Objective: This study was designed to assess the feasibility of gasless abdominal wall-lifting laparoscopic myomectomy.
Methods: This retrospective study evaluated 183 patients without infertility who underwent gasless lifting laparoscopic myomectomy between April 1, 2005 and August 31, 2014. Data were extracted from patients' electronic health records and hospital charts.
Results: The mean age of the 183 patients was 37.9 ± 0.38 years. Mean surgery time was 135 ± 3.7 min, and mean intraoperative blood loss was 329.3 ± 41.4 g. Only eight patients (4.37%) required conversion to laparotomy. Almost all patients required 400–800 ml of autologous blood transfusion, but only four (2.18%) required additional transfusion.
Conclusion: Gasless lifting laparoscopic myomectomy is minimally invasive compared with abdominal myomectomy, and is associated with fewer complications than laparoscopic myomectomy with CO₂ gas.

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Objectives: Clinical management of borderline ovarian tumors (BOTs) during reproductive age has shifted from radical surgery to fertility-sparing surgery. The aim of this study was to evaluate the feasibility of the laparoscopic approach for fertility-sparing surgery for BOTs.
Methods: From August 2012 through March 2014, laparoscopic surgery for ovarian tumors was performed for 557 cases, and a total of 11 cases were diagnosed as BOTs. Six patients were premenopausal, and five selected fertility-sparing surgery. We retrospectively reviewed the clinical and surgical parameters of undergoing laparoscopic surgery for reproductive-age women with BOTs at our institution.
Results: Four cases had mucinous BOTs and one had granulosa-cell tumor. The mean age was 30.8 (20–43) years and mean diameter was 10.1cm (6–22 cm). Two cases had multi-cystic tumor, and all tumors showed no enhancement by contrast magnetic resonance imaging. Laparoscopic ovarian cystectomy was performed in all cases. All cases underwent a secondary laparoscopic surgery as a fertility-sparing surgery and surgical staging including salpingo-oophorectomy of the affected side, partial omentectomy, and peritoneal observation. Appendectomy was performed for one case. The incidence of perioperative morbidities included one case of suspected ureter stenosis. After surgical staging, no case was up-staged, but a residual tumor was found in the affected ovary of one case. After a mean follow-up of 10.3 months (3–19), none had a recurrence or died of the disease. One case had delivered after the two-stage surgery.
Conclusions: Laparoscopic surgery might be feasible and an acceptable intervention for reproductive-age women with BOTs.

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Objective: This study was undertaken to compare LSC using the double meshes and AP-TVM for efficacy and safety.
Method: We evaluated operative time, blood loss, postoperative CRP data, and complications, and compared them between LSC and AP-TVM.
Results: Compared to the AP-TVM group, the LSC group was characterized by small amount of blood loss (135.6±190.8ml vs. 54.8±59.2ml, p<0.05), and a longer operating time (154.6±38.8 minutes vs. 188.6±23.9 minutes, p<0.05), respectively. Surgical stress and complications rates were similar between LSC and AP-TVM (ns). No serious complications were noted.
Conclusion: Although LSC requires longer operating time. POP repair by LSC using the double meshes seems to be safe and has valid outcomes.

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Background: Total laparoscopic hysterectomy (TLH) has become popular for total hysterectomy in recent years. However, the procedure has higher incidence of ureteral injury as compared with abdominal total hysterectomy (ATH). Assessing for hydronephrosis is a useful method of checking for ureteric injury in postoperative follow-up.
Subjects/Methods: The 165 cases of TLH performed at this institution between 2009 and 2014 were retrospectively examined. We investigated the proportion of cases in which late-onset hydronephrosis manifested in the postoperative follow-up period, the surgical findings and clinical course of those cases.
Results: Of the 165 cases, hydronephrosis were observed in three cases (1.8%) during the follow-up period. all of three cases, severe adhesions made with difficulty to identify the ureter in the anterior approach. Hydronephrosis was diagnosed between postoperative days 47 and 82. Ureteral stent placement was performed in one case, the other two cases were observed with conservative follow-up. All of three cases, hydronephrosis have resolved between postoperative days 97 and 131.
Discussion: When severe adhesions necessitate the lateral or posterior approach to ureter identification, as in these cases, the requirement of dissection of periureteral tissue is more extensive as compared with anterior approach. It might be sought that more dissection made reduction of blood flow to the ureter and heat injury due to the energy devices, which could result in a hydronephrosis. In addition, if there is no damage to the ureter, cases of late-onset hydronephrosis may potentially be resolved with conservative management of ureter.

