Ovarian torsion is a surgical emergency. Early diagnosis and prompt intervention are required to relieve symptoms and prevent functional loss. Between April, 2008 and May, 2011, 15 instances of surgically treated ovarian torsion were reviewed. All patients presented with lower abdominal pain and most (12/15) had a detectable ovarian mass. Mean age of patients was 35.9±19.4 years (range, 8-79 years), with 46.6±61.9 hours (range, 4.5-198 hours) as the mean interval of time between onset of pain and surgery. Elapsed time was especially lengthy for three of the patients (two premenarchal girls and one elderly woman). In nine cases, absence of enhancement on computed tomographic (CT) scan was viewed as telltale. The patients were evenly divided by operative technique (seven by laparoscopy; eight by laparotomy). Conservative surgery (ie, detorsion and cystectomy) was performed without consequence in six cases. By follow-up sonography, ovaries were of normal size and showed follicular development in four cases. Lack of enhancement on CT is a key finding in ovarian torsion, enabling early diagnosis. In young women with ischemic adnexa, detorsion should be considered as a conservative measure.

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Objective: A case of cesarean scar pregnancy (CSP) treated by a combination of systemic methotrexate (MTX) administration, selective uterine artery embolization (UAE), and hysteroscopic surgery is reported.
Case: A 37-year-old woman, with a history of two previous cesarean sections, presented with suspicion of a cervical pregnancy at 5 weeks' gestation. A diagnosis of CSP was made by ultrasonography when a gestational sac and viable embryo (without heart movement) were detected near the right cesarean scar. The findings were confirmed by magnetic resonance imaging. In addition, three-dimensional CT angiography showed that the gestational sac was perfused by only the right uterine artery. At first, single dose MTX (50 mg/body intramuscularly) was given. However, it failed, and serum hCG levels increased from 21995 mIU/ml to 38831 mIU/ml, and embryonic cardiac activity was detected. Therefore, the regimen was changed to a fixed multidose MTX regimen, which seemed effective because the serum hCG levels decreased gradually, and the fetal heartbeat was lost. At 9 weeks' gestation, the tissues of conception were removed by hysteroscopic surgery three days after selective right UAE. There were no complications such as heavy bleeding or uterine perforation.
Conclusion: When removing the gestational sac in CSP, hemorrhage may often be difficult to stop. However, there is no consensus about the optimal method for treating CSP. We consider that a combination of systemic MTX administration, selective UAE, and hysteroscopic surgery is a safe and useful treatment for CSP.

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Introduction: Laparoscopic myomectomy has been introduced as a new modality for the treatment of uterine leiomyoma, and one of the advances in laparoscopic technology is the development of electronic morcellators. Morcellation instruments are widely used to remove large myomas through small abdominal incision sites. However, recent evidence suggests that the use of morcellation devices may be a significant risk factor for the development of parasitic myomas. Parasitic myomas can be divided into two categories: iatrogenic parasitic myomas and non-iatrogenic parasitic myomas. The latter are known to be extremely rare. Here, we report a case of possible aberrant implantation and growth of uterine leiomyoma tissue in the abdominal cavity.
Case: A 46-year-old Japanese woman who was referred to us without a previous history of abdominal surgery underwent laparoscopic left salpingo-oophorectomy and right ovarian cystectomy. During the survey of the entire abdomen, 2 peculiar masses were found. One was attached to the left ovary and the other was located on the right round ligament. Histological diagnosis confirmed that these lesions were compatible with uterine leiomyoma.
Conclusion: Iatrogenic parasitic myomas are believed to originate from fragments of uterine tissue that are left in the peritoneal cavity after morcellation. Missed fragments can implant in the abdominal cavity and abdominal wall after neovascularization. The theoretical pathologic basis of non-iatrogenic parasitic myomas is suspected to be the attachment and subsequent growth of subserous myomas that twist from their uterine pedicles. This rare case strongly reinforces the theory that pedunculated subserous myomas can implant and grow in the abdominal cavity.

