Objective: Conservative laparoscopic surgery has been performed for the preservation of fertility. However, this procedure is associated with the disadvantage of persistent chorionic villus (persistent ectopic pregnancy [PEP]). We examined whether PEP could be diagnosed early based on the transition of pre- and postoperative serum human chorionic gonadotropin (hCG) levels and the outcomes of PEP patients.
Methods: The subjects were 265 patients who underwent laparoscopic surgery for tubal pregnancy during the period between April 2005 and March 2014. Their serum hCG values were, in principle, measured before and at 1-2, 3, 7, and 14 days after surgery. We created a standard decay curve using the mean serum hCG ratios, as calculated by dividing the postoperative by the preoperative hCG values, in patients with radical surgery. We compared patients successfully treated by conservative tubal surgery and those with PEP.
Results: Among 265 patients, 153 underwent radical surgery, the other 112 conservative surgery. Among the patients receiving conservative surgery, 24 (21.4%) were diagnosed with PEP. Among these 24 patients, 21 concomitantly received intramuscular administration of methotrexate (MTX) 50 mg, and 5 underwent salpingectomy. The decay curve of the serum hCG ratios after radical surgery was given by y = 1.7704 × -2.16 (R2 = 0.74625). In patients successfully treated by conservative surgery, the postoperative serum hCG ratio showed nearly the same transition as the decay curve. In 8 patients (33.3%) among those with PEP, which was the largest number, the ratio was lower than the decay curve for 2 days after surgery and then showed an increase 3 days after surgery. In 4 patients (16.7%), the ratio showed an increase 14 or more days after surgery. To predict PEP in the early postoperative period, we compared the initial serum hCG ratios measured after surgery and found that the ratio in patients successfully treated by conservative surgery (0.427 ± 0.153) was significantly lower than that in patients with PEP (0.576 ± 0.186) (p < .0001). Analysis with ROC, initial serum hCG ratio 0.509 as cut-off revealed that the specifity was 79.3% and the sensitivity was 66.7%. In 11 patients (78.6%) among the 14 with PEP who underwent hysterosalpingography, tubal patency was observed.
Conclusion: The initial measurement of serum hCG ratios after surgery is considered to be useful for predicting PEP. However, careful follow-up is required because the hCG levels increase more than 2 weeks after surgery in some cases. Tubal patency was also suggested to be maintained relatively favorably with the additional administration of MTX even in patients with PEP.

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Objective: To describe the trends of surgery for benign uterine disease from 1995 through 2012.
Methods: The study comprised 8,629 women who underwent surgery for benign disease from 1995 through 2012. We evaluated the trends in patient background, the rate of hysterectomy or myomectomy, and the surgical route (abdominal, laparoscopically, hysteroscopically, or vaginally).
Conclusions: The myomectomy rate among total uterine procedures increased markedly from 20% to 70%. The route of hysterectomy evolved significantly. The rate of minimally invasive hysterectomy, i.e. vaginal and laparoscopic, increased constantly to 82% of all cases. In regard to myomectomies, the increase in laparoscopic myomectomy was significant. The average age of patients who underwent hysterectomy remained unchanged over this period, but that of myomectomies showed an interesting change. It averaged 32.7 years in 1995, and increased gradually to 38.4 years in 2012. However, the rate of women with infertility among the myomectomy cases remained almost unchanged at approximately 20%. These trends for benign uterine disease are discussed in association with improvements of laparoscopic surgery, i.e., surgical technique and instruments, as well as the changes in women's lifestyles.

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Objective: To realize preoperative diagnosis of uterine adenomatoid tumor (AT).
Subjects: Sixteen cases of AT and 30 randomly selected cases of uterine leiomyoma (LM).
Setting: Takanohara Central Hospital. A referral center of gynecological laparoscopic surgery.
Design: A retrospective comparative study.
Main outcome measure(s): General clinical indices and relative signal intensity (rSI) on MRI images.
Results: No between-group difference was observed with general clinical indices nor with rSI on T1 weighted MRI (rSI/T1). Means of rSI on T2 weighted MRI (rSI/T2) were significantly (p=0.0010) higher in AT than in LM (18.24 ± 9.58 and 6.73 ± 9.10, respectively). Individual rSI/T2 estimates >10 were obtained in the majority (90.9%) of AT group and one third of LM group as well.
Conclusion: Estimation of rSI/T2 could differentiate AT from LM. Accumulation of more cases is, however, essential to draw a more decisive conclusion.