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Objective: Myomectomy is the most popular treatment option for women who have symptomatic myoma nodules and desire to preserve their child-bearing potential. Laparoscopic myomectomy (LM) has been increasingly performed owing to the advances in laparoscopic techniques and instruments. Whether the risk of uterine rupture is greater in LM than in abdominal myomectomy (AM) is yet to be clarified. This study was conducted to evaluate the vascularity of myometrial closure by using magnetic resonance imaging (MRI) and follow the healing process after myomectomy.
Methods: Between June 2013 and July 2014, 4 patients underwent AM and 28 women underwent LM. In all the AM cases (AM group), single interrupted or figure-8 sutures were used. On the other hand, continuous sutures were used in 12 LM cases (group LMa); and single interrupted sutures, in 16 (group LMb). After surgery, contrast-enhanced MRI was performed after obtaining informed consent from the patients. We evaluated the ratio of avascular-to-cross-sectional area of the myoma.
Results: Contrast-enhanced MRI performed 3 months after surgery revealed that the median (range) ratio of avascular-to-cross-sectional area in LMa was 5.0% (2.1%–9.0%), which was significantly larger than those in LMb (1.2%) and AM (0.4%). Although the ratio in LMa at 6 months after surgery was significantly reduced from that at 3 months after surgery, it was still larger than that at 3 months after surgery in LMb.
Conclusion: Vascularization of the myometrium was faster with interrupted sutures than with continuous sutures. We consider contrast-enhanced MRI as an effective examination method for evaluating myometrial vascularity after myomectomy.

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Objective: To evaluate the factors influencing operating time and intraoperative blood loss in patients undergoing total laparoscopic hysterectomy (TLH).
Methods: We enrolled 59 patients who had undergone TLH at our institution between March 2013 and March 2014. We examined the correlations between the operative time of each surgical procedure and uterine size (longitudinal diameter, occipitofrontal, diameter, and transverse diameter) and between operative time and body mass index.
Results: Regression analyses revealed that transverse diameter of the uterine corpus affected the operating time. In addition, we found that only the transverse diameter of the uterine corpus affected intraoperative blood loss while processing the cardinal ligament, and that body mass index affected the operating time while processing the suture of vaginal stump.
Conclusion: Transverse diameter of the uterine corpus is a factor influencing operating time.

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Objective: Cervical pregnancy is a rare condition with an incidence of less than 0.15% of all ectopic pregnancies. The cause of ectopic pregnancy is unknown, however a history of curettage or cesarean section is considered to play a role. We report a case of cervical pregnancy with infected abortion.
Case: A 44-year-old woman, gravida 4 para 2, with a history of 2 spontaneous abortions, presented to a local clinic with irregular vaginal bleeding, lower abdominal pain, and pyrexia. She had undergone a cesarean section at the age of 24 years, and curettage at the age of 40 years. She was admitted to our hospital under the diagnosis of infected abortion. Pelvic magnetic resonance imaging (MRI) indicated cervical pregnancy, ruling out the possibility of cicatricial pregnancy. Despite administration of intravenous antibiotics, she developed sepsis. Total laparoscopic hysterectomy was performed because of uncontrolled infection.
Conclusion(s): Pelvic MRI can efficiently differentiate cervical pregnancy from cicatricial pregnancy, and confirm the status of invasion of chorionic tissue, thus helping in the selection of an appropriate operation method. Total laparoscopic hysterectomy successfully removes the focus of infection in cases of unresponsiveness to intravenous antibiotics, and is the therapy of choice especially in those with no desire for childbearing.