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  Uterine myomas are the most common benign gynecological tumors. For myomas with a typical growth pattern at an early stage, a treatment decision can be made with relative ease. However, in atypical cases, the decision is more difficult. We report 3 cases in which the preoperative diagnosis was challenging. All 3 patients underwent laparoscopic surgery for pelvic masses, which were found to be parasitic myomas.
Case 1: A 31-year-old woman with no surgical history presented at our hospital for evaluation of a pelvic mass. Transvaginal ultrasonography and MRI revealed a well-circumscribed mass in contact with the left side of the uterus. The mass was excised laparoscopically. The pathological diagnosis was necrotic myoma.
Case 2: A 35-year-old woman with no surgical history presented at our hospital for evaluation of a pelvic mass. Imaging via transvaginal ultrasonography and MRI revealed a well-circumscribed mass adjacent to but separate from the right anterior surface of the uterus. The mass was excised laparoscopically. The pathological diagnosis was necrotic myoma.
Case 3: A 28 year-old woman with no surgical history presented at our hospital for evaluation of a pelvic mass. Imaging via transvaginal ultrasound and MRI revealed a well-circumscribed mass located to the right of the uterus. Continuity could not be determined. The mass was excised laparoscopically. The pathological diagnosis was necrotic myoma.
Conclusion: Spontaneous parasitic myomas are extremely rare, and their incidence and pathogenesis are still unknown. We present 3 cases that may contribute to a further understanding of these tumors.

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  Only a few cases of laparoscopic uterine repair of cesarean scar dehiscence have been reported. We report a case of a 27-year-old gravida 1 para 1 patient who initially presented to us with cesarean scar pregnancy. She had a cesarean section because of premature rupture of membranes and breech presentation at 34 weeks of gestation. When she first consulted us, her chief complaint was amenorrhea. She was diagnosed with cesarean scar pregnancy and treated at another institution with dilation and curettage after uterine artery embolization. She consulted us again with concerns about the risks of subsequent pregnancy. Magnetic resonance imaging revealed thinning of the myometrium at the site of the previous cesarean scar, and a lack of endometrium was also suspected. To reconstruct uterine myometrium, we performed laparoscopic uterine scar repair with the patient's informed consent. Sonohysterography (SHG) during the procedure precisely showed the dehiscence of the previous uterine scar. We successfully identified the scar with the light source of the flexible hysteroscope. Post-operative SHG indicated that the thickness of the repaired myometrium was about 9 mm. We cleared the patient for subsequent pregnancy after 3 courses of Kaufmann therapy. It has been suggested that uterine scar dehiscence may increase the incidence of uterine rupture, placenta accreta, or recurrent uterine scar pregnancy, and whether or not uterine scar repair leads to a better prognosis in subsequent pregnancy is still under discussion. Further investigation is required.

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Background: Trocar injury is a considerable complication of laparoscopic surgery. It is mostly noticed at the insertion or removal of trocars, and adequate measures can minimize potential injury. Late onset of hematoma arising from trocar injury is a rare condition.
Case: We performed a laparoscopy-assisted right salpingo-oophorectomy for a giant multilocular cystic tumor of the right ovary in a 42-year-old obese woman (body mass index: 29.6 kg/m²). No bleeding at the port sites was detected during trocar removal under laparoscopic guidance; however, two days after the surgery, we found a subcutaneous and intraperitoneal hematoma centering around one of the port sites, which was punctured by a 5-mm VersaStep™ bladeless trocar. We detected the injury of a vessel, which was probably one of the branches of inferior epigastric artery, near the port site.
Conclusion: It was difficult to detect the inferior epigastric artery or its branches at trocar insertion using a transparent laparoscopic technique in the obese patient; therefore, trocar removal should be carefully performed even when a 5-mm VersaStep™ bladeless trocar is used. Once the trocar injury is identified, during or after laparoscopic surgery, adequate measures, including laparotomy, must be undertaken to resolve it.

