Objectives: Pelvic organ prolapse (POP) is common and increasing along with the aging of the Japanese population. After beginning to perform laparoscopic sacral colpopexy (LSC) at our hospital in 1999, we sought the best procedure for the first few years, eventually settling upon vaginal total hysterectomy (VTH) + colporrhaphy + LSC as our basic method. Herein, we review and report our surgical outcomes.

Methods: During January 2001 – December 2014, we performed LSC in 107 patients. We reviewed their cases retrospectively using medical records. Follow-up data were available for 104 patients. We divided patients into five groups by operative procedure: Group 1 (62 cases), VTH + colporrhaphy + LSC; Group 2 (10 cases), colporrhaphy + LSC; Group 3 (11 cases), total laparoscopic hysterectomy (TLH) + LSC; Group 4 (8 cases), LSC (uterus preserved); and Group 5 (13 cases), double mesh LSC.

Results: For Group 1, the mean operating time (MOT) was 111.2 min, with mean estimated blood loss (MBL) of 62.9 ml. For Group 2, MOT was 108.5 min; MBL was 32.5 ml. Group 3 patients showed MOT of 168.2 min and MBL of 89.2 ml. Group 4 patients showed MOT of 118.5 min and MBL of 36.3 ml. For Group 5 patients, the MOT was 107.7 min and MBL was 40.4 ml. Recurrence occurred in each of Groups 3 and 4. No complication was found in any patient.

Conclusion: Results demonstrate that our LSC can be performed safely, with low risk of POP recurrence.

Objective: We aimed to confirm the safety of total laparoscopic hysterectomy (TLH). We compared surgical morbidity in laparoscopically-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy (LH), and TLH in the treatment of benign gynecologic diseases.

Methods: We conducted a retrospective study and evaluated 69 patients who underwent LAVH (n=34), LH (n=12), or TLH (n=23) between January 2014 and April 2016 at Otsu Municipal Hospital. LH and TLH were performed with the Koh colpotomizer system. TLH was performed with ligation of the uterine artery and identification of the ureter. The results were examined statistically according to patient age, nulliparity rate, body mass index, median uterine weight, postoperative C-reactive protein level, operative complications, operative blood loss, and operative time.

Results: Median age, nulliparity rate, median body mass index, median uterine weight, median postoperative C-reactive protein level, and operative complications showed no significant differences among the three groups (P>0.05). While the median operative time in the TLH group was longer (LAVH: 198, LH: 184.5, TLH: 220.0 min, P>0.05), there were no statistically significant differences among the three groups. The median intraoperative blood loss in the TLH group was significantly less than that in the LAVH group (LAVH: 245.5, LH: 107.5, TLH: 50.0 ml, P<0.01).

Conclusions: TLH with use of the Koh colpotomizer system, ligation of the uterine artery, and identification of the ureter were useful and safe operative methods

Objective: To compare local anesthesia (LA) versus transversus abdominal plane + rectus sheath block (TAP + RS) in terms of postoperative analgesia use following gynecologic laparoscopic adnexal tumor surgery.

Method: The present study retrospectively collected information from 71 patients treated with LA or TAP + RS, and examined postoperative analgesia use following laparoscopic adnexal tumor surgery between April 2013 and March 2015. The surgical procedures included ovarian resection or cystectomy. Postoperative pain was measured using a numerical rating scale immediately after the operation, and 1 h, 3 h, 6 h, 12 h, and 24 h later. The time (in minutes) to first analgesic use following the operation was analyzed.

Results: There were no significant differences in the time to postoperative analgesia use between the LA and TAP + RS groups at all time points examined.

Conclusion: LA appeared to have an effect equivalent to that of TAP + RS in terms of postoperative analgesia use in patients undergoing gynecologic laparoscopic surgery.

Objective: According to the Treatment Guidelines for Uterine Body Cancer by the Japan Society of Gynecologic Oncology, pelvic lymphadenectomy can be omitted in patients with endometrial adenocarcinoma G1 or G2, ≤1/2 myometrial invasion, and no findings of extrauterine lesion. We aimed to identify indications for omitting pelvic lymphadenectomy in selected cases by reviewing cases of total laparoscopic hysterectomy (TLH) for early-stage endometrial cancer retrospectively.

Methods: The study subjects were 17 patients with atypical endometrial hyperplasia complex (AEHC) or stage IA endometrial cancer (endometrial adenocarcinoma G1/G2) who underwent TLH in our department between April 2013 and March 2015. We compared preoperative histopathological diagnosis and imaging findings with postoperative histopathological diagnosis.

Result(s): Twelve patients (AEHC, n = 6 and endometrial cancer, n = 6) had no myometrial invasion and 5 (AEHC, n = 1 and endometrial cancer, n = 4) had ≤1 or 2 myometrial invasions on preoperative magnetic resonance imaging. In the postoperative histopathological study of the patients with endometrial cancer, none of the patients had a myometrial invasion before surgery, 1 patient had no myometrial invasion, 2 had <1 or 2 myometrial invasion, and 3 had ≥1 or 2 myometrial invasion. In the comparison between the preoperative and postoperative histology, 4 cases of AEHC and 3 cases of stage IA endometrial cancer showed progression. Five patients received postoperative adjuvant therapy, and 2 patients had a recurrence.