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Objective: We retrospectively reviewed medical records to investigate the pattern of pitfalls in the diagnosis of ectopic pregnancy (EP) after laparoscopic surgery.
Study Design: From April 2009 through June 2013, 280 women with suspected EP were admitted to our hospital. We retrospectively reviewed the medical records of all these cases in regard to clinical symptoms, serum hCG level, transvaginal ultrasonographic findings, intraoperative findings, and pathological findings.
Results: Among 280 cases of suspected EP, 175 cases underwent laparoscopic surgery, and 18 of these cases (10.3%) were not EP. The distribution of these non-EP cases was: nine cases of spontaneous abortion, four cases of pregnancy with unknown implantation site, three cases of ovarian hemorrhage, and two cases of normal pregnancy. Among these 18 cases, 12 cases underwent laparoscopic surgery without a preceding dilatation and Curettage (D&C), and the remaining six cases underwent a preceding D&C. Among the 18 cases, 11 cases had a tumor mass imaged outside the uterus misdiagnosed as a gestational sac. Normal pregnancy (two cases) and unspecified implantation site (one case) exhibited an anechoic area in the pouch of Douglas, which was laparoscopically diagnosed as ascites.
Conclusions: A misdiagnosis of EP may occur in women with suspected EP. A diagnosis of EP should be considered in women who clinically manifest as spontaneous abortion, unknown implantation site, ovarian hemorrhage, and/or early pregnancy. Accordingly, in the case of an anechoic area in the pouch of Douglas, we recommend the performance of a culdocentesis for the determination of the correct diagnosis. A thorough explanation should be given to the patient that a misdiagnosis is possible even with careful clinical evaluation.

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Objective: Evaluation of the fetal effects of laparoscopic surgery during pregnancy
Design: Case series
Setting: Department of Obstetrics and Gynecology, Osaka City Sumiyoshi Hospital
Patients: Twelve pregnant women who underwent laparoscopic surgery because of an adnexal mass in the first trimester. In six women, uterine artery resistant index (RI), umbilical artery and fetal heart rate were measured.
Interventions: Laparoscopic surgery (anesthesia and pneumopetioneum).
Main outcome measures: Maternal complications, pregnancy loss, as well as intraoperative fetal heart rate and umbilical artery RI.
Results: Gestational age ranged from 9 to 14 weeks, mean operative time was 100 minutes (range: 51- 140 minutes), mean anesthesia time was 146 minutes (range: 76-190 minutes), pneumoperitoneum pressure was ≤8 mm Hg, mean pneumoperitoneum time was 43 minutes (17-69 minutes), and mean duration of tocolysis was 5 days (range: 3-8 days). During laparoscopic surgery, the fetal heart rate remained normal, but umbilical artery RI increased. Mean umbilical artery RI increased was 0.070 mm Hg after induction of anesthesia and further increased by 0.015 mm Hg after the establishment of a pneumoperitoneum. Mean uterine artery RI decrease after induction of anesthesia was 0.220 mm Hg; however, it increased 0.110 mm Hg after establishment of pneumoperitoneum. Fetal heart rate remained in normal. All pregnancy outcomes were normal.
Conclusions: Laparoscopic surgery in pregnancy incurred no maternal complications. However, fetal distress may occur during the procedure. Thus, it is prudent to minimize the duration of anesthesia and pneumoperitoneum.

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Purpose: We report the results of single-port laparoscopically assisted vaginal hysterectomy (SP-LAVH), as employed in our hospital, with the aim of improving cosmetic outcomes.
Patients: This study included 174 of 194 patients undergoing hysterectomy for uterine fibroids in our hospital from January 2012 through December 2013. The 20 patients requiring a laparotomy, based on preoperative evaluation, were excluded.
Methods: SP-LAVH was initially performed; however, when we found it difficult to continue with this approach, we converted the procedure to a multi-port laparoscopically assisted vaginal hysterectomy (MP-LAVH) or abdominal hysterectomy.
Results: The success rate of LAVH was approximately 97%, while that of SP-LAVH was approximately 74%. For SP-LAVH, the mean operative time was 74.5 minutes, the mean blood loss was 399.7 mL, and the mean weight of the removed uterus was 356.4 g. The values of these endpoint parameters were not significantly different from those of patients in whom SP-LAVH had been converted to MP-LAVH. No complications such as organ injury were observed and none of the patients required a transfusion. The success rate of SP-LAVH was lower in patients without than in those with a prior vaginal delivery.
Conclusions: We succeeded in performing a SP-LAVH in 74% of cases and there were no complications. When cosmetic results are taken into account, SP-LAVH, if indicated, is a potential option for a hysterectomy.

