Objective: This study was conducted to analyze whether preoperative magnetic resonance imaging (MRI) can be used as a predictor of difficult total laparoscopic hysterectomy.

Methods: The medical records of 107 patients who underwent total laparoscopic hysterectomy from August 2013 through December 2014 were examined. MRI was performed before operation. Data on uterine weight, surgery time, and blood loss were extracted from the medical charts of all patients. Using MRI, we measured the maximum longitudinal diameter, maximum anteroposterior diameter in the sagittal section, and maximum transverse diameter in the transverse section of each uterus. The approximate ellipsoid volume was estimated from MRI parameters. A correlation coefficient was calculated for the correlation between approximate ellipsoid volume and weight of the removed uterus. The patients were divided into two groups based on operative time (120 minutes) and blood loss (100 mL). We employed a receiver operating characteristic (ROC) curve analysis to determine the best cut-off point to predict difficult total laparoscopic hysterectomy.

Results: The average uterine weight was 326±196 g; operative time, 155±53 minutes; blood loss, 164±274 mL; and approximate ellipsoid volume, 380±225 cm³. As a result of the regression analysis, the regression equation Y (uterine weight) = 0.628X (approximate ellipsoid volume) + 116.4 (R = 0.746, P < 0.0001) was obtained. A strong correlation was observed between maximum transverse diameter and operative time and blood loss. The cut-off value in the ROC curve showed a tendency toward increased operative time and blood loss for a transverse diameter >81 mm and >70 mm, respectively.

Conclusion: The results showed that MRI is a useful preoperative indicator of the uterine weight. Preoperative MRI should be used as a screening procedure as it is a good predictor of difficult total laparoscopic hysterectomy. Our data suggest that total laparoscopic hysterectomy is difficult when removing a large uterus, having the greatest transverse diameter of more than 70 mm.

Objective: This study aimed to investigate the utility and safety of 2-port laparoscopic-assisted myomectomy (2P-LAM), performed without a morcellator, in comparison with conventional laparoscopic-assisted myomectomy (C-LAM).

Methods: We performed 41 laparoscopic-assisted myomectomies from January 2012 to July 2015. Ten patients underwent the 2P-LAM procedure, whereas the others underwent the C-LAM procedure. We performed a statistical analysis of differences in patient characteristics, size and number of myomas, surgery time, blood loss, white blood cell count, hemoglobin level, and C-reactive protein level between the two groups.

Results: There were no significant differences in patients background between the two groups. Furthermore, there were no significant differences in all perioperative variables.

Conclusion: Our results suggests that 2P-LAM is a useful reduced-port surgical method and a valid alternative to C-LAM. Therefore, as some procedures can be performed under direct vision, our new technique is easier to perform than the conventional technique.

Objective: The objective of this study was to evaluate the results of laparoscopic surgery for endometrial cancer covered by statutory health insurance-based care in our hospital.

Methods: The patients who received a diagnosis of stageIA endometrial cancer on preoperative pathological, magnetic resonance imaging, and computed tomographic examinations were treated with laparoscopic total hysterectomy and bilateral salpingo-oophorectomy. In some cases, additional pelvic lymphadenectomy and para-aortic lymph node biopsy were performed. After surgery, we evaluated patient age, operative time, blood loss, number of extirpated lymph nodes, pathological diagnosis, and surgery-related complications.

Results: This procedure was performed in 19 patients. The mean age was 56.5 ± 10.6 years; mean operative time, 309 ± 98 minutes; mean number of extirpated pelvic lymph nodes, 39.6±12.3; and mean blood loss, 250.3 ± 227.8 g. When reviewing 16 patients, excluding those with marked adhesion or large uterine myomas, the mean duration of total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy was 274 ± 76 minutes. The mean blood loss was 151.1 ± 185.8 g. The mean number of extirpated lymph nodes was 33.5 ± 7.7. To date, no surgery-related complications or relapses have been reported. Postoperative chemotherapy was performed for 7 patients (33%), and postoperative radiotherapy for 1 (6%). No adjuvant therapy was performed in the other 11 patients.

Conclusions: Laparoscopic surgery for early endometrial cancer is minimally invasive and postoperative recovery is short. It will be one of the standard treatments in the near future. Therefore, long-term prognosis should be analyzed among the different operative procedures in order to effectively introduce insurance coverage of such new medical technology.

Objective: The advanced energy devices (AED) bipolar-tissue sealing system (BTSS) and ultrasonic device can be used during total laparoscopic hysterectomy (TLH). When we resect the upper ligaments (the fallopian tube and utero-ovarian ligaments) and the cardinal ligaments using AED, it is often necessary to achieve further hemostasis using a bipolar device. The aim of this study is to compare the utility of two AED, BTSS and ultrasonic device, for TLH.

Methods: Our study sample included 20 patients; 11 patients that underwent TLH and resection of the upper and cardinal ligaments using the BTSS and 9 patients that underwent TLH and resection of the same ligaments using the ultrasonic device. We assessed the ligament transection time and the number of times the AED/bipolar devices were introduced and activated.

Results: There were no significant differences in the operation time or the transection times of the upper or cardinal ligaments between the groups. The number of times the AED were introduced and activated during the treatment of all ligaments did not differ significantly between the groups. However, bipolar devices were introduced and activated less often in the BTSS group during the treatment of all ligaments except the right upper ligaments.

Conclusions: Compared with TLH performed using the ultrasonic device, it is less necessary to carry out further hemostasis with bipolar devices when TLH is performed using the BTSS. We feel that the number of times the AED/bipolar devices were introduced was acceptable, and no significant differences in the operation time or the transection time of the upper or cardinal ligaments were observed between the groups.

Objective: Paraovarian cysts have a prevalence approximately 10% that of adnexal tumors, and it is a condition frequently experienced clinically. We conducted a retrospective clinical investigation of cases operated with paraovarian cyst surgery at our hospital.

Methods: The subjects were 145 cases of paraovarian cysts operated on between May 2009 and December 2014 at our hospital. A retrospective evaluation was performed on the preoperative examinations of the paraovarian cyst cases, surgical technique, surgical observations, frequency of torsion of the pedicle, and post-operative pathological diagnosis.

