deformation. LM was performed. The myoma was soft, its boundaries were not clear, and there was extensive contact with endometrium. Operative time, blood loss, and enucleate weight were 181 minutes, 1,000 ml, and 298g. On a transvaginal ultrasound 25 days after the operation, a cystic lesion was noted in the area of the myomectomy. Color Doppler ultrasonography showed a fountain of blood streaming from a single artery into the cyst, while the size of the cyst was not changed. However, a massive hemorrhage erupted even as we were conferring with the patient in the medical examination room. She underwent emergency laparotomy on the same day. Pulsatile bleeding from a 1mm diameter artery in the wound of the myomectomy was observed. We examined the cyst in detail after ligating the artery. The wall of cyst was a structured fibrous myomatous capsule of a white color with a perforation of the intrauterine part. Blood infiltration and hematoma were not seen at all in the myometrium of the cyst.
  We have performed LM on 406 patients in our hospital. This case was the first of its kind, so we are reporting it as a warning for consideration in the LM of the future.

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Parovarian cysts account for about 10% of adnexal tumors and the frequency of torsion is considered to be about 5% of adnexal tumors. The unilateral torsion of an ovarian tumor in a case of bilateral ovarian tumors was diagnosed pre-operatively as torsion in a parovarian cyst coincident with an ipsilateral tumor of the left ovary. The patient, a 29 year old gravid 1, nulliparous woman with no remarkable Family History. She was diagnosed as having bilaterally enlarged ovaries two months earlier at a examination for a Pap smear for Cervical Cancer. A vaginal ultrasonography at this time revealed a mass which was 6.3×8.4cm and was highly serous in nature in the vesicouterine space, and a 8.3×9.3cm mass in the pouch of Douglas which was suspected as being a dermoid cyst. Evaluation of Tumor Marker were within normal. She experienced Acute Abdomen, and since we suspected torsion of an ovarian tumor, we performed an Emergency Laparoscopic Surgery. We found an 8cm parovarian cyst of the left ovary, twisted 540°counterclockwise. The left ovary was enlarged to about 9cm, but was not involved in the torsion. Histopathology showed (1) Left parovarian cyst with hemorrhage, (2) Focal hemorrhagic necrosis in the left salpinx, (3) Mature cystic teratoma in left ovary.

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  A 37-year-old woman with a history of Caesarian section visited our hospital for infertility treatment. She had been treated with 2 years of timing intercourse and 6 attempts of intrauterine insemination with ovarian stimulation by clomiphene citrate following an infertility evaluation at another private clinic. Several bright dots were observed in the myometrium of the uterine cervix by transvaginal ultrasound examination, and the cavity of uterine body could not be visualized due to acoustic shadow. Hysteroscopic examination diagnosed residual silk from the Caesarian section as a foreign body of the uterine cavity. After the removal of the foreign body by hysteroscopic surgery and laparoscopic adhesiolysis around the uterus, the patient became pregnant by timing intercourse. Foreign bodies of uterine cavity are a rare cause of infertility, but in cases of secondary infertility with a history of Caesarian section, hysteroscopy may be a useful examination and the removal of foreign bodies can restore fertility.

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  Total laparoscopic hysterectomy (TLH) is becoming a standard minimally invasive procedure for benign pelvic diseases. However, TLH is not usually indicated in cases of large myomas or with severe adhesions in the cul-de-sac, etc., because TLH has been reported to have a higher incidence of injury to adjacent organs such as the ureters than abdominal hysterectomy. Therefore, we have adapted the retrograde hysterectomy, which has been used in abdominal hysterectomy, to TLH.
  We performed this procedure for 31 patients with indications in our institution from May 2008 to November 2009 with no complications. As a result, we propose that TLH using a retrograde approach can be safely performed in more severe cases.

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Objective: To establish indications for hysteroscopic versus transserosal myomectomy of submucous myomas located deep within the uterine wall.
Design: Retrospective study
Setting: Department of gynecology at a general hospital.
Patients: Twenty-one women with submucous myomas, each with <50% of tumor diameter protruding into the uterine cavity. Twelve women underwent hysteroscopic myomectomy(group A),while transserosal myomectomy was performed for the other nine (group B).
Intervention: Myomectomy,either hysteroscopic or transserosal
In our hysteroscopic myomectomy, the endometrium is incised and opened along the equator of the myoma; it is then separated to enucleate the myoma completely. Thus the endometrium is conserved.
Main Results: Mean maximum diameter of fibroid was 25.5 mm for group A and 40.0 mm for group B; the mean protrusion rate was 28.3 % for group A and 17.2 % for group B. The mean serosa-myoma thickness (SMT) was 15.3 mm for group A and 4.0mm for group B. In 7 cases, maximum diameter of the submucous fibroid was < 30mm, and the SMT was > 6 mm. These fibroids were completely removed by hysteroscopic myomectomy. In one case of submucous fibroids with maximum diameter of > 40mm and SMT of 7 mm, the fibroids were removed by 2 sessions of hysteroscopic myomectomy. In 9 cases of fibroids with maximum diameter of > 40mm or SMT < 5 mm, the tumors were easily removed by transmural myomectomy. In 4 cases with tumor diameters between 30mm and 40mm, the challenge level of transcervical resection varied depending on the SMT, the fibroid location, the presence of complications, and the possibility of obtaining sufficient preoperative dilatation of the cervical canal.
Three patients conceived after hysteroscopic myomectomy and five patients conceived after transserosal myomectomy. Uterine rupture did not occur, and complication rates were low with both procedures.
Conclusion: Transmural excision of submucous myomas may be optimal when maximum tumor diameter exceeds 40mm, whereas hysteroscopic myomectomy is better suited for submucous fibroids with maximum diameter under 30mm. With tumor diameters between 30mm and 40mm, either procedure may be utilized. In such cases, SMT and other factors will be useful determinants of an appropriate surgical approach.

