Objective: To report a rare case of an urachal remnant cyst in the lower abdomen mimicking benign gynecologic disease.
Case: A 50-year-old female presented with lower abdominal pain of three months duration. She had had a history of an abdominal myomectomy at age 39 and a cesarean section at age 40. Pelvic examination revealed a 7 cm midline cystic mass in the lower abdomen. Magnetic resonance imaging (NRI) revealed a cystic lesion near the apex of the bladder, without any significant signs of malignancy. We suspected the possibility of benign gynecologic disease such as an old hematoma or a foreign body granuloma. At laparoscopy, it was noted that the mass was primarily located in the extra corporeal space and directly connected to the bladder. Urologists completely resected the mass including the upper portion of the bladder, and it was pathologically proven to be a benign urachal cyst.
Conclusion: A urachal remnant cyst is a rare disease, which prior to surgery is defined as a lower abdominal mass of unknown origin that could possibly represent a malignancy. Careful preoperative evaluation and an appropriate surgical procedure are important because urachal cancer possesses highly malignant potential.

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Case report: A 19-year-old woman with menstrual irregularity complained of frequent urination.A sclerosing stromal tumor of ovarywas suspected from diagnostic imaging. We performed a total laparoscopic cystectomy;it was possible tocompletely enucleate the ovarian tumor and preserve fertility.

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  Uterine leiomyomas are clinically present in approximately 12-25% of reproductive age women and represent the most common pelvic tumor.^1-2 Subserous myomas originate from the myometrium at the serosal surface of the uterus and sometimes extend between the fold of the broad ligament. Enucleation of a broad ligament tumor is considered to be difficult because of the abundant vascularity. Furthermore ureteral injury can occur. From March 2010 through February 2013, we enucleated those fibroids laparoscopically safely in seven patients; no ureteral damage occurred. However, in one case, a postoperative blood transfusion was required. We discuss a safe procedure for the enucleation of broad ligament fibroids laparoscopically.

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  Approximately 1-4% of pregnant women develop ovarian tumors, 37% of which are mature cystic teratomas. The tumor commonly arises from the ovary; however, it may appear up to the midportion of the genital ridge during primordial germ cell migration, typically in the midline of the body. We describe a case of an ovarian mature cystic teratoma that was markedly displaced upward due to adhesions that formed following a minimal amount of leakage from the tumor contents. The high and extrapelvic localization of the tumor interfered with the determination of the correct preoperative diagnosis.
  The patient visited our department at 29 weeks of gestation with a chief complaint of severe right lower abdominal pain. Magnetic resonance imaging (MRI) revealed that the abdominal tumor containing fat and calcifications at the level of the fourth lumbar vertebra. The pain was relieved by administration of acetaminophen, and the patient received conservative management. After her vaginal delivery at 39 weeks of gestation, the tumor was found to be located at the same position that it was during pregnancy. MRI after delivery showed a normal involuted uterus and normal-appearing ovaries. The right ovary was located between the uterus and the tumor at the level of the fourth lumbar vertebra. The localization of the tumor suggested an extra-ovarian origin.
  The patient underwent laparoscopic surgery six months postpartum. The tumor was connected to the right ovary through a whitish streak; a cystectomy was performed. The pathological diagnosis was a mature cystic teratoma. Our postoperative diagnosis was a mature cystic teratoma arising from the right ovary. Our hypothesis to explain the localization of the tumor was: a small amount of leakage associated with the rupture at 29 week's gestation resulted in adhesions between the tumor and the parietal peritoneum. During uterine involution, the tumor did not descend due to adhesions to the parietal peritoneum and the omentum.
  The displacement of the tumor required a differential diagnosis for tumor origin: ovary, accessory ovary, supernumerary ovary, ovarian implant, and extra-ovarian tissue such as mesentery. When laparoscopic surgery is attempted in cases such as this, preoperative consideration is necessary regarding the appropriate insertion site for the ports.

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  Tubo-ovarian abscess (TOA) is a severe manifestation of pelvic inflammatory disease. Irrespective of medical treatment with antibiotics, surgical procedures are required in most TOA cases. Some reports recently described the effectiveness of laparoscopic drainage for TOA in women with stage III-IV endometriosis. When a case of TOA is complicated with deep endometriosis, it can be difficult to know how to best manage such a condition. In this report, we present a case of TOA complex with deep endometriosis. We firstly chose to perform laparoscopic drainage for TOA, and secondly laparoscopic radical surgery to remove the deep endometriosis in five months.

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  A 21-year-old woman was admitted to our hospital with heavy vaginal bleeding following a first trimester surgical termination of pregnancy. A magnetic resonance imaging (MRI) scan suggested placenta increta. Previous studies have reported superior results with hysterectomy, compared to uterine preservation treatment modalities. However, preserving uterine function is important for the preservation of reproductive potential. In this case, the patient received methotrexate therapy; however, it was unsuccessful. She underwent a uterine artery embolization and her symptoms rapidly disappeared. The placenta increta was small in area; thus, it was resectable with the hysteroscope.

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  A non-communicating rudimentary horn with a unicornuate uterus is a rare Müllerian anomaly. We present a case of a 32-year-old postpartum woman who previously underwent a right salpingo-oophorectomy for a cystic teratoma via laparoscopy at age 29; one month postpartum, she experienced right lower abdominal pain. Transvaginal ultrasonography and magnetic resonance imaging (MRI) suggested a left unicornuate uterus and a right rudimentary horn with hematometra. The MRI also suggested that the horn was attached with filmy adhesions to the left lower uterine segment; no urinary tract malformations were detected. Laparoscopic removal of the rudimentary horn was performed using a bipolar scalpel for dissection. A morcellator was used to extirpate the specimen and no complications occurred. The MRI imaging and laparoscopic surgery were useful for the diagnosis and treatment of a non-communicating rudimentary horn.

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  Because of the use of prophylactic antibiotics, a vaginal cuff infection after a total hysterectomy is relatively rare. We experienced a case of a vaginal cuff abscess that developed after laparoscopic surgery for severe endometriosis.
Case: A 48-year-old woman with history of a previous laparotomy underwent laparoscopic surgery for severe endometriosis because of failed medical therapy. On the first postoperative day, she developed a fever of over 38°C. Despite therapy with several antimicrobial agents, her fever persisted and the vagina cuff began draining. A computed tomography scan revealed an abscess at the site. Repeat surgery was performed nine days later; the procedure included exfoliation of inflammatory adhesions, drainage of the abscess, and lavage of the abdominal cavity. When a vaginal cuff infection occurs, early detection can be effective in its resolution.

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  Laparoscopy has become the standard approach for the treatment of women with benign ovarian tumors. However, laparoscopy with regards to the management of women with borderline ovarian tumors (BOTs) remains controversial.
  Here we describe a case of BOT treated by laparoscopic restaging surgery. A 56 year-old woman, para 2, had a left ovarian mass which was suspected to be an endometriotic cyst. There was no solid part in the mass on imaging studies. She underwent laparoscopic left salpingo-oophorectomy and a pathological examination showed a clear cell borderline tumor in the left ovary. After she gave informed consent for further treatments, she underwent laparoscopic restaging surgery (total laparoscopic hysterectomy, right salpingo-oophorectomy, infracolic omentectomy and washing cytology) 3 months later. Finally her surgical stage was diagnosed as Ic (based on FIGO classification).
  Laparoscopy may become an alternative to laparotomy for the treatment of BOTs. The safety, efficacy and potential benefits of this approach in BOT restaging surgery should be evaluated in further trials.

