Introduction: Recently, the electric morcellator has become commonly employed during a laparoscopic myomectomy (LM). However, reports of the complication of parasitic myomas have also increased. We compared two different LM extraction methods to evaluate their applicability.
Methods: A retrospective study was conducted on 18 women who underwent LM at our hospital from August 2012 through April 2013. We conducted a statistical analysis between the two groups: culdotomy group (n = 8) and morcellator group (n = 10). The differences were statistically significant (P < 0.05).
Results: No significant difference in surgery time, blood, or number of enucleated myomas was found between the two groups. Compared to the morcellator group, the patient age of the culdotomy group was significantly younger (38 vs. 41.5 years; P = 0.016), tumor gross weight of the culdotomy group was less (162 g vs. 340 g; P = 0.011), and the tumor maximum diameter of the culdotomy group was less (61mm vs. 90 mm; P = 0.001). The cutoff value in the ROC curve showed that the tendency to use the morcellator increased for myomas ≥ 7cm.
Conclusion: It is important to evaluate the distensibility of the vaginal wall and maximum tumor diameter prior to laparoscopic myomectomy in order to select the most appropriate method for myoma extraction.

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Objective: We aimed to clarify the trends in outcomes of various types of hysterectomy in our hospital. We also assessed the factors that influenced operating time and intraoperative blood loss in patients who underwent hysterectomy.
Design: We conducted a retrospective study and evaluated a total of 293 patients who underwent abdominal or laparoscopic hysterectomy between 2008 and 2013.
Main Outcome and Measure(s): We measured operating time, intraoperative blood loss, uterine weight, and surgical complications.
Result(s): The proportion of total laparoscopic hysterectomy (TLH) performed has been increasing in recent years. In 2013, TLH accounted for 72.9% of all cases of hysterectomy in our facility. Fourteen of 152 patients (9.2%) in our study who underwent laparoscopic surgery required conversion to laparotomy. Median operating time in TLH was significantly longer than in laparoscopically assisted vaginal hysterectomy (LAVH) and abdominal total hysterectomy (ATH). Median intraoperative blood loss was significantly lower in TLH than in LAVH and ATH. Median weight of the uterus removed by ATH was greater than that removed by LAVH and TLH. In laparoscopic hysterectomy, there was a positive correlation between uterine weight and operating time. Intraoperative complications occurred in two LAVH patients and in four TLH patients. Postoperative complications in the TLH group included two cases of uretero-vaginal fistula and one case of hematoma of the vaginal cuff. Postoperative complications occurred in four cases in the ATH group.
Conclusion(s): Our clinical proficiency with TLH is increasing, and we believe that continued experience and technical improvements in laparoscopic hysterectomy will lead to improved safety and effectiveness of the procedure.

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Background: Preoperative factors were retrospectively analyzed to distinguish malignant transformation (MT) in mature cystic teratoma (MCT) of the ovary.
Methods: Subjects were 73 patients with MCT and 4 patients with MT who underwent surgery from January 2010 to March 2013.
Results: Patients with MT had a median age of 68.5 years, significantly older than patients with MCT who had a median age of 34.0 years. All of the patients with MT (100%) had a tumor 10 cm across or larger while 12 (16%) patients with MCT did. Most patients with MT (75.0%) had an squamous cell carcinoma（SCC） antigen level of 2.5 ng/mL or higher while few (6.7%) patients with MCT did. Most patients with MT (75.0%) had a Carcinoembryonic antigen (CEA) level at or above the cutoff (5.0 mg/mL) significantly higher than the few (3.2%) patients with MCT. In a pelvic MRI, most patients with MT (75%) had a tumor with contrast-enhanced solid portions significantly more than the few (9.5%) patients with MCT.
had a tumor with contrast-enhanced solid part.
Discussion: Most patients with MT were 60 years of age or older and had a tumor 10 cm or larger, a serum SCC antigen level of 2.5 ng/mL or greater, a serum CEA level of 5.0 mg/mL or greater, and a tumor with solid portions that were contrast-enhanced. Laparoscopyic findings should be considered in cases where the aforementioned factors are not present.

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  Laparoscopic surgery results in less postoperative adhesions than a laparotomy, and the adhesion barrier (Seprafilm^®) is used for reducing adhesion formation. Seprafilm^®, a bioresorbable membrane of sodium hyaluronate and carboxymethylcellulose, is effective for adhesion prevention; however, its properties make it difficult to insert into the abdominal cavity and place it at the target area in laparoscopic surgeries. We report a new technique to introduce Seprafilm^® for laparoscopic surgeries by using surgical glove fingers. Seprafilm^® was cut into 4 x 2.4 cm segments and both surfaces were moistened with wet gauze. The films were rolled for placement in the surgical glove fingers and then the glove fingers were inserted into the abdominal cavity through a 12-mm trocar. The Seprafilm^® was then unrolled and placed on the target area after removing it from the glove. Eighty-seven of 96 segments of Seprafilm^® were successfully used in 16 patients who underwent total laparoscopic hysterectomy. This method can provide the use of Seprafilm^® for laparoscopic surgeries at low cost.

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  Gynecologic robotic surgery in the U.S. has spread rapidly; it is more advantageous than conventional laparoscopic surgery in many respects. To date, approximately 250 patients have undergone robotic surgery in our department. With robotic surgery, we instill gas into the abdominal cavity in a similar manner to that of laparoscopic surgery in order to secure space for visualization. Carbon dioxide (CO₂) is usually used for laparoscopic and robotic surgery because it is relatively inexpensive, colorlessness, unscented, non-flammable, and is cleared from the body immediately. However, intraabdominal pressure often becomes unstable when we exchange surgical instruments, suction ascites, or extract vapor. Furthermore, CO₂ can cause major complications such as an air embolus, or acidemia. Recently, we employed the AIRSEAL^® System. This System can reduce CO₂ consumption and also maintain stable intra-abdominal pressure during surgery even when we exchange surgical instruments, suction ascites, or extract vapor. In this paper, we demonstrate the efficacy of this new system. The AIRSEAL^® System is extremely useful because it possesses the ability to reduce stress among the surgeons and assistants.