Results: The mean age of the patients was 38.7 years (13–82 years, median 36 years). The preoperative diagnosis was paraovarian cyst for 53 patients (36%), ovarian cyst for 54 patients (37%), and hydrosalpinx for 3 patients (2%). A total of 35 patients were diagnosed coincidentally during surgery (24%). The surgical approach was intracorporal laparoscopy in 131 patients (90.3%). Torsion of the pedicle was observed in 10 of the 145 patients (6.9%). Torsion of the pedicle occurred in only 19 of the 1,091 cases (1.7%) of ovarian cysts (excluding endometrial cysts) that were operated on in our hospital during the same time period. The histopathological diagnosis was a benign tumor in all cases, and there were no cases of borderline malignant tumors or malignant tumors.

Conclusions: Paraovarian cysts commonly arise in patients of reproductive age. The rate of onset of torsion of the pedicle is higher than that of ovarian cysts at our hospital. When taking the preservation of fertility into consideration, this surgery may be applied to ovarian cysts, even in asymptomatic cases. The majority of cases are benign tumors, and given that it is a condition that can occur in a wide range of ages, we believe that the application of minimally invasive laparoscopic surgery is appropriate.

  Uterine artery embolization (UAE) and transcervical resection (TCR) have been used to successfully treat placental polyps while preserving fertility. In untreated cases, reduced blood flow to the polyp has been documented during follow-up. In fact, we have seen natural recovery in some patients without treatment. In this report, we compare patients with a clinical diagnosis of placental polyp treated by observation alone versus UAE and TCR.

  Subjects included 13 patients diagnosed clinically with placental polyp at our hospital from January 2012 to December 2014. Seven patients underwent UAE and TCR and 6 patients were managed with observation. We compared age, time of onset, serum hCG level, polyp size, and blood transfusion requirement. Patients who underwent UAE and TCR showed more genital bleeding, or had been hope the next pregnancy early after abortion. One patient required blood transfusion, and fertility was preserved in all cases. Menstruation returned in five patients; one patient with a history of menstrual disorder did not show return of menstruation and one patient is currently lactating. Four patients became pregnant after the procedure.

  In patients managed with observation alone, time to confirmed cessation of blood flow on Doppler ultrasonography varied from postpartum day 25 to 201. The polyp was naturally discharged without a large amount bleeding in five patients, and one patient remains under observation. Blood flow loss period; there was no relationship between serum hCG level and polyp size at diagnosis.

  Because we were unable to estimate the duration of bleeding, it is desirable to perform observation in a facility capable of performing UAE and blood transfusion, if required. In cases where excessive bleeding occurred, treatment with UAE and TCR was effective.

Purpose: Laparoscopic surgery for endometrial cancer became covered by health insurance in Japan. As laparoscopic surgery for cervical cancer has been included in "advanced medical care", demand for such procedures for patients with early stage gynecological cancer is increasing. At our hospital, which is a public regional cancer center, total laparoscopic hysterectomy (TLH) has been newly introduced. We report on the first five cases treated with this procedure at our hospital.

Methods: An application was made to the ethical review board at our hospital for the new procedure. The first five cases required the cooperation of a certified doctor in other relevant hospitals. The patients included one case of atypical endometrial hyperplasia, two cases of stage Ia1 cervical cancer (following cervical conization), one case of intraepithelial adenocarcinoma of the cervix (following cervical conization), and one case of persistent high-grade squamous intraepithelial lesion (HSIL) that was initially treated with cervical conization. In each case, TLH and resection of adnexa and/or fallopian tubes was performed. The procedure was divided into six steps, and the time required for each step was measured.

Results: No serious complications occurred postoperatively. None of the patients required any further treatment, even though stage Ia1 infiltrating cervical cancer was found in the resected uterus of the patient with persistent abnormal cytodiagnosis. The time required for identification and severing of the uterine artery tended to decrease with each case. However, the time required for vaginal and peritoneal suturing did not improve.

Conclusions: TLH was successfully introduced in our hospital. Our results suggest that one appropriate indication for this procedure would be for cases of early stage cervical cancer following conization, as in this case, a positive oncologic outcome can be expected with a low risk of serious complications. Safe introduction of laparoscopic procedures requires coordination with other facilities and careful case selection at malignant tumor specializing hospitals that are not yet familiar with laparoscopic surgery. Gynecologic oncologists who are experienced in open surgery require practice using dry box training to learn suturing and ligature techniques to make the transition from open to laparoscopic procedures.

Objective: To evaluate the efficacy of optical access trocar with Kocher clamps in obese women.

Methods: We retrospectively analyzed 24 women who underwent gynecological laparoscopic surgery at the Nara Medical University from April 2008 to September 2015 and whose body mass index was over 30 kg/m². We inserted the first trocars by open access, closed access or optical access. In the course of this period, we modified optical access using Kocher clamps. The first step of optical access is to make an incision from the navel to the transversalis fascia, this was similar to open access. The next step includes pulling up the edge of the transversalis fascia using Kocher clamps. We evaluated the differences between the insertion methods.

Results: There were advantages in using optical access with Kocher clamps. One advantage was the significantly shorter time required to insert the first trocar compared with that required using open access (p = 0.0094). The frequency of failure to enter using optical access with Kocher clamps was also significantly lower compared with that of failure using other insertion methods (p = 0.0251). In addition, we observed no major organ injuries and required no blood transfusions.

Conclusion: Optical access trocar with Kocher clamps is a safe and fast technique for insertion of the first trocar during gynecologic laparoscopic surgery in obese women.

Objectives: The purposes of this study were to assess the appropriate operative procedures for adnexal masses during pregnancy and to determine what kind of pregnant women with adnexal masses are especially suitable for total laparoscopic ovarian cystectomy.

Design: A retrospective study was conducted in 17 patients who underwent surgical treatment for adnexal masses during pregnancy at our institution between January 2010 and November 2013.

Patients and interventions: Three pregnant patients with adnexal masses underwent open laparotomy and 14 underwent laparoscopic surgery. In the open laparotomy group, two patients had preoperative suspicion of ovarian malignancy and one patient was diagnosed with ovarian torsion at 17 weeks of gestation. In the laparoscopic surgery group, eight patients whose ovarian tumor size was less than 8 cm underwent total laparoscopic surgery and 6 patients whose tumor size was greater than or equal to 8 cm underwent laparoscopic-assisted surgery.