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  Making a differential diagnosis is difficult between recurrent metastatic ovarian cancer and primary malignant ovarian tumor in patients who have a previous history of cancer and who are found to have ovarian tumor. We report a case of metastatic ovarian cancer in which diagnostic laparoscopic surgery was effective in deciding on the treatment strategy. A 46-year-old woman was referred to our department for a detailed examination. She was undergoing adjuvant chemotherapy after surgery for ileocecal cancer, which was diagnosed in the surgery department of our hospital when she was 45 years old. The serum levels of carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA19-9) were increasing, and a contrast-enhanced CT examination of the abdomen showed mild enlargement of her left ovary. Transvaginal ultrasound showed that both ovaries were of normal size, but diffusion-weighted MR imaging indicated a high intensity area in the left ovary. ¹⁸F-fluorodeoxyglucose (FDG) PET/CT showed abnormal accumulation of FDG in the left ovary and the right lower abdominal cavity. Diagnostic laparoscopic surgery was performed to differentiate between metastatic ovarian cancer and primary malignant ovarian tumor. Both adnexae were found to be of normal size intraoperatively, but an approximately 1 cm diameter tumor extending into the omentum was observed in the right lower quadrant. Laparoscopic left adnexectomy and omental tumorectomy were performed. The postoperative histopathologic diagnosis was metastatic adenocarcinoma. Diagnostic laparoscopic surgery is less invasive, so it is likely to be useful in making differential diagnoses and in deciding on appropriate treatment strategies.

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  Retained surgical sponges (RSS) are inflammatory masses due to surgical sponges remaining after surgery. We experienced an RSS case of a 58 year old woman who was scheduled for a laparoscopic cholecystectomy. She had a past medical history of a cesarean section 30 years earlier. A CT scan imaged a mass with well-defined margins in her right lower quadrant. Suspecting a gynecologic disease such as an ovarian tumor, we further examined her with a pelvic exam, ultrasound (US), and magnetic resonance imaging (MRI). Under a diagnosis of the right ovarian tumor, we performed laparoscopic removal of the pelvic mass following the cholecystectomy. Laparoscopic findings were a 5 cm diameter mass surrounded by the right adnexa, greater omentum, and colon. Pathologic examination revealed that the mass contained numerous threads (foreign bodies), histiocytes, multinucleated giant cells, and ossification. The final diagnosis was RSS incurred at a surgical procedure 30 years ago. This case illustrates the need to include RSS in a patient with a history of past surgery and evaluate imaging studies in this context.

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  While laparoscopic sacrocolpopexy is a well-established laparoscopic procedure in the management of pelvic organ prolapse in Western countries, laparoscopic sacrocolpopexy is not widely accepted in Japan. We report four cases in which laparoscopic sacrocolpopexy was performed to treat severe pelvic organ prolapse. The patients were in the 7th and 8th decades of life. Two patients were pelvic organ prolapse quantification (POP-Q) stage III and two patients were POP-Q stage IV. Two of the four patients (# 1 and 2) had pollakisuria and stress urinary incontinence pre-operatively. While intraoperative bleeding was not excessive, the operative time tended to be prolonged, ranging from 210-313 minutes {275.25±45.68 (mean±SD) minutes}. A complication occurred in one patient (# 3). Specifically, strangulation ileus resulting from trocar site herniation occurred on post-operative day 2, for which emergent surgery was required. The anatomic recurrence rate was 25% (1 of 4). Patient # 3 had recurrent prolapse 7 months after the laparoscopic surgery and re-operation was performed. The pre-operative urinary symptoms in patient # 1 were improving. Patient # 2 was improving, but not completely. Laparoscopic sacrocolpopexy may be useful in the management of pelvic organ prolapse; however, improvement in the surgical technique is needed to decrease invasiveness and reduce the complication and recurrence rates.

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  Needle laparoscopy, or laparoscopy with reduced size instruments, has been recently introduced with the aim of minimizing the size of surgical scars. In needlescopic surgery, we generally use four 2-3 mm ports. Several reports have shown that needlescopic surgery is less painful than single port laparoscopy. Although needlescopic surgery requires special slender instruments, it is considered to be easier to introduce than single port laparoscopy because the instruments are used in the same manner as standard laparoscopic instruments. In regard to manipulation, it is easier to establish triangulation in the operation field because the configuration of the ports for needlescopic surgery is the same as that of conventional laparoscopic surgery. We successfully performed needlescopic total laparoscopic hysterectomy (needlescopic TLH) using a 3 mm diameter laparoscope, a 3 mm manipulation port, and a 2.4mm diameter forceps (Endo Relief^®) via smaller ports. After appropriate training, needlescopic TLH can be performed safely as a less invasive alternative to standard laparoscopy. It provides an excellent cosmetic result.

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  Teratomas of the fallopian tube are rare and the majority of them are found at the time of surgery. Here, we report on a case of mature teratoma of the fallopian tube found incidentally at the time of laparoscopic surgery for an ovarian teratoma.
  A 37-year-old, nulliparous woman underwent laparoscopic surgery for a teratoma of the right ovary following hysteroscopic surgery for endometrial polyps. At the time of laparoscopic surgery, there were hairs out of the fimbriae of the right fallopian tube and there was a small tumor within the ampullary region of that area. Laparoscopic resection was performed because she desired pregnancy. Pathological examination showed a mature teratoma of the right fallopian tube and another of the ipsilateral ovary. Three months later, hysterosalpingography(HSG) confirmed patency of bilateral fallopian tubes. The patient conceived spontaneously five months after laparoscopic surgery and she delivered a healthy baby vaginally.
  Most tubal teratomas are found incidentally at the time of surgery. When we encounter such a rare disease, we must decide strategy during surgery.

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Case Report: Approximately 1% of ectopic pregnancies are abdominal pregnancies; these pregnancies may be life threatening. We present four cases in which abdominal pregnancy was successfully managed by operative laparoscopy and two cases in which abdominal pregnancy was managed by laparotomy, together with a review of the published literature. In the four cases, which were managed by laparoscopy, the products of conception and blood clots were resected laparoscopically with controlled hemostasis. In two cases, conversion from a laparoscopy to a laparotomy was necessary because bleeding at the implantation site was uncontrollable. Operative laparoscopy is an appropriate method for the treatment of an abdominal pregnancy when the site of implantation does not involve the surface of the intestinal tract. However, abdominal pregnancy accompanied by active bleeding from the site may require conversion from laparoscopy to laparotomy.

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Case Report: A persistent ectopic pregnancy (PEP) refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to avoid a salpingectomy of the affected fallopian tube, trophoblastic tissue may remain. In about 3-20% of these cases, the major portion of the ectopic growth is removed, but some trophoblastic tissue escapes removal and continues to grow, generating a new rise or prolongation of hCG levels. We report here a rare case of PEP after a salpingectomy. The patient was a 22-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. We performed emergent laparoscopic salpingectomy, and followed up on hCG revels and ultrasonography as an outpatient. On the 38th postoperative day, she was transported to our hospital by ambulance; she was in shock and suffering severe abdominal pain from intra-abdominal bleeding. We performed the second emergent laparoscopic surgery, and bleeding from the severed end of the fallopian tube was present. We excised the residual fallopian tube. Trophoblastic tissue was identified in the specimen, and PEP was confirmed via pathological examination.

