We reported a case of peritoneal pregnancy which was completely cured by the resection of the gestational sac by the operative laparoscopic procedure. We performed a laparoscopic operation on a 34 year old woman who had serious low abdominal pain at five weeks and one day gestation, with the pre-operative diagnosis of lt. tubal pregnancy. Unexpectedly, the gestational sac was located on the peritoneum of the vesicouterine pouch. We performed a complete resection of the gestational sac taking care to avoid excessive blood loss. The total blood loss was 1100g, and the operation time was 1 hour and 51minutes. The urine hCG level was under 0.2 IU/L 82 days after the operation without additional medication. Lower blood flow at the implantation site of gestational sac, a smaller size of gestational sac, and an earlier gestational period are important factors for the successful treatment of women with peritoneal pregnancy by laparoscopic operation.

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  A 37-year-old woman developed growing teratoma syndrome (GTS) involving an immature teratoma of the ovary that developed during adjuvant platinum-based chemotherapy. At initial surgery, the patient was diagnosed with immature teratoma of the ovary (pT2c (a) NxM0) with peritoneal and contralateral disseminations. After the fertility-sparing surgery, she underwent chemotherapy with BEP comprising bleomycin, etoposide, and platinum. During adjuvant chemotherapy, her serum alpha-fetoprotein level normalized; however, the size of the pelvic tumor increased. She underwent laparoscopic surgery for her peritoneal dissemination. Surgical specimen indicated a mature teratoma. No recurrence was observed after the second operation. The possibility of GTS should be considered in the follow-up of a patient with previous history of an ovarian germ cell tumor. GTS is defined as an enlargement of a mature teratoma, which arises during or after chemotherapy for malignant germ cell tumors. When GTS is suspected, surgery should be considered. In our case, GTS was successfully treated using laparoscopic surgery.

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  Lower limb compartment syndrome is caused by abnormal increases in intracompartmental pressures in a non-expansile fascial space. It results not only in muscle necrosis, pararesthesia, and renal failure, but may also necessitate amputation of the lower limb or cause the patient's death. It is believed to be a rare complication following gynecologic surgery; however, gynecologists should be aware of the risk factors for this life-threatening disease. We report a case of a 38-year-old obese woman (body mass index = 27) presenting with lower limb compartment syndrome after laparoscopic-assisted myomectomy performed in a lithotomy position. Postoperatively, she complained of pain in her left lower extremity and paresthesia after 1 day; drop foot appeared after 2 days. Five days postoperatively, she underwent fasciotomy to reduce the pain. Her drop foot recovered after 9 weeks, and she fortunately became able to walk almost normally. This case highlights the importance of assessment for risk factors for lower limb compartment syndrome, which can be a life-threatening complication.

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  Duplication cysts of the alimentary tract are uncommon congenital lesions that can occur anywhere along the path between the oral cavity and the anus, with a reported incidence of 1 in 20,000. Treatment is dependent upon the patient's age, whether the lesion is cystic, tubular, or in communication with the true intestinal lumen, and whether one or more anatomic locations are involved. Duplication cysts are diagnosed most frequently in children younger than 2 years. In the current study, we report a case of duodenal duplication cyst in an adult female that was removable by laparoscopy. Whereas the preoperative diagnosis was an ovarian endometriotic cyst that was later classified as endometriotic cyst of the supernumerary ovary during surgery, postoperative histological diagnosis revealed a duplication cyst of the alimentary tract. Because duplication cysts usually share a common wall as well as a common blood supply with the normal intestine, the adjacent bowel segment must also be removed along with the cysts. In this particular case, the common blood supply between the cyst and normal intestine was minimal, and there was no luminal communication with the adjacent intestine. It was therefore possible for a safe resection of the cyst to be done using laparoscopy without necessitating a bowel resection.

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Objective: To report a case of leiomyomas on the rudimentary uterus in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.
Design: Case report.
Setting: Department of Obstetrics and Gynecology, Nagasaki University School of Medicine.
Patient: A 39-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome presented with lower abdominal pain and a pelvic mass.
Intervention: Diagnostic and therapeutic laparoscopy.
Main Outcome Measure: Histologic examination.
Result: Laparoscopy revealed leiomyomas on the rudimentary uterus. Further histologic examination of a biopsy suggested tissues consistent with endometrioid appearance that clearly demonstrated expression of the estrogen and progesterone receptors when probed with monoclonal antibodies. However, this endometrium did not consist of the typical basal and functional layers, and the patient reported no response to hormonal withdrawal.
Conclusion: Leiomyomas of the bilateral rudimentary uterus were diagnosed in this MRHS patient via laparoscopic surgery. Normal endometrium should have a functional layer and basal layer, which could not be established via histologic examination in this case. Furthermore, the basal layer demonstrated estrogen and progesterone receptors, but did not possess the ability to exfoliate, indicating that this endometrium is non-functional. These results suggest a relationship between the basal layer and the lack of normal endometrial function in the rudimentary uterus of this patient with Mayer-Rokitansky-Küster-Hauser syndrome.