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  We report 5 cases of ovarian borderline mucinous tumor diagnosed after laparoscopic surgery. The patients were aged 14, 24, 26, 48 and 73 years. Two of the younger patients (14 and 26 years) had huge unilateral ovarian tumors occupying almost the whole of the abdomino-pelvic cavity. They selected fertility-preserving and laparoscopic surgery because their tumors had no sign of malignancy preoperatively. The 3 other patients had unilateral tumors ranging in from 6 to 8 cm, and all appeared to be benign. All patients underwent laparoscopic surgery, and there have been no recurrences. In the past several decades the bulk of surgical therapy has shifted from a radical approach to a more conservative one. There are various methods of surgery. Laparoscopic surgery is often chosen for benign tumors. However, there are reports of cases diagnosed as mucinous borderline tumor after laparoscopic surgery. A precise preoperative diagnosis of mucinous borderline tumor is difficult. Because of the absence of specific preoperative criteria, diagnosis may not be made until after surgery or pathologic examination. Moreover, as these borderline tumors frequently occur in younger patients, considerations of preserving fertility and reducing postoperative morbidity can make the clinical management more challenging. Ovarian borderline tumor with noninvasive implants is traditionally considered to be non-aggressive. Recurrence is delayed and transformation to high-grade carcinoma is rarely documented. However, in the rare cases of recurrence or metastasis, careful and prolonged follow-up is needed after operation, and informed consent is very important.

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  Pseudomyxoma peritonei results from rupture of a mucocele. Mucoceles of gastrointestinal origin must be differentiated from ovarian tumors. Atypical, proliferative mucinous tumors and well-differentiated intestinal type mucinous adenocarcinoma may arise in a mature cystic teratoma. Pseudomyxoma peritonei has a poor prognosis, and difficulty in preoperative differential diagnosis of ovarian tumors and mucocele is an important factor. We experienced 2 cases of pseudomyxoma peritonei diagnosed at laparoscopic surgery after preoperative diagnosis of ovarian tumor. In case 1, the tumor was on the posterior rectum, and the distance with the uterus had been observed by MRI. At surgery, the ovaries were normal, and the rectal origin of the tumor was confirmed. In case 2, the CEA was elevated, but there was not a solid portion of ovarian carcinoma suspicious for tumor, and the tumor was diagnosed as appendiceal in origin. Both cases had presented atypical shapes for ovarian tumor on MRI. Because the differential diagnosis of mucocele is difficult, gynecologists sometimes encounter them at surgery. Early intervention before rupture is important, and MRI and laparoscopic surgery are important for diagnosis of pseudomyxoma peritonei.

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  An ectopic ovary is a very rare condition. A 27-year-old woman underwent laparoscopy because of a dermoid cyst on the right ovary and was found to have a cystic mass in the mesentery of the sigmoid colon. Despite thorough inspection, her left ovary was not found in the usual place. The left infundibulopelvic ligament was also nonexistent. Pathological examination revealed ovarian stromata in the cystic mass in the mesentery of the sigmoid colon.

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  Interstitial pregnancy has increased in prevalence, and accounts for 2% to 4% of all tubal pregnancies. The actual rate of occurrence of interstitial twin pregnancy is unknown because of the rarity of this condition. Here, we report an interstitial twin pregnancy that was treated using laparoscopy; to the best of our knowledge, this is the third report of such a case. A 36-year-old woman with a 6-week history of amenorrhea underwent dilatation and curettage because of a suspected spontaneous abortion; chorionic villi were not found in the uterine contents. Transvaginal ultrasonography performed 9 days later showed an empty uterus with a thin endometrium and a single gestational sac containing 2 viable embryos with growth corresponding to the eighth gestational week in the right interstitial area. The patient was clinically diagnosed with an interstitial twin pregnancy and underwent emergency laparoscopic surgery. Extensive membranous adhesions involving both adnexa were found. After an adhesiotomy was performed, the right cornu was seen to be dilated to approximately 5 cm in diameter, with surface hyperemia and no signs of rupture. Vasopressin was injected into the myometrium, and a right cornual resection and salpingectomy were performed. Both ovaries remained adherent in the retroperitoneum. To prevent persistence of the ectopic pregnancy, the patient was administered methotrexate, and the urine level of human chorionic gonadotropin decreased to normal 4 weeks after surgery. However, at that time she began to complain of dull back pain. Computed tomography revealed a cystic lesion (diameter, approximately 5 cm) in the right ovary, and dilatation of the right renal pelvis and ureter. The size of the follicular cyst decreased when the patient began menstruating, and the right hydronephrosis improved 8 weeks after surgery. In conclusion, in patients with extensive pelvic adhesions involving the ovaries, an obstructed urinary tract may be the result of ovarian swelling. Therefore, it is important to be aware of adhesions involving the ovaries and the location of the ovaries in relation to the urinary tract.