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Objective: A laparoscopic myomectomy (LM) is sometimes repeated because of residual or recurring myomas. The purpose of this study was to examine the characteristics of the cases of repeat LM retrospectively.
Materials and methods: The clinical data of 19 women undergoing a repeat LM among 1,707 cases of LM from January 2005 through August 2012 in our hospital were analyzed. All myomas were diagnosed with a MRI, and LM was performed via the pneumoperitoneum method.
Results: Ten patients (52.9%) were pretreated with a gonadotropin releasing hormone agonist. The average duration between the first and second LMs was 34.2 months (range: 2 to 76 months). The average number of enucleated myomas was 6.1 (range: 1-22) in the first operation and 7.0 (range: 1-23) in the second procedure. In 12 cases, the myomas were almost completely enucleated; however, small remnants may have remained. In contrast, in the other seven cases, we determined that residual myomas resulted in the repeat LM. The main reasons for the residual myomas were: 1) status several myomas in close proximity; 2) myomas not well visualized; and 3) degenerative myomas, which were difficult to discriminate from normal myometrium.
Conclusions: The primary reason for a repeat LM was the unavoidable recurrence of myoma; however, residual myomas were the indication for the reoperation in conditions such as 'myoma complex' and 'degenerative myoma'. In those cases, meticulous surgical technique should reduce the need for a repeat LM.

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Case: The patient, 35-year-old primipara, was brought to our hospital by ambulance with lower abdominal pain. Under a diagnosis of ectopic pregnancy-related rupture of the left fallopian tube, laparoscopic left salpingectomy was performed on the same day. During surgery, 1,000 mL of blood was aspirated but large clots remained. The course was favorable, and the patient was discharged 7 days after surgery. However, she was brought to our hospital by ambulance with lower abdominal pain 19 days after surgery. Under a diagnosis of infection related to hematoma remaining in the abdominal cavity, an antimicrobial agent was administered, but 39°C or higher persisted. Pelvic CT revealed an abscess with enhancement of the capsule in the left lower abdomen. CT-guided drainage of the bloody abscess was performed 20 days after surgery. Pyretolysis was achieved the following day, and the patient was discharged.
Discussion: Percutaneous abscess drainage is routinely performed under ultrasonic guidance. On the other hand, CT-guided approach could facilitate selection of sites in which drainage ismore safely and effectively conducted. The use of an aspirating tube or closing drain with a large diameter during laparoscopic surgery may reduce the risk of infection. For laparoscopic surgery for ectopic pregnancy-related rupture, techniques regarding the management of massive clots in the abdominal cavity must be devised. Furthermore, CT-guided drainage of abscess formation may be an effective treatment method.

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Objective: To describe the procedure of two sites laparoscopy using EZ access (EZ access 2-port) and EZ access 2-port using 3 mm port and devices (EZ access 2-port-3 mm), and present the usefulness of these reduced port surgeries.
Subjects: From April 2008 through December 2013, we performed 278 cases of EZ access 2-port, 51 cases of EZ access 2-port 3 mm, 52 cases of single site laparoscopy (SSL), and 246 cases of conventional laparoscopy (4-port).
Methods: We conducted a retrospective analysis of the following: (1A) a comparative analysis of operative time between SSL and EZ access 2-port for resection of an ovarian tumor: (1B, 1C) a comparative analysis of surgery time and weight of the uterine myomas between conventional laparoscopy and EZ access 2-port on myomectomy: and (1D, 1E) a comparative analysis of operative time and uterine weight between conventional laparoscopy and EZ access 2-port on hysterectomy.
In addition, we evaluated: (2A) a comparative analysis of operative time between EZ access 2-port and EZ access 2-port-3 mm on resection of the ovarian tumor: and (2B, 2C) a comparative analysis of operative time and weight of the uterus between EZ access 2-port and EZ access 2-port-3 mm for a hysterectomy.
Results: In 1A, there was a significant difference (P = 0.0033) in operative time between SSL and EZ access 2-port for resection of an ovarian tumor. The surgery time of EZ access 2-port was shorter than that of SSL. In 1B and 1C, there was no significant difference in surgery time and weight of the uterine myomas between conventional laparoscopy and EZ access 2-port on myomectomy. In 1D and 1E, there was a significant difference (P = 0.000003) in surgery time between conventional laparoscopy and EZ access 2-port on hysterectomy. The surgery time of EZ access 2-port was shorter than that of conventional laparoscopy. There was no significant difference in uterine weight between conventional laparoscopy and EZ access 2-port on hysterectomy.
In 2A, there was no significant difference in operative time between EZ access 2-port and EZ access 2-port-3 mm for resection of an ovarian tumor. In 2B and 2C, there was no significant difference in operative time and uterine weigh between EZ access 2-port and EZ access 2-port-3 mm for a hysterectomy.
Conclusions: EZ access 2-port is an extremely useful method of reduced port surgery. The operative time of EZ access 2-port was shorter than that of SSL. The operative quality of EZ access 2-port compared to conventional laparoscopy was maintained. EZ access 2-port-3 mm is less invasive surgery; thus, we favor reduced port surgery via selection of these reduced port procedures.