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  Endometriosis is a common condition that affects women of reproductive age. It mainly occurs in the pelvis and involves the bowel in 3-37% of cases.
  We report a case of intestinal endometriosis accompanied by ileocecal obstruction. The patient was a 50-year-old woman, gravida 0, para 0 who was admitted for ileus to the local hospital. A cystic tumor was identified in her ovary. She was transferred to this hospital because of suspected ileus related to the ovarian cyst.
  Although an ileus tube was inserted, ileus did not improve, and a contrast study showed ileocecal obstruction. Ileocecal resection and salpingo-oophorectomy were performed laparoscopically for intestinal endometriosis and ovarian endometriotic cyst.
  Pathological examination confirmed the presence of endometrial tissue in the lamina propria mucosae and muscularis propria of the ileum. Seventeen months after surgery, there are no signs of intestinal endometriosis recurrence.

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  Low-grade Endometrial stromal sarcoma is a rare tumor that constitutes less than 1% of malignant uterine tumors. Because low-grade endometrial stromal sarcoma is located in the myometrium, it can be easily confused with uterine leiomyoma or adenomyosis uteri, so its diagnosis is often based on the postoperative pathology report. We present a case where low-grade ESS was diagnosed after a total laparoscopic hysterectomy (TLH) performed in the presence of an undiagnosed endometrial stromal sarcoma. A 48-year- old woman (who had had 4 pregnancies, 4 births) with a chief complaint of hypermenorrhea was referred to our department. Pelvic ultrasound and MRI revealed a degenerative interstitial leiomyoma that measured 23×20mm. We performed TLH. Histopathologic examination revealed a cellular neoplasm composed of spindle cells with myometrial invasion and lymphatic invasion. The tumor cells were positive for CD10 and for smooth-muscle actin, which resulted in the diagnosis of low-grade endometrial stromal sarcoma. After obtaining the patient's consent we performed bilateral salpingo-oophorectomy 3 months after the TLH. Lack of gross dissemination and negative peritoneal cytology were confirmed at the second surgery. The follow-up at 3 months after the second surgery TLH has been favorable.

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  Anti-N-methyl-D-aspartate (NMDA)-receptor encephalitis is a paraneoplastic encephalitide that causes various symptoms. It occurs especially in young women, with about 60% of cases being associated with ovarian teratoma.
  We report two cases of emergency laparoscopic surgeries for anti-NMDA-receptor encephalitis associated with ovarian teratoma.
Case 1: A 17-year-old woman had headache, fever and vomiting. A week later, she also had abnormal behavior and hallucination and entered hospital. CT scan detected left ovarian teratoma. As anti-NMDA-receptor encephalitis was suspected, she underwent laparoscopic left ovarian cystectomy. She needed post-operative respirator management for 2.5 months. Although discharged after 4.5 months, she was sent to a psychiatrist after 7 months because of domestic violence. The pathological diagnosis was an immature teratoma, but there is no sign of recurrence.
Case 2: A 26-year-old woman had fever, headache and fatigue. A few days later, she also had memory disorder and entered hospital. CT scan detected right ovarian teratoma. As anti-NMDA-receptor encephalitis was suspected, she underwent single incision laparoscopic right salpingo-oophorectomy. She needed post-operative respirator management for 9 months and left hospital after 1 year. The pathological diagnosis was a mature teratoma.
  Antibodies against NMDA-receptor were positive in both cerebrospinal fluids.
  Early diagnosis and surgery are important for quick recovery of anti-NMDA-receptor encephalitis associated with ovarian teratoma. Even so, patients don't necessarily recover quickly without aftereffects. We should review operative methods, because the patient is young and cannot agree and immature teratoma prevalence is high. Whether a tumor is benign or malignant, it is important to prevent leakage of tumor contents whenever possible.