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  Ovarian torsion causes acute abdomen, and it is increasingly being treated with laparoscopic surgery, even in emergencies. Herein, we report a case of a 27-year-old woman who underwent laparoscopic surgery for excision of mesenteric lymphangioma, which could not be easily differentiated from ovarian torsion. Three days before her visit to our department, she visited her former physician because of lower abdominal pain and was diagnosed with an ovarian cyst. She then visited our department because of worsening lower abdominal pain. Ultrasonography showed a multilocular cystic tumor (9 cm in diameter), and tenderness was noted over the pelvis. Therefore, ovarian torsion was suspected, and emergency laparoscopic surgery was performed. We detected a smooth surface tumor in the pelvis; the tumor originated from the sigmoid colon mesentery. No abnormal findings were observed in the uterus and bilateral adnexa. The tumor was excised; multilocular cysts were recognized on the cut surface of the excised specimen, and serous fluid in the cyst was observed. A diagnosis of mesenteric lymphangioma was made via histopathological examination.
  Lymphangiomas commonly develop in the neck and armpits in children and rarely develop in the mesentery in adults. Although laparotomy was previously the treatment of choice for these tumors, laparoscopic surgery is being increasingly used for treatment in recent years. It is important to differentiate mesenteric lymphangiomas from ovarian cysts, and concurrent use of computed tomography (CT), magnetic resonance imaging (MRI), and other imaging modalities can help increase the rate of diagnosis. However, lymphangiomas are sometimes only detected during surgery, and it is important to work closely with other hospital departments in such cases.

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  Primary peritoneal tuberculosis is a rare disease that may mimic peritoneal carcinomatosis because of similar clinical pictures, including radiologic and laboratory test results. The differential diagnosis requires consideration of a wide range of benign and malignant gynecologic and gastrointestinal candidate conditions. A 74-year-old woman was referred to our hospital and presented with ascites and left ovarian cysts. The concentration of CA125 in the serum was 230.7 U/mL. Transvaginal paracentesis revealed that cytology of ascites was negative for cancer, but magnetic resonance imaging (MRI) and computed tomography (CT) suggested possible peritoneal dissemination. We performed bilateral salpingo-oophorectomy and peritoneal biopsy by laparoscopy and found multiple miliary deposits on the peritoneal surface, the Pouch of Douglas, most of the intestine, liver, and diaphragm. Upon histological examination, epithelioid granulomatous lesions with necrosis were apparent. No cancer cells were found in either the ovaries or fallopian tubes. Therefore, a diagnosis of peritonitis tuberculosis was established, and Mycobactrerium tuberculosis was later identified in cultures of the peritoneum. Herein, we have demonstrated an effective and minimally invasive procedure for diagnosing peritoneal tuberculosis via laparoscopy.

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  A rare instance of endometriosis, coupled with a right inguinal hernia, is described herein. The patient, a 31-year-old nulliparous Japanese female, reported a palpable right inguinal mass (rounded and soy-bean sized) that became painful during menstruation. Blood counts and other laboratory tests were all within normal limits. By magnetic resonance imaging (MRI), a poorly circumscribed mass, 10 mm across, was visible in continuity with the right round ligament. The mass was isointense on T1-weighted images (T1WIs) but slightly hyperintense on T2WIs (compared to adjacent muscles), showing homogeneous enhancement with intravenous Gd-DTPA contrast. Its presence was detected on diffusion-weighted imaging as well. The MRI showed no signs of associated pelvic disease. Specifically, pelvic endometriosis was not evident, although in addition to inguinal hernia, desmoid tumor, and hemangioma, this was a diagnostic consideration. Laparoscopy was eventually conducted, revealing a small inguinal hernia with a distinct mass peripheral to the sac. Several endometriotic lesions were also observed on the capsule of left ovary. Inguinal herniorrhaphy was thereafter performed, during which the mass and hernia sac were excised together. Histologically, the mass was largely fibrous in nature, with a few endometrial-type glands dispersed, confirming a diagnosis of endometriosis. The patient was discharged 2 days postoperatively in excellent condition. On follow-up, the groin pain had completely resolved.