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  Giant peritoneal inclusion cysts have been excised via laparotomies. We report a case in which a giant peritoneal inclusion cyst was successfully evacuated by laparoscopic-assisted surgery after securing a visual field by transvaginal puncture. The patient was a 44-year-old woman who had been diagnosed with a uterine myoma at another hospital at 42 years of age; she underwent a total laparoscopic hysterectomy and laparoscopic right adnexectomy. She returned to the same hospital with a chief complaint of a lump in her abdomen of six months' duration; she was diagnosed with a left ovarian tumor and was referred to our hospital. A diagnosis of a peritoneal inclusion cyst was made, and laparoscopic-assisted surgery was performed. Because the lesion was too large to allow a laparoscopic visual field, 1,100 mL of fluid was removed from the cyst transvaginally. The bladder peritoneum and sigmoid mesocolon were then dissected; the cyst wall was then opened revealing normal left adnexa within it. Then, the surgery was completed by opening the pouch of Douglas. The patient's postoperative course was uneventful, and she was discharged on postoperative day 3. There have been no signs of recurrence. Laparoscopic-assisted surgery is a useful procedure for radical treatment of peritoneal inclusion cysts; however, it may be difficult to perform if the cyst is large. When a patient with such a cyst presents to us, we transvaginally puncture the cyst and evacuate it; thus, enabling safe and successful completion of laparoscopic-assisted surgery.

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Introduction: Growing teratoma syndrome is defined as a chemotherapy-resistant tumor occurring after initial therapy for an immature ovarian teratoma or testicular seminoma; its histological findings are that of a mature teratoma. In past case reports, the lesions were almost always benign, and were treated surgically if the tumor exhibited enlargement and/or clinical symptoms were present. We report a case of growing teratoma syndrome, successfully treated with laparoscopic surgery.
Case presentation: The patient is a 30-year-old, nulligravida Japanese female. She had an acute abdomen with torsion of the right ovarian tumor pedicle; therefore, she underwent a laparotomy for a right salpingo-oophorectomy. The histologic diagnosis was an immature ovarian teratoma. She underwent three courses of bleomycin, etoposide, platinum (BEP) chemotherapy; complete remission was attained; however, 26 months after the resection, we discovered a tumor in the Pouch of Douglas but the AFP tumor marker was not elevated. Therefore, we suspected the tumor to be growing teratoma syndrome and resected it laparoscopically. The histology of the specimen was in accordance with preoperative diagnosis.
Conclusions: The literature does not contain any previous reports of a growing teratoma syndrome resected laparoscopically. In this case, the lesion was located deep in the pelvis; therefore, visualization by laparoscopy was very useful for attaining complete resection of the tumor. In addition, laparoscopic visualization was also beneficial for locating intraperitoneal micro-metastases.

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  Fallopian tube torsion caused by a paraovarian or paratubal cyst during pregnancy is rare. A 30 year old woman (gravida 2, para 1) was referred to our hospital with acute-onset right abdominal pain and a coinciding cyst measuring 5cm detected by ultrasonography at 37 gestational weeks.
  Although ovarian torsion was suspected, her symptoms were mild, and in consideration of operative difficulty, we decided to postpone laparoscopic management until after delivery. At 38 gestational weeks, she delivered a male infant (2810g) after induction. Her symptoms continued and laparoscopic surgery was performed at 6 days after delivery, which revealed right fallopian tube torsion due to a paraovarian cyst. The right ovary was intact. The right fallopian tube and the paraovarian cyst was necrotized, adhered to the peripheral peritoneum, and was resected laparoscopically with relative ease. Her postoperative course was uneventful.

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Objective: To report a case of a quiescent Nuck's hydrocele with endometriosis revealed after laparoscopic surgery.
Design: Case report.
Setting: Department of Obstetrics and Gynecology, Tohoku University Hospital.
Patient: A 36-year-old woman who was diagnosed with bilateral endometrial cysts underwent laparoscopic surgery.
Main Outcome Measures: Ultrasonography, CT, MRI, and histologic examination.
Results: We performed a laparoscopic bilateral ovarian cystectomy and pelvic adhesiolysis with ≤ 10 mm Hg intra-abdominal pressure. Postoperatively, however, the tumor appeared to be enlarging with increased pain in her left groin. Before the laparoscopic surgery, she was aware of something swelling and then resolving spontaneously; however, she assumed that it was one of the multiple myoma lesions palpable on her abdominal wall. We could not diagnose it as a Nuck's hydrocele by ultrasonography. An MRI taken before laparoscopy was reviewed and found to show a Nuck's hydrocele with endometriosis. An open surgery was planned and the preoperative CT showed a Nuck's hydrocele enhanced with previous contrast agent used in hysterosalpingogram. We removed the Nuck's hydrocele and reinforced the surgical site with mesh. Histological examination confirmed a Nuck's hydrocele with endometriosis and inflammation.
Conclusions: A Nuck's hydrocele in an adult female is very rare; to the best of our knowledge, this is the first case revealed following laparoscopic surgery. The Japanese literature contains only 5 case reports of a Nuck's hydrocele with endometriosis. We assume that a quiescent Nuck's hydrocele with endometriosis can be revealed with laparoscopic intra-abdominal pressure and imaging enhancement with contrast dye. We recommend that a quiescent inguinal hernia or Nuck's hydrocele should be identified prior to laparoscopic surgery because high laparoscopic intra-abdominal pressure might exacerbate those conditions.

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[Objective] To describe a patient with endometrial polyps showing normal cytology that were found to be malignant only after resection.
[Design] Case report.
[Setting] General hospital.
[Patients] A 38-year-old patient with prolonged menstruation and lower abdominal pain.
[Intervention] Hysteroscopic resection of endometrial polyps.
[Main outcome, Measures] Hysteroscopy showed multiple small polyps without atypical vessels. The endometrial cytological findings were normal. The diagnosis of endometrial cancer was confirmed only after an operative procedure.
[Conclusions] The risk of endometrial cancer in endometrial polyps is low in premenopausal women. Because it is difficult to predict the presence of malignancy, operative evaluation of polyps should be undertaken to confirm the diagnosis.