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  An 80-year-old elderly woman with ovarian fibroma underwent single incision laparoscopic salpingo oophorectomy. On postoperative day 4, she complained of headache and dizziness, and she gradually developed disturbance in consciousness such as hallucinations and disorientation. Laboratory findings revealed severe low serum sodium concentration at 107 mEq/l, plasma osmolality at 219 mOsm/l, and a high urine sodium concentration at 72 mEq/l. Anti-diuretic hormone ( ADH ) level was elevated ( 4.6 pg/ml ) despite low plasma osmolality. Although severe intravascular dehydration findings such as tachycardia and hypotension were not observed, computed tomography imaging showed a flattened inferior vena cava, suggesting decreased extracellular volume. The pathogenesis underlying the hypotonic hyponatremia was diagnosed as mineralocorticoid responsive hyponatremia of the elderly, which is a subset of renal salt wasting syndrome, rather than a syndrome of inappropriate secretion of antidiuretic hormone. She was treated with fludrocortisone ( 0.1 mg/day ), following hypertonic and isotonic infusion.
  In elderly patients, postoperative complications, including electrolytes disturbance, may occur frequently, because of their reduced anti-stress capability. Careful postoperative management is required even in those patients who underdo minimally invasive endoscopic surgery.

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  Pelvic organ prolapse (POP) can be managed surgically by a variety of procedures either vaginally or laparoscopically with or without mesh graft. However, in cases of premenopausal women, choosing the best way to manage the disease is difficult, considering the high physical activity and the need for preservation of sexual function. Treatment of POP is more challenging when coexistence of a uterine myoma causes an anatomical deviation. A premenopausal 50-year-old woman presenting with POP-quantification stage 3 with 4.7 cm cervical myoma was successfully treated with laparoscopic sacralcorpopexy (LSC) by using double mesh, covering both the anterior and posterior vaginal walls widely. The patient is doing well without recurrence for 20 months after the surgery with the remaining cervical myoma in place. As we have many surgical alternatives now, choosing the best procedure adapting the conditions of individual patients is important.

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  Recently, the nose of laparoscopic surgery has increased. Laparoscopic surgery for early-stage uterine endometrial cancer has been covered by national health insurance since 2014.
  Therefore, since then, laparoscopic surgery for early-stage uterine endometrial cancer is likely to be performed more often. However, paraaortic lymphadenectomy is not covered by national health insurance. Generally, the frequency of lymph node metastasis and recurrence of early-stage uterine endometrial cancer is low, but pelvic and paraaortic lymphadenectomy is necessary when deciding the FIGO stage of uterine endometrial cancer. This is one of the main indications for adjuvant therapy. A patient who was considered in the low risk group experienced recurrence after laparoscopic surgery for early-stage uterine endometrial cancer. The recurrence was from paraaortic lymph node metastasis. This indicates that pelvic and paraaortic lymphadenectomy is necessary even in early-stage uterine endometrial cancer, and that attentive follow-up is required.

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  Interstitial pregnancy is a relatively rare type of ectopic pregnancy. Because intraoperative blood loss is greater than with other ectopic pregnancies, it was hard to perform laparoscopic cornual wedge resection for interstitial pregnancy in the past.
Aims: To evaluate the outcome of laparoscopic management of interstitial pregnancy.
Methods: Eight patients underwent laparoscopic cornual wedge resection for interstitial pregnancy with or without local methotrexate and vasopressin injection between June 2010 and May 2014 at St. Marianna University School of Medicine Hospital. The preoperative diagnosis, treatment, and outcomes were assessed.
Results: Ectopic pregnancy could be diagnosed preoperatively in all 8 patients based on serum HCG, vaginal ultrasonography, and contrast-enhanced computed tomography or magnetic resonance imaging. Interstitial pregnancy was diagnosed in 4 patients. The mean serum HCG level was 16517.0 mIU/ml (3255.3-71407.9 mIU/ml). Laparoscopic cornual wedge resection was performed successfully in 7 patients, but 1 patient required conversion to laparotomy because of abdominal adhesions. The mean of operating time was 121 min (90-151 min) and the mean blood loss was 51g (0-303 g). One patient subsequently achieved intrauterine pregnancy and was delivered by cesarean section.
Conclusions: Laparoscopic cornual wedge resection of interstitial pregnancy was performed in 8 patients. Interstitial pregnancy could be diagnosed in 4 patients using serum HCG or imaging. There is an elevated risk of uterine rupture after laparoscopic cornual wedge resection if serum HCG is high or pregnancy is longer than 6 to 7 weeks. Therefore, early diagnosis of interstitial pregnancy is important for successful laparoscopic cornual wedge resection.