Conclusion(s): Pelvic lymphadenectomy in patients with a low risk of recurrence could be omitted. However, some cases showed progression based on postoperative histology. Thus, further study about the indication for omitting lymphadenectomy seems necessary.

Objective: This study aimed to estimate the incidence of surgical site infection (SSI) and identify its risk factors, in patients who underwent laparoscopic surgery.

Method: A retrospective analysis of our hospital's database was performed. Patients who were diagnosed with adnexal tumor or ectopic pregnancy and underwent laparoscopic surgery for the same between April 2012 and March 2016 were included. The following risk factors were studied: the amount of bleeding during surgery, operative approach (single-port or multi-port), operative procedure (cystectomy, salpingo-oophorectomy or salpingectomy), duration of the surgery, history of diabetes mellitus (DM), body mass index (BMI) and age. For each factor, univariate analysis was performed. Then multivariate analysis was performed for the factors found to be significant.

Result: A total of 326 laparoscopic surgeries were performed during the period. The incidence of SSI was 1.8% (6/326). The study found that all of the patients who were diagnosed with SSI were operated upon using the approach of single-port laparoscopy. Furthermore, univariate analyses showed that advanced age, single-port operative approach and the procedure of salpingo-oophorectomy were significant risk factors for SSI (p<0.05). However, these three factors were mutually confounding. Multivariate analysis indicated that advanced age (odds ratio: 1.07; 95% confidence interval, 1.02-1.13) was the most significant risk factor for SSI.

Conclusion: According to this study, SSI was associated with advanced age. However, older patients often opted for salpingo-oophorectomy, which was often performed via the single-port laparoscopic approach in our hospital. These three factors - age, salpingo-oophorectomy and single-port laparoscopic surgery - were significantly correlated with each other and are confounding factors. Hence, we need to have a high index of suspicion to prevent SSIs, especially for older patients who undergo single port laparoscopy gynecological surgeries.

Objective: Clinical features of mature ovarian teratoma cases were investigated.

Methods: A total of 185 patients with mature ovarian teratoma surgically treated at our hospital between 2009 and 2013 were included in this study. Clinical data were obtained from patients' medical records. Clinical variables were analyzed by student's t-tests. Pearson correlation analyses were performed to analyze the correlation between tumor size and tumor markers (squamous cell carcinoma antigen (SCC) and CA19-9).

Results: Pearson correlation coefficients between tumor size and SCC, and tumor size and CA19-9 were 0.270 and 0.413, respectively. Age, tumor size, and squamous cell carcinoma antigens in the laparotomy group were significantly higher than those in the laparoscopy group. In the salpingo-oophorectomy group, only age was significantly higher than that in the cystectomy group.

Conclusion: Age, tumor size, and squamous cell carcinoma antigens may affect the decision to perform laparotomy in mature teratoma patients. Since tumor markers are related to tumor size, we should consider the possibility of the effect of tumor size in cases of ovarian mature teratomas with abnormal tumor markers.

Objectives: To evaluate the efficacy of a new snare system for hysteroscopic polypectomy with a small-caliber diagnostic flexible hysteroscope.

Method: We performed a retrospective analysis of 512 women who underwent hysteroscopic polypectomy with a small-caliber diagnostic flexible hysteroscope using the Lin polyp snare system between January 2011 and July 2016 at Kawasaki Municipal Hospital.

Results: The mean age was 39.1±7.4 years (range, 22 to 81 years). Indications for hysteroscopy were infertility (n=201, 39%), abnormal uterine bleeding (n=138, 27%), menorrhagia (n=88, 17%), abnormal ultrasound findings (n=79, 15%), and others (n=6, 1%). In 301 women (59%), polyps were removed by using the Lin snare system, whereas in 182 women (36%), the Lin snare system and a Lin polyp grasper were used. In 17 women (3%), the specimens could not be retrieved after cutting the polyps. The pathological diagnoses were endometrial polyps (n=372, 73%), endometrium (n=67, 13%), endometrial hyperplasia complex (n=10, 2%), atypical endometrial hyperplasia (n=6, 1%), adenomyoma (n=2, 0.4%), atypical polypoid adenomyoma (n=2, 0.4%), endometrioid adenocarcinoma (n=1, 0.2%), leiomyoma (n=1, 0.2%), and cervical polyp (n=1, 0.2%). There were 29 failed procedures (6%). No complications other than bleeding for several days were encountered.

Conclusions: By using the Lin snare system, endometrial polyps can be removed with a small-caliber diagnostic flexible hysteroscope, without requiring cervical dilation, anesthesia, analgesia, or a tenaculum. This procedure may replace blind dilation and curettage for intrauterine pathologic evaluation.

Objective: To examine the efficacy of transcervical resection (TCR) for subseptate uterus in patients with infertility or recurrent miscarriage.

Design: Retrospective study.

Patients: Twenty-five patients with infertility or recurrent miscarriage who underwent TCR for subseptate uterus in Nagasaki University Hospital between October 1996 and June 2014.

Interventions: TCR and laparoscopic surveillance under general anesthesia.

Main outcome: Pregnancy rate and live birth rate after TCR.