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Objective: We retrospectively assessed perioperative risk for laparoscopic salpingo-oophorectomy in elderly women.
Design: We performed 13 laparoscopic salpingo-oophorectomy procedures in women aged 70 and older. During the same period, 18 patients aged 45 to 59 also underwent bilateral laparoscopic salpingo-oophorectomy. We defined the latter group of patients as the control group. We compared the older group with the control group with regard to underlying diseases, preoperative evaluations, surgical methods, intraoperative complications, postoperative complications, and hospitalization.
Results: The median age of the older patients was 74 years (range, 70-83 years). Ten of the 13 older patients had an underlying disease. Three patients were obese (Body Mass Index > 25). Four patients received perioperative anticoagulant therapy. All of the tumors were benign in the final pathological diagnosis. For the laparoscopic procedure, abdominal air pressure was fixed at 8 mmHg. All of the patients underwent surgery only under general anesthesia. The average duration of the operation was 110 min (range, 46-110 min). Average blood loss was 16 ml (range, 0-140 ml). No perioperative complications were observed. All of the patients began walking 1 day after surgery. The median inpatient hospital stay was 4 days (range, 3-7 days). Two patients had subcutaneous hematoma as a postoperative complication, which did not need any treatment or postponement of hospital discharge. Comparisons between the older group and control group revealed that only the rate of underlying disease was significantly different.
Conclusion: Laparoscopic salpingo-oophorectomy for aged women must be conducted cautiously because such patients have a high prevalence of underlying disease. Almost all of the procedures were conducted safely, suggesting that this surgical indication could be expanded for aged women.

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Objective: To examine the results of treatment of a surgical site infection (SSI) with a single antibiotic after laparoscopic surgery.
Design: Retrospective Study
Setting: General hospital
Methods: We examined the results of treatment of a surgical site infection by two antibiotic dosage methods. The old group comprised 1,241 cases from April 2005 through March 2010; the new group comprised 870 patients treated from April 2010 through May 2013. The old group received Cefazolin 2g/day (postoperative day 0-1) intravenously (IV) and Cefdinir 300 mg/day orally (postoperative day 2-6). We divided the new group into two dosage methods. New group 1 received Cefazolin 1 g IV one time. New group 2 received Fromoxef 1g IV 6 hours postoperatively and 2 g/day IV daily (postoperative day 1-3) in addition to the dosage given to new group 1.
Results: New group 1 comprised 770 cases; new group 2 comprised 100 cases. In the old group, the number of SSIs was 20: 15 (1.2%) superficial incisional SSIs; and 5 (0.4%) deep incisional or organ/Space SSIs. In new group 2, 5 SSIs (0.5%) occurred. Three (0.3%) were superficial and three (0.3%) were deep or organ/space SSIs.
Conclusions: We did not note any significant difference in the number of SSIs between the two groups (P = 0.06). We suggest that simplification of antibiotics dosage is possible in approximately 90% of cases. We confirmed that simplification of antibiotic dosage does not increase the risk of a SSI. Accumulation of additional cases would be necessary to strengthen this finding; however, we are of the opinion that the new dosage provided quality medical care and reduced expense.

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Objective: We investigated the prognosis of women with ureteral endometriosis after laparoscopic ureteral resection and ureteroneocystostomy.
Study Design: From 2008 through 2012, we followed nine cases of ureteral endometriosis after laparoscopic ureteral resection and ureteroneocystostomy. We evaluated for any presence of hydronephrosis, improvement of pelvic pain (VAS levels), and renal function with radioisotopes before and after surgery.
Results: We found no recurrence of hydronephrosis six months postoperatively. The VAS levels of pelvic pain also improved six months postoperatively. Three cases were examined with renal radioisotopes and all three cases were found to have improved function.
Conclusion: Laparoscopic ureteral resection and ureteroneocystostomy improved the renal function of women with ureteral endometriosis.