Measurements and main results: There were no intraoperative or major postoperative complications. Hospitalization was longer after laparotomy than laparoscopy. All patients' pregnancies after surgery were uneventful, except for that of one patient who developed gestational hypertension. All neonates were healthy and there were no fetal anomalies. Conclusions: Having an adnexal mass of less than 8 cm in size is a favorable indication for total laparoscopic ovarian cystectomy in pregnant women. For patients whose ovarian tumor size is at least 8 cm, cystectomy is the best option.

Objective: The purpose of this study was to determine the causes of massive blood loss during total laparoscopic hysterectomy (TLH).

Methods: A retrospective case study analysis of 453 patients who underwent TLH between April 2010 and April 2014 in our hospital was performed. Clinical characteristics of those with intraoperative blood loss more than 500 mL (group A) and those with less than 500 mL (group B) were compared. Furthermore, the mean intraoperative blood loss was compared between the group with cervical fibroma and that with fibroma at other sites, the group with complicated endometriosis and that without, and the group with history of abdominal surgery and that without. The surgical video records of each case in group A were carefully reviewed to find specific causes of massive bleeding.

Results: Intraoperative blood loss volume of 500 mL or more was present in only 10 patients (2.2%). Complication with endometriosis and a history of abdominal surgery were significantly more common in group A than in group B. No significant difference in mean surgical blood loss was observed by fibroma site (cervical vs other). Review of the videos revealed that massive blood loss occurred due to multiple reasons in some cases.

Conclusion: These results suggested that the complications of endometriosis, history of abdominal surgery, and their combination might induce massive blood loss during the TLH procedure.

Introduction: Endometrial polyps can cause infertility and their removal is recommended. Transcervical resection (TCR), which is commonly selected, is performed using a resectoscope under anesthesia. Recently, use of the Lin snare system (Snare) has been reported for polyp removal without anesthesia. Snare uses a diagnostic flexible hysteroscope with an outer diameter of 3.1 mm. However, the effects on infertility are unclear. We investigated infertile patients with endometrial polyps at our hospital and compared pregnancy rates based on the two different methods.

Materials and Methods: Between January 2008 and April 2014, we analyzed 64 patients who were postoperatively followed-up for at least 12 months. The patient backgrounds and pregnancy rates were investigated retrospectively for both groups. TCR was performed under general anesthesia, with hospitalization. Snare was used with no anesthesia and no cervical dilatation on an outpatient basis. Since the introduction of Snare at our hospital in 2012, it has been the first choice.

Results: No significant differences were observed between both groups for patient backgrounds. Pregnancy rates were 42.9% (21/49) in the TCR group and 60.0% (9/15) in the Snare group, indicating no significant difference. Five patients underwent both procedures. The two patients treated with Snare for post-TCR recurrence were both pregnant, and two of three patients who underwent additional TCR following difficulties with Snare were pregnant.

Conclusions: Our study indicated that the pregnancy rate after using Snare was not inferior to that after TCR. Our results suggested that Snare could be useful for polyp removal in the treatment of patients with infertility.

Objective: In postmenopausal women, the cervix atrophies and retracts, thus making conization increasingly difficult, and results in a tissue specimen that is frequently inadequate. Total hysterectomy is recommended in patients with positive conization margins or cervical intraepithelial neoplasia (CIN) who do not desire children. In such patients, we performed total laparoscopic hysterectomy (TLH). The aim of this analysis was to confirm the efficacy of TLH for the treatment of CIN.

Methods: The medical records of 39 patients who underwent TLH for CIN from August 2013 through December 2015 were examined. The preoperative biopsy sample and postoperative diagnosis were compared. TLH was performed using four trocars placed in a diamond configuration in the same manner as that for benign diseases. In principle, we used uterine manipulators. During vaginal incision, a vaginal pipe was inserted. Data on uterine weight, surgery time, and blood loss were extracted from the medical charts of all patients.

Results: The mean age of the patients was 50.5 years (range, 35-76 years), and 53.8% were postmenopausal. Among the 39 cases, 23 (59.0%) had the same pathological results, and 7 (17.9%) were undervalued by biopsy. In 8 cases, pathological assessment was extremely difficult or impossible because of crush artifacts and other factors. There was no persistence or recurrence of CIN after TLH. The average uterine weight was 139±162 g, surgery time was 119±41 minutes, and blood loss was 57±228 mL.

Conclusion: The results showed that TLH is almost identical to hysterectomy in terms of therapeutic efficacy, and that it should be accepted as a treatment for CIN. Our data suggested that adequate colposcopy is considered necessary for the accurate diagnosis of cervical lesions. It is necessary to recognize that pathological assessment is occasionally difficult.

Objective: Traditionally, laparotomy has been the main surgical treatment in gynecologic oncology. However, the recent development of various devices and the results of randomized controlled studies have enabled the introduction of total laparoscopic hysterectomy for early-stage endometrial cancer. The aim of this single-center study was to compare laparotomy and laparoscopy for endometrial cancer.

Patients: We analyzed a cohort of 68 patients who were diagnosed with Grade 1-2 endometrioid adenocarcinoma of stage IA and underwent laparotomy (n = 35) or laparoscopy (n = 33) at our hospital between January 2012 and December 2015.

Results: The estimated blood loss and the duration of hospital stay were significantly lower, and the operating time including lymphadenectomy was significantly shorter in the laparoscopy group than in the laparotomy group. There was no significant difference between the groups with regard to the operating time without lymphadenectomy. No blood transfusions were required, and there were no severe complications, deaths, or recurrences in the laparoscopy group.

Conclusion: Even in our hospital, which started providing laparoscopic surgeries recently, laparoscopic surgery for early-stage endometrial cancer was performed safely. One of the greatest benefits of laparoscopic surgery is the magnification of the operative fields and performing surgeries that require a high level of precision. Therefore, laparoscopic surgery seems to be suitable for patients requiring surgery in gynecologic oncology.

Objective: This study aimed to determine the appropriate timing of sexual intercourse by vaginal stump mucous membrane observation after total laparoscopic hysterectomy (TLH).

Methods: We retrospectively evaluated 50 patients who received TLH in Tokushima Red Cross Hospital by the same gynecologist between November 1, 2013, and March 31, 2015. We observed the vaginal stump mucous membrane by colposcopy at approximately 1, 3, and 6 months after TLH.