Result: Pregnancy rates in primary infertility, secondary infertility, and recurrent miscarriage groups were 50% (4/8), 50% (2/4), and 100% (13/13), respectively. The live birth rates in the primary infertility, secondary infertility, and recurrent miscarriage groups were 83% (5/6), 100% (2/2) and 86% (18/21), respectively. Of 25 deliveries after TCR, 12 were performed by caesarean section. Although one caesarean section was performed for perioperative uterine perforation, the others were performed for obstetric indications: repeat caesarean section (5/12), breech presentation (3/12), placenta previa (1/12), placental abruption (1/12), and arrested labor (1/12).

Conclusion: Pregnancy and live birth rates improved in patients with recurrent miscarriage after TCR for subseptate uterus.

  Laparoscopic sacrocolpopexy (LSC) provides patients with a safe and low relapse-rate procedure for Pelvic Organ Prolapse (POP), and a shift has been observed from traditional vaginal surgery to laparoscopic surgery in our hospital. From March 2015 to September 2016, 25 cases with POP underwent LSC after an uterus subtotal hysterectomy was performed, which fixed the double mesh suture of the vaginal wall and the L5 anterior longitudinal ligament. Upon introduction, patient's age, comorbidities, and lower urinary tract disorders were evaluated preoperatively to determine the adaptation by the appropriate questionnaire, Core Lower urinary tract Symptom Score (CLSS) and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Surgical manipulation in the pouch of Douglas seems to be a rate-limiting step of surgery. Identification of the Levator ani muscles is crucial for accurate recognition of the pelvic floor midline, including the rectum, by appropriate towing. In addition, this stage is also important to prevent the complications of de novo defecation disorders.

Objective: The aim of this study was to evaluate the efficacy of combination use of a resectoscope for microwave endometrial ablation (MEA).

Materials and methods: From January 2013 to February 2016, 36 patients with menorrhagia underwent MEA. We used the resectoscope to remove ablated endometrium. Fibromas or polyps in the uterine cavity were cleared with a resectoscope before MEA. Hematological improvement, operative time, complications, number of ablations, additional ablations, and improvement in hypermenorrhea were evaluated.

Results: The hemoglobin level improved in all patients, including 15 who became amenorrheic. The resectoscope was additionally used for MEA in 24 cases. Additional ablation was performed in 15 patients (41.7%). One patient had postoperative endometritis without combined use of the resectoscope.

Conclusion: Our procedure is useful for debris removal, additional ablation when non-ablated tissue is identified, MEA after clearing of an irregular uterine cavity, and identification of pathology.

  Submucosal myomas often become pedunculated and pass through the cervix, resulting in episodes of major genital hemorrhage. We attempted the removal of prolapsed uterine myomas in an outpatient, using a loop ligator device (ENDOLOOP PDS II ETHICON^®). Here, we report our experience with successful removal of multiple transvaginal uterine myomas by ligation of the stem. A 52-year-old patient (gravida 3, para 2) presented with severe anemia secondary to hypermenorrhea. Colposcopic examination, transvaginal ultrasonography, and pelvic magnetic resonance imaging led to the diagnosis of a prolapsed uterine myoma. For personal reasons, the patient requested outpatient management and underwent treatment with loop ligation. Following ligation, the hypermenorrhea improved, without exacerbation of anemia or signs of infection. The submucosal myoma gradually receded due to the decreased blood flow caused by ligation. At 41 months after initial evaluation, myoma resection was performed using hysteroscopy. The uterine myoma was suspended by a thick stem; therefore, several ligation treatments were performed over an extended period. Ligation was aimed at cutting off the blood flow to the prolapsed uterine myoma. Even if blood flow could not be completely cut off, ligation was expected to decrease the uterine myoma size by decreasing blood flow.

Objective: We report laparoscopic surgery for an infertile woman with a peritoneal inclusion cyst (PIC) surrounding the entire ovary and a hydrosalpinx of the opposite side, which were considered to have been caused by endometriosis and chlamydia infection.

Patient: The patient had a history of untreated chlamydia infection. Ultrasound and magnetic resonance imaging revealed a PIC and a hydrosalpinx. In order to improve chances of conception, the patient underwent laparoscopic surgery. The PIC was formed with a thin layer of tissue lining the left tube and the broad ligament; the left ovary was completely surrounded by the PIC. At the time of surgery, adhesion by endometriosis and a hydrosalpinx of the right tube were observed. The surgery proceeded in the following stages: 1. complete resection of the cyst wall; 2. adhesiolysis between the uterus and the rectum, and also between the right ovary and the broad ligament; 3. removal of endometrial lesions; 4. salpingostomy of the right fimbria.

Conclusion: Surgery for PIC removal to prevent its negative influence on oocyte retrieval and its enlargement during pregnancy is effective for infertile women. Laparoscopic surgery should be the first choice in terms of its minimal invasiveness and curativeness. However, superior laparoscopic surgical skill is required because many PIC cases have extensive adhesion in the pelvis, such as in our case, which makes surgery difficult. As PIC with infertility is expected to also present with a tubal disorder, patients need to be well informed of the treatment plan in advance.

