Introduction: Transumbilical single-port access laparoscopic surgery has a lower rate of incisional morbidity and a favorable cosmetic outcome. However, the procedure is sometimes difficult to perform because of collision between the forceps and the scope. Therefore, we have used pre-bent forceps and a 5 mm-diameter long scope since April 2012. This study aims to evaluate the feasibility and efficacy of the revised single-port access laparoscopic surgery.
Methods: We evaluated 29 cases of transumbilical single-port access total laparoscopic hysterectomy (SPA-TLH) using straight forceps or pre-bent forceps.
Results: The pre-bent forceps group had shorter operative times for the procedures of ligating uterine arteries, dividing the cardinal ligament, incising the vaginal wall, and suturing the vaginal stump, compared with the straight forceps group.
Conclusion: SPA-TLH using a pre-bent forceps and a 5 mm-diameter long scope could be more feasible, compared with SPA-TLH without such instruments.

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Objective: To evaluate the relative difficulty of laparoscopic hysterectomy (LH) for adenomyosis by categorizing them into four subtypes.
Methods: We retrospectively collected 56 cases of adenomyosis treated by laparoscopy at our hospital from January 2007 to December 2012. After subcategorizing them into four subtypes on the basis of MRI geography (subtype 1: intrinsic subtype, subtype 2: extrinsic subtype, subtype 3: intramural subtype, subtype 4: indeterminate subtype), we statistically analyzed the surgical results including operation time, blood loss during operation and conversion rate to open surgery using Mann-Whitney U test.
Results: The operation time for subtype 1 adenomyosis was shorter than that for subtype 2 adenomyosis (147 vs. 215 min, p<0.005). Compared to subtype 2/3, subtype 1 had small amount of blood loss during operation (260 vs 60/ 230 ml, respectively, p<0.05). Compared to subtype 2/ 3/ 4, subtype 1 has small proportion of conversion to open surgery (0 vs 25/ 20/ 10.3 %, respectively,), which was not statistically significant. We further revealed that revised American Society for Reproductive Medicine (rASRM) score of subtype 2 patients was higher than those of subtype 1/3 patients (60 vs 2/ 2 points, respectively, p<0.005, p<0.01).
Conclusions: Categorization of adenomyosis based on MRI finding was considered to be an efficient method because of the increased amount of blood loss and elevated rASRM score of subtype 2 adenomyosis. Therefore, subtype 2 was considered to be the most difficult entity of adenomyosis in LH. Although the difficulty of LH for subtype 4 adenomyosis should be further investigated, our analysis implied the importance to categorize adenomyosis by MRI, and this method can be useful for evaluating the difficulty of LH.

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Objective: The aim of this study was to report the feasibility and long-term prognosis of laparoscopic surgery for early-stage endometrial cancer compared to laparotomy. Methods: Sixty-six patients with clinical stage I endometrial cancer were surgically treated between July 2004 and June 2014. Thirty-six patients were treated with laparoscopy (laparoscopy group [LS]), and 29 were treated with laparotomy (laparotomy group [LT]). The surgical procedures were hysterectomy, salpingo-oophorectomy, and para-aortic-pelvic lymphadenectomy. We compared perioperative morbidities, recurrence rates, progression-free survival, and overall survival for both groups.
Results: One patient was converted from laparoscopy to laparotomy due to metastatic cancer. The mean operative time was longer and hospitalization after surgery was shorter in the LS group. In the LS group, intra-operative and postoperative complication rates were not higher than in the LT group. There were no differences between the groups in terms of recurrence rates, progression-free survival (94.4% LS; 82.1% LT), and overall survival (97.2% LS; 90.0% LT).
Conclusion: Laparoscopic surgery for early-stage endometrial cancer was performed safely and was not inferior to laparotomy in terms of long-term prognosis.

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Objective: To evaluate risk factors associated with ovarian endometrioma recurrence after laparoscopic cystectomy.
Design: A retrospective study.
Setting: Minoh City Hospital.
Patients: This study included 81 women who underwent laparoscopic cystectomy for ovarian endometrioma and were followed up postoperatively for more than 4 months.
Interventions: Laparoscopic cystectomy and postoperative medical treatment.
Main outcomes: Eighteen variables (age at surgery, body mass index, age at menarche, parity, infertility, pain, previous surgery for ovarian endometriosis, previous medical treatment of endometriosis, tumor marker, size of the largest cyst, single or multiple cysts, unilateral or bilateral involvement, laterality [left or right], revised American Society for Reproductive Medicine [r-ASRM] score, r-ASRM stage, uterine myoma, postoperative medical treatment, and postoperative pregnancy) were evaluated to assess their effects on the risk of ovarian endometrioma recurrence.
Results: The recurrence rate was 12.3% (10/81 patients). The 5-year cumulative recurrence rate was 37%. The size of the largest cyst, presence of multiple cysts, and previous medical treatment were associated with ovarian endometrioma recurrence. The recurrence rate was significantly lower in the women who received postoperative medical treatment (3.3%) than in the women who did not receive medication (20.6%).
Conclusion: In this study, the size of the largest cyst and the presence of multiple cysts were associated with ovarian endometrioma recurrence after laparoscopic cystectomy. The continuous postoperative medical treatment decreased the risk of ovarian endometrioma recurrence.