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  We report a case of fallopian tube cancer diagnosed by laparoscopy. The patient was a 68-year-old woman who presented at a clinic with a chief complaint of irregular vaginal bleeding. She was found to have a slightly enlarged left ovary and a high serum CA546 level of 51 U/mL. Transvaginal ultrasonic tomography at the initial visit imaged a tumor measuring 3.5 cm x 3.4 cm in the left adnexa. An ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography scan detected an abnormal FDG accumulation located solely in the left adnexal tumor; the SUVmax was 9.2. Because the tumor was suspicious for malignancy, the patient underwent diagnostic laparoscopy; it revealed papillary tumor-like lesions in the swollen left fallopian tube and the left fimbria. An intraoperative diagnosis of left fallopian tube cancer was made, and the procedure was immediately converted to a laparotomy. After performing a total hysterectomy and bilateral salpingo-oophorectomy, cytological examination of the rapidly-frozen specimens revealed adenocarcinoma of the left adnexa. The procedure was then expanded to an omentectomy and a pelvic and para-aortic lymphadenectomy. The histopathologic diagnosis was primary serous adenocarcinoma of the left fallopian tube. The clinical stage of the patient's disease wasIIC (pT2cN0M0). The patient's postoperative course was good, and she was discharged on postoperative day 11. The patient received six courses of adjuvant chemotherapy in combination with paclitaxel and carboplatin. She is now two years postoperative with no signs of recurrence.

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  An interstitial pregnancy is a relatively rare type of ectopic pregnancy. However, the incidence is increasing because of the increase in sexually transmitted diseases and assisted reproduction technology. Treatment primarily consists of methotrexate drug therapy and surgery. In particular, laparoscopic surgery is increasing as a result of improvements in technology and surgical technique. However, laparoscopy is contraindicated for use in an interstitial pregnancy because of the risk of massive hemorrhage. From March 2009 through November 2012, we experienced four cases of laparoscopic surgery for interstitial pregnancy at our hospital. Despite the risk of massive hemorrhage, two were treated by a laparoscopic cornual wedge resection. In addition, the remaining fallopian tube after salpingectomy is a risk factor for interstitial pregnancy. We report four cases and a review of pertinent literature.

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  We report three cases in which umbilical endometriosis developed after a laparoscopic subtotal hysterectomy (LSH) for uterine myoma without endometriotic lesions.
Case 1: A 36-year-old, gravida 2, para 2 underwent an LSH for uterine myoma. Removal of the uterus was performed using the peeling technique with an umbilical trocar. Twelve months postoperatively, induration appeared at the umbilical region (approximately 20 mm) and the right trocar region (approximately 5 mm). Therefore, a lumpectomy was performed 18 months after the initial surgery. The pathologic diagnosis was heterotopic endometriosis. Because the umbilical tumor relapsed 27 months following surgery, Dienogest was administered; eight months later, the tumor had resolved. The umbilical tumor reappeared two months after terminating the orally administered treatment; therefore, resection of the umbilical tumor was performed 55 months after the initial surgery.
Case 2: A 44-year-old gravida 3, para 2 underwent an LSH for uterine myoma. The tumor was morcellated using a morcellator, then extracted using an umbilical trocar. Approximately 19 months postoperatively, an approximately 18 mm area of induration appeared near the umbilical region; therefore, a resection was performed. The pathological diagnosis was heterotopic endometriosis.
Case 3: A 45-year-old gravida 2, para 2 underwent an LSH and left salpingectomy for a uterine myoma and left paraovarian cyst. The hysterectomy involved morcellation and extraction through the umbilical region. An approximately 46 mm area of induration with hemorrhage appeared in the umbilical region 70 months postoperatively. Due to the suspicion of an umbilical tumor, a needle biopsy was performed at the site; the pathologic diagnosis was heterotopic endometriosis. She is currently receiving Dienogest treatment as an outpatient, and is being followed-up with the possibility of surgical extraction in mind.
Conclusion: Although endometriosis is a common gynecological disease, umbilical endometriosis is rare. Therefore, the disease that developed in these three cases was likely due to growth of endometrial tissue in the umbilical region at the time of tissue removal.

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  Endometriosis is a chronic disease that occurs roughly in 10% of women. Endometriosis can be found in anywhere in the body, but the most common lesions are in the ovary, known as endometrioma and accounting for 55% of endometriosis. Laparoscopic excision is the most frequently chosen form of treatment for endometrioma, to reduce pelvic pain and prevent loss of fertility. There is a problem with endometrioma recurrence after surgery, however. The recurrence rate is said to be almost 30% three to five years after surgery, and prophylaxis of endometrioma recurrence is thus a major issue. We experienced a case of endometrioma relapse in the same ovary after four months of laparoscopic surgery in a 25-year old woman who had suffered with endometrioma for more than seven years. The size of the endometrioma began to increase so we decided to operate after GnRHa therapy for six months. Two months after laparoscopic excision, we started to use oral contraceptives to avoid recurrence, but this occurred anyway, four months after the laparoscopic surgery, so a second laparoscopic excision was performed.
  We were sure to remove the whole lesion macroscopically, and again used oral contraceptives to prevent recurrence for two months after operation. One possible reason for the recurrence is that we started to use oral contraceptives after the resumption of menses. It may be that the most important way to prevent recurrence is to start medication therapy soon after the laparoscopic excision.

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  The early diagnosis and minimally invasive management of ectopic pregnancy are usually possible because of the development of highly sensitive urine pregnancy tests and ultrasonography. We herein report a rare case of chronic ectopic pregnancy which was difficult to diagnose before laparoscopic surgery due to a negative urine pregnancy test. A 21-year-old female (gravida 1, para 0) presented with right lower abdominal pain and irregular vaginal bleeding. A urine pregnancy test with a sensitivity of 25 IU/L was negative at triage. Since a 4 cm heterogeneous mass was identified on the right side of the uterus by transvaginal ultrasonography, a degenerative uterine myoma was diagnosed. Since the symptoms lasted another month without relief, MRI and CT were performed, but no definitive diagnosis was made. Thereafter, a laparoscopic examination revealed that the right fallopian tube was swollen to 4 cm in diameter, with extensive circumferential inflammatory adhesions. Another urine pregnancy test was performed during the operation because a tubal pregnancy was suspected, but it was negative. After laparoscopic right salpingectomy, the symptoms improved. Based on a histological examination of the surgical specimen showing degenerated villi and viable trophoblasts, chronic right tubal pregnancy was diagnosed. In conclusion, although a urine pregnancy test is useful and essential to rule out ectopic pregnancy in females of reproductive age presenting with abdominal symptoms, the possibility of chronic ectopic pregnancy should be considered even in cases with negative results. Laparoscopic surgery can be useful for diagnosis and treatment when a chronic ectopic pregnancy is suspected.

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  An ovarian carcinoid tumor is extremely rare and is classified as a borderline malignant tumor. We report a case of strumal carcinoid tumor arising in a mature cystic teratoma (MCT) of the ovary treated with fertility-preserving laparoscopic surgery. A 21-year-old woman presented with a pelvic mass accompanied by lower abdominal pain. Magnetic resonance imaging revealed tumors in both the right and left ovaries with multi-cystic parts, which were 10 cm and 9 cm in diameter, respectively. Examination of the resected specimens revealed that each cyst cavity was filled with hair, sebaceous material, and cartilage. Histological analysis showed that the left ovarian tumor contained a small focal lesion of strumal carcinoid tumor in a MCT. In conclusion, although an ovarian tumor demonstrates characteristics typical of MCT, it may include small borderline malignant lesions.