Introduction: Ovarian teratomas are benign tumors. While bowel obstruction is a common complication of advanced ovarian cancer, it is rarely described in cystic lesions such as ovarian teratomas. To our knowledge, the case we describe herein is the first reported case of large bowel obstruction due to a large benign ovarian teratoma treated using laparoscopic surgery.

Case: A 19-year-old woman with complaints of acute abdominal pain was admitted to our hospital. Computed tomography and magnetic resonance imaging revealed a 12-cm left ovarian teratoma that caused compression of the sigmoid colon with consecutive dilation of the ascending colon and small bowel. We diagnosed the patient as having an intestinal obstruction. After an unsuccessful conservative ileus treatment including a starvation cure and intravenous administration of fluids for 2 days, we performed a laparoscopy and found a large cystic tumor originating from the left adnexa. No adhesions were observed in the pelvic space. After removal of the tumor via left cystectomy, histological findings confirmed a benign teratoma. The patient's hospital stay was uneventful, and the bowel obstruction symptoms resolved immediately.

Conclusion: The clinical course of our patient provides the following important insights: Ovarian teratomas can present intestinal obstruction. With accurate preoperative diagnosis and careful management, intestinal obstruction due to ovarian teratoma can be treated using laparoscopy.

Introduction: Lipoleiomyomas are rare and asymptomatic benign tumors with an incidence of 0.03-0.2%. Pathologically, mature fat cells are mixed with smooth muscle cells. Here, we report the case of successful laparoscopic resection of uterine tumor which was preoperatively diagnosed as ovarian dermoid cyst and was diagnosed as lipoleiomyoma by perioperative pathology.

Case presentation: A 70-year-old postmenopausal women (gravida/para = 2/2) was referred to our hospital with an ovarian tumor detected by transvaginal ultrasonography and magnetic resonance imaging (MRI). Her tumor marker levels were not elevated. We scheduled a laparoscopic bilateral salpingo-oophorectomy using the TANKO method. Intraoperative findings were normal bilateral adnexa and a tumor emerging from the posterior uterine wall. After transection of the uterine body using a monopolar electric scalpel, a yellow mass was visualized and removed using Crow forceps. The tumor was excised in one piece through the umbilical trocar. The tumor underwent rapid intraoperative pathological diagnosis and was confirmed as lipoleiomyoma. We added one auxiliary trocar at the lower left abdomen to begin double-incision laparoscopic surgery. The myometrium was closed in two layers using 1-0 Monocryl^® sutures. Laparoscopic tumor resection and bilateral salpingo-oophorectomy were performed. The tumor was confirmed as a lipoleiomyoma postoperatively.

Conclusion: Lipoleiomyoma should be considered in the differential diagnosis of masses in the fatty tissue, but accurate preoperative diagnosis is difficult using MRI. In addition, since malignancy is possible (leiomyosarcoma in the fatty tissue and immature ovarian teratoma), informed consent regarding the possibility of malignancy is required before surgery.

BACKGROUND: With the increase in the cesarean section rate, the complications associated with cesarean section wounds have also increased. The presence of a cesarean scar defect and diverticulum has recently been identified as a source of persistent, irregular vaginal bleeding, menstrual pain, secondary infertility, and lower abdominal pain, known as cesarean scar syndrome.

CASE: A 33-year-old woman presented with menstrual and lower abdominal pain in association with an anterior extrauterine cystic mass detected by pelvic ultrasound, thought to represent a cesarean scar diverticulum. The cystic diverticulum was laparoscopically excised, and the lower anterior uterine wall was repaired. The postoperative course was good and the patient was discharged on the fifth day after surgery. Menstrual and lower abdominal pain resolved after surgery.

CONCLUSION: In cases of cesarean scar syndrome associated with a cystic diverticulum, laparoscopic surgery should be considered, especially when menstrual and lower abdominal pain is present.

  Yolk sac tumors are found in approximately 1% of all ovarian malignancies. Many cases of yolk sac tumors develop at a young age. For the treatment of yolk sac tumors, early initiation of postoperative chemotherapy is effective. Generally, for good effects from postoperative chemotherapy for yolk sac tumors, surgery is performed to preserve the patient's fertility. We present a case of peritoneal dissemination, which was diagnosed as a yolk sac tumor using laparoscopic biopsy. The tumor developed postadnexectomy for a mature cystic teratoma and we were able to start early postoperative chemotherapy. A 16-year-old girl was hospitalized due to a sensation of abdominal fullness. Magnetic resonance imaging revealed a giant abdominal tumor that was suspected of being an immature teratoma. We performed left uterine adnexectomy and omentectomy using laparotomy, based on an intraoperative rapid diagnosis of an immature teratoma. The final pathological diagnosis was a mature cystic teratoma, so the patient did not receive any postoperative treatment. Seven months after surgery, she experienced lower abdominal pain. Computed tomography revealed peritoneal dissemination, and the serum alpha-fetoprotein level was 1938 ng/ml. We performed a tissue biopsy using laparoscopic surgery, and we made a diagnosis of a yolk sac tumor. We promptly administered BEP chemotherapy (bleomycin, etoposide, and cisplatin) after laparoscopic surgery, and treatment has been successful. This case shows that laparoscopic surgery could be a minimally invasive diagnostic method for patients who should start receiving chemotherapy soon after surgery.