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Objective: This study aimed to analyze the safety and feasibility of laparoscopic surgery for early-stage endometrial cancer.
Methods: We performed laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy in 10 patients with pathologically diagnosed grade 1 or 2 endometrioid adenocarcinoma. The expected preoperative clinical stage 1A (International Federation of Gynecology and Obstetrics staging guidelines 2009) was diagnosed by magnetic resonance imaging and computed tomography. We analyzed the operation time, amount of bleeding, number of resected lymph nodes, perioperative complications, postoperative activities of daily living (ADL), and pathological findings.
Results: The average operation time was 273.9 min, the average bleeding was 40 g, and the average number of resected lymph nodes was 21.6. Postoperative lymphocyst infection occurred in one case. In early-stage endometrial cancer, laparoscopic surgery improved postoperative ADL and shortened hospital stays compared to laparotomy. Postoperative pathological examination revealed one case of grade 3 endometrioid adenocarcinoma. A further case was diagnosed as stage 3A because ovarian metastasis was identified.
Conclusions: The safety and feasibility of laparoscopic surgery, and good postoperative ADL in patients with early-stage endometrial cancer were confirmed by our results. Gynecologists experienced in laparoscopic and oncologic surgery can be introduced easily to laparoscopic surgery for early-stage endometrial cancer.

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  We experienced a case of Fallopian tube torsion that was diagnosed preoperatively. A 47-year-old nulligravida presented at the emergency department of Maebashi Red Cross Hospital with the chief complaint of sudden onset of severe lower abdominal pain just after defecation. On physical examination, severe tenderness and rebound pain in the right adnexa were noted. Computed tomography (CT) showed multilocular images in both adnexa, and magnetic resonance imaging (MRI) suggested bilateral hydro- or hemato- salpinges. Neither pentazocine nor nonsteroidal anti-inflammatory drugs (NSAIDs) relieved her pain. Emergency laparoscopy revealed torsion and convolution of the right Fallopian tube, a left hydrosalpinx, and perihepatic fibrous adhesions. A bilateral salpingectomy was performed. Her postoperative course was uneventful. Pathological examination revealed hemorrhage, severe edema, and partial degeneration of the right Fallopian tube consistent with torsion of the right Fallopian tube; no evidence of malignancy was present. A preoperative test for chlamydial antigen in the cervix was negative. However, serum antibodies for chlamydia trachomatis showed a positive result for IgG and a negative result for IgA; thus suggesting previous existence of chlamydial pelvic peritonitis. The clinical features and images led to the correct preoperative diagnosis, and led to a prompt decision to perform emergency laparoscopic surgery. Fallopian tube torsion, although uncommon, should be included in the differential diagnoses of acute lower abdominal pain in women.

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Objective: To report a case of ovarian carcinoid.
Design: Case report.
Patient: A 31-year-old woman with a mature cystic teratoma.
Intervention: Diagnostic and therapeutic laparoscopic surgery.
Results: We performed a laparoscopic left ovarian cystectomy as the primary surgery. The pathological diagnosis was insular carcinoid with a mature cystic teratoma. As a secondary surgery, we performed a laparoscopic left salpingo-oophorectomy. No malignant cells were found.
Conclusion: Appropriate management of ovarian carcinoid has not been elucidated to date. A review by Gardner GJ, et al. published in Journal of Gynecologic Oncology may be useful for appropriate management of these tumors. This case may contribute to a further understanding of these tumors.

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  Leiomyomas of the Fallopian tube are rare and their correct diagnosis is extremely difficult. A 39-year-old woman presented with lower abdominal pain. Magnetic resonance imaging revealed a solid extrauterine mass 12 cm in diameter with an area of decreased enhancement. Our preoperative diagnosis was torsion of a subserosal uterine leiomyoma. Laparoscopic surgery was performed and the tumor was found to have originated from the isthmus of the left Fallopian tube. A laparoscopic left salpingectomy was performed. Her postoperative course was uneventful. The final pathology report noted a primary tubal leiomyoma with ischemic changes. We report a case of torsion of a tubal leiomyoma, which was successfully managed laparoscopically.