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  An acute abdomen in pregnancy is often challenging to diagnose. Physicians routinely encounter patients' hesitation regarding invasive interventions, difficulty in obtaining consent from patients and families, and restrictions on the use of diagnostic imaging modalities during pregnancy. This report presents a case of an acute abdomen during pregnancy, managed by laparoscopy. A 30-year-old female at 4 weeks, 4 days gestation was admitted to the hospital complaining of epigastric discomfort and lower abdominal pain. She was diagnosed with an acute abdomen and peritonitis; acute appendicitis or pelvic inflammatory disease was thought to be the probable cause. Abdominal ultrasonography was used to refine the differential diagnosis, but the findings were inconclusive. After consultation with general surgeons, the decision was made to administer antibiotic therapy. This treatment was effective, and she was discharged on day 11. She was hospitalized again on day 20 with recurrent abdominal pain. Abdominal ultrasonography was again performed but as before, the results were inconclusive. Although the use of computed tomography was suggested, the patient and her family did not consent. Therefore, she underwent laparoscopic surgery for both diagnosis and treatment. Laparoscopy revealed that her appendix was swollen with pus; appendectomy was performed based on a diagnosis of acute appendicitis. She recovered without any complications and was discharged on postoperative day 6.

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Objective: Some patients are suffered from persistent pain after hysterectomy and the reason of the pain is usually unknown. We experience a case of laparoscopic adhesiolysis and cutting of vaginal stump for persistent pain after hysterectomy.
Case: A 22 years old female patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for gender identity disorder in a foreign country. She complained lower abdominal pain soon after surgery and it persisted. The diagnosis was infection of the vaginal stump for the first, but the pain was not resolved after treatment with a course of antibiotics. The point of the tenderness was on the left side of the half of the vaginal stump. Blood examination, ultrasonography, upper and lower endoscopy, and CT did not reveal the reason of persistent pain. Diagnostic laparoscopy revealed the existence of adhesion and a cord like structure of the vaginal stump. The pain was diminished after laparoscopic adhesiolysis and cutting the cord like structure of the vaginal stump.
Conclusion: Diagnostic laparoscopy can be of benefit to abdominal pain with unknown reason. Laparoscopic adhesiolysis and cutting the cord like structure of the vaginal stump were effective to the resolve of the pain of this patient.

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Objective: To report a rare case of a mesothelial cyst in the lower abdominal extraperitoneal space, mimicking a urachal cyst.
Case: A 43-year-old nulligravid female complained of lower abdominal pain, ongoing for about 6 months. Physical examination revealed a pelvic mass reaching the height of the umbilicus. Magnetic resonance imaging showed a 15 × 6 cm cystic tumor in addition to a uterine leiomyoma and an ovarian endometriotic cyst. Laparoscopic surgery revealed that the huge cystic tumor extended into the lower abdominal extraperitoneal space, similar to a urachal cyst, and was adherent to the ovarian endometriotic cyst. The resected tumor was diagnosed pathologically as a mesothelial cyst.
Conclusion: Mesothelial cysts occur most frequently in the peritoneal cavity of reproductive-aged women and are often accompanied by endometriosis. Endometriosis is often associated with pelvic peritoneal defects. This report suggests that a mesothelial cyst may extend into the lower abdominal extraperitoneal space through a peritoneal defect caused by endometriosis.