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  We present a case of laparoscopic bladder injury, a single case in a total of 127 total laparoscopic hysterectomies (TLHs). The incidence of laparoscopic bladder injury is reported to be 0.2- 2.0% of TLHs. The injury was noted following the patient's complaint of urinary incontinence 14 days after undergoing TLH. The vesicovaginal fistula was diagnosed by cystoscopy. A retrospective review of the moving images of the surgical operation revealed that we cut the bladder by monopolar diathermy in poor visibility due to smoke. Secondary surgical repair was performed via laparoscopy. Final closure of the fistula was achieved abdominally since the laparoscopic approach was unsuccessful. The American Association of Gynecologic Laparoscopists (AAGL) recommends routine cystoscopy after TLH because only 25-50% of urinary tract injuries caused during TLH are recognized during the procedure.

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  Currently, endoscopic surgery is a common treatment for infertility patients. However, some single-incision laparoscopic surgery (SILS) procedures are difficult for the gynecologic generalist; these include anastomosis offallopian tubes, falloposcopic tuboplasty (FT) for tubal occlusion, mass reduction ofadenomyosis, and knot-tying techniques. As a general rule, total laparoscopic surgery is more difficult than laparoscopic assisted surgeryusing a wound retractor for gynecologic generalists. We were able to perform anastomosesin the isthmus and the intramural segment of the tubes through the wound retractor. Mass reduction of adenomyosis was also performed. During FT procedures; furthermore, manualassistance facilitatedthe recanalization process. Thus, a wound retractor is an extremely usefulinstrument for these types of procedures. Although SILS has recently been performed for gynecological diseases, knot-tying techniquefor intracorporeal suturing is one of rate-limiting steps impacting the acceptance of SILS. Wecreated a new, simplified method of knot-tying for SILS. The benefit of this technique isthat it does not require any special skills; any surgeon able to perform intracorporealsuturing should be capable of tying knots during SILS.

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Objective: Seprafilm^®, an adhesion barrier in sheet form, is very difficult to insert into the abdominal cavity with laparoscopic surgery. Therefore, we created a new device that facilitates insertion of Seprafilm^® into the abdominal cavity through a 5mm diameter trocar.
Methods: This device comprises a 5 mm outer tube and an inner tube. Seprafilm^® was cut into 6.4 × 7.4 cm pieces, attached at the inner tube, rotated into the outer tube through a slit configuration, and then inserted through the 5 mm trocar. We used this device during a laparoscopic myomectomy (LM) for 14 patients.
Results: The average time required from beginning of the loading procedure into the device until attachment to the uterus was 3.3 min (2.0-5.5 min). This time was less than that reported in previous studies; furthermore, the success rate of insertion and attachment to the uterus was high at 86.3%.
Conclusions: We have determined that this new device can be more effective for the insertion of Seprafilm^® into the abdominal cavity than the other techiniques.

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Objective: The aim of this study was to determine whether the optical direct trocar insertion technique using Kocher clamps can be used to establish a safe and rapid mode of entry during laparoscopic surgery.
Design: The study was performed retrospectively
Setting: The study was carried out at the Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital.
Patients: The study included 242 patients who underwent laparoscopic surgery between October 2009 and September 2010, and 278 patients who underwent laparoscopic surgery between October 2010 and September 2011.
Interventions: In October 2010, the method for performing the first puncture for trocar insertion was changed from lifting the abdominal wall by hands to raising the umbilicus using Kocher clamps. With this new modification, the bottom of the umbilicus is sufficiently exposed to appropriately insert the first trocar with ease.
Methods: The entry time was measured and compared between the conventional method and the new method.
Result: The entry time was shorter for the new method compared with that for the conventional method (3.5±2.2min vs. 5.6±3.7min). No remarkable complications were observed.
Conclusion: The new method was faster and safer than the conventional method.

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  Because of later marriage and postponement of childbearing, the number of fibroid cases being treated via uterine preservation procedures is increasing. Although the available choices for uterine preservation are increasing (i.e., gonadotropin releasing hormone analogs, uterine artery embolization, and focused ultrasound ablation), a myomectomy is the only well-established procedure for preservation of fertility. In order to decrease blood loss and ensure safety during a myomectomy, the most important element is prompt suturing of the myometrium. However, when we perform a laparoscopic myomectomy, several restrictions make suturing difficult (i.e., needle direction, suturing speed, and visibility of the lower wound margin). Therefore, it is necessary to carefully choose the suturing method.
  We consider that the best suturing method should be one with less tissue handling, decreased number of sutures and knots, and excellent tissue approximation. Although the Smead-Jones suture is one of the suturing methods used on abdominal fascia with a midline incision, we have applied this suturing method to restore the myometrium. The Smead-Jones suture does not require the backward manupulation of the needle as used in the mattress or baseball suture. Therefore, under a laparoscopic surgery, this suture facilitates needle handling. Furthermore, by suturing all layers, the Smead-Jones suture decreases the number of knots; furthermore, excellent tissue approximation without wound tension and dead spaces can be achieved. One note of caution: when a Smead-Jones suture is used to restore the myometrium, we should apply adhesion barriers to the wound, because of the increased amount of exposure of the stitches on the serosa. Further studies are needed to determine whether using of the Smead- Jones suture contributes the prevention from thinning of the uterine wound.

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Objective: We examined infertility cases with endometrial polyps.
Design: Retrospective study.
Setting: Infertility clinic.
Patients: Fifty-eight infertile women undergoing transvaginal ultrasonography and hysteroscopy
Intervention: Transvaginal ultrasonography and hysteroscopy
Main outcome measures: The size and location of endometrial polyp
Results: We compared the patient group in which the results of transvaginal ultrasonography and hysteroscopy corresponded (Corresponding Group) and the patient group in which the results did not correspond (Non-Corresponding Group). The average size of endometrial polyps in the non-corresponding group (7.8 ± 2.8 mm) was significantly less than those in the corresponding group (12.4 ± 5.1 mm). In the Corresponding Group, 90% of the endometrial polyps were detected within the upper two-third of the uterine cavity (fundal side), and 10% of the endometrial polyps were detected in the lower one-third of the uterine cavity (cervical side). In the Non-Corresponding Group, 44% of the endometrial polyps were detected within the upper two-thirds of the uterine cavity (fundal side), and 56% of the endometrial polyps were detected in the lower one-third of the uterine cavity (cervical side).
Conclusions: Endometrial polyps that are not detected by transvaginal ultrasonography can be identified by hysteroscopy. Because the polyp size was small in the Non-Corresponding Group and more than 50% of the endometrial polyps are located in the lower portion (cervical side) of the uterine cavity, the endometrial polyps in the Non-Corresponding Group may not be a cause of infertility.