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Objective: The purpose of this study was to evaluate the laparoscopic management of tubo-ovarian abscess.
Methods: We retrospectively evaluated 12 patients with tubo-ovarian abscess who received laparoscopic management in Kariya Toyota General Hospital between January 1, 2008, and December 31, 2013. Clinical and laboratory data were evaluated.
Results: The median age of the patients was 40 years (range, 26–57 years). Laparoscopic adnexectomy was performed in 10 patients, and laparoscopic cystectomy was performed in 2 patients. The infection focus was a chocolate cyst in 9 patients, the fallopian tube in 2 patients, and the normal ovary in 1 patient. The mean operation duration was 164.2 minutes, and the mean blood loss volume was 290 mL. Seven patients were treated primarily with intravenous antibiotics. However, the treatment was ineffective in all of the patients. Nevertheless, all of the patients were discharged within 3 to 10 postoperative days.
Conclusion: Laparoscopic management requires a high-skill technique but is an effective treatment strategy for tubo-ovarian abscess.

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Objective: The aim of this study was to determine the indications for laparoscopic myomectomy (LM) that trainees are able to perform safely.
Methods: Seventy patients who underwent LM for solitary uterine myoma between 1995 and 2014 were included in this study. The patients were divided into two groups, namely the "LM by a qualified gynecologic laparoscopist" and "LM by trainee" groups. We analyzed the myoma diameter, operation time, amount of bleeding, the time between uterine incision and myomectomy, the time from myomectomy to the completion of the first suture, and the total myomectomy time.
Results: A correlation was found between myoma diameter, operation time, and amount of bleeding. The trainees performed LM with less than 200 mL of blood loss in the patients with myomas smaller than 7 cm in diameter, but the amount of bleeding often exceeded 500 mL when the myoma was bigger than 8 cm.
Conclusions: Trainees should undergo training for quick suturing after myomectomy and select cases with myomas smaller than 7 cm in diameter.

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  Compared with open procedures, laparoscopic surgery is more dependent on the ability of power devices. We performed total laparoscopic hysterectomy (TLH) using THUNDERBEAT™, which integrates ultrasonic vibration and tissue dissection with advanced bipolar energy in a single multifunctional instrument. We compared the operative outcomes of 15 TLHs with THUNDERBEAT™ and 34 TLHs with the conventional technique using a bipolar grasper and solely ultrasonic device (SonoSurg™). We found no significant difference in operative time and blood loss between THUNDERBEAT™ and bipolar grasper and SonoSurg™. However, we realized that THUNDERBEAT™ has better sealing ability and dissection speed than those of other devices. We believe the operative outcomes of TLH will be improved by THUNDERBEAT™ further accumulation of cases.

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Objective: Systematic lymphadenectomy is a necessary procedure for International Federation of Gynecology and Obstetrics (FIGO) staging of endometrial cancer (EC). This study aimed to compare the surgical and survival outcomes between patients with stage IA- EC who underwent laparoscopic pelvic (PLND) and para-aortic lymph node dissection (PALND) and those who underwent the same procedure without PALND.
Methods: This was a retrospective study. In this study, we compared two groups treated at our hospital: Group A (n=15) underwent PLND and PALND between 2004 and 2007, and Group B (n=24) underwent PLND between 2008 and 2013. All these cases were staged IA EC (FIGO 2008) preoperatively, as determined by the use of computed tomography, magnetic resonance imaging, glucose analog (18F)-fluoro-2-deoxy-D-glucose positron emission tomography (PET), and endometrial biopsy.
Results: The median operating time was 465 min (IQR 438-505.5) for Group A versus 336 min (301.5-367.8) for Group B (p<0.0001). The median blood loss was 269 ml (186.5-667) for Group A versus 112 ml (83-255) for Group B (p=0.005). The median number of lymph nodes removed was 40 pelvic nodes (32.5-53) for Group A versus 41 pelvic nodes (34.5-48.2) for Group B (p=0.89), and 17 para-aortic nodes (12.5-22) for Group A versus 8.5 para-aortic nodes (5.75-11.5) for Group B. The number of metastatic lymph nodes was 1 for Group A and 2 for Group B (p=0.93). The number of patients assigned to post-operative stage IA EC was 12 in Group A and 15 in Group B. For stage IB: 1 in Group A, 5 in Group B; for stage II: 0 in Group A, 1 in Group B; for stage IIIA: 1 in Group A, 1 in Group B; for stage IIIC1: 0 in Group A, 2 in Group B; and for stage IIIC2: 1in Group A, 0 in Group B (p=0.88 ). The number of patients undergoing adjuvant therapy was 4 for Group A and 14 for Group B (p=0.15). The median follow-up period was 98 months (79.5-106.2) for Group A and 32.5 months (11-53.3) for Group B. One patient had a recurrence (Group B). All patients were alive without evidence of disease.
Conclusions: Our results suggest that laparoscopic pelvic lymph node dissection without PALND is sufficient for preoperative stage IA EC.