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Objective: We investigated emergency laparoscopic surgery for gynecological disease in our hospital, and analyzed the clinical characteristics of patients and findings of ruptured vs. un-ruptured ovarian endometriotic cyst.
Design: From April 2005 to March 2009 and April 2009 to September 2010, we treated a total 1,847 patients by laparoscopic surgery at Nagasaki Municipal Hospital (1251 cases) and Saiseikai Nagasaki Hospital (596 cases). We retrospectively analyzed operative reports, video images and laboratory data.
Result: The frequency of emergency operation was 18% (334/1,847cases) during this period. Preoperative clinical diagnosis was as follows: ectopic pregnancy (166 cases), torsion of ovarian tumor (55 cases), ovarian bleeding (43 cases), ruptured ovarian endometriotic cyst (37 cases), pelvic inflammatory disease (11 cases), and other (20 cases). Among the 37 patients with suspected cases of ruptured ovarian endometriotic cyst before surgery, 10 cases were found un-ruptured at laparoscopic surgery. Among the 43 patients diagnosed preoperatively with ovarian bleeding, two cases were found to be ruptured endometriotic cyst at laparoscopic surgery. We compared cases in the ruptured group (n=29) versus the un-ruptured group (n=10) according to preoperative clinical and laboratory findings including age of the patient, affected site (right or left), body temperature, tenderness of cul-de-sac, rebound tenderness, leukocyte count, serum CRP/CA125 level, diameter of the tumor, and MRI findings. We found that the age of the patient (33.6 ± 7.8 vs. 28.1 ± 5.1yrs), the leukocyte count (11,993 ± 4,127 vs. 8,500 ± 4,046/μl), and the incidence of rebound tenderness (96% vs. 22%) were significantly higher in the ruptured group when compared with the un-ruptured group.
Conclusion: A substantial proportion of patients with ovarian endometriotic cyst were found with ruptured cysts during emergency laparoscopic surgery at our hospital. Although it is relatively difficult to accurately diagnose ruptured ovarian endometriotic cyst, careful physical examination and clinical investigation are essential in the preoperative assessment of patients with suspected ruptured ovarian endometriotic cyst.

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  A number of patients with multi-focal and/or giant fibroids visit our clinic, a microinvasive surgery specific facility, seeking laparoscopic treatment because of its potential advantage both in cosmesis and preserved fertility. Laparoscopically assisted myomectomy (LAM) with supra-pubic mini-incision is our procedure of choice in these cases. In this report, our experience of LAM is retrospectively reviewed in order to assess optimal indication for the laparoscopic approach. A total of 677 patients who underwent LAM between 2005 and 2010 were included in this analysis. The maximum diameter of the enucleated fibroids was 8.93 ±3.29 (mean ±SD) cm and the number of enucleated fibroids was 13.44 ±29.46 (mean±SD). There was statistically significant correlation between the number of fibroids and operative time, and between the number of fibroids and blood loss. Although some cases are technically demanding, the laparoscopic approach seems to be feasible, even in cases of multi-focal and/or giant fibroids that are generally treated by the open approach. Further experience and technical improvement will be required to more definitively establish the acceptably safe and reasonable indications for the laparoscopic approach.

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Objective: The efficacy of diagnostic laparoscopy should be re-considered due to the improved success rate of assisted reproductive technologies (ART).
Methods: We retrospectively reviewed clinical records of 126 women who were examined by both hysterosalpingography (HSG) and diagnostic laparoscopy for unexplained and tubal infertility, and of 186 women undergoing in vitro fertilization and embryo transfer (IVF-ET) due to unexplained infertility, between January 2002 and December 2009 in the Department of Obstetrics and Gynecology, University of Tokyo.
Results: The mean age of patients undergoing laparoscopy was 33.2±3.7 years and the mean duration of infertility at first visit was 40.6±26.6 months. In assessing for tubal patency, laparoscopic findings differed from HSG findings in 45 women (35.7%). The cumulative pregnancy rate without ART after laparoscopic surgery was 42.4%. We compared the pregnancy rates between patients with normal tubes and those with abnormal tubes, who were treated during laparoscopy. The pregnancy rate of the patients with abnormal tubes was relatively high (64.3%) compared with that of the patients with normal tubes (36.5%) (P = 0.06). The cumulative pregnancy rate of patients undergoing IVF-ET was 52.7% (mean age: 37.4±3.7 years old) ; that of patients over 40 years old was 28.4%.
Conclusions: The evaluation of tubal pathology by HSG alone can be limited. Laparoscopic surgery can be a useful adjunct in accurate diagnosis of infertility and improvement of fecundity, especially for patients with tubal pathology that can be treated laparoscopically. However, older women may still require further IVF-ET treatments.

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