Results: Among 50 patients, 49 (98%) showed no healing at approximately 1 month after TLH, and 1 (2%) showed a state consistent with partial healing. At approximately 3 months after TLH, among 49 patients (one was unable to undergo a medical examination due to residing overseas), 3 (6.1%) showed no healing, 27 (55.1%) partial healing, and 19 (38.8%) complete healing. At approximately 6 months after TLH, among the total 50 patients, 1 (2.0%) showed partial healing and the other 49 (98.0%) complete healing.

Conclusion: At 6 months after TLH, almost all cases showed complete healing as regards the vaginal stump mucous membrane, and the trends observed herein can be judged as indicating the appropriate timing of sexual intercourse. However, individual differences must also be noted, as complete healing after TLH in 3 months would allow patients to engage in sexual intercourse at this time point.

Objectives: We retrospectively studied asymptomatic fallopian tubal ectopic pregnancies by pelvic magnetic resonance imaging (MRI).

Material and Methods: The study included 31 women with suspected asymptomatic ectopic pregnancies who underwent transvaginal ultrasound scanning, determination of human chorionic gonadotrophin level, and MRI at the Otsu Municipal Hospital. All women underwent laparoscopic or abdominal surgery, and histological examination revealed tubal pregnancy. We evaluated the following 4 key MRI features: presence of a gestational sac-like structure (GS), a surrounding acute hematoma with low-intensity attenuation on T2-weighted images (AH), an enhanced tubal wall on post-contrast images (ET), and/or high signal intensity on both T2- and diffusion-weighted images (DWI) outside the uterus.

Results: The 4 key MRI features had 100% sensitivity and 87.1% predictive accuracy for ectopic pregnancies. Among the 4 key MRI features, the presence of a GS had the highest level of sensitivity and predictive accuracy for asymptomatic tubal pregnancies. DWI also had a high degree of sensitivity. However, the presence of many patients without a final diagnosis of ectopic pregnancy showed the limitation of reliance on DWI.

Conclusions: Our results indicate that in patients with an asymptomatic fallopian tubal ectopic pregnancy, 4 key MRI features are an optimal diagnostic tool because of their 100% sensitivity and 87.1% predictive accuracy. MRI should be considered the gold standard for early diagnosis of tubal pregnancy. We conclude that MRI is more useful in laparoscopic conservative surgery for tubal pregnancy.

  OHVIRA (Obstructed Hemivagina and Ipsilateral Renal Anomaly) syndrome is characterized by double uterus, double vagina, one-sided vaginal obstruction that causes hemivaginal hematoma, and congenital renal defects on the same side as the hematoma. A woman generally develops this syndrome during her puberty, possibly before her first experience of sexual intercourse. The presence of these conditions often makes both, pelvic examination and transvaginal ultrasonography challenging for establishing a preoperative diagnosis of OHVIRA syndrome. Our 13-year-old patient underwent the following diagnostic procedures before the surgery: transvaginal ultrasonographic scanning, pelvic magnetic resonance imaging, and abdominal computed tomography; thereafter, transvaginal resectoscopic surgery for the obstructed vagina was performed successfully. A resectoscope gave a good transvaginal view in the small hemivaginal vault of each side.

  Isolated fallopian tube torsion is extremely rare; the preoperative diagnosis is challenging. Pregnancy complicates the pain localization as the intra-abdominal organs are displaced by the enlarged uterus. Here, we report a case of isolated fallopian tube torsion in the third trimester of pregnancy, which was successfully diagnosed with laparoscopy and unnecessary early termination of pregnancy was prevented. A 33-year-old woman, gravida 3 para 3, was referred to our hospital with a complaint of persisted severe right lower abdominal pain at 33 weeks of gestation. On physical examination, tenderness at the inside of the right anterior superior iliac spine was noted. Trans-abdominal ultrasonography revealed a cystic structure with solid mass, measuring 5.3 × 3.3 cm, at the point where tenderness was elicited. Because of the unremarkable past gynecological history and the pain localization, it was difficult to consider ovarian tumor pedicle torsion or degeneration of myoma. Therefore, diagnostic laparoscopy was performed, which revealed isolated right fallopian tube torsion. Therefore, she underwent laparoscopy-assisted right salpingectomy. The patient recovered fully, her pregnancy progressed well, and she delivered a healthy female baby at 36/5 weeks of gestation. It is necessary to suspect the possibility of isolated fallopian tube torsion when a cystic lesion is detected on trans-abdominal ultrasonography. Although the availability of an adequate field of surgery with laparoscopy is difficult in late pregnancy, laparoscopy is useful for determining the differential diagnosis of acute abdomen even in pregnant patients. Further studies are needed to determine the exact criteria for laparoscopic surgery during pregnancy.

  We experienced a case of ovarian cancer derived from a small endometrial cyst. Total simple hysterectomy, bilateral adnexectomy, and partial omentectomy were performed at the first operation, based on the pathological report of borderline tumor or more of the left ovary. The final pathological report of permanent specimens was endometrioid adenocarcinoma. Two weeks after the first operation, we performed laparoscopic staging surgery, including transperitoneal, laparoscopic paraaortic lymph node sampling.

  To date, we have performed transperitoneal, laparoscopic paraaortic lymph node dissection for 4 cases of ovarian cancer, including this case, and 6 cases of endometrial cancer. Our procedure is described here in detail. In this limited number of cases, the mean operative time was 132.6 minutes, mean blood loss was 88 ml, the mean number of retrieved paraaortic lymph nodes up to the left renal vein (up to B1) was 22.6, and the mean length of stay after this operation was 5.9 days. Severe complications were not observed in any of the cases, and there were no metastatic lymph nodes in this series.

  Our procedure of transperitoneal, laparoscopic paraaortic lymph node dissection appears safe and feasible.

Introduction: Cystic adenomyosis, which leads to a relatively rare clinical condition wherein a cyst is formed by repeated local hemorrhage from endometriosis of the myometrium, presents a difficulty in preoperative diagnosis. We report a case of a patient who was diagnosed with rupture of cystic adenomyosis using laparoscopic surgery.