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Objective: We investigated the reproductive performance of women with a single fallopian tube after conservative laparoscopic surgery for a tubal pregnancy.
Study Design: From August 1992 through April 2010, we treated 300 hundred cases of tubal pregnancy with conservative laparoscopic surgery (salpingotomy). Tubal patency was assessed by either hysterosalpingography (HSG) or second-look laparoscopy (SLL) three months postoperatively. We confirmed pregnancy outcome by contacting all women by telephone and/or mail.
Results: Among 300 cases, 22 patients (7.4%) with a single fallopian tube underwent a laparoscopic salpingotomy for tubal pregnancy. Conservative surgery was successful in 14 of 22 cases (64%); eight cases were converted to a salpingectomy due to complete rupture of oviduct mucosa and continuous bleeding. No difference in surgical outcome was observed between the successful and unsuccessful cases in regard to gestational age, intraoperative hemorrhage, size and location of the pregnancy mass, and presence of fetal heart beat (FHB). However the unsuccessful cases were more frequently associated with higher pre-operative serum hCG levels than the successful cases (12,610±13,344 versus 3,604±3,045 IU/L; P < 0.05; χ² test). In eleven of 14 successful cases, the postoperative serum hCG level gradually declined. However, the remaining three of 14 cases developed a persistent ectopic pregnancy (PEP). Among these three cases, two cases required an additional methotrexate (MTX) injection due to an inadequate decline in the serum hCG level and one case of PEP subsequently ruptured. Postoperative tubal patency was confirmed in 9 of 14 cases (HSG: 7 cases, SLL: 2 cases). Among 13 married women who desired a future pregnancy and were trying to achieve a pregnancy after the surgery, pregnancy was confirmed in 8 cases (62%).
Conclusions: A higher tubal patency rate and a satisfactory reproductive outcome were observed after conservative laparoscopic surgery for tubal pregnancy in women with a single fallopian tube. This report strengthens the clinical value of a laparoscopic salpingotomy for tubal pregnancy.

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Objective: To compare a transverse abdominal plane nerve (TAP) block and epidural anesthesia in terms of effectiveness for postoperative analgesia following gynecologic laparoscopic surgery.
Design: Non-randomized trial
Setting: The TAP block was conducted by an anesthesiologist. With the use of ultrasound, 20 ml of 0.375% ropivacaine was injected into the right and left sides of the tissue plane between the internal oblique and the transversus abdominis muscles. In epidural anesthesia, the continuous infusion was administered at a rate of 4 ml/h of 0.375% ropivacaine using a PCA dose of 2 ml with a lock-out time of 30 min. The catheter was extracted on postoperative day 2. Pentazocine, ketoprofen, and loxoprofen sodium were used for analgesia, unless contraindications existed.
Patients: The patients underwent gynecologic laparoscopic surgery at our hospital.
Intervention: The patients were divided into two groups. The Epi Group received epidural anesthesia and the TAP Group received a TAP block. Using a visual analog scale (VAS) and a Prince Henry pain scale, the postoperative patient pain was separately measured at rest and at motion through postoperative day 3. The frequency of analgesic use was also monitored.
Main outcome: The TAP Group had higher VAS and PRS scores than the Epi Group primarily on postoperative days 1 and 2..
Results: The TAP group comprised eight patients and the Epi Group comprised 12 patients for Epi-group. Through postoperative day 2, the pain scale scores in the TAP Group were significantly higher (Student's t-test; P < 0.05) than those of the Epi Group. The mean time for the first postoperative analgesic use was 7 h 42 min in the Epi Group and 56 min in the TAP Group. The frequency of analgesic use was significantly higher in TAP Group than in the Epi Ggroup at any postoperative time point (3, 6, and 12 h).
Conclusion: The TAP block was found to be less effective than epidural anesthesia for postoperative analgesia after gynecologic laparoscopic surgery.

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Objective: In an effort to shorten hospitalization days for laparoscopic adnexal surgery, various procedures were carried out both before and after the surgery.
Setting: We explained the laparoscopic procedure with a pamphlet. In addition, we streamlined the clinical path for efficiency and standardization of the treatment and nursing care. Operations were performed under total intravenous anesthesia; a transversus abdominis plane (TAP) block was used.
Patients: 191 patients who underwent laparoscopic adnexal surgery in our department from April 2007 through March 2010. Patients were requested to ambulate three hours after surgery and fed dinner on the day of surgery. Patients were discharged on the morning after surgery when possible and presented at the outpatient department one or two weeks later.. We compared 166 cases discharged the day after surgery to 25 other cases that were not discharged the day after surgery.
Results: The average hospital stay was 3.28 days. The average age of the patients with longer hospital stays was about 10 years older than the patients who were discharged on the first postoperative day. Surgery time, blood loss, and hospital costs were comparable. The main reasons for prolongation of the hospital stay were patient request, advanced age, and pain. Only four patients complained of difficulties after discharge.
Conclusions: Patients readily accept discharge on the day after surgery, if the process is explained to them before surgery. The main reasons for non-adherence to this policy are rare cases of advanced age or excessive blood loss.

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Objective: To examine five types of pelvic pain relief in women with endometriosis after laparoscopic surgery for deep infiltrating endometriosis (DIE)
Patients: A total of 28 patients underwent laparoscopic surgery by lateral approach for DIE between February 2010 and April 2012.
Main outcome measures: VAS levels of their five subjective symptoms.
Results: VAS levels were depicted as follows. The VAS levels of dysmenorrhea were 51±33 (mean ± SD) before surgery, 19±24 at one month post-surgery, and 24±27 at 12 month post-surgery. The VAS levels of non-menses pain were 36±28 before surgery, 17±23 at one month post-surgery, and 19±29 at 12 month post-surgery. The VAS levels of lumbago were 38±28 before surgery, 25±27 at one month post-surgery, and 31±30 at 12 month post-surgery. The VAS levels of dyspareunia were 30±32 before surgery, 9±20 at one month post-surgery, and 11±16 at 12 month post-surgery, The VAS levels of dyschezia were 27±33 before surgery, 8±16 at one month post-surgery , and 9±17 at 12 month post-surgery. The recurrence rates of the five symptoms at 12th months were as follows: dysmenorrhea38%(3/8), non-menses pain3%(1/8), lumbago13%(1/8), dyspareunia13%(1/8) and dyschezia0%(0/8).
Conclusion: The recurrence rates of pelvic pain such as non-menses pain, lumbago, dyspareunia, and dyschezia, were low at the 12th postoperative month following laparoscopic surgery by lateral approach to DIE lesion.These result suggest that recurrence rates of the five types of pelvic pain in women with DIE at the12th post-operative month vary, depending on the type.

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Objectives: We evaluated the accuracy of using enhanced computed tomography (CT) findings in the diagnosis of ovarian torsion and using preoperative levels of C-reactive protein (CRP) as a marker for adnexal necrosis.
Subjects: Sixty-six patients who were surgically treated for ovarian torsion between January 2009 and August 2012 at our institution were included in this study.
Methods: We retrospectively studied: (1) the relationship between the presence of pathological necrosis and the time from the onset of ovarian torsion to the operation, (2) the relationship between pathological necrosis and the preoperative CRP value, (3) differences between macroscopic and pathological findings of necrosis, (4) the incidence of observing significant findings (fallopian tube thickening or twisted pedicle) related to adnexal torsion when using enhanced CT for the diagnosis of ovarian torsion.
Results: (1) There was a significant difference (P = 0 .03) in the incidence of pathological necrosis in patients who had experienced ovarian torsion of < 12 h (25% incidence of necrosis) and patients who had experienced ovarian torsion of ≥ 24 hr (60% incidence of necrosis). (2) Twenty-two cases of ovarian torsion were CRP positive and 44 cases were CRP negative. There was a significant difference in the percentage of the CRP positive cases and CRP negative cases which showed pathological necrosis, (63.6% and 31.8%, respectively, P = 0.02). (3) Forty-one of the 66 torsion cases showed macroscopic necrosis; however, 29.2% of these were not pathological necrosis. (4) Of the 66 torsion cases, 75.6% showed some significant findings on enhanced CT scans.
Conclusions: (1) A prolonged time from the onset of ovarian torsion to an operation leads to pathological necrosis. (2) The CRP value is a good surrogate marker for the presence of pathological necrosis. (3) Macroscopic findings sometimes misdiagnose ovarian necrosis. (4) Enhanced CT helps in the accurate diagnosis of ovarian torsion.