Background: The number of gynecological laparoscopic procedures is increasing. Power morcellation has been widely employed to break up large uterine fibroids and remove fragments from the abdominal cavity. In recent years, several studies have reported parasitic leiomyoma (PM), resulting from the spread and growth of fibroid tissues in the abdominal cavity after the use of power morcellation for laparoscopic hysterectomy or myomectomy.

Case: A 46-year-old para 1 woman had undergone total laparoscopic hysterectomy for a large uterine leiomyoma at the age of 41 without use of power morcellation. Fiftynine months later, she was found to have intrapelvic tumors. Following surgical resection they were diagnosed as iatrogenic PMs.

Conclusions: It is possible that iatrogenic PM can occur even if power morcellation is not used. Surgeons must be careful to remove as many small fragments of fibroids as possible. We should be aware of the risk for iatrogenic PMs in all surgical procedures for uterine fibroids. To our knowledge, this is the first report of a case of iatrogenic PM after total laparoscopic hysterectomy without the use of power morcellation.

  We report two cases of omental pregnancy. Ectopic pregnancy accounts for approximately 1%–2% of all pregnancies, but its incidence has increased with the increased use of assisted reproductive technology. Abdominal pregnancy is an extremely rare condition that accounts for approximately 1% of ectopic pregnancies. Preoperative diagnosis of abdominal pregnancy is challenging. Recently, many reports have indicated that magnetic resonance imaging is a useful diagnostic test for abdominal pregnancy. Laparoscopic surgery is the first-line therapy for ectopic pregnancy. We performed laparoscopic surgery in two cases of omental pregnancy without severe complications. These results suggest that laparoscopic surgery for abdominal pregnancy is safe and effective.

Objective: Various developmental cysts arise in the retrorectal space because the 3 germ layers in this region are involved in fetal development. We encountered 2 patients with developmental cysts in the retrorectal space that were difficult to differentiate from an endometrial cyst before surgery; the cysts were laparoscopically diagnosed and treated.

Patients: Both patients had a medical history in which an endometrial cyst was suspected; however, when the intra-abdominal cavity was examined, no abnormal finding was observed, and the abdomen was closed. In both patients, the presence of endometrial cysts measuring 7 cm on the right side of the rectum were suspected on preoperative magnetic resonance imaging. On laparoscopy, cysts were present in the right posterior region of the rectum in the retroperitoneal space and were excised. Pathological examination identified cystic hamartomas and epidermoid cysts.

Conclusion: Complete excision is necessary because this lesion may lead to infection and conversion to malignancy. The procedure is performed in the deep extraperitoneal pelvic region, and requires corresponding knowledge and experience with gynecological malignancies; however, laparoscopic surgery may be feasible.

Introduction: Breakage of instruments during laparoscopic surgery is rare, but may carry serious medicolegal implications. We report a patient in whom a small piece of broken instrument was found 10 years after surgery, and was laparoscopically removed with the guidance of intraoperative X-ray fluoroscopy.

Case presentation: A 45-year-old gravida 0, para 0 woman had undergone laparoscopic myomectomy 10 years ago in our hospital. Submucous myoma was detected by ultrasonography at another hospital. She underwent magnetic resonance imaging (MRI) for planning further treatment. MRI was canceled because of an artifact. She was referred to our hospital after an unidentified metal object was detected by pelvic MRI. The patient had no history of other surgeries. After abdominal X-ray examination and computed tomography, we assumed that the object, approximately 3 mm in diameter, was a remnant of her previous surgery. Informed consent was obtained. Because she preferred laparoscopic removal, we carefully removed the object, which was located under the right uterosacral ligament, along with surrounding connective tissue under X-ray fluoroscopy.

Conclusion: With increasing numbers of laparoscopic surgeries, remnant iatrogenic foreign bodies, as in the present case, may be found more frequently in the future. It is important for surgeons to prepare for such situations with appropriate informed consent to remove unexpected breakage of instruments. When small foreign bodies buried in the tissue are removed, it may be better to remove these remnants en bloc with the surrounding tissue under fluoroscopic guidance.

  The goal of primary debulking surgery (PDS) in ovarian cancer is to achieve complete resection of the tumors. There are, however, many complications after this surgery, because of its invasiveness. Small bowel obstruction is one of the major complications of PDS. The rate of incidence of small bowel obstruction after PDS has been reported as 30%. While adhesive small bowel obstruction has traditionally been managed via the open approach, it often induces another adhesive small bowel obstruction after surgery. Therefore, patients with small bowel obstruction may benefit from the laparoscopic approach due to its low invasiveness. We report a case of laparoscopically assisted surgery performed for adhesive small bowel obstruction following PDS. A 48-year old woman had small bowel obstruction 10 days post-PDS. Twenty days after the surgery, she developed septic shock and disseminated intravascular coagulation (DIC) due to bacterial translocation from the small bowel obstruction. After recovering from the septic shock and DIC, we performed a laparoscopically assisted surgery to relieve the adhesions of the small bowel obstruction. Surgery was performed using the GelPOINT^® advanced platform as the main platform. There were many severe adhesions between the small bowel, pelvic wall and the sigmoid colon. We successfully relieved most of the adhesions by laparoscopic surgery, and directly repaired the defective parts of the serosa of the small bowel, accessing them from the small incision part of the main platform. The patient recovered well without recurrence of either the small bowel obstruction or the ovarian cancer. Due to its decreased degree of invasiveness, laparoscopic surgery, rather than open surgery, might be more appropriate when treating adhesive small bowel obstruction.