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Objective: Radical hysterectomy with pelvic lymphadenectomy is standard therapy for cervical cancer. The standard surgical lymph node assessment is a systematic lymphadenectomy, but the procedure is associated with lymphedema and lymphocysts. A sentinel lymph node (SLN) is the first node draining the lymphatic flow from a primary tumor. If the SLN is negative for metastasis, nodes after the SLN are also considered to be negative. We report our experience using a new laparoscopic fluorescence imaging system with indocyanine green (ICG) for SLN detection with cervical cancer.
Methods: Participants included 12 patients treated from April 2014 to April 2015. Median age was 41.8 years (range, 27-56years) and median body mass index was 20.2 kg/m² (range, 15-31 years). Patients underwent SLN mapping by intracervical injection of ICG at 3 and 9 o'clock positions. Following SLN mapping, radical hysterectomy and pelvic lymphadenectomy was performed.
Result: Median SLN count was 2.8 (range, 1-7). The overall and bilateral detection rate was 100% (12/12) and 83% (10/12), respectively. Positive SLNs were identified in 2 of 12 patients (16%). SLNs were identifided in the external iliac, internal iliac, obturator and common iliac regions and sensitivity, specificity and NPV were all 100%.
Conclusions: Fluorescence imaging using ICG is a feasible and safe method for SLN detection. In the future, this technique may represent a useful treatment for patients with early cervical cancer.

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  Cesarean scar pregnancy (CSP) reportedly accounts for 6.1% of all ectopic pregnancies in women with a history of at least one Cesarean section delivery. Because of the increasing incidence of Cesarean section deliveries, the number of reported patients with CSP has increased over time. Fertility-sparing treatments for CSP include uterine artery embolization, local methotrexate injection, and laparoscopic or open surgery, while hysterectomy is one treatment for women who do not wish to preserve fertility. Here we report the case of a 39-year-old woman who developed CSP 18 years after a Cesarean section delivery, and underwent total laparoscopic hysterectomy.
  The patient presented at 8 weeks of gestation with symptoms of CSP. Because she wanted an abortion, she and her partner requested a hysterectomy. We subsequently performed total laparoscopic hysterectomy at 8 weeks and 5 days of gestation. Her postoperative course was uneventful, and she was discharged 5 days after surgery.

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  We report a case of heterotopic pregnancy resulting in intrauterine fetal death (IUFD) after laparoscopic resection of an ectopic pregnancy. A 30-year-old woman, who conceived after ovulation induction with clomiphene, was referred to our hospital because of abdominal pain at 6 weeks of gestation. Ultrasound examination showed an intrauterine fetus with a heartbeat, a 3-cm right adnexal mass, and intra-abdominal hemorrhage. We diagnosed a heterotopic pregnancy with miscarriage in a right tubal pregnancy. With careful observation, the intra-abdominal hemorrhage resolved. However, we discovered an abscess in the right adnexa at 11 weeks and 1 day of gestation. Concurrently, chorioamnionitis was suspected because the patient developed purulent discharge and high fever. Antibiotics were administered, but appeared to be ineffective. Therefore, laparoscopic salpingectomy was performed at 11 weeks and 6 days of gestation. Macroscopic and microscopic examination revealed villi and abscess in the excised Fallopian tube. Subsequent to surgery, the amniotic fluid volume kept decreasing, probably because of chorioamnionitis. The fetal heartbeat disappeared at 16 weeks of gestation, and the fetus was delivered at 17 weeks. In this case, the infection of gestational products in the Fallopian tube might have been the cause of chorioamnionitis. Therefore, earlier surgery might have prevented IUFD. In the treatment of heterotopic pregnancy with a live intrauterine fetus, we tend to elect observation because of concern for the fetus. From our experience, surgery should be elected for heterotopic pregnancy in accordance with the treatment criteria for ectopic pregnancy.