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  A 24-year-old woman was referred to us because of persistent vaginal bleeding after curettage for a delayed miscarriage. Transvaginal color Doppler ultrasonography and MRI revealed a mass measuring 3 × 2 cm with abundant blood flow in the uterine cavity. Her hCG was 4.7 mIU/ml. We diagnosed retained placenta or placental polyp on the basis of the characteristic clinical findings. Hysteroscopic transcervical resection (TCR) was performed with perioperative endovascular placement of occlusion balloon in both internal iliac arteries. Endoscopy revealed a 3-cm broad-based yellow polypoid tumor on the posterior wall of the uterine corpus. The procedure lasted 23 minutes, and the inflation time of balloon catheters was 13 minutes. The estimated blood loss was small. There were no technique-related problems or complications. The sheath catheter was removed immediately after the operation. The pathological diagnosis was placental polyp. TCR with internal iliac artery balloon occlusion appears to be a good procedure for treating placental polyp.

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  A 38-year-old woman was referred to our department for bicornuate or septate uterus and primary infertility. Pelvic examination revealed a longitudinal vaginal septum and a doubled uterine cervix. Magnetic resonance imaging revealed a smooth fundus with a complete uterine septum and cervical duplication. Incision of the complete longitudinal vaginal septum was performed, followed by hysteroscopic complete dissection of the whole uterine septum with laparoscopic assistance. Intraoperative monitoring was performed using laparoscopy and transabdominal ultrasound. No intra- or postoperative complications were encountered. After surgery, no adhesions were found in the uterine cavity. She achieved pregnancy through in vitro fertilization after 8 months. She delivered a healthy baby at 39 weeks and 1 day of gestation. Hysteroscopic surgery is a promising method to treat a septate uterus. In this case, we performed a "septum section" by only cutting the septum without its complete resection from the uterus. Moreover, we incised not only the corporal portion but also the cervical portion of the septate uterus. These modified techniques are simple, rapid, and safe. Examination of more cases is needed to conclude the effectiveness of these methods.

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Objective : Mature cystic teratoma of the greater omentum is a very rare tumor which is difficult to diagnose accurately before treatment, and its origin is not yet clear. We experienced a case of mature cystic teratoma of the greater omentum resected by laparoscopic surgery.
Patient : The patient had a history of right salpingo-oophorectomy by laparoscopic surgery because of struma ovarii in another hospital. She was referred to our hospital after transvaginal ultrasonography in follow-up examination revealed recurrence of the tumor. Magnetic resonance imaging findings were suggestive of mature cystic teratoma of the right ovary, but given her right adnexa had been resected we diagnosed her mature cystic teratoma of left ovary.
We performed laparoscopic surgery. Intraoperatively the left ovary was normal, and there was no right adnexa. Careful examination of the abdominal cavity showed a 7 cm tumor in the inferior greater omentum. There was no tumor adhesion to the uterus or adnexa, and it was resected easily by a vessel-sealing device. Gross examination showed a tumor consisting of fat and hair, and the pathological diagnosis was mature cystic teratoma of the greater omentum.
Conclusion : It is important that ectopic mature cystic teratoma is considered when transvaginal ultrasonography findings are suggestive of tumor. Laparoscopic surgery is useful for the detection of accidental tumor in the abdominal cavity and for the resection of mature cystic teratoma of the greater omentum.

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  Several difficulties can be experienced during surgery of obese women with endometrial cancer, such as unclear surgical field view, bowel dysfunction, and wound dehiscence or infection after surgery, particularly, in laparotomy cases. However, many researchers report that obese women with early stage endometrial cancer can be safely managed through laparoscopy, with an excellent surgical outcome, shorter hospitalization, and less postoperative pain than those managed through laparotomy. We report the case of a highly obese woman with endometrial cancer who underwent laparoscopic modified radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. The patient was 43 years old, gravida 2, para 0, weighing 109 kg, with BMI of 44.8 kg/m², and diagnosed preoperatively with endometrial cancer stage IB (FIGO staging) and endometrioid adenocarcinoma of grade 2. The patient was placed on a MagicBed^® (vacuum posture fixing device) and the abdominal wall was lifted with fixation-tapes. Vital signs were recorded in various postures under general anesthesia, before all surgical procedures. Endclose^® was used for lifting up the uterus and for wound closure. Surgery was performed uneventfully under a clear operative view. The patient was discharged on the 6^th day. On the 17^th day, paclitaxel-carboplatin chemotherapy was initiated, as the histopathology results had revealed pelvic lymph node metastasis. The preparation and invention to the surgery resulted in satisfactory outcome without any complications, although the patient was obese. Considering the ergonomic aspects related to surgeons, further inventions are necessary for long and complicated surgeries such as the para-aortic lymph nodes dissection in case of malignant tumor.