  We encountered a case of chemical peritonitis caused by iatrogenic complication after laparoscopic cystectomy in a patient with ovarian mature cystic teratoma (MCT).

  A 40-year-old woman, gravida 0, underwent laparoscopic cystectomy for MCT. During surgery, contents from the MCT leaked and diffused into the abdominal cavity. After the operation, she complained of fever and lower abdominal pain. Computed tomography demonstrated several findings of peritonitis, such as a thickened peritoneum and ascites. She was diagnosed with peritonitis and treated initially with antibiotics; however, this was not effective. Since we suspected chemical peritonitis, we proposed reoperation. Although she rejected our proposal, oral adrenocortical steroids were administered. Fortunately, her condition promptly improved.

  Currently, laparoscopic cystectomy for young patients with MCT has become very common. The leakage of contents from MCTs is sometimes inevitable, and once chemical peritonitis occurs, its treatment is often very difficult. We think the most important prophylaxis for chemical peritonitis is minimizing the leakage of MCT contents, and if leakage diffuses into the abdominal cavity, thorough lavage should be required during operation.

  We report a case of endosalpingiosis found during a second laparoscopic myomectomy. Endosalpingiosis is often seen in lymph nodes that are resected because of gynecologic malignancy and is usually an insignificant incidental finding. It may rarely form a macroscopic mass that arises from the peritoneum. The patient was a 27-year-old woman, gravida 1 para 1, who underwent laparoscopic myomectomy due to hypermenorrhea. Four years after the first operation, the second myomectomy was performed for a recurrent myoma node. During the second operation, a walnut sized tumor on the mesothelium was found. Pathological examination revealed it to be salpingiosis. Surgical implantation of resected tissues is not a rare complication and patients must be properly informed of this possibility prior to surgery.

  Endometriosis may occur in various parts of the body, but it rarely forms a cystic mass outside of the ovary. We had a case of extra-ovarian endometrial cyst that underwent laparoscopic surgery.

Case: A 38 year-old, gravida 1, para 1 woman experienced acute abdominal pain and was taken to the receiving hospital by ambulance. She was hospitalized for 6 days on diagnosis of a ruptured endometrial cyst. After discharge she was referred to our hospital. She underwent abdominal myomectomy 4 years prior and cesarean section 2 years before the current episode. Ultrasonography and magnetic resonance imaging (MRI) scan detected an endometrial cyst of 10 cm in size and normal bilateral ovaries. The origin of the mass was not clear. A slight elevation in tumor markers CA125 (77.6 U/mL) and CA19-9 (47.2 U/mL) was observed. She underwent laparoscopic surgery after one month. At laparoscopy, a fist-sized cyst was detected in the ventral portion of the uterus and chocolate-like, dark brown fluid pooled in the abdominal cavity. The cyst adhered extensively to the surrounding tissue; thus, we peeled off the adhesions and removed the cyst. The cyst was attached to the right uterosacral ligament. The uterus and both ovaries were normal and showed no anatomical connection with the cyst. The pathological diagnosis was endometrial cyst, but there was no evidence to suggest any involvement of the ovary. Her postoperative course was uneventful and she was discharged at postoperative day 3. There has been no sign of recurrence for 5 years.

  Uterine lipoleiomyoma is a rare, benign neoplasm that is composed of smooth muscle tissue and mature adipocytes. We report a case of lipoleiomyoma, which was diagnosed using sonography, CT, and MRI, and was treated laparoscopically. A 75-year-old postmenopausal woman developed a growing mass in her uterus, which was visualized using hyper-echoic sonography. The mass exhibited fat attenuation on CT, hyper-intensity on T1 weighted images, and low signal intensity on fat saturated MRI. To ensure a definitive diagnosis and to prevent future symptom development, we successfully performed a total laparoscopic hysterectomy. We confirmed our diagnosis through histological analysis.

  A 50-year-old woman underwent total laparoscopic hysterectomy for CIN3. The vaginal cuff and retroperitoneum were closed with a barbed suture (V-Loc™180). She had an uneventful postoperative course and was discharged on postoperative day 5. On postoperative day 12, she returned to our department with sudden onset of abdominal pain and vomiting. Physical examination revealed rebound tenderness, and contrast-enhanced computed tomography showed strangulated bowel obstruction. An emergency laparotomy was performed; the end of the barbed suture was ingrowing into the mesentery of the small bowel. The small bowel around the suture was adhered to the pelvic peritoneum. The suture was cut, the adhesion was separated manually, and the suture material was explanted from the small bowel. No bowel resection was required. She had an uneventful subsequent postoperative course.

  Although the use of a barbed suture is convenient and timesaving, it may be implicated as a cause of bowel obstruction. This complication may be avoided if there is no exposure of the free end of the barbed suture in the peritoneal cavity.