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Laparoscopic surgery is increasing in popularity due to its minimal invasiveness; however, procedure-specific complications are inevitable. We report a case in which a rivet from the hinge of a grasping forceps was successfully retrieved, although initially lost in the abdominal cavity during laparoscopic myomectomy (LM).
The patient was a 41-year-old nulliparous woman with a large myoma located on the uterine fundus. The size of the myoma reached 20 cm in diameter. After 5 courses of gonadotropin-releasing hormone agonist therapy, she was scheduled for LM. During the LM, a rivet unexpectedly dropped into the abdominal cavity. Abdominal radiographs were taken immediately, and we began to laparoscopically search for the rivet, primarily in radio-opaque areas. After 30 minutes of searching, a 2-mm rivet was found and retrieved. Complications are bound to occur during laparoscopy; however, not only preventive maintenance but also appropriate strategies to deal with this type of complication are necessary.

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Case 1: A 29-year-old nulliparous woman underwent laparoscopic surgery to explore possible cause of infertility. Mild endometriosis was found and endometriotic lesions located on bilateral sacrouterine ligament and posterior uterine surface were extensively electrocauterized. Afterwards, the patient conceived with ICSI-ET at the age of 31 years. At 36⁺² weeks' gestation, the patient complained of sudden lower abdominal pain. Fetal cardiotocogram showed persistent fetal bradycardia and she was transported to our hospital. Emergency laparotomy was performed immediately upon arrival. Prolapse of fetal lower extremity from the uterine cavity along with massive hemoperitoneum was observed and a stillborn female baby weighing 2690 g was extracted. Removal of accumulated blood revealed a complete longitudinal uterine rupture along the posterior uterine wall.
Case 2: A 35-year-old nulliparous woman with the history of one laparotomy and two laparoscopic surgeries underwent laparoscopic adenomyomectomy. Three months later, the patient was conceived with IVF-ET. At 28⁺⁵ weeks' gestation, the patient complained of sudden lower abdominal pain. Fetal cardiotocogram showed severe late fetal deceleration and she was transported to our hospital. On admission, massive hemoperitoneum was suspected upon examination with ultrasonography, leading to emergency laparotomy. A female baby weighing 1484 g was delivered by lower-segment cesarean section. Removal of accumulated blood revealed a complete longitudinal uterine rupture in the lower part of posterior uterine wall. The newborn suffered from severe intraventricular hemorrhage, resulting in diffuse cerebral atrophy.
  In laparoscopic surgery, "limited use of electrocautery against the uterus" and "multilayered closure of the myometrium" should be kept in mind.

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  Since the Food and Drug Administration warning in 2011 against transvaginal mesh operation for pelvic organ prolapse, this operation is avoided owing to its severe complications. Instead, laparoscopic sacrocolpopexy (LSC) is selected by many urogynecologists. For the strong attachment between the cervix and mesh, supracevical hysterectomy is usually performed before LSC. Uterine removal from the intra-abdominal space requires intraperitoneal shredding or morcellation of the specimen. In cases of unexpected uterine malignancy, shredding or morcellation of the uterine specimen may interfere with the appropriate staging and increase the risks of malignant cell dissemination. We here report a case of uterine endometrioid adenocarcinoma diagnosed after supracervical hysterectomy and sacrocolpopexy for pelvic organ prolapse. The patient was 49 years old (gravida 4, para 2). She underwent laparoscopic supracervical hysterectomy and LSC for pelvic organ prolapse. Preoperative transvaginal ultrasound did not show thickening of the endometrium, and the endometrial cytology was negative. However, the pathologic examination after the initial operation showed uterine endometrioid adenocarcinoma, stage I. Accordingly, she was referred to our hospital and underwent trachelectomy, pelvic lymph node dissection, and paraaortic lymph node biopsy. This case indicates that we need to be aware of the possibility of uterine malignancy in cases of laparoscopic supracervical hysterectomy and LSC.

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  We report a case of hematometra after laparoscopic surgery. The patient was a 66-year-old woman, gravida 2, para 2, without significant medical history. Initial medical examination revealed a right ovarian tumor following which the patient was referred to our hospital. At the initial visit, a transvaginal ultrasound detected an 8 × 4 cm right ovarian tumor. Surgery was recommended and planned. Blood tests showed a mild inflammatory response, while tumor markers were within the normal reference intervals. A right adnexectomy was performed laparoscopically using a uterine manipulator. The surgery was uneventful, but the patient became febrile and blood tests showed an inflammatory response with a white blood cell count of 9500/µL and a C-reactive protein level of 11.9 mg/dL, 2 to 4 days after the operation. Transvaginal ultrasound and computed tomography revealed a mild pooling of fluid in the uterine cavity, which was diagnosed as a hematometra. The hematometra was drained resulting in the lowering of the patient's temperature. The patient was subsequently discharged from the hospital on postoperative day 7. A culture of the drained uterine cavity fluid did not reveal any significant bacterial presence. The pathological diagnosis was a benign mature cystic teratoma of the right ovary. After being discharged, the patient continues to do well.