Case: The patient was a 31-year-old nulliparous, nulligravid woman. Her past medical history was unremarkable. Her menstrual cycle was regular, occurring every 28–30 days. She visited the emergency department with a chief complaint of lower abdominal pain on the eighth day of her menstruation. Because a mass was found at the left adnexal region on computed tomography scan, she was suspected of having a gynecologic disorder and was referred to our hospital. At initial examination in our hospital, the patient had tenderness in the whole abdominal region. Transvaginal ultrasound sonography revealed that she had an 8-cm myoma and a 6-cm mass with an irregular border located at the left adnexal region. The mass was near the left ovary, and this matched the area with direct and rebound tenderness. Magnetic resonance imaging revealed a 6-cm mass with an irregular border with low-signal intensity, including partial and fairly high-signal intensities and mixed areas of high- and low-signal intensities on T1- and T2-weighted imaging, respectively. The imaging showed normal-sized bilateral ovaries. Based on the clinical course and image findings, subserosal myoma volvulus was suspected, and emergency laparoscopic surgery was performed. A large amount of clot was observed in the abdominal cavity. The bilateral adnexae were normal, whereas myoma-like masses were found in the uterus. One of these masses projecting from the anterior wall of the uterus ruptured with continuous hemorrhage. The mass was excised from its base through transection using an ultrasonic coagulation device. Histopathologic examination findings showed a mass with hemorrhage; the cystic wall showed zonal endometrioid glandular epithelia and interstitial changes. Smooth muscle bundles were found around the wall. Thus, this patient was diagnosed with a rupture of cystic adenomyosis. The postoperative course was good, and she was discharged five days after surgery.

Conclusion: As a rare example of a rupture of cystic adenomyosis, which was difficult to diagnose, we treated a patient with acute abdomen using laparoscopic surgery. Although rare, we think that a rupture of cystic adenomyosis should be considered as a cause for an acute abdomen.

Objective: Two types of nerve transection have been used to treat endometriosis-related pain at the time of laparoscopic conservative procedure. However, laparoscopic uterosacral nerve ablation (LUNA) carries the risk of causing parasympathetic nerve damage and has been reported to provide no pain relief. Conversely, although laparoscopic presacral neurectomy(LPSN) has been proven to achieve additional pain relief, it has a high level of technical difficulty and is associated with issues such as hemorrhage, constipation, or urinary urgency. Theoretically, the ablation of the left and right hypogastric nerves just before the inferior hypogastric plexus, where the sympathetic and parasympathetic nerves branching from the superior hypogastric plexus meet, makes it possible to selectively and safely resect only the sympathetic nerves. However, this surgical technique has not been reported. In this paper, we report a case of laparoscopic hypogastric nerve transection (LHNT).

Case: A 45-year-old, nulliparous woman presented with menstrual pain, chronic pelvic pain, and an endometriotic cyst in her left ovary. Laparoscopic left adnexectomy, ablation of the endometriotic lesion on the peritoneum, and bilateral LHNT were performed. Postoperative evaluation after 6 months indicated that the pain had improved, and no episodes of urinary urgency or newly developed constipation were observed.

Conclusions: Hypogastric nerves could be laparoscopically identified. LHNT was a feasible procedure and did not cause any clear impairments to urinary or bowel function. The results suggest that LHNT in combination with the currently performed endometriotic lesion removal in patients for whom postoperative hormonal agent use is difficult could reduce endometriosis-associated pain.

Objective: Peritonitis rarely occurs following surgery. Many cases can be cured with antibiotic therapy, but some cases are resistant to conservative treatment.

Case: A 54-year-old female underwent surgery for treatment of ovarian clear cell adenocarcinoma. Intraoperatively, the sigmoid colon was excised due to adhesions related to the left ovarian tumor. Pyrexia continued after surgery; as the symptoms and blood test suggested reoccurrence of inflammation was observed on postoperative day 6, computed topography was performed. Ascites and paralytic ileus were noted; however, no infectious source was identified. Antibiotic administration was initiated. However, since the blood test suggested the inflammatory reaction had worsened, laparoscopic examination was performed on the 14^th postoperative day, which showed intestinal dilation and erythema of the central pelvic peritoneum, and diffuse peritonitis was diagnosed based on the clinical and CT findings and white coating was found within the pelvis but the cause was not identified; therefore, the interior pelvis was cleaned and a drain was placed in the pouch of Douglas and left to provide postoperative drainage. Although the inflammatory reaction recurred on the 6th day after repeat surgery, the inflammation was improved and the patient was discharged on the 14th day after the second operation.

Conclusion: Laparoscopy was beneficial for the treatment of diffuse peritonitis resistant to conservative treatment, following surgery for ovarian cancer.

Case Report: A 27-year-old gravida 0 woman was referred to our hospital because of lower abdominal and anal pain. Transvaginal ultrasonography showed no gestational sac in the pelvis, and a hypoechoic lesion suspicious for a pelvic hematoma was seen in the cul-de-sac. Serum hCG level was 472.2 mIU/ml, and hemoglobin level was 11.0 g/dl. She had signs of peritoneal irritation. Therefore, we performed laparoscopy, which showed that the uterus, bilateral tubes, and both ovaries were entirely unremarkable. There were approximately 300 ml of blood and clots in the peritoneal cavity. On further exploration, there was a small bleeding site in the cul-de-sac, which was a suspected implantation site. Slight active bleeding was controlled by cauterizing the site using bipolar forceps. All clots were aspirated and sent for pathological examination, which revealed the presence of chorionic villi and trophoblastic and mesothelial cells, confirming a primary abdominal pregnancy. Her postoperative course was uneventful, and the patient was discharged on the 5th postoperative day with serum hCG level of 66.3 mIU/ml. In the month after surgery, the serum hCG level rapidly declined. In this case, the clinical findings met the criteria used to diagnose a primary abdominal pregnancy described by Suddiford, and the laparoscopic procedure was effective for diagnosis and treatment of peritoneal pregnancy.