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  Retroperitoneal mature cystic teratoma is relatively rare. We report a case that was first diagnosed as an ovarian teratoma by preoperative imaging, but later found to be a retroperitoneal mature cystic teratoma by laparoscopic resection. The patient was a 40-year-old woman, gravida 1, para 1, with history of regular of 28-day menstrual cycles. She had an appendectomy at 14 years of age. She was diagnosed with a right ovarian tumor at another hospital then referred to our hospital. Pelvic MRI showed a 50 mm tumor in the right doral pelvic peritoneum with hyperintensity on T1-weighted images and on fat-suppressed images, suggesting a possible mature cystic teratoma of the right ovary. Laboratory values were normal, except for slightly high CA19-9 (41.8 U/mL). Laparoscopy revealed normal-sized non-swollen ovaries and an approximately 50-mm retroperitoneal tumor in the right pelvis. The retroperitoneum was incised and the tumor was carefully isolated from the surrounding tissues. The tumor was placed in a collection bag and removed through the 12-mm port. The patient was discharged on the third postoperative day in excellent condition. The pathological diagnosis was retroperitoneal mature cystic teratoma. In this case, we first suspected an ovarian tumor and performed laparoscopy. However, a retroperitoneal tumor was found and was removed by laparoscopic surgery. Although retroperitoneal mature cystic teratoma is rare, it should be considered during preoperative evaluation. This type of tumor may be removed by laparoscopic surgery if it is relatively small with no marked malignancy.

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  We encountered two cases of parasitic peritoneal leiomyomatosis occurring after laparoscopic myomectomy using a morcellation device. Case one is a 42-year-old, gravida 2, para 1 woman who underwent laparoscopic myomectomy (LM). Two years later, she underwent laparotomy, during which five tumors were resected. These tumors were smooth and solid, 3mm to 3cm in diameter, and separate from the uterus. Case two is a 42-year-old, gravida 0 woman who underwent LM. Two years and 11 months later, she underwent LM, during which three tumors, 1-4cm in diameter., were resected from the pelvic peritoneum. In both cases, the histopathological findings were that of a benign leiomyoma, and a diagnosis of parasitic peritoneal leiomyomatosis was made. Recently, reports on parasitic peritoneal leiomyomatosis and disseminated peritoneal leiomyomatosis after laparoscopic morcellation of uterine myoma or the uterus itself have been increasing, therefore prompting us to further examine the prevention and management of these iatrogenic diseases.

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  Inguinal endometriosis is a rare form of the condition; it accounts for less than 1% of the cases. Surgery is the primary treatment; however, it cannot be established as the procedure of choice because of the rarity of the disease and the fact that excision includes the round ligament. This case report deals with the treatment of inguinal endometriosis. The patient is a 39 year-old married woman with no history of pregnancy. She did not suffer from dysmenorrhea; however, she experienced right inguinal catamenial swelling beginning at 36 years of age. She experienced catamenial pain beginning at age 39 years. Inguinal pain was severe as measured by the Verbal Rating Scale. A groin hernia was not noted on computerized tomography (CT) . Right inguinal endometriosis was diagnosed and the patient underwent laparoscopic surgery, which confirmed mild endometriosis. The right inguinal region was laparotomically dissected. The round ligament was severed at the position of the internal oblique muscle. This point was selected because its extension to the lateral inguinal fossa appeared uninvolved. The pubic tubercle portion of the ligament was excised en-bloc and extracted. The pathological examination found that the pubic tubercle portion was stump-negative; however, the other side was positive. A groin hernia has been reported to be concurrent with 1/3 of the cases of inguinal endometriosis. A confirmation of the presence of a groin hernia is necessary before operation. For the prevention of recurrence, a radical excision with an extended resection to extract the round ligament up to the lateral inguinal fossa is necessary. Furthermore a confirmation of the hernia gate from the abdominal cavity should be made. Laparoscopy may become the procedure of choice for an abdominal approach. This report is significant in that it may result in the prevention of the need for repeat surgical procedures.

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  Umbilical endometriosis is rare disease. A 45 year old woman with anemia, hypermenorrhea, and dysmenorrhea was diagnosed with a submucosal myoma and a right ovarian endometrioma. She underwent laparoscopic hysterectomy and right salpingo-oophorectomy. During the procedure, we noticed and umbilical nodule and extracted it. Pathological examination revealed that the mass was umbilical endometriosis. The umbilical region is a common site for laparoscopic procedures; thus, gynecologists should be aware of the possibility of umbilical endometriosis and possess the necessary skills to manage it surgically.