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Objective: To clarify the trends in indication and outcome of our laparoscopic techniques for gynecological disease
Design: Retrospective cohort study
Setting: Tertiary care university hospital
Patients: 520 cases who performed laparoscopic surgery in our institution from 2001 to 2011
Intervention: Retrospective analysis
Main outcome, Measure: We retrospectively reviewed the status of laparoscopic surgery in our institution over an 11-year period.
Results: The median age of patients undergoing such procedure was 31.0 years old (11-76), and the most frequent operative diagnosis was benign ovarian tumor (349 cases, 67.1%), followed by ectopic pregnancy (73 cases, 14.0%), and investigation of infertility (30 cases, 5.8%). Most cases received the procedure for ovarian disease, and only 15 cases (2.9%) received laparoscopic surgery for uterine disease. The number of conversions to laparotomy was 7 cases (1.3%). Two cases with massive bleeding requiring blood transfusion and 3 cases with digestive tract injury, recognized as a surgical complication. Postoperative complications included 2 cases with infection and one case with ileus requiring surgical treatment.
Conclusion: The number of laparoscopic surgeries in our institution is increasing, following a general trend. Although our incidence of digestive tract injury was slightly higher than that of the general probability, the outcomes of our laparoscopic surgeries have been acceptable. Nevertheless, we need fewer cases of surgery for uterine disease compared to other facilities in Japan. Our next step is to increase the number of laparoscopic surgeries, expanding the indication of laparoscopic surgery, especially for uterine disease.

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Objective: Among all types of laparoscopic hysterectomies, laparoscopic subtotal hysterectomy (LSH) is a relatively simple and easy procedure. However, LSH is particularly difficult in patients with uterine sarcoma. We retrospectively examined the usefulness and problems associated with this operation in the perioperative period in our institution.
Design: One hundred thirty-two laparoscopic hysterectomies were performed in our institution between 2009 and 2012. Among the 132 cases, we investigated 128 cases (the remaining 4 cases had to be converted to laparotomy). We divided the 128 cases into two groups: LSH (n = 84) and non-LSH (cases that underwent other types of laparoscopic hysterectomies, n = 44). We compared the LSH group with the non-LSH group in terms of age, parity, operative time, amount of bleeding, weight of the resected lesions, postoperative length of stay, and pre- and postoperative hemoglobin levels. Furthermore, we describe two uterine sarcoma cases to address the problems associated with LSH.
Results: The LSH group was superior in terms of operative time, weight of the resected lesions, postoperative length of stay, and pre- and postoperative hemoglobin levels. On the other hand, two cases that were initially diagnosed as uterine myoma underwent LSH. These cases were later histopathologically diagnosed as uterine sarcoma.
Conclusions: In situations where screening of cervical and endometrial cancer is possible, LSH is superior compared to other laparoscopic hysterectomies and reduces the burden on medical personnel and patients in the perioperative period. However, LSH remains difficult in patients with uterine sarcoma, and this problem needs to be resolved in future.

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Study Object: A detail anatomical structure of pelvic nerve networks, and their functions are still unsolved. The object of this study is to reveal complete anatomical structures of the pelvic nerve networks ( hypogastric nerve, pelvic splanchnic nerves (S2-4), pelvic nerve plexus, and it's vesical branches), and also to assess the correlation between the bladder function and the status of the sparing pelvic nerve networks after the laparoscopic radical hysterectomy.
Design and setting: We dissected and exposed complete anatomical structures of the pelvic nerve networks in fresh cadavers, and through this cadaveric study, we categorized laparoscopic radical hysterectomies into three groups (group A:complete preservation, group B:incomplete preservation group C: complete sacrifice ) based on the status of the sparing pelvic nerve system
Patient: Total 42 cases (group A:23 cases, group B:8 cases, group C:11 cases)
Measurements and main results: Bladder functions of each groups are evaluated respectively by the Uro-dynamic study.
  The recovery rate of the sensory nerve function is 100%(23/23) in Group A, 75%(6/8) in Group B, and 0%(0/11) in Group C respectively.
  The recovery rate of the motor nerve function is 26%(6/23) in group A, 0%(0/8) in Group B, and 0%(0/11) in Group C.
Regarding the sensory function, there is no statistically difference between group A and B, however, group C is statistically lower than these two groups.
  Regarding the motor function, group A is statistically higher than group B and C. And there is no statistically difference between group B and C.
  Trough our data, we revealed that the sensory nerve is predominantly distributed at the lower (dorsal) half of the pelvic nerve networks, in contrast, the motor nerve is predominantly distributed at the upper (ventral) half.
Conclusion: Depends on the risk of the cervical cancer, the bladder function after the laparoscopic radical hysterectomy can be controlled flexibly.

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Objective: The adoption of laparoscopic surgery to treat gynecological cancer has been very slow in Japan despite the merits of this procedure, including shorter hospital stays, reduced postoperative pain and earlier resumption of activity. We analyzed the safety and feasibility of performing laparoscopic pelvic lymphadenectomy for early-stage endometrial cancer.
Methods: Between June and December 2010, we performed laparoscopic pelvic lymphadenectomy in five patients with grade 1 or 2 endometrioid adenocarcinoma confirmed on pathological specimens collected via hysteroscopy and endometrial curettage and expected stage 1A disease based on MRI and CT scans. We analyzed the rates of intraoperative and postoperative complications, operative time, amount of bleeding, number of lymph nodes and pathological findings.
Results: We experienced no cases of intraoperative or postoperative complications. The average operative time was 259 minutes (4 hours and 19 minutes), the average amount of blood loss was 159 g and the average number of lymph nodes was 18.2. All cases were confirmed to be endometrioid adenocarcinoma of G1 or G2 with myometrial invasion < 1/2 on pathological examination.
Conclusions: We performed laparoscopic lymphadenectomy in five cases of early-stage endometrial cancer without complications. The results suggest the safety and feasibility of performing laparoscopic lymphadenectomy in patients with early-stage endometrioid adenocarcinoma of G1 or G2.

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Objective: Endometrial polyp is defined as an endometrial hyperplastic tumor, usually found in young and sometimes in peri-menopausal women, which can induce conditions such as abortions, irregular bleeding, and irregular periods due to hormonal instability. 'Dienogest' is a synthetic progestin which exerts a suppressive effect on follicular and ovarian functions. Due to its effects, endometrial cells become smaller and atrophic. For the purpose of achieving complete polypectomy, we administered this medication for preparation of the uterine cavity prior to hysteroscopic resection.
Designs and Methods: We report herein 14 women with uterine cavity tumors. All 14 women gave informed consent prior to treatment with dienogest, starting at the nearest menstrual period before surgery. The women took 2 mg of dienogest orally starting the first day of the last menstrual period, continuously until the day before surgery. We observed the entire endometrium in the uterine cavity and the endoscopically-detected polyp was removed. We compared women who received dienogest with non-treated women.
Results: We endoscopically identified a polyp due to atrophy of the surrounding endometrium, facilitating accurate resection of endometrial polypoid tissues. Furthermore, we were able to identify other small endometrial polyp, which could also be resected.
Conclusion: By using dienogest preoperatively, we confirmed that a better visual field can be endoscopically acquired in the uterine cavity than in non-treated women. Furthermore, endometrial polypoid tissues can be accurately and easily resected, confirming that dienogest enhances operative quality. Preoperative dienogest administration is useful for hysteroscopic resection of endometrial polyps.