  A 79-year-old woman who had diabetes mellitus, dementia, and breast cancer was referred to our hospital because of ascites. She had no respiratory syndrome. Blood tests revealed an elevated CA125 level (1,224 U/mL), but other tumor markers were within their normal limits. Chest radiography and abdominal computed tomography (CT) detected no signs of malignancy or tuberculosis, but positron emission tomography/CT disclosed abnormal FDG uptake in the omentum, mediastinal lymph node, and diaphragm. Microbiological testing and cytological examination of ascites yielded negative results. We conducted diagnostic laparoscopy while wearing N95 masks and found numerous tiny nodular lesions on the peritoneal surfaces. Pathological examination showed epithelioid granuloma and Langhans giant cells with caseous necrosis, which are characteristic to tuberculosis. Although the Ziehl-Neelsen staining result was negative, interferon-gamma release assays were positive. Tuberculous peritonitis (TBP) was diagnosed, and a combination drug regimen of isoniazid, rifampicin, and pyrazinamide was administered. She has been free from recurrence since the completion of chemotherapy. Throughout the clinical course, Mycobacterium tuberculosis was undetected. TBP is a form of abdominal and pelvic tuberculosis that accounts for about 0.04% of all cases of tuberculosis. The risk is increased in patients with cirrhosis, acquired immune deficiency syndrome, diabetes mellitus, steroid use, or underlying malignancy, and those undergoing continuous ambulatory peritoneal dialysis. TBP, which might be confused with widespread ovarian cancer, should be included in the differential diagnosis of ascites. Because preoperative diagnosis of TBP is difficult, laparoscopic surgery is helpful to distinguish TBP from ovarian cancer. We also suggest the importance of assessing the risk of infectiousness of TBP patients.

Background: Fitz-Hugh-Curtis syndrome (FHCS) is a condition of perihepatitis associated with gonococcal or chlamydial infection, characterized by perihepatic adhesions between the liver capsule and the diaphragm or the anterior peritoneal surface. The possibility of women with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) experiencing sexually transmitted diseases is very low. We report a rare case where a woman with MRKHS was detected with perihepatic adhesions accidentally during laparoscopic surgery.

Case report: A 73-year-old virgin patient, who had established MRKHS, presented with right ovarian tumor. Magnetic resonance imaging revealed dermoid cyst of the right ovary and we performed laparoscopic surgery. Surgery was successful, but we found violin-string adhesions between the liver capsule and the anterior peritoneal surface. The serum tested negative for chlamydial IgA and IgG.

Comment: This case shows that perihepatic adhesions can occur because of reasons other than gonococcal or chlamydial infections.

  We present a case of complete androgen insensitivity syndrome (CAIS) treated by laparoscopic gonadectomy. Case: A 19-year-old phenotypical female, who complained of primary amenorrhea, was referred to our hospital. Physical examination revealed the absence of the proximal vagina and female external genitalia. Pelvic magnetic resonance imaging revealed bilateral pelvic masses, and the absence of both the uterus and the vagina. Hormonal examination revealed elevated serum testosterone level at 8.3 ng/mL (normal values in female adults, 0.06-0.86 ng/mL). Her karyotype was 46,XY. Therefore, we diagnosed complete CAIS. She underwent laparoscopic gonadectomy. Histopathological examination showed immature seminiferous tubules and Leydig cells in both gonads. Her postoperative course was uneventful and she was discharged on postoperative day 5. She is being treated with and will continue to receive hormone replacement. Care for patients with CAIS needs to be individualized, flexible, and holistic because they are often raised socially as women. Laparoscopic gonadectomy in patients with CAIS is useful, because it is less invasive and has improved cosmetic results compared with open surgery.

  Lipiodized oil has been widely used for hysterosalpingography because it has superior imaging capability. We report a case of prolonged retention of lipiodized oil suspicious for foreign material in the abdomen. A 34-year-old woman who had undergone hysterosalpingography for evaluation of primary infertility visited our hospital with complaints of lower abdominal pain. She was found to have a metal-like shadow in the right side of the pelvis that was present on abdominal radiography performed at another facility. Computed tomography showed a high absorption range with halation in the right side of the pelvis. We suspected retention of metallic material because she had a history of cesarean section in our hospital several years prior, but we did not consider the likelihood of prolonged retention of lipiodized oil. Laparoscopic surgery was performed for diagnosis. During the operation we did not find any metallic material in the pelvis; we confirmed the position of the mass by using X-ray imaging and resected a cystic mass from the right side of the pelvis. The cyst showed high absorption on radiography and contained a yellowish oily fluid. We carried out a combustion experiment and it was found that the oily fluid included iodine; we therefore concluded that the cystic mass was due to prolonged retention of lipiodized oil rather than metallic material. It is necessary to consider the possibility of prolonged retention of lipiodized oil in patients with a history of hysterosalpingography.

  An ovarian carcinoid tumor is rare and is classified as a borderline malignant tumor. We report a case of stromal carcinoid tumor arising in a mature cystic teratoma of the ovary, which was managed with diagnostic and therapeutic laparoscopic surgery. A 31-year-old woman with constipation had a right ovarian tumor identified on a postnatal medical examination. Magnetic resonance imaging revealed a 10-cm tumor in the right ovary with multiple cystic components. We performed a laparoscopic right salpingo-oophorectomy. Histological analysis showed that the right ovarian mass contained stromal carcinoid tumor in a mature cystic teratoma. In conclusion, although an ovarian tumor demonstrates characteristics typical of a mature cystic teratoma, accompanied by constipation, it may include small borderline malignant lesions. In general, ovarian carcinoid tumors are slow growing, and have a good prognosis, but some cases of metastasis or recurrence have been reported. Therefore, these borderline tumors require careful evaluation

  Here we report on a case of an external iliac artery injury that occurred during total laparoscopic radical hysterectomy that was managed laparoscopically.

  The patient was a 41-year-old woman, gravida 6 para 1, who underwent a total laparoscopic radical hysterectomy for the treatment of clinical stage IB1 cervical adenocarcinoma. The right external iliac artery was lacerated during the monopolar dissection of a broad ligament, which induced severe bleeding. The bleeding was stopped by grasping of the lacerated site with an atraumatic grasper. An endovascular clip was placed both proximal and distal to the lacerated site, which was repaired with an uninterrupted intracorporeal suture. The endovascular clips were then removed and hemostasis was confirmed. The right external iliac artery was occluded for a total of 28 minutes. The laparoscopic surgery did not require a laparotomy.

  The patient has since been followed up for 14 months without recurrence or complications in the right lower extremity.

  This case demonstrates that we must practice stopping severe bleeding and making efforts to prevent it.