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  Management of a recurrent ovarian tumor often requires multiple surgical procedures. However, repeated abdominal surgery can be a burden for the patient both physically and psychologically. A 45 year old nulligravida underwent a left abdominal salpingo-oophorectomy due to an ipsilateral ovarian cystic tumor; the tumor was subsequently diagnosed histologically as a granulosa cell tumor (GCT). She was referred to our hospital due to an incidentally-detected right ovarian cystic tumor one year after the first surgery. A laparoscopic right salpingo-oophrectomy and hysterectomy was performed out because a recurrent GCT was suspected. However, the right ovarian cyst was found to be benign by histologic diagnosis. One year and 10 months after the second surgery, a solid peritoneal tumor was found on the right abdominal wall. The tumor was well-demarcated, and was resected laparoscopically. One year and four months after the third surgery, a well demarcated tumor was detected anterior to the rectum. The tumor was located at the vaginal cuff, and was resected laparoscopically. The third and fourth tumors were histopathology confirmed as a GCT recurrence. She is currently undergoing three consecutive chemotherapy cycles with pepleomycin, etoposide, and cisplatin. It is known that ovarian GCT can recur repeatedly over a period of years, and the standard treatment is surgery. Therefore, recurrent GCT patients often endure multiple surgical procedures and are exposed to the risk of acute and chronic surgical complication. Laparoscopic surgery is usually is not recommended for ovarian tumors suspicious of malignancy; however, adopting a laparoscopic approach to minimize surgical damage might be appropriate for selected cases, such as recurrent GCT.

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  An interstitial pregnancy accounts for only 1-2.5% of tubal pregnancies; however, the incidence of interstitial pregnancies is increasing as a result of artificial reproductive technology and the spread of sexually transmitted diseases such as Chlamydia tracomatis. Because of the difficulty of early diagnosis, the mortality rate of interstitial pregnancies is higher than that of other sites. We report a rare case of repeat ectopic pregnancy in the ipsilateral fallopian tube after laparoscopic wedge resection for an interstitial pregnancy. The patient is a 32-year-old gravida 1, para 0 woman. She suffered a left-sided interstitial pregnancy and underwent a left cornual wedge resection via laparoscopic surgery two years earlier. She presented at our hospital with the chief complaint of lower abdominal pain at 7 weeks of gestation; an ectopic pregnancy was suspected. We performed laparoscopic surgery and discovered that her left fallopian tube was swollen, which was indicative of a tubal pregnancy; therefore, we performed a left salpingectomy. The patient's postoperative course was uneventful and she was discharged on postoperative day 5. Her serum hCG decreased, and pathology revealed products of conception in the fallopian tube. In view of this case, we recommend that a salpingectomy should be performed when interstitial pregnancy is found in order to avoid an ipsilateral tubal pregnancy.

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  Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is one of the paraneoplastic encephalitides and is associated with ovarian teratoma. A 33-year-old woman presented with headache and abnormal behavior. Because an acute psychosis was suspected, she was initially admitted to psychiatry. A few days later, she developed confusion, auditory hallucinations, and catalepsy. Furthermore, she showed unresponsiveness, fever, and involuntary movement. She required airway management because of hypertonia and bleeding of the tongue. She was then transferred to the neurology department of our hospital. Her brain imaging and whole body CT scan were normal. Non-herpetic encephalitis was suspected based on her blood and cerebrospinal fluid (CSF) examinations and clinical findings. Intensive care, including ventilatory support and steroid pulse therapy, was performed. Although she was taken off the ventilator 40 days after admission, higher brain dysfunction remained. Therefore, a second CT scan was performed, and a left ovarian teratoma that was not previously seen was identified. Anti-NMDAR encephalitis was suspected, and she was referred to gynecology for tumor resection. She underwent a single incision laparoscopic salpingo-oophorectomy 78 days after admission. Usual postoperative management was performed, though the patient was seen to perform wound curettage by herself immediately after surgery. Her higher brain dysfunction recovered gradually and was almost normal one year after surgery. Antibodies against NMDAR were positive in the CSF and blood. In terms of postoperative management, single incision laparoscopic surgery may be appropriate surgical approach in patients with anti-NMDAR encephalitis because communication with such patients is often difficult immediately after surgery.

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  Laparoscopic techniques have evolved from predominantly diagnostic to extensive operative procedures. Surgical techniques traditionally performed in an open fashion are being conducted laparoscopically with increasing frequency. With these developments, the indications for laparoscopic suturing have increased accordingly. Caution is required to avoid breaking or losing a needle during extracorporeal suturing. We describe the breakage and subsequent recovery of 1.5 mm segments of surgical needles during a laparoscopic myomectomy and a total laparoscopic hysterectomy. Most current research has focused on preventative and detection strategies for lost needles; however, there are no known methods of completely preventing occurrences of these unforeseen events. In this paper, we discuss a literature review of needles lost during laparoscopic surgery.