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Objectives: To evaluate the reproductive outcomes of infertile patients who underwent laparoscopic surgery for hydrosalpinx and to propose a guideline for repeated assisted reproductive technology (ART) failures in patients with hydrosalpinx.
Design: Retrospective analysis.
Setting: The Gynecologic Laparoscopic Surgery Group of Kurashiki Medical Center and IVF Center at the Kurashiki Medical Clinic.
Patient(s): The study included 31 infertile patients with bilateral tubal obstruction who were treated from January 2010 to October 2013. Nine of these patients underwent laparoscopic surgery because of repeated pregnancy failures after ART. We suggested the clinical records of patients who immediately conceived after surgery.
Intervention(s): Laparoscopic salpingectomy and salpingostomy.
Main Outcome Measure(s): Pregnancy after surgery.
Result(s): Among the patients with severe hydrosalpinx who underwent salpingectomy, there were 4 patients with a hydrosalpinx diameter > 25 mm and 3 patients with a hydrosalpinx diameter < 25 mm. All the patients undergoing salpingostomy had fallopian tubes that were undetectable on ultrasound scanning (USS). The reason for repeated failure of ART for the patients undergoing salpingectomy was disordered implantation of good-quality embryos, while for the patients undergoing salpingostomy, there was 1 case of disordered implantation of good-quality embryos and 1 case with inadequate embryos. [Case 1] A 35-year-old nulliparous woman had severe hydrosalpinx that was diagnosed as swelling of the oviduct on hysterosalpingography (HSG), vaginal USS, and magnetic resonance imaging (MRI). The patient repeatedly failed to conceive, despite the transfer of high-quality blastcysts. After laparoscopic salpingectomy was performed, successful implantation was achieved with the first blastcyst transfer. [Case 2] A 26-year-old nulliparous woman repeatedly failed to conceive after ART. High-quality blastcysts were not obtained during 3 ART cycles. The patient was diagnosed with mild hydrosalpinx because the fallopian tubes were only visible on HSG but not on USS or MRI. Laparoscopic salpingostomy was performed. The patient conceived spontaneously 2 months after surgery.
Conclusion(s): The therapeutic strategies for patients with hydrosalpinx and failure to conceive after repeated ART should be based on both the severity of hydrosalpinx and the type of ART failures.

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Objective: To determine the present status of morcellation during a laparoscopic myomectomy via a multicenter questionnaire.
Design: Postal questionnaire survey.
Setting: 180 member hospitals of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE).
Patients: None
Interventions: None.
Main outcome measures: Common clinical practices.
Results: In order to determine the safest procedure, the author submitted a multicenter questionnaire to gynecologic laparoscopists who were certified by the JSGOE. We received 107 completed surveys (60% response rate). Some differences were found between electric morcellation and extraction via an incision in the posterior vaginal fornix. Difficulties were encountered with electrical morcellation in regard to the size and hardness of the leiomyomas; in addition, the cost of the device was a factor. When difficulty is encountered with electrical morcellation, the surgeon should consider conversion to a laparoscopic assisted myomectomy, crushing with an ultrasonic incision apparatus, use of a scalpel, and extraction from the vaginal fornix or abdominal incision. Rare complications associated with either approach were reported, including bladder and bowel injury. Maintaining an adequate field of view and an appropriate position of the morcellator to avoid squeezing it into the abdominal cavity is important.
Conclusions: The result of the questionnaire revealed that methods are available that can reduce complications with a laparoscopic myomectomy; these methods evolve with the surgeon's experience. This paper might aid laparoscopists in the development of appropriate methods for morcellation during a laparoscopic myomectomy; thus, increasing the safety of the procedure.

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  For increasing the degree of minimally invasive therapy, reduction of the number of ports has been performed. A number of advantages have been proposed, including the cosmetic result, less incisional pain, and the ability to convert to a standard multiport laparoscopic surgery if necessary. However, the procedure has an increased level of technical difficulty because the distance between the ports is significantly less than with the conventional multiport laparoscopic procedure. Therefore, various surgical techniques and an exclusive platform have been developed. We compared the homemade glove method (glove method) with three commercial items. We reviewed 32 cases of single port laparoscopic surgery performed from April 2012 through August 2013 in our hospital Four methods, SILS™ Port, GelPOINT, EZ access, and the glove method, were compared. The size of the wound, setup time, surgery time, amount of intraoperative bleeding, and cost were assessed. The forceps and scissors that we used, were the conventional straight type. There was no significant difference between the four methods in regard to the size of wound, setup time, surgery time, or the amount of intraoperative bleeding. We found that the glove method was the most useful of the four methods because of its flexibility of trocar use. The glove method and the EZ access method are cheaper than the other two. In single port laparoscopic surgery using straight forceps, we concluded that the glove method is superior to the other three; therefore, we have we adopted the glove method as the method of choice. We plan to accumulate additional cases, devise procedures, and consider expansion of its adaptation.

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Introduction: Borderline ovarian tumors (BOTs) account for 10-20% of ovarian epithelial tumors. Despite its moderate incidence and increase in laparoscopic surgery, the literature contains scant reports regarding the laparoscopic management of these tumors. This may be due to the difficulty in making a preoperative diagnosis.
Objectives and methods: This study was focused on investigating the characteristics of laparoscopic surgery for a BOT. We retrospectively reviewed the medical charts of 32 patients who were pathologically diagnosed with a BOT from April 2009 through March 2013. We compared age and observation period, tumor size, surgery time, amount of bleeding, length of hospital stay, frozen section, intraoperative tumor rupture, emergency surgery, fertility surgery, clinical stage, recurrence, and recurrence-free-survival (RFS) between 19 patients who underwent laparoscopy and 13 patients who underwent a laparotomy.
Results: The laparoscopic group had shorter hospital stays (4 days (range: 2-13) vs. 7 days (range: 6-19); P < 0.01), less frequent frozen section (2/19 (11%) vs. 7/13 (54%); P = 0.011), more frequent rupture (12/19 (63%) vs. 2/13 (15%; P = 0.009), fertility sparing surgery (13/19 (68%) vs. 1/13 (8%); P = 0.008) .
Conclusions: Laparoscopic surgery for a BOT should be performed with meticulous care in order to avoid rupture. However, laparoscopic surgery for a BOT appears to be safe since no significant difference in RFS between the two groups was found.