  Tumors of the appendix sometimes mimic right ovarian tumors. In postmenopausal women, distinguishing between these tumors preoperatively is difficult because the normal ovarian structures cannot be confirmed. We experienced a case of a mucinous cystic tumor of the appendix that was preoperatively misdiagnosed as an ovarian cyst. The patient was a 67-year-old postmenopausal woman with a growing cystic mass in the right adnexal region. Transvaginal ultrasonography revealed a cystic lesion 47 × 24 mm in diameter in the region of the right adnexa. Magnetic resonance imaging showed similar findings. During laparoscopy, the cystic lesion was found to be a distended appendix. Based on histologic examination following laparoscopic appendectomy, low-grade appendiceal mucinous neoplasia (LAMN) was diagnosed. This tumor should be considered in the differential diagnosis of right lower abdominal cysts.

  Atypical polypoid adenomyomas (APAMs) are rare uterine tumors that occur predominantly in premenopausal women. They are benign mixed epithelial and mesenchymal tumors; however, they may recur after treatment, and may coexist with complex atypical endometrial hyperplasia (C-AEH) and endometrial carcinoma.

  A 36-year-old woman presented to our facility with infertility and intrauterine tumor. She underwent transcervical resection and laparoscopic tubectomy for in vitro fertilization-embryo transfer. Pathological examination after surgery revealed APAM with CAEH. Subsequently, the patient was treated with medroxyprogesterone acetate to preserve fertility.

  Optimal management of APAM has not yet been established. However, fertility preservation should be considered, under close monitoring, for women who desire to get pregnant.

  We performed a two-stage laparoscopic surgery in granulosa cell tumor of juvenile type. It was controversial that borderline tumors of the ovary were safely treated by laparoscopy.

  A 12-year-old woman was referred to our hospital for irregular menses. Magnetic resonance imaging (MRI) of the pelvis revealed a 6cm-sized solid and cystic mass, and uterine endometrium was thick. Serum estradiol was high level, and LDH and AFP were within normal limits. The laparoscopic procedure was done. The tumor was soft, and we could strip the tumor from right ovary easily. Microscopically, tumor cells which were composed hyperchromatic nuclei, eosinophilic or clear cytoplasm showed in a diffuse sheet-like pattern or in loose short fascicles or a trabecular growth fashion. Mitotic figures were encountered in some areas. The feature was compatible with granulosa cell tumor of juvenile type. A two-stage laparoscopic surgery performed was right salpingo-oophorectomy.

Introduction: Delayed diagnosis of tubal pregnancy may cause intra-abdominal hemorrhage secondary to tubal rupture or tubal abortion and progress to a shock state. Recent advances in transvaginal ultrasound devices and simplified measurement of blood hCG levels have made it possible to perform early pregnancy diagnosis before the onset of symptoms and to provide early treatment. We describe a patient with an ampullary tubal pregnancy in whom the fetus grew until week 11 of gestation without resulting in either rupture or miscarriage. This patient could be treated with laparoscopic surgery.

Case presentation: The patient was a 37-year-old woman, gravida 0, para 0. Pregnancy had been achieved using artificial insemination at a nearby clinic. She received a diagnosis of pregnancy with uterine malformation and was referred to our hospital at 10 weeks and 5 days of gestation. The blood hCG level was 154,243.8 IU/L. A pregnancy in the left rudimentary uterine horn of the right unicorn uterus was suspected based on ultrasound and MRI examination. At 11 weeks and 1 day of gestation, she underwent laparoscopic surgery under general anesthesia. She had a small amount of hemorrhagic ascites and the uterus was normal in size without findings of uterine malformation; accordingly, pregnancy in the rudimentary uterine horn and abdominal pregnancy were both ruled out as possibilities. The fimbria of the fallopian tube was enlarged to 80 mm in size from the left ampulla of the uterine tube, and she thus received a diagnosis of left ampullary tubal pregnancy. She underwent left salpingectomy, and the fetus and chorionic tissue were confirmed internally. The right adnexa showed no abnormal findings.

Conclusion: Normally, preoperative diagnosis of tubal pregnancy is difficult because it is considered unlikely that such a pregnancy would continue until week 11 of gestation asymptomatically; therefore, laparoscopic diagnosis under direct vision was needed in this case.

  Bowel endometriosis sometimes causes repeated intestinal obstruction during menstruation. Recently, there are an increasing number of cases of bowel endometriosis treated with laparoscopic bowel resection. We had a case of ileal endometriosis with recurrence of intestinal obstruction during menstruation. A 34 year-old woman was referred with a left ovarian endometrioma 4 cm in diameter. She had just recovered from conservative treatment of intestinal obstruction, which had developed during menstruation. We planned a laparoscopic cystectomy of her left ovarian endometrioma. She relapsed with intestinal obstruction during menstruation, which was again treated conservatively. Computed tomography at the onset of intestinal obstruction showed stenosis of the distal ileum. Ileal endometriosis was suspected as the cause of this stenosis. Her next menstrual period was estimated to overlap with the planned laparoscopic operation. Another recurrence of intestinal obstruction during her next menstruation could necessitate a delay in the operation, or a conversion to laparotomy. She was treated with dienogest for prevention of intestinal obstruction recurrence for one month before the operation. Concurrent laparoscopic resection of the left ovarian endometrioma and ileal endometriosis was performed as scheduled without recurrence of intestinal obstruction. Pathological examination confirmed ileal endometriosis and left ovarian endometrioma. No recurrence of either ovarian endometrioma or intestinal obstruction has been detected for one year after the operation. Our experience suggests that it would be better to avoid planning laparoscopic surgery during menstruation in suspected bowel endometriosis, or to start drug treatment to prevent endometriosis-associated bowel obstruction.

Prolusion: The syndrome of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) was initially reported in 1922. An accurate diagnosis can typically be made on the basis of patient history and examination, and appropriate imaging, in combination with pathological diagnosis of the vaginal (or perivaginal) cystic wall. A definitive treatment is vaginoplasty to relieve the obstruction. In our case, a minimally invasive transvaginal endoscopic procedure helped in the diagnosis as well as treatment of this condition.

Case report: A 22-year-old virgin girl with a chief complaint of lower abdominal pain was referred to our hospital. Pelvic examination, ultrasound, computed tomography, and magnetic resonance imaging revealed uterus didelphys, left ovarian cyst, and right renal agenesis, and raised a suspicion of an obstructed right vagina. Diagnostic flexible transvaginal endoscopy indicated a flat hemivaginal septum with a pinhole and left uterine cervix, but no right cervix. A preoperative diagnosis of OHVIRA syndrome and left ovarian cyst was made. Laparoscopic left ovarian cystectomy was initially performed. Then, the vaginal septum bulged by injection of saline through the ureteral stent (5Fr) introduced using an angle-type guide wire was fenestrated through a transvaginal endoscopic incision. The patient reported no symptoms at her follow-up visit 28 months after the surgery.