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Objective: Anti-N-methyl-D-asparate (NMDA)-receptor encephalitis associated with ovarian teratoma was first reported in 2007. Here we report two cases of anti-NMDA-receptor encephalitis associated with immature ovarian teratomas, which were diagnosed and successfully treated with laparoscopy.
Design: Case report.
Setting: Academic medical center.
Patients: Two women, aged 31 and 22 years old, were admitted to our hospital with acute encephalitis.
Results: Clinical course was unusual to encephalitis, so we performed abdominal CT to evaluate other differential diagnosis. Diagnostic imaging revealed ovarian teratoma in both patients. For the first case, we selected laparoscopic bilateral ovarian cystectomy as primary surgery. Following pathological diagnosis indicating immature teratoma in the left ovary, we performed laparoscopic left salpingo-oophorectomy. For the second case, rapid intraoperative diagnosis revealed immature teratoma, for which we performed laparoscopic right salpingo-oophorectomy. In both cases, neurological symptoms completely resolved after surgery.
Conclusion: Early diagnosis and surgical treatment are important for quick recovery of anti-NMDA-receptor encephalitis associated with ovarian teratoma. Because of the high prevalence of immature teratoma in such cases, laparoscopic surgery with intraoperative rapid diagnosis is recommended.

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  We report a case of ileocecal endometriosis accompanied by frequent episodes of intestinal obstruction associated with menstruation during observation for ovarian endometriomas. The clinical diagnosis was confirmed on endoscopic surgery. The patient was 40-year-old woman, gravid 0, para 0. She initially presented at the emergency department of our hospital because of dysmenorrhea. Ovarian endometriomas were detected at initial examination, and either surgery or drug therapy was recommended, but the patient declined treatment and was observed. Thereafter, frequent episodes of intestinal obstruction occurred, coinciding with monthly menstruation during follow-up. Diagnostic endoscopic surgery was performed after receiving informed consent from the patient. Strong adhesions were found in the ileocecum and were regarded to be the cause of the obstructions. The ileocecum was resected along with the ovarian endometriomas. Pathological examination confirmed that these adhesions had been caused by ileocecal endometriosis. Endometriosis is a frequent cause of dysmenorrhea, and the majority of cases are diagnosed and treated by gynecologists. However, when endometriosis involves portions of the small intestine such as the ileocecum, such as in our patient, internists are often initially consulted for symptoms of intestinal obstruction, and surgical treatment requires collaboration with a general surgeon. This case highlights the need for multi-departmental cooperation in the diagnosis and treatment of ileocecal endometriosis.

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Objective: To describe the experience and usefulness of lymphatic mapping and laparoscopic sentinel node biopsy in early stage cervical cancer.
Design: Retrospective study
Patients: Patients diagnosed with cervical cancer at the early stage (FIGO Ib1) were included.
Interventions: Radiocolloid tracer and patent blue dye to identify sentinel lymph nodes were used.
Results: In 11 months, 8 patients were included. Using laparoscopy, we detected and biopsied lymph nodes less than 1 cm. The sentinel node detection rate was 87.5%, and negative predictive value was 100%.
Conclusion: Laparoscopic biopsy of sentinel lymph nodes in early stage cervical cancer is a safe procedure and lymph node metastasis during surgery could be accurately predicted.

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  Para-aortic lymphadenectomy up to the renal vein is the standard surgical treatment for patients with a recurrence risk of endometrial cancer. We report detailed steps of a transperitoneal laparoscopic para-aortic lymphadenectomy surgical technique. This procedure was performed in 19 patients with endometrial, cervical and ovarian cancers as a staging surgery. The median number of retrieved para-aortic lymph nodes based on the extent of lymphadenectomy from patients with cervical (up to 326B2) and endometrial/ovarian cancer (up to 326B1) was 15 and 25, respectively. Blood loss was 162 ml in patients with endometrial/ovarian cancer and 5 ml in patients with cervical cancer. No intra-operative complications occurred in this series. This feasible, safe transperitoneal para-aortic lymphadenectomy procedure should be considered if laparoscopic surgery, including para-aortic lymphadenectomy, is a surgical treatment option.