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  An atypical polypoid adenomyoma (APAM) is a benign mixed epithelial and mesenchymal tumor. Histologically, an APAM features a biphasic proliferation of atypical endometrial glands within myofibromatous stroma. To emphasize the potential risk for myometrial invasion, APAM with markedly complex glands is designated "atypical polypoid adenomyoma of low malignant potential" (APA-LMP). We report a case of a 27-year-old infertile woman with an atypical polypoid adenomyoma coexistent with atypical endometrial hyperplasia. She underwent hysteroscopic transcervical resection followed by medroxyprogesterone acetate therapy. After a complete response was achieved, she received clomiphene therapy and subsequently underwent in vitro fertilization-embryo transfer (IVF-ET). Although APAM is a benign tumor, a persistent lesion or recurrence is frequently observed. Occasionally, APAM coexists with endometrial hyperplasia or carcinoma. Clinical management of APAM has not been elucidated; however, fertility conservation should be considered if it is followed by careful observation.

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  Single-incision laparoscopic surgery (TANKO) has been developed in an attempt to improve cosmetic results. However, TANKO is often more technically difficult than multi-port laparoscopic surgery (MLPS) because of the restricted mobility; furthermore, several prospective randomized controlled trials have shown that TANKO has only cosmetic advantages. Moreover, if TANKO is performed on a patient with a shallow umbilicus and sparse subcutaneous adipose tissue, the umbilical scar may be highly visible because of the requirement of a larger periumbilical skin incision for TANKO, compared to MLPS. To resolve this problem, we describe a method of umbilicoplasty using TANKO for removal of ovarian tumors in three patients. All three patients were satisfied with the cosmetic result.

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Case: A 63-year-old woman (gravida/para = 0/0) with an unremarkable past medical history was referred to our hospital for an ovarian tumor detected by routine examination. A unilocular mass was evident on magnetic resonance imaging but the findings did not clearly suggest malignancy. Tumor marker levels were elevated (CA125, 53.6 U/ml; CEA, 13.0 ng/ml), but whole-body inspection failed to locate apparent malignancies. At the patient's request, we performed laparoscopic bilateral salpingo-oophorectomy. An approximately 12-cm tumor was found in the left ovary. The right ovary was normal size, with mild conglutination around the ovary being the only abnormality detected. Diagnostic histopathological examination of the resected ovaries revealed the presence of a serous cystadenoma in the left ovary and an endometrioid adenocarcinoma (Grade 1; 7 mm × 5 mm) in the right ovary. Tumor capsule rupture was absent and no tumor was found on the external surface of the right ovary. The patient was diagnosed as having pT1aN0N0 (Stage Ia) ovarian cancer, confirmed by staging laparotomy, and is currently under observation.

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  Misplacement and retention of a small surgical device should be avoided because it may result in complications such as infection or injury. Compared to a laparotomy, because of limited visualization during laparoscopic surgery, loss of a small surgical device is more likely and detection is more difficult.
  A 48-year-old woman underwent a total laparoscopic hysterectomy for cervical adenocarcinoma in situ. During the surgery, we used 5 mm metallic clips for bundling the tapes, which marked the ureters. When we removed the tapes and clips through a 12 mm trocar following removal of the uterus, one of metallic clips was missing. Laparoscopic exploration of the abdominal cavity, a search of the entire operating room, and exploration of the interior of the trocar failed to detect the clip.
  We then ordered abdominal X-rays while the patient was still under anesthesia; however, the item was not located. Subsequently, an X-ray of the trocar detected the clip buried deep within it. Detection of small devices are difficult during laparoscopic surgery; therefore, we should handle them carefully.

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Background: A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary, and occasionally the other adjacent pelvic organs. These abscesses are found most commonly in women of reproductive age and are typically resulted from ascending infection of genital tract. Treatment modalities for TOAs include intensive antibiotic therapy, minimally-invasive drainage procedures, invasive surgery, or combination of these interventions.
Case: A 30 years-old woman had a TOA with endometrioma after appendectomy. We treated her by anti-biotic therapy and laparoscopic surgery. But, her TOA relapsed as a severe infection of multiple-drug-resistant bacteria. Therefore, we performed a secondly CT-guided-drainage of the abscess and long course of antibiotic therapy.