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Objective: To investigate the feasibility of a total laparoscopic hysterectomy (TLH) for large uteri weighting over 500 g.
Design: Retrospective analysis.
Setting: Department of Obstetrics and Gynecology, Fukui Red Cross Hospital, Japan.
Patients: A total of 156 women who underwent a TLH from 2009 through 2014 for symptomatic uterine leiomyomas and/or adenomyosis at our institution were divided into two groups based on uterine weight: > 500 g (Group A; n = 32) and < 500 g (Group B; n = 124). Outcome measures were evaluated by comparison of the two groups in regard to patient characteristics, surgical outcomes, rates of conversion to laparotomy, and complications.
Results: Intraoperative blood loss and surgery time were significantly greater in Group A than Group B (blood loss: 325 ± 550 ml vs. 123 ± 175 ml; surgery time: 246 ± 50 min vs. 183 ± 44 min; P < 0.05). Rate of conversion to laparotomy was significantly higher in group A than Group B (9.4% vs. 0.8%; P < 0.05). There were no significant differences in the incidence of total postoperative complications (9.4% vs. 5.6%) or major postoperative complications that required further treatment (3.1% vs. 3.2%).
Conclusions: Despite the increased intraoperative blood loss, surgery time, and rate of conversion to laparotomy, a TLH for a large uterus (> 500 g) can be performed without an increased risk of post-operative complications. However, surgeons have to be proficient with specific surgical approaches for a large uterus and be aware of the potential risk of conversion to laparotomy.

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Objectives: Colposuspension after a hysterectomy is essential for patients with pelvic organ prolapse (POP). Shull's method is one of the most popular transvaginal colposuspension methods. It uses the uterosacral ligaments and has been reported to be a superior procedure. However, sometimes it is difficult to identify the ligaments in POP patients; thus, increasing the risk of recurrence. In addition, the uterosacral ligaments are very close to the ureters; thus, there is a risk of ureteral injury during the procedure. We report a novel laparoscopic colposuspension procedure, which reduces the risk of recurrences and ureteral injury.
Material and methods: From July 2013 to April 2014, POP patients with Delancey level 1 injury who underwent a laparoscopic Shull's colposuspension were enrolled in this study. The operative procedure was as follows. The uterosacral ligaments were detected before hysterectomy and separated from the ureters. After the hysterectomy, three sutures were placed between the vaginal cuff and the uterosacral ligaments bilaterally. The pouch of Douglas was closed with a continuous retroperitoneal suture.
Results: The study group comprised 59 patients. The average patient age was 68 years (range: 49-80 years), the average surgery time was 146 minutes (75-252 minutes), the average blood loss was 83 ml (range: 10-500 ml). The only complication was one bladder injury (2%). No recurrences had occurred at postoperative month 3.
Conclusions: A laparoscopic uterosarcal ligament colposuspension was found to reduce the risk of the recurrence, ureteral injuries, and surgical site infections; in addition, it avoids the use of mesh usage. This colposuspension method appears to be one of the most useful methods for POP patients.

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  A gastrointestinal stromal tumor (GIST) is the most common type of mesenchymal tumor of the gastrointestinal tract. A GIST often presents with an extra-intestinal growth pattern or peritoneal dissemination. It requires a differential diagnosis that includes malignant gynecologic tumors; however, ovarian metastasis of a GIST is extremely rare. We are reporting a case of a GIST metastatic to the ovary, diagnosed with laparoscopic surgery, which required differentiating from a malignant ovarian tumor. The patient was a 59-year-old woman referred to our department for a detailed evaluation of a left ovarian mass. She had a history of an intestinal GIST at the age of 56, which was completely excised. Three years after the operation, a chest-abdominal computed tomography imaged a left ovarian mass and multiple nodules in the mesentery, greater omentum, and the right lung. Because a GIST seldom metastasizes to the ovary, a diagnostic laparoscopy to differentiate from primary malignant ovarian tumors was performed. A left salpingo-oophorectomy and a biopsy of a peritoneal tumor was performed; the histopathologic diagnosis was a GIST metastatic to the left ovary with peritoneal dissemination. Consequently, the patient underwent molecular targeted therapy. The possibility of a mesenchymal tumor of the gastrointestinal tract such as a GIST should be considered in the differential diagnosis of a pelvic mass. Less invasive laparoscopic surgery facilitates intraperitoneal excision of the tumor and a histological diagnosis. Laparoscopic surgery can be useful for making a definitive diagnosis and treating malignant tumors.

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Introduction: Chylous ascites due to lymphorrhea following a para-aortic lymphadenectomy is a rare complication. Chylous ascites usually resolves spontaneously; however, some cases of intractable chylous ascites persist despite fasting therapy or a low fat diet. We report a case of intractable chylous ascites that was resolved via laparoscopic surgery.
Case: A patient with uterine corpus cancer underwent a modified radical hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy. Although the surgical drainage was significant postoperatively, the patient's postoperative status was good. Therefore, she was discharged two weeks after the surgery. However, one week later, she presented at the hospital with the chief complaint of abdominal distension. An ultrasound examination revealed a large amount of ascites. Chylous ascites was determined with a paracentesis. The ascites was temporarily controlled by octoreotide acetate administration for nine days; however, she experienced a recurrence of chylous ascites two weeks later. Therefore we decided upon a laparoscopic procedure. We discovered leakage between the duodenum and the left renal vein. We could not separate and ligate the leaking duct. Therefore we selected to apply fibrin adhesive spray occlusion to the leakage area. Subsequently, the ascites gradually resolved. No recurrence occurred by 12 months after the surgery.
Conclusion: If chylous ascites does not resolve spontaneously, laparoscopic surgery may prove effective for resolution of the ascites.