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Objective: Laparoscopic surgery includes advantages such as: ① Less postoperative pain, ② Shorter hospital stay, ③ Less postoperative adhesions, and ④ Cosmetic postoperative wound. Currently, it is possible to treat most benign gynecological diseases by laparoscopic surgery. The use of laparoscopic equipment has increased in a number of surgical specialties. Selection of the appropriate equipment must take into account the type of surgical procedures for which it will be used.
Methods: Our hospital owns three types of rigid laparoscopes manufactured by Olympus. Co. Ltd., (3 mm, 5 mm, and 10 mm diameter) and the choice of instrument has been at the surgeon's discretion.. Therefore, we designed this study to evaluate predictors for the most appropriate diameter laparoscope for a surgical procedure; we performed comparison examinations of the illumination level and viewing area provided by each laparoscope diameter.
Results: Using an illuminometer, the degree of brightness was compared at a distance of 30 cm from the subject. The degree of illumination per each laparoscope diameter increased as the diameter increased (Figure 1). The degree of illumination was 330 luxes with a 3 mm diameter scope. A 2.44-fold difference in brightness was observed between laparoscopes with a diameter of 3 mm and 10 mm.
Conclusions: It is important to select an endoscope diameter according to the surgical procedure. Selecting a laparoscope with a diameter of 5 mm was found to be the most suitable for a variety of surgical procedures for benign gynecological disease.

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Introduction: In an attempt to reduce pain and improve cosmetic outcome in laparoscopic surgery, there has been a recent drive to reduce port sizes (mini-laparoscopic surgery: MLS) or port number (single-site laparoscopic surgery). We evaluated the safety and efficacy of MLS in the patients with endometriosis and compared its outcome with that of the conventional laparoscopic surgery (CLS).
Methods: MLS was conducted with one 5-mm port for a 5-mm laparoscope as well as one 5-mm port and two 2.3-mm ports for the MiniLap Grasper. Conventional laparoscopic surgery (CLS) employs one 12-mm port for a 10-mm laparoscope and three 5-mm ports. A total of 24 patients with endometriomas underwent MLS (13) or CLS (11). We compared patient characteristics, operative findings, complications, postoperative pain medicine requirements, and serum CRP levels.
Results: The total r-ASRM (Revised American Society for Reproductive Medicine classification of endometriosis) scores for patients with endometriomas were not significantly different between the MLS (56.5) and the CLS (52.9) groups. Two of 13 patients were converted from MLS to CLS because of severe tubal adhesions. However, no major postoperative complications were encountered. Median operating times were similar between MLS (123 minutes) and CLS (107 minutes). The mean frequency of analgesic administration and serum CRP levels were significantly lower following MLS than following CLS (Mean frequency 1.5±0.53 for MLS and 2.7±0.6, CRP 0.66±0.28 for MLS and 1.00±0.53 for CLS). Cosmetic outcomes were superior with MLS, compared to CLS.
Conclusions: Compared to conventional laparoscopic surgery, the use of mini-laparoscopic techniques resulted in decreased incisional pain in the early postoperative period while improving cosmetic appearance.

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Objective: To evaluate the safety and efficacy of laparoscopy compared to laparotomy for treatment of adnexal masses in pregnancy, with a particular attention to the pregnancy outcome.
Design: Retrospective study.
Setting: Private hospital.
Patients: 19 women with adnexal masses in pregnancy.
Interventions: Seven women who underwent laparoscopy and 12 women who underwent laparotomy from 2001 through 2010.
Main outcome measures: We reviewed patient age, weight, gestational weeks at time of surgery, surgery time, blood loss, hospital stay, histology, tumor diameter, and pregnancy outcome.
Results: The averages of the following were: age, 33.5 years; weight, 52.6 kg; gestational weeks, 14; and tumor diameter, 7.7 cm. There were no significant differences between those of the laparoscopy group and the laparotomy group. The average surgery time in the laparoscopy group (96 minutes) was longer than that of the laparotomy group (46 minutes). The advantages for patients in the laparoscopy group were significant reduction in average blood loss (10 ml) and shorter average hospital stay (4.8 days). Spontaneous abortion and preterm labor occurred in two cases (one abortion at 17 weeks' gestation and one preterm labor at 36 weeks' gestation) in the laparoscopy group and in one case in laparotomy group (preterm labor at 35 weeks' gestation). The abortion and preterm labor rate in the laparoscopy group (28.5%) was not significantly different than that of the laparotomy group (8.3%).
Conclusions: Our study suggests that laparoscopy for adnexal mass in pregnancy is effective and feasible as a minimally invasive procedure. It is necessary to accumulate further data before we can confirm the safety and efficacy of laparoscopy in pregnancy.