  Asherman syndrome is defined by the presence of intrauterine adhesions and is a possible complication of miscarriage, uterine inflammation, myomectomy, cesarean delivery, or uterine artery embolization (UAE). It can cause menstrual disturbances, infertility, and placental abnormalities. There is no clear consensus on treatment. We report a patient with Asherman syndrome who conceived 2 years after hysteroscopic adhesiolysis.

  A 27-year-old primipara with a 7-cm myoma delivered a male infant at term, and UAE was performed for postpartum hemorrhage. Two weeks later, she experienced degeneration of the myoma and underwent hysteroscopic myomectomy with dilation and curettage. No measures were taken to prevent intrauterine adhesions. Two years postoperatively, she sought evaluation at our hospital for amenorrhea. Hysteroscopy revealed filmy stenosis of the internal os and dense adhesions involving the left side of the uterine cavity. Adhesiolysis was performed by blunt dissection, and an intrauterine device was placed to prevent further adhesion formation. Two years after the adhesiolysis, the patient conceived. She delivered a female infant by cesarean at 37 weeks of gestation. During surgery, the left intrauterine surface was noted to be macroscopically normal and adhesions were not visualized; however, placenta accreta was present.

  It is important to be aware of the risk of Asherman syndrome and to take measures to prevent intrauterine adhesions in high-risk patients. It is controversial whether cesarean or vaginal delivery is better for patients who conceive after intrauterine adhesiolysis. Our patient's course suggests that cesarean delivery might be better, as physicians can deal with unexpected placenta accreta.

Background: Primary peritoneal carcinoma is a relatively rare malignant neoplasm of the female genital tract, and is managed in the same way as advanced ovarian carcinoma. Although laparotomy is usually the method of choice for diagnosis and treatment, it may be associated with postoperative morbidity or mortality. Furthermore, co-existent medical complications may rule out this surgical approach. We report a case of primary peritoneal carcinoma complicated by Trousseau's syndrome that was successfully diagnosed and treated with laparoscopic surgery.

Case: A 58-year-old woman presented to the emergency room with left hemiplegia, facial paralysis, and dysarthria. She was diagnosed with multiple cerebral infarction. A computed tomography was performed to investigate the underlying cause of the coagulopathy and the elevated level of serum CA125. It demonstrated a thickening of the omentum, without other abnormalities. As we suspected primary peritoneal carcinoma, a laparoscopic exploration was performed, which revealed a solid tumorous mass in the omentum, although no intraperitoneal tumor spread was observed. A partial omentectomy and bilateral salpingo-oophorectomy were performed. The omental mass was diagnosed as high-grade serous carcinoma. The ovaries and fallopian tubes were free of tumorous involvement. The patient received six cycles of carboplatin and paclitaxel for stage IIIc primary peritoneal carcinoma, and is currently free of recurrence or metastases.

Conclusion: Laparoscopic surgery is a safe and useful surgical approach for the diagnosis and treatment of primary peritoneal carcinoma, even in patients with significant comorbidities.

  A 12-year-old girl had complained of abdominal pain for 1 month. She visited a local clinic because of fever over 38°C. The fever continued despite administration of antibiotics, and she was referred to the Department of Pediatrics at our hospital, which in turn referred her to the Department of Gynecology because she had massive ascites. No abnormal findings were detected in the uterus or ovaries by ultrasonography. Enhanced computed tomography revealed massive ascites, peritoneal thickening, many small nodules in the omentum, and bilateral pleural effusion. Serum CA125 level was remarkably elevated (1,538 U/ml). In addition, adenosine deaminase levels in ascetic fluid were elevated (136 U/l). Cytological examination of the ascites showed many neutrophils but no malignant cells. Laparoscopic examination was performed for diagnosis, which revealed diffused miliary white modules in the whole abdomen. Peritoneal biopsy was performed, and pathological examination showed formation of epithelioid granuloma with partial necrosis. The clinical diagnosis was tuberculous peritonitis.

  Symptoms such as fever and ascites disappeared after the administration of antituberculotic drugs (INH+RFN+PZA+EB). The treatment is being currently continued at the Department of Pediatrics.

  A 37-year-old woman, gravida 1, para 0, was referred to our hospital because of uterine malformation. Pelvic examination revealed a longitudinal vaginal septum and doubled uterine cervix. Magnetic resonance imaging revealed no external fundal indentation, a complete uterine septum, and cervical duplication.

  We performed vaginal septectomy and hysteroscopic metroplasty. After the resection of the vaginal septum, we inserted the Hegar dilator into the right cervical os and pushed it against the wall to reveal the position of the septum. Next, we incised the corporal portion of the septate uterus by using a loop- type monopoles electrode. We placed the intrauterine device (IUD; FD-1 Fuji Latex Co., Ltd.) in the uterine cavity. We removed the IUD after two cycles of Kaufmann therapy.

  Seven months after the operation, she became pregnant spontaneously. During pregnancy, no symptoms indicating a threatened abortion or premature delivery were observed. We performed a cesarean section because of breech presentation at 38 weeks 4 days of gestation. No serious complications such as uterine rupture and placenta accrete occurred.

  Hysteroscopic metroplasty for septate uterus seems to be a simple and relatively safe procedure, and seems to improve the obstetric outcome in a population of women with previous miscarriages. After operation, careful management is necessary during pregnancy and labor.