Conclusion: Transvaginal endoscopy is a minimally invasive technique that facilitates the definite diagnosis, and enables safe and precise treatment of OHVIRA syndrome.

  The preoperative diagnosis of malignant transformation of a mature cystic teratoma is difficult. A 33-year-old woman received laparoscopic cystectomy under the diagnosis of a mature cystic teratoma, and the frozen biopsy result indicated squamous cell carcinoma arising from the mature cystic teratoma. On the same day as the biopsy, we performed right adnectomy, followed by total hysterectomy, left adnectomy, low anterior resection of the rectum, and omentectomy, 1 month after the first surgery. At the second surgery, the tumor had spread to the intra-pelvic cavity, omentum, and biopsy wound scar. Even in patients aged less than 40 years with a tumor size less than 10 cm, we need to check for the presence of squamous cell carcinoma and examine the findings on magnetic resonance imaging thoroughly.

  Atypical polypoid adenomyoma (APAM) is a rare uterine tumor that occurs predominantly in premenopausal women. The clinical management of APAMs remains to be established. We report the case of a 46-year-old nulliparous patient who underwent hysteroscopic transcervical resection (TCR) for an atypical polypoid adenomyoma or adenofibroma. As the cervical myoma involved the uterus, the tumor (3.6×2.4 cm) could not be resected completely because of the risk of perforation of the uterus. The patient chose watchful waiting instead of our advice of hysterectomy or further treatment. The residual tumor measured 3.8×1.5 cm after TCR and had grown to 4.8×1.0 cm 6 months later. Furthermore, endometrial biopsy revealed that the APAM had low malignant potential. Subsequently, she underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. The final diagnosis was APAM.

Objective: While the use of reduced port surgery is increasing, problems remain with respect to specimen retrieval. In our department, retrieval was previously performed through an 11mm port when operating on adnexal diseases. We are currently exploring the use SLIM BAG II (Hakko Co., Ltd.) for retrieval through a 5 mm port. In this retrospective study, we investigated the feasibility and efficacy of using SLIM BAG II in laparoscopic surgery applied to adnexal diseases.

Methods: Between March 2014 and October 2015, 86 patients underwent laparoscopic surgery in our department. These included 36 cases of ectopic pregnancy and 50 cases of other adnexal diseases. Among the ectopic pregnancy surgeries, 12 employed SLIM BAG II using a 5 mm port, and 24 employed probe covers with access through a 11mm port. The SLIM BAG II was used for all 50 surgeries for other adnexal diseases. A total of 62 surgeries were performed using SLIM BAG II, 27 employing small bags, and 35, regular sized bags. We assessed the surgeries with regard to the specimen size, operative time, amount of bleeding, complications, retrieval time, and inflammatory response.

Results: There were no complications in any of the 62 surgeries employing SLIM BAG II. The mean specimen size was 34.0±17.2 mm in surgeries using the small bag, and 51.5±27.5 mm in those using regular sized bags. There were no bag size changes during any of the operations. In the cases of ectopic pregnancy, there were no significant differences between the SLIM BAGII and probe cover groups with respect to retrieval times, C-reactive protein levels (postoperative day 1), or pain. White blood cells (postoperative day 1) showed no increase in the SLIM BAG II group, while an increase was observed in the probe cover group (5.97±2.75 vs 8.62±2.79; p=0.005). There was no specimen retrieval leakage in the SLIM BAG II group, but it occurred in three cases in the probe cover group (12.5%).

Conclusion: This study showed that SLIM BAG II was feasible and safe for specimen retrieval via a 5 mm port, indicating that the use of these bags could contribute to reduced port surgery. SLIM BAG II is especially recommended for use in extracting thin-walled specimens in adnexal surgeries for ovarian endometrioma, paraovarian cysts, hydrosalpinx, ovarian serous cystadenoma, and ectopic pregnancy.

Objective: Prevention of adhesions is important after a surgery. Although a sodium hyaluronate- and carboxymethylcellulose-based membrane is useful as an adhesion barrier, its properties make it difficult to insert into the abdominal cavity. We developed a method for inserting a sodium hyaluronate- and carboxymethylcellulose-based membrane into the abdominal cavity via a 5-mm trocar.

Methods: Each sodium hyaluronate- and carboxymethylcellulose-based membrane sheet (total 2 sheets) was cut into 8 pieces. Two pieces were moistened using steam, with one piece on placed top of another over a thermos bottle. The sodium hyaluronate- and carboxymethylcellulose-based membrane pieces were rolled around a forceps and inserted into the abdominal cavity via a 5-mm trocar. This method was used in 10 cases (8 times per case, total 80 times).

Results: The average time required for inserting the sodium hyaluronate- and carboxymethylcellulose-based membrane pieces (8 times) was 333 seconds (250 seconds–434 seconds). The success rate of insertion and attachment of the membrane was 92.5% (74 / 80). In 6 cases, failure occurred at the step of spreading the rolled up pieces after inserting them into the abdominal cavity.

Conclusions: This new method is effective for inserting sodium hyaluronate- and carboxymethylcellulose-based membranes into the abdominal cavity without requiring special tools.

  Complete androgen insensitivity syndrome (CAIS) is caused by genetic defects associated with vaginal and uterine agenesis in women with a 46,XY karyotype. These defects cause the body to be unable to respond to androgen. CAIS is associated with abnormal testicular development, and gonadectomy is generally recommended in early adulthood to avoid the risk of germ cell malignancy. The procedure is managed laparoscopically if the gonads are intra-abdominal. However, there has been no report of a detailed method of laparoscopic gonadectomy in a CAIS patient with inguinal canalicular gonads. Herein, we report a case of CAIS in siblings. In case of the elder sibling, the palpable inguinal canalicular gonads were removed via inguinal incision. In the case of the younger sibling, the right palpable inguinal canalicular gonad and the left unpalpable inguinal canalicular gonad were removed through laparoscopic gonadectomy. The surgical procedures for laparoscopic gonadectomy are described.