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  Although ectopic pregnancy tends to be diagnosed in the early phase because of improved technology, we sometimes encounter cases with hypovolumic shock caused by intraabdominal hemorrhage. Here, we report two cases of ectopic pregnancy with intraabdominal hemorrhage that underwent laparoscopic surgery using cell salvage. Case 1 was a woman in her 30s (0 gravida, 0 paras). She visited the clinic previously with lower abdominal pain 8 weeks and 3 days from her last period. She was diagnosed with suspected ectopic pregnancy with intraabdominal hemorrhage and transported to our hospital. Upon arrival, her vitals were the following: blood pressure, 106/56 mmHg; pulse, 100 beats/min; shock index, 0.94; Hb, 8.4 mg/dl; urine hCG, 13,990 IU/l. The postoperative diagnosis was rupture of the right ampulla of tube pregnancy, and laparoscopic right salpingotomy was performed. We collected an intraabdominal hemorrhage amount of 3,336 ml, and 1,484 ml was restored by cell salvage. No blood transfusion was performed. Anemia (Hb, 8.9 mg/dl) was found on postoperative day 1. She was discharged from the hospital on postoperative day 5 with iron infusion. Case 2 was a woman in her 30s (1 gravida, 1 paras). She visited the clinic previously with lower abdominal pain 11 weeks and 2 days from her last period. She was transported to our hospital with interstitial pregnancy with intraabdominal hemorrhage. Her vitals were the following upon arrival: blood pressure, 88/44 mmHg; pulse, 92 times/min; shock index, 1.05; Hb, 9.0 mg/dl. The postoperative diagnosis was rupture of right interstitial pregnancy, and laparoscopic right pars interstitial resection was performed. We collected an intraabdominal hemorrhage amount of 3,260 ml, and 928 ml was restored by cell salvage. No blood transfusion was performed. Anemia (Hb, 9.3 mg/dl) was found on postoperative day 1. She was discharged from the hospital on postoperative day 5 with iron infusion. Blood transfusion by cell salvage can omit crossmatching tests and is thought to be a very useful method for enabling successful laparoscopic surgery with stable blood pressure status.

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  Laparoscopic myomectomy (LM) is becoming a standard method for treating patients requiring minimally invasive endoscopic surgery with uterine fibroid. However, laparoscopic surgery has resulted in new complications, because of the use of novel instruments and methods. Collating reports on such cases is very useful for the development and improvement of laparoscopic surgery. From May 2009 to April 2011, 497 patients underwent LM at our hospital. Here, we report 4 cases in which we could not remove intrauterine manipulators after the operation.
  The manipulators, which were broken or sutured in the uterine cavity, were removed immediately in all cases. The manipulator could be removed via the cervix in 1 case by using a hysteroscope; however, in 3 cases, the suture thread had to be cut to remove the manipulator, and the wound had to be resutured using a laparoscope. We have provided the surgical notes and suggest precautions in these rare cases.

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Objective: Laparoscopic hysterectomy (LH) and total laparoscopic hysterectomy (TLH) are associated with a higher incidence of urinary tract injury. We investigated whether ureteral catheter placement immediately before surgery improves intraoperative outcomes and protection of the urinary tract in laparoscopically assisted vaginal hysterectomy (LAVH), LH, and TLH.
Methods: There were 56 patients treated by LAVH, 30 by LH, and 13 who underwent TLH, constituting 99 cases, all performed by the author. Pre-operative placement of ureteral catheters was conducted in 85 cases, including all of the LH and TLH cases and 42 of the 56 LAVH cases. Operative procedures, operating times, uterine weights, blood loss, and intraoperative complications were examined retrospectively.
Results: The time necessary for ureteral catheter placement was about 20 min. Although we converted 2 cases from LAVH to laparotomy, no serious complications, including ureteral injury, developed in any of the surgeries. The ureteral catheter placement caused the ureters to jut like tents, which allowed us to easily confirm their course laparoscopically. With LAVH, the operating time and intraoperative bleeding in the catheter-placement group were significantly worse than in the non-catheter placement group. Blood loss during TLH was significantly reduced compared to LAVH or LH in the presence of the catheters .
Conclusions: The pre-operative placement of ureteral catheters did not improve intraoperative outcomes in LAVH. Although ureteral catheters may contribute to protection of the urinary tract, the present results suggest that ureteral catheter placement is not essential for laparoscopic hysterectomy.