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  We report a rare case of granulosa cell tumor in the broad ligament of the uterus which was diagnosed after laparoscopic surgery. The patient was a 29-year-old married woman, gravida 2, para 0. After visiting a previous hospital with a chief complaint of irregular menstruation, she was referred to our hospital for ovarian tumor diagnosis. Transvaginal ultrasonography showed a 5-cm tumor near the normal right ovary, and MRI also showed a mass containing cystic components and some solid elements located dorsal to the normal right ovary. Levels of the tumor markers CA19-9, CA125, and SCC were within their normal ranges. Based on these results, the patient underwent laparoscopic surgery for suspected right paraovarian tumor. A tumor growing in the right broad ligament was found, and laparoscopic resection of the right paraovarian tumor was performed. The histopathological examination showed an adult-type granulosa cell tumor. The patient has had no recurrence for 15 months since surgery.

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  We report a case of occult ovarian cancer diagnosed by histopathological examination after a laparoscopic surgery that was performed for endometrial cancer. A 57-year-old postmenopausal woman (gravida 0), who had a history of undergoing myomectomy 22 years ago, was referred to our hospital for positive Pap cytology of the endometrium. Uterine curettage biopsy examination revealed endometrioid carcinoma of grade 1. Magnetic resonance imaging showed thickening of the endometrium and an endometriotic cyst in the left ovary. The patient underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymphadenectomy. The pathological examination revealed endometrioid carcinoma in the uterine corpus and left ovary. Subsequently, she underwent omentectomy and para-aortic lymphadenectomy for staging of the ovarian cancer. No residual malignant lesions were identified. After the surgery, six cycles of a regimen of paclitaxel and carboplatin was administered. Moreover, there was no evidence of recurrence 10 months after the surgery. It is important to be aware of the possibility of coexisting ovarian malignancy with endometrial cancer, especially in patients of young age or in those with coexisting endometriosis.

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Objective: We experienced a rare case of lymph node recurrence in stage IA1 squamous cell carcinoma after conization, which was diagnosed using laparoscopic surgery.
Design: Case report.
Patient: A 44-year-old woman, who was previously diagnosed with stage IA1 cervical cancer following conization, was further diagnosed with multiple pelvic lymph node recurrences by laparoscopic surgery following computed tomography and [18F]-fluorodeoxyglucose-positron emission tomography-computed tomography.
Conclusion: Lymphatic recurrences are rare in stage IA1 squamous cell carcinoma of the cervix; therefore, patients with low-risk features could be safely followed-up after conization. When early-stage lymphadenopathy is identified in a patient, the laparoscopic approach might be a viable option for the diagnosis of pelvic lymph node recurrence.Furthermore, in a patient with stromal invasion likely of stage IA2 cervical cancer, like in this case, aggressive surgical management may be considered.

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  Laboratory animal training in gynecologic laparoscopic skills mainly uses the lower abdominal organs, whereas surgical laparoscopic training uses epigastric organs such as the stomach, liver, and gallbladder. This study evaluated the usefulness of training for gynecologists and surgeons that uses lower abdominal and the epigastric organs of the same animal. Training time for each department was 5 h. This report included analyses of the results of questionnaire surveys of 13 trainees (7 gynecologists, 6 surgeons). The problem of joint laparoscopic laboratory animal training in gynecology and surgery was "shortened training time" and "limitations of procedure". With respect to the degree of satisfaction with joint laboratory animal training in gynecology and surgery, most trainees replied that they were "satisfied". Laboratory animal training as a collaboration between gynecology and surgery reduces cost and can provide effective training.

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