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  A low grade endometrial stromal sarcoma (LGESS) is characterized by slow progression and late recurrence; therefore, it is important to manage recurrent disease with surgery and progestin therapy. We report a case treated by laparoscopic surgery for pelvic disseminations of a LGESS. A 49-year-old woman underwent a vaginal hysterectomy for uterine fibroids seven years ago; it was pathologically diagnosed as a LGESS postoperatively. She refused both a re-operation, including bilateral salpingo-oophorectomy, and adjuvant hormone therapy. Almost seven years after the surgery, she underwent video-assisted thoracic surgery (VATS) on two occasion for excision of multiple pulmonary nodules; she also received high dose medroxyprogesterone acetate therapy (600 mg/day). Subsequently, new metastatic pulmonary nodules and pelvic cystic masses, which were suspicious for metastatic disease of the ovaries appeared. We strongly recommended surgery. At surgery, both ovaries had a normal appearance; however, there were several disseminated nodules near the vaginal stump. All these tumors did not deeply invade the intraperitoneal space; therefore, we could readily and completely remove them without any intra-operation adverse events. Postoperative histology revealed recurrence of a LGESS to the pelvis and both adnexa. Presently at approximately postoperative 12 months, no postoperative complication has been reported with the remaining lung nodule showing a decreasing tendency. We conclude that complete surgical excision has a potent effect on LGESS, even for recurrent tumors. Furthermore, laparoscopic surgery is recommended because it is a less invasive procedure with a lower risk of postoperative complications.

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  Laparoscopic surgery for gynecological tumors is a common procedure performed in Japan. The performance of a total laparoscopic hysterectomy (TLH) has been increasing at many hospitals in recent years; furthermore, operative techniques are developed independently at each facility. Ureteral injury is a common TLH complication. Some studies have reported that ureteral injury is up to 35 times more common in a TLH, compared to a conventional abdominal or vaginal hysterectomy. Surgeons should strive for prevention of ureteral injury during a TLH. Routine use of a ureteral stent is performed before TLH at our hospital. It is among the most useful methods for prevention of a ureteral injury.
  We use a ureteral stent for all cases of TLH. Unfortunately, we experienced one case among 125 TLH cases in which a ureteral injury occurred. The patient was a 47-year-old woman who underwent a TLH because of hypermenorrhea due to multiple myomas. We report the course of the case and describe the cause of the injury.

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Introduction: A parasitic myomas is defined as a pedunculated subserosal myoma, which is completely separate from the uterus, and receives its blood supply from other organs. The incidence of iatrogenic parasitic myomas has been increasing over the past decade; the cause is due to the implantation of excised uterine myoma fragments in the peritoneal cavity. We report a case of a parasitic myoma that developed after a laparoscopic myomectomy performed with an electric morcellator.
Case: A 47-year-old, gravida 0, who had a previous history of a laparoscopic myomectomy performed with an electric morcellator nine years ago, was referred to our hospital; her chief complaint was hypermenorrhea and she was found to have multiple myomas and a right ovarian cyst. Magnetic resonance imaging revealed a uterus comparable in size to that of a newborn head and multiple myomas. No other abnormal intraperitoneal masses were detected. She underwent a total abdominal hysterectomy and right salpingo-oophorectomy. Unexpectedly, four round and smooth masses, which were completely separate from uterus, were detected on the rectum and the sigmoid colon. The largest one (3 cm in diameter) was fed by small vessels from the sigmoid colon. These fibroid tumors were completely excised. Based on the intraoperative findings, parasitic myomas were suspected. The histopathologic findings confirmed leiomyomas.
Conclusions: We report a case of parasitic myomas that were discovered nine years after a laparoscopic myomectomy. Surgeons must be aware of the potential of development of iatrogenic parasitic myomas. Thus, meticulous attention should be paid to complete removal of fragments from excised myomas, especially after using an electric morcellator.

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Background: Torsion of the adnexa is one of the common causes of an acute abdomen in women; however, its association with an isolated fallopian tube lesion is uncommon. The clinical presentation is often nonspecific, and when there is a need to preserve fertility, prompt diagnosis and surgical detorsion is essential. We describe a case of fallopian tube torsion accompanied by periappendicitis diagnosed and successfully treated with laparoscopy.
Case: A 41-year-old woman with a prior history of an ovarian pseudocyst treated with laparoscopic surgery presented to our ER with a chief complaint of right lower quadrant abdominal pain of three days duration. The physical examination revealed tenderness and rebound tenderness of the lower abdomen. A CBC revealed signs of inflammation. CT showed mildly enlarged appendix and a multicystic 5 cm pelvic mass. The patient was referred to our department; pelvic examination was not helpful in differentiating whether the pain originated from the adnexa or the appendix. Transvaginal ultrasound detected bilaterally normal ovaries. With the pre-operative diagnosis of appendicitis with a pelvic mass, an emergency laparoscopy was performed. A right hydrosalpinx, twisted 720 degrees was noted. The distal end of the fallopian tube was necrotic and partially ruptured. An adhesion was present between the right tube and the mildly enlarged and reddened appendix. Adhesiolysis, tubal detorsion, salpingectomy, and appendectomy were performed. Her postoperative course was uneventful.
Conclusions: Preoperative diagnosis was difficult because the inflammation had extended to both the fallopian tube and appendix. However, minimally invasive laparoscopy enabled adequate diagnosis and treatment.