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  We report a rare case of a malignant lymphoma that was diagnosed by pelvic lymph node biopsy during a total laparoscopic hysterectomy for cervical carcinoma in situ (CIS). The patient was a 65-year-old woman with an unremarkable past history. She was referred to our hospital because a cervical cancer screening revealed a high-grade squamous intraepithelial lesion (HSIL). A cervical biopsy revealed squamous cell carcinoma in situ, which was confirmed by cervical conization. Moreover, she complained of an enlarged lymph node in her left neck. For this reason, she was referred to the department of otorhinolaryngology six days after the conization. Although fine-needle aspiration cytology of the cervical lymph node was performed twice, the results were negative. Because she refused a lymph node biopsy, antibiotics were given under the presumptive diagnosis of cat scratch disease. We recommended a total laparoscopic hysterectomy for the cervical CIS after providing informed consent. During the procedure, we biopsied a right obturator lymph node, which was noted to be enlarged with a pelvic MRI. Histologic examination revealed no residual tumor in the cervix; however, the lymph node was diagnosed as a grade 2 follicular lymphoma. She was subsequently diagnosed as a stage III malignant lymphoma (Ann Arbor classification) and is currently receiving R-CHOP chemotherapy in department of hematology. In our experience, laparoscopic lymphadenectomy is useful not only for the diagnosis of gynecological malignancies but also for the diagnosis of non-gynecological malignancies. Laparoscopic surgery can determine the cause of lymph node enlargement within the scope of less invasive surgery.

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Background: Unilateral absence of an ovary and fallopian tube is very rare. We report a case of right ovarian and tubal absence discovered during surgery for left adnexal torsion caused by a left ovarian dermoid cyst.
Case report: A 19-year-old virgin patient presented by ambulance with worsening lower abdominal pain. She had menarche at age 14 followed by a regular 26-day menstrual cycle. Computed tomography revealed a 10-cm adnexal mass containing fat and calcification, and adnexal torsion was suspected. The patient underwent surgical laparoscopy, and the left adnexa was found in torsion (triple twist), with an edematous, black-bluish, enlarged ovary. We untwisted the pedicle, excised the ovarian cyst, and then noticed the absent right adnexa. Rudimentary right round and infundibulopelvic ligaments were present. We found and removed a solitary 1.5-cm nodule located just below the peritoneum of the cul-de-sac containing cartilage and hair. Pathological examination revealed that the left ovarian cyst was dermoid with marked congestion, and the cul-de-sac nodule was an " old-looking" dermoid cyst. On second-look laparoscopy, the left ovary demonstrated normal color and follicle development. Left tube patency was confirmed by chromopertubation with indigo carmine.
Comment: Two etiopathogenic causes are postulated for this very rare case of ovarian and tubal absence with a normal uterus: congenital developmental defect and missed torsion of the adnexa. The present case appears to involve the latter, because the patient had no other genitourinary anomalies. The finding likely resulted from asymptomatic torsion, with a probable ectopic right ovary present in the cul-de-sac.

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  Uterine leiomyomas are commonly encountered benign gynecologic tumors. However, cases of extrauterine leiomyomas are relatively rare and often present diagnostic challenges. We report a case of an acute abdomen caused by an extrauterine leiomyoma that was completely isolated from other organs and was laparoscopically diagnosed. A 39-year-old woman gravida 4 para 4 with a history of a fist-sized uterine myoma at the age of 30 years, was admitted to our hospital because of the acute onset of right lower abdominal pain. The patient had undergone a cesarean section for placenta previa six days before admission. Transvaginal ultrasound revealed a 7.3 × 6.1 cm solid tumor and the physical examination revealed tenderness at the right lower abdomen. Torsion of a subserosal leiomyoma or right ovarian tumor was suspected; therefore, laparoscopic surgery was performed for diagnosis and treatment. Both adnexa were found to be normal-sized, and a tumor completely isolated from surrounding structures was observed. The postoperative histopathologic diagnosis was leiomyoma. Cases of parasitic leiomyomas after laparoscopic myomectomy associated with morcellation are increasingly being reported. In contrast, cases of spontaneous parasitic leiomyomas remain extremely rare because the origins of the tumors are unknown. This case was considered to be a pedunculated subserosal myoma that had spontaneously separated from the uterus and was found prior to parasitization to other organs. Therefore, this case demonstrates a natural pathogenic mechanism of a spontaneous parasitic leiomyoma.

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  Single port access laparoscopic surgery is a form of scarless surgery. However, manipulation of instruments is difficult with this approach. Reduced port laparoscopy, with new reduced-size instruments, has recently been introduced. This technique is likely to become more popular than single port laparoscopy because it can be performed with less difficulty. In this case report, we present a new concept for single port access laparoscopy, which was successfully employed in a case of extensive intra-abdominal adhesions.

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