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Objective: The aims of this study were to evaluate the use of laparoscopic surgery for early-stage endometrial cancer, with regard to the feasibility, safety, and outcomes of the procedures.
Methods: Six patients with clinical stage IB, G1-2 endometrial cancer diagnosed preoperatively underwent laparoscopy. The surgical procedures included hysterectomy, salpingo-oophorectomy, and pelvic lymphadenectomy. The outcomes and operative procedures were evaluate.
Result(s): All 6 patients were successfully treated using laparoscopy. The mean operative time was 318 minutes (range, 265-387 minutes), mean amount of bleeding was 304 g (range, 100-664 g), mean number of excised lymph nodes was 35.8 (range, 22-50), and mean duration of postoperative hospitalization was 5.7 days (range, 5-7 days). Severe adverse events were not encountered.
Conclusion(s): Laparoscopic surgery that is based on the procedures for total laparoscopic hysterectomy for benign disease and for laparotomy for malignant disease appears to be feasible for early-stage endometrial cancer, if care is taken with the anatomical structures in the retroperitoneal space.

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Objective: Total vaginal hysterectomy (TVH) and total abdominal hysterectomy (TAH) are presently the standard procedures for total hysterectomy. Since the advent of laparoscopically assisted vaginal hysterectomy (LAVH), our institution has actively performed LAVH to establish it as standardized procedure for patients with uterine myomas and those with uterine adenomyosis. This report investigates the parameters to determine LAVH to be considered a standardized procedure.
Method: In our institution, 282 LAVH cases were performed from 1995 to 2001 (Group I), 258 cases from 2002 to 2010 (Group IIa) by "experts", and 83 cases by non-expert Ob/Gyn surgeon (Group IIb). The groups were compared by age and parity of the patients; uterine weight; operative time; blood loss; rates of intraoperative conversion to open surgery; and intra- and post-operative complications. The trend in the annual rate of LAVH was also examined.
Results: There were no significant differences in age, parity, blood loss, or conversion to open surgery. Uterine weight was significantly lower (350g) and operative time significantly longer (163min) in Group IIb than in Groups I (400g/143min) and IIa (411g/143min). The annual LAVH rate has increased continually, from 16.2% in 1995 to 85.7% in 2010.
Discussion: Because no difference was observed in blood loss or complication rates among the three groups of patients, the authors have concluded that LAVH can be performed by all gynecological surgeons. Presently, LAVH is performed for the majority of patients requiring total hysterectomy. Therefore, LAVH has been established as the institution's standardized procedure for total hysterectomy.

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Objective: To evaluate the safety and efficacy of laparoscopic surgery for ovarian fibromas and fibrothecoma.
Design: Retrospective study.
Setting: Osaka Medical College Hospital, Hokusetsu General Hospital.
Patient(s): Nineteen women who underwent laparoscopic surgery for ovarian fibroma and fibrothecoma between May 2007 and July 2011.
Intervention(s): Fourteen women underwent conventional laparoscopy, and five women underwent single-incision laparoscopic Surgery (SILS).
Main outcome, Measure(s): Operation time and complications.
Result(s): The operation time was not significantly different between the conventional laparoscopy group and SILS group. No remarkable complications were observed in either group.
Conclusion(s): Laparoscopic surgery, particularly SILS, can be an alternative surgical approach for ovarian fibromas and fibrothecoma.