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  Tight suturing is necessary in cases of myomectomy, but this is difficult to achieve in single-port access laparoscopic operations. However, this problem was overcome with the appearance of ligation-free suture thread (V-Loc™180). Three patients have since become pregnant and achieved successful delivery by cesarean section. No symptoms attributable to myomectomy were seen during any of these pregnancies. This experience demonstrates the usefulness of ligation-free suture thread for fertility-preserving single-port access laparoscopic myomectomy.

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Introduction: Uterine myoma is one of the most common diseases among gynecological benign tumors. However, the torsion of uterine leiomyoma is very rare. We reported here two cases of torsion successfully managed by laparoscopic surgery.
[Case 1] A 33-year-old nulligravid woman visited a local hospital with lower abdominal pain. Conservative therapy for suspected ovarian hemorrhage temporarily relieved her symptoms. However, 5 days later, the pain increased and she was transferred to our hospital. A solid mass with tenderness was observed on the left side of Douglas' pouch. Magnetic resonance imaging (MRI) performed at the previous hospital showed a 5-cm mass attached to the uterus. Emergency laparoscopic surgery was performed for suspected pedicle torsion of a subserous myoma. A dark red 5-cm-diameter pedunculated subserous myoma with 180° counterclockwise torsion was detected around the left round ligament. The pedicle was dissected with electrocoagulation using forceps and collected with a morcellator. The histopathological diagnosis was leiomyoma with vascular changes due to torsion.
[Case 2] A 33-year-old woman (gravida 1 para 1) suddenly experienced lower abdominal pain 7 months after vaginal delivery. After visiting a local hospital, she was referred to our hospital with a diagnosis of suspected subserous myoma degeneration. Significant abdominal tenderness was noted, and transvaginal ultrasound showed a 9-cm mass. Blood testing revealed sign of severe inflammation with a white blood cell count of 15,700/μL and C-reactive protein (CRP) level of 26.9 mg/dL. Myoma degeneration and pedicle torsion were suspected based on MRI findings. She underwent emergency laparoscopic surgery. A pedunculated subserous myoma growing from the posterior wall of the uterus with 720° clockwise torsion was observed. The pedicle was dissected with vessel sealing instrument (LigaSure™, COVIDIEN JAPAN) and collected with a morcellator. The histopathological findings showed smooth muscle cell hyalinization with hemorrhage.
Conclusion: Even uncommon in clinical practice, torsion of subserosal uterine myoma can be successfully managed by laparoscopic surgery.

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Girls usually experience only mild pain during their first menstrual cycle, and severe pain at menarche is occasionally indicative of a uterine anomaly.
Case report: An 11-year-old girl, who had been diagnosed with a left renal defect and ureterocele 2 years previously, presented to our emergency room with severe dysmenorrhea 1 day after her second menstrual cycle began. Imaging revealed the presence of a double uterus, left cervical cyst, and ipsilateral renal defect. Thus, she was diagnosed with Wunderlich syndrome. Although cyst drainage was attempted, the wall was too rigid. In addition, uterus bicornis unicollis was noted during laparoscopy. Finally, an intraoperative diagnosis of Herlyn-Werner syndrome was made during laparoscopic left hysterectomy.
Discussion: Herlyn-Werner syndrome, obstructed hemivagina and ipsilateral renal anomaly syndrome, and Wunderlich syndrome are rare Mullerian anomalies that have many common features.
Conclusion: Diagnosis of these syndromes in girls is difficult, and the treatment differs in each case. Hence, flexibility in treatment is essential.