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Objective: To determine the efficacy of a mechanical pump (Hydroflex irrigation system) for preventing fluid overload in hysteroscopic surgery.
Design: Retrospective study
Patients: A total of 74 patients who had undergone hysteroscopic surgery.
Intervention: We compared the surgical outcomes between the three groups (Group A: monopolar electrodes using sorbitol as irrigant and fluid is delivered to the resectoscope by means of gravity; Group B: bipolar electrodes using saline as an irrigant and adjustment of fluid pressure with pressure cuffs; Group C: bipolar electrodes using saline as an irrigant and adjustment of fluid pressure with mechanical pumps.)
Main outcome measures: surgery time, amount of fluid consumption, myoma size, and complications.
Results: There were no significant differences in surgery time and serum sodium levels between the three groups. Compared to Group A, fluid consumption and the diameter of the resected myomas were significantly larger in Group B and Group C. The complication rate of fluid overload was significantly higher in Group B.
Conclusions: In hysteroscopic surgery, intrauterine pressure must be appropriately controlled to maintain a balance between excessive pressure, inadequate pressure, increased intravasation, and reduced visibility. Mechanical pumps appears to be useful and convenient for the prevention of fluid overload.

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  Due to vaginal narrowing or cervical atrophy, it is sometimes difficult to safely perform conization in menopausal women. Total hysterectomy is recommended in patients with positive conization margins or cervical intraepithelial neoplasia who do not desire children. In such patients, we performed total laparoscopic hysterectomy (TLH) following approval from the Ethics Committee of our hospital.
  Nine patients underwent TLH between June 2010 and March 2012. TLH was performed using four trocars placed in a diamond configuration in the same manner as that for benign diseases. In principle, we did not use uterine manipulators, and lifted the uterus with a 2-0 nylon thread using a straight needle. When separating the bladder from the uterine cervix, a vaginal pipe was inserted. The ureter and uterine artery were identified first, and then the latter was ligated and cut. Total hysterectomy was performed with the extrafascial technique. None of the patients required conversion from laparoscopic to open abdominal hysterectomy, or underwent re-surgery due to complications, and all of them were discharged on the fifth postoperative day. Unlike when performing total hysterectomy for fibroids or adenomyosis, surgery is performed without the insertion of manipulators; therefore, we need to exercise some ingenuity to lift the uterus. Although TLH poses some problems in post-conization patients, such as "the site of incision is difficult to see even if a vaginal pipe is inserted," it can be performed with some ingenuity.

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  Laparoscopy has been widely proposed as an alternative to a laparotomy for the treatment of early stage endometrial cancer. The purpose of this study was to assess the efficacy, safety, and prognosis of laparoscopic surgery. We retrospectively analyzed the results of laparoscopic surgery for patients with early stage endometrial cancer at the Department of Obstetrics and Gynecology, Niigata University Medical & Dental Hospital between 2003 and 2011. A total of 44 patients underwent laparoscopic surgery by three different surgeons. Blood loss and number of lymph nodes removed were not statistically significant between surgeons. Although a significant difference in surgery time (P = 0.0017) was initially observed between surgeons, this difference became insignificant as the surgeons gained experience. With increasing surgeons' experience, laparoscopic surgery is useful for the treatment of early stage endometrial cancer.

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Objective: To evaluate the management of young women with endometriosis after conservative laparoscopic surgery.
Design: Retrospective study.
Setting: Department of Obstetrics and Gynecology, Kochi Medical School.
Patients: Sixty-four women aged < 30 years, diagnosed and treated for endometriosis by laparoscopic surgery.
Interventions: Laparoscopic evaluation and treatment of endometriosis.
Main outcome measures: Background of 64 women with endometriosis who were less than 30 years old: (1) Recurrence rate (RR) of pelvic pain associated endometriosis in 62 women had pelvic pain before laparoscopic surgery; (2) Recurrence rate (RR) of ovarian endometriomas in 42 women who underwent laparoscopic excision or ablation of ovarian endometriomas. Furthermore, fertility prognosis for 14 women who desired a pregnancy was assessed.
Results: The median age was 25.2 years (range: 16-29 years); the median duration of postoperative follow-up was 3.3 years (range: 1-152 months) surgery. Nineteen women (30%) were categorized at rASRM stageI-II, and 45 women (70%) were at stage III-IV. After surgery, 34 women underwent medical therapy for the prevention of endometriosis recurrence; 23 were administered a GnRH agonist, and 11 received oral contraceptives (OCs). RR of pelvic pain was 16%, and RR of an ovarian endometrioma was 24%. None of the women who received OCs experienced a recurrence. In 14 women who were desirous of pregnancy, 10 achieved a spontaneous pregnancy within two years of marriage.
Conclusions: The results suggested that postoperative medical treatment with OCs prevents the recurrence of endometriosis and pelvic pain in young women; the therapy also prevents the formation of ovarian endometriomas. In addition, laparoscopic surgery for endometriosis did not impair the fertility of young women with endometriosis.

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Objective: The objectives of this study were: (1) to compare intimal thickening with hysteroscopic findings as well as hysteroscopic and pathological findings observed in menopausal patients; and (2) confirmation of the usefulness of endometrial curettage in combination with hysteroscopy.
Methods: During a three year period from January 2008 through December 2010 at Kizawa memorial hospital, 42 patients in whom intimal thickening was accurately measured by transvaginal ultrasound (TVS) were included in this study. The hysteroscopic findings, degree of intimal thickening, and results of histopathological examination of these cases were retrospectively studied. Hysteroscopic findings, based on gross findings, were classified into five types: polyp-shaped thickening, uterine myomas, thickening without atypical blood vessels, thickening with atypical blood vessels, and atrophy.
Results: The mean age of the 42 women was 58.2±5.8 years, and the mean age of menopause was 50.2±4.6 years. The mean endometrial thickness before surgery was 8.9±3.7 mm. The most common pathologic finding was endometrial polyps (22/42; 52%). When hysteroscopic findings revealed that the thickening was polyp-shaped, pathological findings also revealed endometrial polyps in 19/23 (83%). Endometrial hyperplasia was found in 5/42 (12%). Endometrial cancer was observed in 2/42 (5%). In all cases, the endometrial polyps were resectable by combined hysteroscopy. In this study, postmenopausal bleeding occurred in 10/42 (24%); 3/5 (60%) had endometrial hyperplasia, and 2/2 (100%) had endometrial cancer.
Conclusions: Curettage combined with hysteroscopy allows for accurate diagnosis and treatment and is particularly valuable for evaluation of postmenopausal bleeding.

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