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  We report a case of an intrauterine tumor mass caused by an embedded intrauterine device (IUD). The patient was preoperatively diagnosed as a submucous leiomyoma of the uterus and underwent a hysteroscopic myomectomy. We discovered the IUD postoperatively inside the submucous leiomyoma. The patient is a 73 years old gravida 2, para 2. She had a history of hypertension and was on oral medication. She had forgotten that she had undergone an IUD insertion. At her clinic visit, her chief complaint was metrorrhagia. An endometrial polyp was suspected and she was referred to our hospital. A transvaginal ultrasound examination imaged a tumor-like lesion in the uterine cavity with both hypoechoic and hyperechoic areas. Magnetic resonance imaging (MRI) showed a well-circumscribed tumor with focal high signal intensity in T2 weighted images. Both the cervical and endometrial cytology were negative at her previous clinical examination. We performed an outpatient hysteroscopy and found a pedunculated mass at the uterine fundus. The preoperative diagnosis was a submucous leiomyoma; she underwent a myomectomy via operative hysteroscopy under general anesthesia. Complete resection of the myoma was performed, and an IUD was discovered inside the resected myoma. She had a benign postoperative course, and no post-myomectomy adhesions developed.

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  During cancer treatment, cryopreservation of oocytes is sometimes performed before administering chemotherapy or radiation therapy, which may affect fertility. In general, controlled ovarian stimulation (COS) is required to collect oocytes; however, ovarian hyperstimulation syndrome(OHSS) may occur in patients with polycystic ovary syndrome (PCOS), which is associated with an increased risk of OHSS. We report a case of a breast cancer patient with PCOS who requested cryopreservation and underwent laparoscopic ovarian drilling (LOD). The patient was 34 years old female with no previous history of pregnancy. Since menarche, she experienced irregular menstrual cycles; after a medical workup, she was diagnosed as PCOS. Four months after her marriage, she was diagnosed with breast cancer in the left breast. Radiation therapy was administered after the patient underwent a partial mastectomy and before administration of chemotherapy. During this Radiation period after mastectomy, about one-and-a-half months , the patient underwent LOD for the treatment of PCOS; we also collected five immature oocytes from the puncture fluid for cryopreservation. Radiation therapy was interrupted for only one day to perform the LOD with reduced port surgery (RPS). After LOD, the patient underwent COS; two mature oocytes were harvested and frozen.
  Although our institution did not perform assisted reproductive technology (ART), we were able to cryopreserve oocytes from the punctured fluid; this was accomplished by collaborating with an institution that specialized in ART. Simultaneous collection of oocytes during LOD is useful for ART including in vitro fertilization (IVF). In addition, the current trend toward reduced port surgery (RPS) can shorten the length of hospital stay. Thus, it is expected that the implementation of LOD will expand in the future.

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  An immature teratoma is a rare ovarian tumor of germ cell origin; it occurs in 1% of malignant ovarian tumors and only 1-2% of ovarian teratomas. The frequency is higher among younger women; however, it is difficult to distinguish from a mature cystic teratoma preoperatively. When a patient suffers an acute abdomen, laparoscopic surgery is a treatment option. We report two cases of an immature teratoma that were diagnosed after laparoscopic surgery for an acute abdomen.
Case 1: A 28-year-old gravida 0 visited a local physician who diagnosed an acute abdomen and a 7 cm ovarian tumor. The patient was referred to our facility. Because CT and MRI indicated a rupture of a left ovarian teratoma, an emergency surgery was performed on the day of admission to remove the left ovarian tumor. Postoperatively, the pathologic diagnosis was an immature teratoma, grade 1, stage I c (a).
Case 2: A 40-year -old gravida 0 presented with the chief complaints of abdominal distension and right lower back pain. Because a 12 cm right ovarian tumor was found, and it was suspected to be a twisted ovarian teratoma, an emergency surgery was performed to excise the ovarian tumor together with the left adnexa, which was twisted 360 degrees. Postoperatively, the pathologic diagnosis was an immature teratoma, grade 1, stage I c (b).
  Eighteen months postoperatively, no evidence of recurrence has been found in either case.

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Objective: To report successful release of ovarian torsion in two cases of ovarian hyperstimulation syndrome (OHSS) by laparoscopic surgery.
Case 1: A 28-year-old woman (gravida 1, para 0) with a second pregnancy confirmed 3 days before presentation was transported to our hospital by the ambulance because of the sudden onset of severe abdominal pain. Her medical history included a first pregnancy terminated by spontaneous abortion, a diagnosis of polycystic ovary syndrome (PCOS) at a nearby hospital, and clomiphene citrate administration to stimulate ovulation. On examination, her right ovary was enlarged and accompanied with ascites. We made a diagnosis of OHSS and suspected ovarian torsion because of the uncontrollable pain. Diagnostic laparoscopy confirmed ovarian torsion; thus, we released the ovary. She achieved spontaneous labor at 40^th week of gestation and delivered a healthy 3350-g baby girl.
Case 2: A 31-year-old woman (gravida 0) diagnosed with PCOS and right-side salpingemphraxis at a nearby clinic, who was planned for in vitro fertilization following a short protocol to induce ovarian stimulation, experienced abdominal distension and consulted us 5 days after egg retrieval. Upon admission to our hospital, we detected enlarged ovaries and ascites and made a diagnosis of OHSS. Because she complained of severe abdominal pain the next day, we suspected ovarian torsion and released the right ovary by laparoscopic surgery.
Conclusions: Ovarian torsion should be detorsioned as soon as possible to preserve ovarian function and reduce the risk of complications. For patients presenting with abrupt abdominal pain, OHSS should be considered and diagnostic laparoscopy should be performed without delay. Furthermore, for such cases before 9 weeks of gestation, luteal supplementation is a valid treatment option.

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  An ovarian carcinoid tumor is extremely rare; the incidence is about 1.3% of all carcinoid tumors. A case of a primary ovarian carcinoid tumor with a mature cystic teratoma diagnosed after laparoscopic surgery is presented. The patient is a 35- year-old gravida 2, para 2 who was diagnosed with a left ovarian tumor during her second pregnancy. Magnetic resonance imaging (MRI) revealed a mature cystic teratoma. In the third postpartum month, she underwent a laparoscopic assisted ovarian cystectomy. The pathological examination revealed that most of the tumor was a mature cystic teratoma, including a small focal lesion of insular carcinoid tumor, which showed a positive reaction with chromogranin- A. Therefore, a laparoscopic left salpingo-oophorectomy was performed. Although the prognosis of this tumor is favorable, careful periodic examinations might be necessary because a small number of cases can recur.