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Introduction: In deciding whether laparoscopic surgery is necessary for suspected ovarian tumors, an accurate preoperative evaluation should be performed. We report a young patient with familial breast and ovarian cancers diagnosed as primary ovarian cancer after laparoscopic cystectomy and treated with radical surgery.
Patient: The patient was a 34-years old woman, 0 gravida 0 para, who had a family history of cancer and was suspected to have hereditary breast and ovarian cancer (HBOC) syndrome. After presentation at a local clinic, she visited our hospital with no complaint of a pelvic cystic mass. Although only the serum CA125 level was high on laboratory examination, magnetic resonance imaging and computed tomography revealed an 8-cm mass without a solid part in the left adnexa and metastasis. Therefore we performed laparoscopic left ovarian tumor cystectomy without intraoperative rupture. The resected tumor was pathologically diagnosed as a serous papillary adenocarcinoma. After the initial surgery, we finally performed a simple total hysterectomy, as well as adnexectomy, omentectomy and pelvic lymph node dissection. The clinical disease stage wad Ic(b). The patient underwent six cycles of TC chemotherapy (paclitaxel. 175mg/m2 and carboplatin. AUC5 q3w). The patient is now disease free.
Conclusion: Laparoscopic surgery plays an important role in gynecological malignant surgery, not only for being minimally invasive but also for its diagnostic value. Informed consent should be obtained from the patient in order to perform the appropriate therapy. More attention should be given to patients' familial and genetic background, especially for young patients with suspected ovarian cancer.

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  Primary carcinoma of the fallopian tube is a rare tumor, accounting for only between 0.3% and 1% of all gynecological malignancies. Its symptoms include abnormal vaginal bleeding, vaginal discharge, lower abdominal pain, and pelvic mass. The nonspecific nature of these symptoms makes preoperative diagnosis difficult. We report a case of primary carcinoma of the fallopian tube suspected in a combined positron emission tomography and computed tomography (PET-CT) study during follow-up for gastric cancer, and diagnosed by using laparoscopy. A 57-year-old woman (gravida 0) with a history of gastric and thyroid cancers presented to our department with a possible left adnexal mass. Internal examination and ultrasonography revealed an enlarged uterus with multiple myomas and a solid mass in the left adnexa, 25×13 mm in size. Magnetic resonance imaging was subsequently performed, and the tumor was enhanced on gadolinium-enhanced T1-weighted imaging and showed high signal intensity on diffusion-weighted imaging. PET-CT revealed no distal metastases. We suspected a metastatic or primary malignant adnexal tumor. After providing informed consent, the patient underwent a laparoscopic surgery. In the distal left fallopian tube, a 3-cm lesion with a smooth surface was found. Disseminated malignant nodules were not observed, and the peritoneal washing cytological examination result was negative. Only salpingo-oophorectomies were performed because of the fact that metastatic tumors are difficult to distinguish from primary fallopian tube carcinomas during surgery. The histopathological diagnosis was high-grade carcinoma of the left fallopian tube, and staging laparotomy was performed later. The patient had no recurrence at 12 months after the surgery. Laparoscopic surgery may be useful in distinguishing metastatic tumors from primary malignant adnexal tumors.

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  The incidence of trocar site hernia is reported to be about 0.2% after gynecological laparoscopic surgery. A 44-year-old woman underwent laparoscopic right salpingo-oophorectomy for endometrial cyst of the right ovary. Her body mass index was 19.1 kg/m². After a 5-mm incision was made with a scalpel at the umbilical area, a 5-mm trocar was inserted by using a Veress needle. This umbilical port was used as the camera port. The postoperative period was uneventful and the patient was discharged on the 5th operative day. At home, the patient noticed a watery discharge from the umbilical trocar wound on the 6th postoperative day. At presentation, she was afebrile and her blood counts were normal. A viable portion of the omentum was prolapsed through the umbilical trocar site. Trocar site hernia was diagnosed, and an urgent laparoscopic surgery was performed. The omentum was reduced laparoscopically and the prolapsed omentum was excised. She was discharged the day after the reoperation, and had an uneventful postoperative course. Trocar site hernia less than 10 mm is a rare complication after gynecological laparoscopic surgery. Recent systematic reviews have suggested that umbilical trocar port, obesity, and fascial closure are not associated with a higher risk of trocar site hernia. However, the depth of the abdominal wall of the umbilicus should be noted in regard to umbilical trocar site hernia. We believe that attention should be paid to patients with thin and fragile abdominal wall of the umbilicus even if the BMI is high.

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Introduction: In the field of gynecology, there have been few reports of laparoscopic surgery following renal transplantation. Thus, important aspects of perioperative management have not yet been elucidated. Here, we report a case of laparoscopic surgery for ectopic pregnancy following renal transplantation.
Case presentation: The patient, a 37-year-old nulligravid woman who had undergone right kidney transplantation, presented to her local physician with abdominal pain and abnormal vaginal bleeding. She was diagnosed with a right tubal pregnancy and transported to our hospital, where she was scheduled to undergo a single-port laparoscopic, right tubal resection. Preoperative transabdominal sonography was performed to confirm the transplanted kidney's location in the pelvis. The patient was at risk for postoperative wound infection because she was receiving immunosuppressants; however, no signs of infection were observed. Furthermore, since she had renal dysfunction prior to surgery, pain control was managed with minimal analgesics that could have adverse effects on the kidneys. Renal dysfunction was not exacerbated.
Conclusions: For patients with ectopic pregnancies following renal transplantation, laparoscopic surgery may need to be performed, as it is less invasive compared with laparotomy. Furthermore, single-port laparoscopic surgery has a lower risk of renal injury during port insertion than multiple-port laparoscopic surgery.