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Objective: To evaluate the histological influence of preoperative treatment with dienogest on the resection of endometrial polyp.
Designs: Retrospective Study
Setting: General hospital
Methods: We explained the study to, and obtained informed consent from, 15 patients diagnosed with an endometrial polyp between April 2008 and February 2012. Dienogest was administered orally to these women at a dose of 2 mg/day from the second day of the menstrual cycle until the evening of the day before surgery. The histological effects of dienogest were examined based on a postoperative histopathological examination.
Results: Histological examination showed that the boundary between a polyp and the normal endometrium was distinct and also that the endometrial polyp showed some discriminative changes.. These included hemorrhagic erosion of the epithelial surface, atropic changes in deep glands, decreases in stromal cells, edematous accumulation in the stroma, and infiltrations, mostly by lymphocytes, findings that are rarely seen in the normal endometrium. Obvious changes in both the surface epithelium and the stroma were observed after about 7 days' preoperative administration of dienogest, whereas changes were limited to the surface area after about 14 days' treatment.
Conclutions: Dienogest seems to induce an acute inflammatory reaction in the endometrial polyp after about one week of treatment, and repair occurs in the stromal area after 2 weeks. Further investigation of the appropriate duration of preoperative administration with dienogest is needed.

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Objective: To assess the factors influencing operative time and intraoperative blood loss in patients who had undergone laparoscopic myomectomy (LM).
Methods: The study involved 374 patients who had undergone LM at our hospital between May 2009 and April 2011. We examined the relationships between operative time, intraoperative blood loss, maximum myoma diameter, number of resected myomas, and myoma growth patterns (5 groups: intramural, submucosal, subserosal, pedunculated subserosal, and intraligamentous).
Results: There was a correlation between maximum myoma diameter, operative time (y = 0.73x + 51.51; r = 0.393), and intraoperative blood loss (y = 3.76x - 121.12; r = 0.456). Furthermore, the number of resected myomas was correlated with operative time (y = 5.06x + 81.71; r = 0.308) and intraoperative blood loss (y = 3.49x + 99.55; r = 0.049). There was a significant difference in operative time between pedunculated subserosal myomas and intraligamentous myomas, but there was no significant difference in intraoperative blood loss between myomas displaying different growth patterns.
Conclusions: The maximum myoma diameter was a factor influencing operative time and intraoperative blood loss. In addition, the results suggested that operative time was influenced by the number of resected myomas and the growth patterns of myomas.

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  Our hospital was established 6 years ago as an institution that specializes in the laparoscopic surgery. A recent increase has been observed in the number of women who develop multiple and giant uterine myomas, indicating the need to react according to each case. In this report we present a method of laparoscopically assisted hysterectomy that we introduced as a countermeasure against multiple and giant uterine myomas. We review and compare the 312 cases of laparoscopic hysterectomy that we have performed and discuss on the selection of operation method based on the review. Further experience and technical improvements in laparoscopic hysterectomy based on each case will lead to improved safety and proper indications.

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  The aim of this study was to develop a useful training device for training of laparoscopic skills required for total laparoscopic hysterectomy (TLH). This training device was created based on the following measurements: the distance from the fulcrum to the site of surgery, including uterine vessels, vaginal stump, and pelvic peritoneum and the angle of forceps in patients who underwent TLH between November 2008 and May 2010. This training device enabled training of laparoscopic ligation of uterine vessels, suturing the vaginal stump, as well as the pelvic peritoneum. Illumination was unnecessary; this training device was easy to carry because it weighed only 800 g.

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  Malignant transformation of endometriotic cyst occurs in approximately 0.7% cases. Although mural nodules are considered the most valuable imaging finding in diagnosis of ovarian cancers associated with endometriotic cyst, they are difficult to distinguish from clots with endometriotic cyst. Therefore, we often perform laparotomy for benign endometriotic cyst to rule out ovarian cancer. We selected six patients who underwent laparotomy for suspected ovarian cancer associated with endometriotic cyst, but who were confirmed not to have ovarian cancer pathologically. We retrospectively studied the clinical and imaging features of these six patients. We suspected malignant transformation of endometriotic cyst in patients with mural nodules on MRI or absence of shading on T2-weighted images as well as in older patients, however, mural nodules in the six patients were not enhanced or had unclear enhancements on T1-weighted contrast-enhanced images; all nodules showed benign contents such as fibrotic tissue, edematous stroma, and clots. Our study showed that mural nodules which are not clearly enhanced T1-weighted contrast-enhanced image appear to have low potential for malignancy. Therefore, in such cases, careful diagnosis using the dynamic subtraction study and minimally invasive surgery such as laparoscopy may be considerd.