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Objective: We investigated reproductive outcomes after laparoscopic linear salpingotomy for isthmic tubal pregnancy.
Methods: From March 2000 to August 2011, we treated 19 cases of tubal isthmic pregnancy by conservative laparoscopic surgery consisting of salpingotomy with local injection of methotrexate (MTX).
Results: Sixteen cases (84%) were successfully treated, but 3 cases were converted to laparoscopic salpingectomy. Out of 16 cases, 2 (13%) were diagnosed with persistent ectopic pregnancy. Seven of 13 patients (54%) demonstrated patency of the treated tube by hysterosalpingography or second look laparoscopy. It was possible to evaluate subsequent fertility for 12 patients, 6 of whom obtained an intrauterine pregnancy and one who had a repeated ectopic pregnancy.
Conclusion: We propose that laparoscopic salpingotomy with local injection of MTX for isthmic pregnancy is suitable in selected cases, if careful management is offered.

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Objective: To evaluate the reproductive outcomes after radical salpingectomy or conservative surgery for ectopic pregnancy (EP), with attention to tubal patency and peritubal adhesions.
Design: Retrospective study.
Setting: Department of Obstetrics and Gynecology, Tottori Prefectural Central Hospital.
Patients: Among 94 patients who underwent surgery for EP between 2000 and 2010, 51 patients who desired subsequent pregnancy were followed.
Interventions: Of the 51 patients, 40 had undergone salpingectomy and 11 had received conservative surgery.
Main outcome measures: The pregnancy rate and the time to conception after surgery were examined. The intrauterine pregnancy (IUP) and repeat EP (REP) rates were compared between the salpingectomy and conservative surgery groups. The revised American Fertility Society (re-AFS) adnexal adhesion scores were compared between the IUP and REP groups.
Results: A total of 35 of the 51 (68.6%) patients had pregnancies during the follow-up interval. Twenty (57.1%) patients conceived within 1 year, and 30 (85.7%) conceived within 1.5 years after surgery. Postoperative hysterosalpingography confirmed patency of the contralateral tube in 22/25 of the salpingectomy cases and in 8/9 of the conservative surgery cases.
  The variation in IUP rates for salpingectomy (47.1%) and conservative surgery (77.8%) was not statistically significant. No significant difference was found in the REP rate between the salpingectomy (8.8%) and conservative surgery (11.1%) groups. However, the re-AFS adhesion score was significantly lower in the IUP group compared with the REP group (1.2±0.4 vs. 5.8±2.3, respectively).
Conclusions: Women without contralateral tubal damage can be expected to conceive within 1.5 years after surgery for EP, regardless of surgical procedure. REP is related to adnexal adhesions.

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  Total laparoscopic hysterectomy (TLH) may be difficult to complete in patients with adhesions due to endometriosis or anatomical distortions due to large myomas and cervical myomas. Our purpose is to consider methods for completing TLH in these difficult cases by referring to the basics of our standard procedure. In cases of cervical myoma, a myomectomy can correct anatomical distortion and facilitate safer and easier TLH. In cases of endometriosis, ureteral injury can occur due to adhesions and anatomical distortion. To address this, we initially identify and isolate the ureter and expose the ureteral tunnel to track its course. These steps help us overcome difficulties during the procedure, enabling a safe TLH. In addition, in our experience, a retrograde approach to the vagina is useful in cases with cul-de-sac adhesions. With these techniques, it is possible to complete TLH safely even in difficult cases. We were able to complete simple hysterectomy totally laparoscopically in 99% of cases.

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  EZ access (Hakko Medical, Nagano, Japan) is a silicon cap for the would retractor LAP PROTECTOR™ that makes it possible to insert multiple trocars without air leak. We performed 2-port laparoscopic myomectomies with a lower abdominal 5mm trocar and an umbilical EZ access and found that EZ access is useful not only for cosmetic purpose, due to the reduced number ports, but also for efficient myoma traction through the umbilical port, where it keeps a certain distance from the uterus. After EZ access is removed, the umbilical wound can be kept open with LAP PROTECTOR so the myoma can be morcellated with the scalpel and easily removed. We concluded that EZ access is useful tool for 2-port laparoscopic myomectomy.