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  Recently, imaging studies have markedly improved the preoperative diagnostic accuracy. However, the intraoperative diagnosis differs from the preoperative diagnosis in certain cases. We report a case of retroperitoneal schwannoma that was preoperatively diagnosed as an ovarian tumor, wherein the tumor location was determined by laparoscopy and the application of pressure on the abdominal wall. A 48-year-old woman (gravida: 3, para: 3) presented with lower abdominal discomfort. Ultrasonography and magnetic resonance imaging (MRI) indicated the presence of bilateral multicystic ovarian tumors in her right and left ovaries (diameters: 75 mm and 31 mm, respectively). Hence, she was referred to our hospital for treatment. Although the right ovarian tumor could be clearly observed by transvaginal ultrasonography, the left ovarian tumor could not be identified due to its relatively smaller size. Laboratory values, including the levels of CA19-9, CA125, and CEA, were normal. Nevertheless, she was diagnosed as having bilateral ovarian tumors, and laparoscopic surgery was performed for treatment. Laparoscopic observation indicated a 75-mm tumor in the right ovary, but showed normal appearance of the left ovary. After laparoscopic bilateral salpingo-oophorectomy was performed, as the left ovary tumor diagnosed on preoperative MRI remained unidentified, pressure was applied on the abdominal wall adjacent to the site where the left ovary tumor was suspected, and the site was laparoscopically observed. Accordingly, a retroperitoneal schwannoma was accurately identified, and was completely resected thereafter via laparotomy with a minimal incision. The histological diagnosis was schwannoma of the femoral nerve.

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  Uterine cystic adenomyosis is a relatively common disease in young women. Patients with cystic adenomyosis have severe dysmenorrhea and surgical treatment is required in most cases. A 29-year-old woman was admitted to our hospital with severe lower abdominal pain. Magnetic resonance imaging revealed features suggestive of an ovarian endometrial cyst. Hysterosalpingography revealed a normal uterine cavity and patent fallopian tubes. The patient was diagnosed with cystic adenomyosis. She was treated initially using hormone therapy with a gonadotropin releasing hormone (GnRH) agonist. This was effective; however, the symptoms recurred when the treatment was discontinued. Therefore, laparoscopic enucleation of the cystic lesion was performed, resulting in a statistically significant reduction in dysmenorrhea.

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  Growing teratoma syndrome (GTS) is characterized by the enlargement of peritoneal implants containing only mature components during or after chemotherapy for malignant germ cell tumors.
  We managed a case of GTS in a 19-year-old woman who was diagnosed and treated using laparoscopic surgery. At the initial laparotomy, we performed a right salpingo-oophorectomy, partial omentectomy, and biopsy of peritoneal disseminations, and the patient was diagnosed with grade3 stage2C immature teratoma, which was treated with four courses of BEP (Bleomycin, Etoposide, Cisplatin) chemotherapy.
  Postoperative magnetic resonance imaging (MRI) and Positron emission tomography (PET-CT) revieled new lesions on the bilateral uterosacral ligament, whereas no tumor marker levels were elevated. We laparoscopically resected the uterosacral lesions, GTS. No recurrent disease was observed after the second operation.
  It is difficult to distinguish recurrence or metastasis of malignant germ cell tumors from GTS, therefore surgery should be considered. Recurrent GTS occurs in some cases following laparoscopic surgery, thus a minimally invasive method presents a good option for possible frequent surgeries. Moreover, laparoscopy is suitable to visualize details even when the lesion is deep within the pelvis.
  In conclusion, laparoscopic surgery should be considered as an alternative strategy in some GTS cases.