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  A cesarean scar pregnancy (CSP) is one of the most dangerous forms of ectopic pregnancy. We report a case of a 33-year-old gravida 5 para 3 who was referred to our hospital at 6 weeks, 2 days of gestation from another facility with a diagnosis of CSP. A sagittal view of a transvaginal ultrasonogram imaged a gestational sac 32 mm in diameter in the anterior wall of the uterine isthmus, a fetus with a fetal heart beat, and abundant vascular flow around the gestational sac. The serum hCG level was 64,999 IU/l. It increased for a short interval to 125,512 IU/l after the systemic administration of methotrexate (MTX). We performed uterine artery embolization (UAE). Subsequently, the serum hCG level gradually declined, and we identified the disappearance of the fetal heart beat and vascular flow around the gestational sac. After another UAE, we performed a hysteroscopic resection when the serum hCG level declined to < 10,000 IU/l. The serum hCG level showed a negative conversion 60 days after the first MTX administration. During the follow-up period the thickness of the muscular layer of the uterine isthmus became remarkably thin; therefore, we performed a laparoscopic repair of the uterine scar. The patient subsequently achieved a normal pregnant and delivered a live infant at 30 weeks, 0 days of gestation by cesarean section. We stress that it is extremely important to avoid situations such as hemorrhage or rupture during treatment of a CSP. Therefore, we must carefully employ a combination of MTX administration, UAE, and hysteroscopic resection. This case suggests that laparoscopic repair of a uterine scar is a useful procedure, which leads to a better prognosis for future pregnancy, particularly in cases in which the muscular layer is extremely thin. Further study of CSPs is needed.

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  Internal herniation through a fenestra of the broad ligament is very rare, and constitutes 4-7% of all internal herniations. Since common hernia content is small or large intestine, herniation of an ovary through a fenestra of the broad ligament is extremely rare; only 6 cases have been reported. We experienced a case of a broad ligament hernia of a left ovarian endometrioma. A 38 year-old woman was referred to our hospital for evaluation of infertility and an ovarian cyst. Ultrasonography and MRI imaged a lower abdominal cyst, 9.5cm in diameter, at vesicouterine pouch.
  Laparoscopy revealed that the left ovary passed through the defect of the left broad ligament, and an endometrioma was present in the vesicouterine pouch. The right adnexa and right broad ligament were normal. The left ovarian cyst was enucleated and the dislocation of the left ovary was corrected. The fenestra was in the peritoneal defect of the endometriotic lesion, and it was difficult to close the fenestra by suturing due to tension. After electrocoagulation, a tissue-sealing sheet was placed on both sides of the fenestra. Compared to an intestinal hernia through a fenestra of the broad ligament, an ovarian hernia is common in younger women, strongly associated with endometriosis, and is right side dominant; however, it is less associated with parity. A fenestra of the broad ligament is a potential cause of herniation; it is necessary to close the defect if it is observed or produced during surgery.

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Background: Placental polyps can causes massive postpartum hemorrhage. The traditional treatment for a placental polyp is a hysterectomy. However, for patients desirous of a subsequent pregnancy, an alternative treatment option is uterine artery embolization (UAE) and hysteroscopic surgery.
Patients: Case 1 is a 35-year-old Japanese gravida 0, para 0 who had an unremarkable medical and family history. She delivered at another hospital, and was transferred to our hospital because of massive hemorrhage secondary to residual placenta. The residual placenta was completely excised at our hospital. One month later, she was again transferred to our hospital due to recurrent hemorrhage; a placental polyp was imaged by an ultrasound examination. She was strongly desirous of uterine preservation; therefore, she was successfully treated by UAE and hysteroscopic resection of the placental polyp.
Cases 2 through 5 had similar clinical findings as that of Case 1 and were successfully treated by UAE and/or hysteroscopic surgery.
Conclusions: UAE and hysteroscopic surgery is effective for the treatment of a placental polyp. Conversely, some cases of placental polyps spontaneously resolve without any treatment. Therefore, we must recognize that there are many cases of placental polyps that can be treated with uterine preservation, if the general patient status is stable.

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  As increasing surgical procedures for very elderly patients, especially over the age of 85, are performed, maintaining the activity of daily living (ADL) postoperatively is becoming an important issue. We report two cases of very elderly patients who underwent emergency laparoscopic surgery and were discharged without any postoperative complications or ADL decline.
Case 1: A 92-year-old woman who was receiving anticoagulant therapy for chronic atrial fibrillation presented with a chief complaint of persistent abdominal pain. An abdominal MRI revealed a 27×11 cm ovarian tumor. On the third day after admission, the patient developed acute respiratory failure because of compression of the diaphragm caused by a pleural effusion and the ovarian tumor; therefore, the patient underwent emergency laparoscopic surgery.
Case 2: An 89-year-old woman with a history of hypertension who was taking an antiplatelet agent presented at our hospital with a chief complaint of the sudden onset of lower abdominal pain. An abdominal CT scan demonstrated an intra-abdominal tumor and ascites. Rupture of an ovarian tumor was suspected and emergency laparoscopic surgery was performed.
  In both cases, although perioperative intensive care was required, the patients were discharged with a status comparable to their preoperative ADL because of early rehabilitation. Due to the fact that a number of very elderly patients have underlying conditions, appropriate multidisciplinary management of perioperative and postoperative complications are required. If we can apply quality assurance to the performance of minimally invasive laparoscopic surgery, it will facilitate the maintenance of the ADL in very elderly patients.