Background: Fitz-Hugh-Curtis syndrome (FHCS), or perihepatitis, is a condition associated with pelvic inflammatory disease characterized by perihepatic "violin string" adhesions between the liver capsule and peritoneal surfaces of the anterior right upper quadrant. The acute adhesions of FHCS are known to be a possible cause of ileus. However, reports of ileus caused by obsolete adhesions of FHCS are few.

Case: A 75-year-old woman presented with an abdominal pain that moved from the right quadrant to the lower abdomen. Computed tomography (CT) revealed a left ovarian cyst 18 cm in diameter and a small intestinal obstruction. She was treated conservatively with bowel rest and nasogastric tube decompression; however, her symptoms did not improve with these conservative treatments. On the eighth day, we performed laparoscopic surgery for ileus release and left salpingo-oophorectomy. We found the small intestine fixed above the liver by perihepatic "violin string" adhesions and released the obstruction by pulling out the intestine. After the surgery, because of a previous infection, we tested her for Chlamydia trachomatis antibody. Thus, the ileus turned out to be caused by obsolete FHCS. In addition, the CT scan obtained at hospitalization showed characteristic adhesions between the liver and peritoneal surfaces, which suggested FHCS.

Conclusion: Perihepatic adhesions of FHCS are sometimes found during laparoscopic surgery and can cause obstructive ileus even long after an inflammation. CT is effective in identifying FHCS adhesions.

  Chylous ascites due to lymphorrhea is one of the complications following abdominal oncologic surgery. Chylous ascites requires long-term treatment and leads to a delay in additional treatment. We tried to detect and prevent chylous ascites. A 46-year-old woman with endometrial cancer and ovarian cancer underwent laparoscopic pelvic lymph node dissection and para-aortic lymph node (b1) dissection. She was fed milk as a high-fat diet 3 hours before the surgery. We could successfully detected chyle leakage after b1 dissection and performed clipping.

Introduction: Single-site laparoscopy is a type of reduced-port surgery. As there is no visible scarring, its use is rapidly increasing. Ectopic abdominal pregnancy is rare. Accordingly, there is no definitive treatment. There are few reports of abdominal pregnancy treated with single-site laparoscopy. We experienced a patient whose abdominal pregnancy was successfully treated with single site-laparoscopy.

Case presentation: A 28-year-old woman was sent to our hospital because of suspected tubal pregnancy. A gestational sac and small fetus with a heartbeat were identified behind the uterus, near the left ovary. The serum hCG level was 30,760 mIU/ml. We decided to perform single-site laparoscopy. Both Fallopian tubes were normal, and an area suspicious for abdominal pregnancy was found in the cul-de-sac. We confirmed the site of ectopic pregnancy using intraoperative transvaginal ultrasound, and excised the region containing villi. The postoperative course was good, with little pain and satisfactory wound healing.

Conclusion: Single-site laparoscopy is a good option for a patient with abdominal pregnancy.

Objective: To clarify the feasibility of microwave endometrial ablation (MEA) using hysteroscopy to check the degree and range of endometrial ablation.

Design: Retrospective Analysis.

Setting: Department of Obstetrics and Gynecology, Shizuoka Kosei Hospital, Japan.

Patient(s): A total of 43 women who underwent MEA for hypermenorrhea between 2013 and 2016 were divided into two groups based on the availability of hysteroscopic examinations: MEA with no detailed hysteroscopy (group A; n=14) and MEA following detailed hysteroscopy (group B; n=29). Outcome measures were evaluated with regard to patient characteristics, surgical outcomes, rates of amenorrhea, and complications.

Result(s): The number of ablations performed in group A was significantly higher than that in group B (P<0.01). The volume of perfusate was lower in group A than in group B (P<0.01). There were no significant differences in the total operative time, blood loss volume, or rate of amenorrhea. No major operative complications that required further treatment occurred in group B.

Conclusion(s): Despite multiple hyseroscopic procedures, there was no difference in operative time due to the decreased number of ablations. Introducing hysteroscopy in MEA could reduce the excess ablations and potential risk of complications.

  In a laparoscopic surgery, direct visibility is low and the movements of the forceps are restricted. Hence, tying a laparoscopic knot, especially an intracorporeal knot, is a challenging task. Mastering the intracorporeal knot should be a skill to be mastered by any laparoscopist. Some of the technical limitations in mastering this method are: a restricted range of manipulation of the instrument through the port placement sites, a narrow operative field, and a difficult visualization along with a decreased 3-dimensional spatial understanding while tying the knot. Two new methods of tying the knot namely "Pointing method" and "Swing method" are presented here. In these methods, the series of movements of the tip of an instrument are analyzed in a given dimension. In the Pointing method, the tip of the instrument in the dominant hand moves to and fro along a hypothetical line, which is drawn between a port placement site of the dominant hand and the point where the knot will be placed. In the Swing method, the tips of the instruments in both hands are swung from right to left along the surface of an imaginary plane that contains the two port placement sites and the knotting point in a line. In both these methods, the movement of the tips of the instruments is reduced from 3-dimensional axis to one- or a two- dimensional axis. Thus, the presented methods are easy to understand theoretically and make it easy to master the intracorporeal knot.