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Objective: The incidence of pelvic organ prolapse (POP) has been increasing in the aging society. Recently, the use of tension-free vaginal mesh (TVM) and laparoscopic sacral colpopexy (LSC) have become the new standard method. We reviewed our cases to evaluate the effectiveness of LSC for POP.
Methods: We reported 6 cases of LSC performed at our hospital from 2010 to 2013. We reviewed age, indication, length of hospital stay, operation duration, amount of bleeding during operation, complications, and postoperative recurrence.
Results: Two cases were of vaginal vault prolapse, and 3 were of recurrence after surgery for POP. The mean age of the patients was 63.1 ± 8.8 yr; length of hospital stay, 7.16 ± 0.9 days; operative duration, 213 ± 67.4 min; and amount of bleeding, 66.7 ± 108 mL. No complications occurred after surgery. Five patients underwent the single-mesh method, and one patient underwent the double-mesh method. There were no recurrence cases after surgery.
Conclusion: LSC has a longer operative duration than TVM or vaginal hysterectomy and colporrhaphy, but has many advantages such as less invasiveness and usefulness in preservation of vaginal function. anterior-TVM will become the standard method for cystocele. On the other hand, posterior-TVM has been discouraged because of the risk of rectal damage. LSC would be the standard method for prolapse of the uterus and vaginal vault prolapse. However, the method is still under discussion. Further reviews and improvements of LSC are necessary to make it a more efficacious operative method for pelvic organ prolapse.

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  We present a case of endometrial cancer detected incidentally after a total laparoscopic hysterectomy for adenomyosis. A 45-year-old woman was referred to our department with the chief complaint of hypermenorrhea, abnormal genital bleeding, and anemia. Cytological and histological examinations of the uterus showed no evidence of malignancy. Magnetic resonance imaging and pelvic ultrasonography revealed an indistinct tumor in the posterior wall of the uterus. We made a diagnosis of adenomyosis and performed total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The histopathological findings revealed that it was an endometrioid adenocarcinoma G2. We additionally performed computed tomography (CT)/positron emission tomography CT and found swelling of a para-aortic lymph node. Therefore, she underwent a pelvic/para-aortic lymphadenectomy via an abdominal operation 61 days after the initial operation. The cancer had spread to 11 lymph nodes. Then, she received adjuvant chemotherapy. We found no evidence of recurrence 1 year after the second surgery.

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Background: A 12-mm port is needed for the insertion of a thread for uterine myometrium sutures and laparoscopic power morcellation. Reduced port surgery and needlescopic surgery are becoming standard procedures for which a 12-mm port is not appropriate. The Food and Drug Administration has limited the use of morcellation, hence another method for extraction of uterine myomas is needed.
Method: The EZ-access was placed at the umbilicus with the EZ-link combined with the EZ-sheath. The thread could be inserted through the EZ-link, and myoma extraction was less complicated using a cold knife through the EZ-access.
Result: Insertion of 9–13-mm-diameter forceps is possible through the EZ-link and EZ-access used as a 12-mm port. To prevent air leak through the EZ-link when 5-mm devices are used, the EZ-link was inserted inside the EZ-sheath.
Conclusion: The EZ-link combined with the EZ-sheath as a 12-mm port is beneficial from the cosmetic and economic viewpoints.

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  To enhance one's skills in laparoscopic surgery, it is essential to learn and master the technique for tying laparoscopic knots. A knot that is made laparoscopically tends to loosen, and the loosened knot is known as an air knot. Once an air knot is formed, it is difficult to untie and then to re-tie it appropriately. The slip knot is an alternative and useful knot to prevent the formation of air knots. We present a newly developed knot tying technique, termed as the Uchimuso slip knot technique. The Uchimuso slip knot technique consists of two throws. The formation of the first single wrap throw is similar to that of the conventional instrument tie technique. The second throw is crucial to forming the new slip knot. This second single wrap throw is formed via a sequential movement by simulating a winning technique in sumo wrestling, known as Uchimuso. The Uchimuso slip knot is easy to learn and master, particularly in the case of laparoscopic intracorporeal knot tying.

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  Deeply infiltrating endometriosis (DIE) is defined as subperitoneal invasion by endometriotic lesions. These lesions are considered very active and are strongly associated with pelvic pain. The incidence of DIE is reportedly 20 % in all cases of endometriosis, with uterosacral ligaments representing the most frequent location. Therefore, the resection of uterosacral ligaments is effective in reducing the pelvic pain and dyspareunia that is experienced by patients with endometriosis. However, the operation is associated with a risk of injury to the ureter and rectum; a laparoscopic resection is more useful and safer than open surgery, particularly in patients with adhesion in the pouch of Douglas. Thus, in our study, we initially identified and isolated the ureter and open spaces around the uterosacral ligaments. From June 2012 to December 2013, 262 patients underwent laparoscopic resection of the uterosacral ligaments. Of these, 10 (3.8 %) patients had mild dysuria after the operation, but all cases improved within 2 months. One (0.38 %) patient required clean intermittent catheterization after the operation, which was discontinued 14 months later. Bilateral hydronephrosis occurred in one (0.38 %) patient, which required ureteral dilatation. No ureteral or rectal injury occurred in any patient. Therefore, if the operation is carefully performed, it is possible to safely resect the uterosacral ligaments in patients with endometriosis.

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