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  Pelvic organ prolapse (POP) patients present various clinical findings. It is important to diagnose and repair the injured parts of the pelvic floor in each POP patient. The appropriate surgical procedure should be performed for each patient with considering their age, occupation, and life habits. We report a case that presented severe POP with large vaginal mucosal defect and underwent laparoscopic uterosacral colposuspension. She was 75 years old woman, gravid 4, para 1, with severe POP. She complained anuresis and had felt a sense of discomfort soon after the spontaneous delivery 30 years ago. Initially, TVM (tension-free vaginal mesh) operation was planned after curing the vaginal mucosal defect. The ring pessary insertion and estrogen/progesterone administration were performed. Unfortunately, anuresis and pyelonephritis occurred repeatedly and surgical treatment must be given emergently. We performed laparoscopic hysterectomy and vaginal vault suspension by using uterosacral ligaments (Shull's method). The advantages of this operation are low risk of ureter injury, firm colposuspension, completion with basic gynecologic laparoscopy, and no need for mesh. The patient discharged after 7 days after the operation without any complications and no recurrence has confirmed for three months after the operation. This operation will be one of the useful POP procedure.

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Objective: To describe an occult endometrial adenocarcinoma discovered unexpectedly after a vaginal hysterectomy performed for uterine prolapse.
Design: Case report
Patient: a 52-year-old perimenopausal gravida 3, para 3 who presented with symptomatic pelvic organ prolapse.
Intervention: a vaginal hysterectomy performed for uterine prolapse followed by a laparoscopic salpingo-oophorectomy.
Results: The patient was preoperatively diagnosed with uterine prolapse, small myomas, and an endometrial polyp. Preoperative multiple endometrial samplings appeared normal except for the presence of an endometrial polyp. An early stage endometrial adenocarcinoma was discovered unexpectedly after a vaginal hysterectomy for uterine prolapse. Therefore, she underwent a laparoscopic bilateral salpingo-oophorectomy six weeks after the initial procedure. The pathologic findings showed no evidence of residual cancer. Two years postoperatively, there was no evidence of recurrence.
Conclusions: In cases such as this, the patient must be informed of the possibility of recurrent disease when a laparoscopic bilateral salpingo-oophorectomy without the lymphadenectomy is chosen. In addition, the treatment of early stage endometrial adenocarcinoma by a vaginal hysterectomy followed by laparoscopic surgery may be one of the options for carefully selected patients who wish to undergo minimally invasive surgery.

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  A 25-year-old female patient was referred to our hospital because of abdominal pain and an intrapelvic cystic tumor. The cystic lesion was located just under the abdominal wall and the tumor appeared to arise from the left ovary. The patient underwent laparoscopic surgery, which revealed that the tumor was a retroperitoneal cyst. Because the cyst wall was extremely thin, complete excision of the tumor was difficult; thus, laparoscopic fenestration was alternatively performed. A total of 150 mL clear yellow serous fluid was drained; cytology was negative for malignancy. Postoperatively, she conceived and delivered an infant. No recurrence of the tumor was observed. Most retroperitoneal tumors are generally solid and rarely present as a cystic lesion. Complete excision of the tumor is recommended due to the possibility of malignancy. Fenestration of the cyst is also an accepted choice of treatment for cases in which complete excision is difficult and diagnostic imaging studies show no signs of malignancy. Even though retroperitoneal cysts can be safely excised laparoscopically, laparoscopic surgery does not remain a standard treatment for retroperitoneal cysts. Here, we report a case of the retroperitoneal cyst presenting as an intrapelvic cystic tumor. Gynecologists also unexpectedly encounter retroperitoneal cysts because it is difficult to differentiate retroperitoneal cysts from ovarian cysts in some cases. Gynecologists must consider retroperitoneal cysts as a differential diagnosis of intrapelvic cystic tumors and be cognizant of the therapeutic strategies for retroperitoneal cysts.

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  The use of a power morcellator during laparoscopic myomectomy has been reported to be associated with the development of so-called parasitic myomas due to the dissemination and survival of morcellated tissue into the abdominal cavity. The U.S. Food and Drug Administration (FDA) released a safety communication, which stated that the agency discourages the use of a laparoscopic power morcellation during a hysterectomy or myomectomy due to the risk of disseminating unsuspected malignant tissue. Based on this situation, we developed a method to safely use the power morcellator in which tissue fragment dissemination is prevented. A fibroid was separated from the uterus with the use of a retrieval bag, and delivered from the abdominal using a power morcellator under direct vision with the pouch of the retrieval bag fully open. Using this method, no dissemination of tissue fragments was observed. The patient was diagnosed with an apoplectic leiomyoma. This is a rare histological type accompanied by petechial bleeding and the accumulation of infarcts in the fibroid; it differs from the most common type of leiomyoma. This case was diagnosed as a benign tumor; however, malignant uterine tumors cannot be excluded in some cases. Our method is useful not only for the prevention of parasitic tumors, but also when unsuspected malignant uterine tumors are encountered.

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  We examined the clinical usefulness of intratubal vasopressin and methotrexate administration during conservative laparoscopic surgery for tubal pregnancy. A total of 49 patients who underwent conservative laparoscopic surgery for tubal pregnancy from January 2003 through December 2012 were enrolled in the study. All patients who had vasopressin and methotrexate (10 mg) injected into the tubal pregnancy during conservative laparoscopic surgery were treated by either a linear salpingostomy or fimbrial milking evacuation (removal of embryonic tissue alone). In 48 (98%) of 49 patients, the fallopian tubes were preserved by the conservative laparoscopic surgery, which included the intratubal injection of vasopressin and methotrexate. The incidence of persistent ectopic pregnancy was 0 (0%) of 50, and a recurrent ipsilateral tubal pregnancy was observed in 7% of 15 patients who achieved another pregnancy. The intratubal injection of vasopressin and methotrexate during conservative laparoscopic surgery for tubal pregnancy is a safe and more effective regimen for preservation of the fallopian tube as well as prevention of a persistent ectopic pregnancy.

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