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Objective: To examine the operative outcomes of laparoscopic salpingotomy for ampullary tubal pregnancy.
Methods: Using a retrospective cohort, we examined 142 patients who underwent laparoscopic salpingotomy for ampullary tubal pregnancy at Sendai City Hospital and NTT East Japan Tohoku Hospital between March 2000 and July 2011. Of the 142 patients, 106 had intraoperative injection of local methotrexate (MTX).
Results: Laparoscopic salpingotomy was completed in 142 patients, but in 3 cases (2.1%), the surgery was converted to salpingectomy. There were 127 of 142 patients who had an uneventful postoperative course, while 15 patients (10.6%) were diagnosed with persistent ectopic pregnancy (PEP). PEP occurred in 9 (8.5%) of the 106 patients who received local MTX treatment. There were 116 patients who underwent hysterosalpingography or second look laparoscopy, and in 98 (84.5%) of them, the patency of the treated tube was confirmed. Postoperatively, 55 patients achieved pregnancy.
Conclusion: Laparoscopic salpingotomy for ampullary tubal pregnancy can be considered a useful surgical procedure to preserve fallopian tube function when careful management is performed.

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Objective: The refusal of a blood transfusion, by Jehovah's witnesses for religious reasons, becomes problematic when an extended surgical procedure is recommended. The purpose of the current study is to investigate the safety and efficacy of laparoscopic surgery for gynecologic disease in Jehovah's witness patients.
Methods: During the 28 years from 1984 to 2011, gynecologic operation was performed in 54 Jehovah's witness patients. Of these, laparoscopic surgery was performed in five patients (age range 27-63) with ovarian tumor. The clinical features were examined retrospectively.
Results: Three women had unilateral ovarian cystectomy, and bilateral ovarian cystectomy and unilateral salpingo-oophorectomy was performd in one patient each. Operating times ranged from 90 to 225 minutes, and intraoperative total blood loss ranged from a small amount (<20ml) to 550ml. The final pathologic examination revealed three cases of endometrial cyst, one mature cystic teratoma, and one mucinous cystadenoma. The postoperative course was uneventful ; all patients were discharged from the hospital three to five days after operation.
Conclusion: Full informed consent and careful perioperative management should be performed for Jehovah's witness patients. A clear and satisfactory preoperative informed consent is provided to both patients and relatives in our University hospital. Laparoscopic surgery is considered to be a useful procedure for gynecologic disease in Jehovah's witness patients. This minimally invasive surgery is usually performed with a small amount of blood loss. However, we should convert to open surgery immediately if unexpected hemorrhaging occurrs.

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Objective: To assess infertility treatment and perinatal outcomes after endoscopic surgery for patients of reproductive age.
Methods: We investigated the backgrounds of 157 patients in regard to post-operative diagnosis, surgical procedure, and surgical complications. Moreover, we investigated infertility treatment and perinatal outcomes in 36 pregnant women and examined infertility treatment and perinatal outcomes in 11 patients with surgical complications.
Results: In about half of the cases, the post-operative diagnosis was an ovarian cyst (primarily endometriotic or dermoid cysts). Blood transfusion and further surgery were not necessary in 11 cases with operative complications. Following surgery, a total of 36 cases involved conception following infertility treatment.. Among 19 patients that delivered, eight underwent a cesarean section. The indication for cesarean section was breech presentation in five women. Four women who suffered operative complication underwent infertility treatment; two of them conceived and delivered by cesarean section. The surgical complication of one case was uterine perforation by a uterine manipulator; that of one other was abdominal bleeding postoperatively.
Conclusions: We found no severe adverse outcomes, including perinatal outcomes, or impact on infertility treatment following endoscopic surgery for women of reproductive age. Further investigation regarding ovarian reserve is necessary to confirm the impact of endoscopic surgery on infertility treatment and perinatal outcome for these women.

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