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  Compared to myomectomy by laparotomy, laparoscopic myomectomy (LM) results in less postoperative pain and a shorter hospital stay. Furthermore, LM has a particular advantage in that it reduces the risk of postoperative adhesions when pregnancy is desired. We evaluated the reproductive outcomes after LM including the risk factors in subsequent pregnancies. Among the 432 patients who underwent LM in our department between January 2005 and December 2010, 153 patients desired to preserve fertility. Among the 153 patients, 88 patients (58%) had a total of 107 pregnancies after LM. Of those, 71 pregnancies (66%) were spontaneous, 7 pregnancies (7%) required intrauterine insemination IUI), and 28 pregnancies (26%) required IVF. The mean (± SD) age was 36.1 ± 3.6 years in the pregnant group (88 patients), and was 38.2 ± 3.5 years in the non-pregnant group (65 patients). We found a negative correlation to achieving a pregnancy with patient age at the time of LM (HR: 0.94; 95% CI: 0.88-0.99; P = 0.039). The following reproductive outcomes were noted: 58 pregnancies (91%) were term deliveries, 6 pregnancies (9%) were preterm delivery (from 33 to 36 weeks), 27 pregnancies (28%) were spontaneous abortions, and one (1%) was an ectopic pregnancy. Although there was one silent uterine rupture in this study, the location of rupture was not at the site of a uterine scar. It is unclear whether the laparoscopic procedure is associated with the silent uterine rupture. We found that the main factor determining fertility after LM was patient age. Reproductive outcomes are relatively good following LM.

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Objective: To compare the operative results of single port access laparoscopic surgery using SILS port™ (multi-channel port method), SSL (multiple trocar method), and EZ Access (multi-channel port method).
Patients: A total of 28 women who underwent single port access laparoscopic surgery at our department between November 2010 and April 2011.
Main outcome measures: Insertion time of access device, surgery time, and blood loss. Features of each method were compared.
Results: Single port access laparoscopic surgery was completed in 26 women. Conversion to the conventional method was required in two cases. A significant difference was not found in regard to port insertion time, surgery time, and blood loss between the three groups: SILS (n = 15), SSL (n = 6), and EZ access (n = 5). In SSL, it was not necessary to make a large fascial incision; however, difficulty was encountered in the collection of the extracted tissue and the insertion of the anti-adhesion material in the SILS group. No difficulty was encountered in collection and insertion among patients in the SILS group. However, the surgeon should be skilled in the cross procedures using curved forceps and cost was higher in SLS than the other groups. EZ Access was found to have several advantages such as simultaneous performance of other procedures, easy collection and insertion, and comparatively low cost.
Conclusions: We found that tissue extraction was difficult with SSL and that EZ Access was the preferred method for collection of extracted tissue.

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  Although laparoscopic surgery is less invasive than an open procedure, it is often more difficult to acquire an adequate surgical field, compared to an open procedure. The Endoractor is a compressed sponge designed for organ retraction. It can be easily inserted into abdominal operative field through a 12 mm or larger obturator. Because the Endoractor is composed of close to 100% cellulose, it does not cause tissue damage. We can place the Endoractor into the abdomen rolled up, and then expand it with normal saline to displace the bowel. We compared 12 laparoscopic myomectomies with the Endoractor, and 36 procedures without the Endoractor to evaluate its effectiveness. We found no significant difference in surgical time and blood loss with or without the Endoractor. In addition, we found that the Endoractor is very effective for visualization of the operative field. Especially, when the patient position is altered from Trendelenburg, the Endoractor prevents the bowel from obscuring the operative field.

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Objective: To examine the factors that affect achieving a pregnancy following laparoscopic surgery for infertile women with endometriosis.
Design: Retrospective study
Setting: Department of Obstetrics and Gynecology, Shimane Prefectual Central Hospital
Patients: A total of 33 infertile women with endometriosis underwent laparoscopic surgery.
Main Outcome Measures: We compared a number of pertinent factors between pregnant and non-pregnant women. Statistical analyses were performed using Fisher's exact test and the Student's t-test. All results were considered statistically significant at P < 0.05.
Results: Of 33 women who underwent laparoscopic surgery, 22 achieved a pregnancy. Among those 22 pregnant women, 14 women were pregnant within one year after laparoscopic surgery. No significant differences were found between pregnant and non-pregnant women regarding age, size of endometriomas, adhesion score, peritubal adhesions, periovarian adhesions, or posterior cul-de-sac obliteration. The pregnancy rate for women with a peritoneal lesion score of 6 points was significantly lower than that of women with a peritoneal lesion score of 0-2 points.
Conclusions: We are of the opinion that the peritoneal lesion score directly correlates with endometriosis-associated infertility. Furthermore, laparoscopic surgery is useful for the treatment of women with to endometriosis-associated infertility.

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