Objectives: The objectives of this study were to discuss the disease state and recent topics related to the redevelopment of an ovarian cyst after the treatment of anti-N-methyl-D-aspartate (NMDA) receptor encephalitis. Herein, we present a case report with its postoperative course, and describe the problems in patients who redevelop ovarian cyst with no symptoms of encephalitis.

Case: The subject developed anti-NMDA receptor encephalitis, for which abdominal surgery for bilateral resection of an ovarian cyst was performed. While the patient was discharged from the hospital 3 months post-surgery, after the encephalitis symptoms had improved, the ovarian cyst subsequently redeveloped, and thus laparoscopic resection of the ovarian cyst on the affected side was performed in our hospital. Redevelopment of an ovarian cyst was confirmed again on the same side 2 years after the surgery performed in our hospital.

Conclusion: Although redevelopment of encephalitis has been reported in patients with anti-NMDA receptor encephalitis, no therapeutic methods have been established for the redeveloped ovarian cyst in the absence of encephalitis symptoms.

  Since its pathological conditions have become more widely recognized, it is expected that more cases will accumulate, thus allowing further discussion and the establishment of therapeutic policies for the redeveloped ovarian cyst.

Objective: Polycystic ovary syndrome (PCOS) is one of the causes of ovulatory disorders and infertility. Clomiphene citrate is the first-line treatment for PCOS patients. Gonadotropin therapy or laparoscopic ovarian drilling (LOD) is recommended as the second-line treatment for clomiphene resistant PCOS. Which cases respond to LOD remain unclear. In this study, we examined predictors of successful LOD to clarify the position of LOD in the treatment strategy for PCOS.

Materials and Methods: This study included 19 anovulatory women with clomiphene-resistant PCOS who underwent LOD between September 2012 to June 2016. We retrospectively examined patients in an ovulatory group (n = 15) and a non-ovulatory group (n = 4) in terms of age, luteinizing hormone level, follicle-stimulating hormone level, body mass index, anti-Müllerian hormone level, and number of drillings.

Results: Fifteen (78.9%) of 19 patients regained spontaneous ovulation after LOD. The pregnancy rate was 63.2% (12/19). After LOD, ovulatory group had a significantly lower preoperative AMH than the non-ovulatory group (9.71 ng/ml vs 20.70 ng/ml, p = 0.0227). At a cutoff of 12.7 ng/ml, AMH had a sensitivity of 76.9% and a specificity of 100% in the prediction of non-ovulation after LOD.

Conclusion: Laparoscopic ovarian drilling is an effective treatment for clomiphene-resistant PCOS. AMH is suggested to be a useful predictor of ovulation after LOD.

Objective: To clarify the feasibility and safety of laparoscopic surgery for endometrial cancer.

Materials and Methods: Ninety-one patients with endometrial cancer who had undergone laparoscopic surgery in our institution between August 2012 and June 2016 were retrospectively studied. Data regarding surgical procedures, blood loss, surgical time, number of harvested lymph nodes, complications, and prognosis of the patients were obtained from medical records and analyzed.

Results: All patients had a pathologically confirmed endometrial cancer before the surgery, and their median age was 56 years. Of these, 57 patients underwent total laparoscopic hysterectomy (TLH) and bilateral salpingo-oophorectomy (BSO), and 34 patients underwent lymph node dissection in addition to TLH and BSO. After the surgery, histological examination showed that 78% of cases were high-grade endometrioid adenocarcinoma and 69.2% were the International Federation of Gynecology and Obstetrics (FIGO) stage IA. No case needed conversion to laparotomy or blood transfusion. Based on the Common Terminology Criteria for Adverse Events, complications with grade 3 or more were seen in 6.6% of patients intra-operatively, including venous and nerve injury, and seen in 6.6% of patients post-operatively, including ileus and pelvic abscess. During the follow up period (median of 23 months), 5 patients experienced recurrence, and no patient died of cancer. The rate of complications, number of harvested lymph nodes, and rate of good prognosis of our patients were not lower than that reported by previous studies.

Conclusion: The safety of laparoscopic surgery for endometrial cancer performed in our institution was found to similar to that performed in other countries. It should be more widely used worldwide and in Japan for stage IA patients and might be considered for patients with stage IB or higher endometrial cancer.

Objective: This study was conducted to analyze whether the 3-dimensional (3D) laparoscopic surgical systems can be used safely and efficiently for total laparoscopic hysterectomy (TLH) at our hospital.

Design: We retrospectively compared the outcomes of TLH using a 3D laparoscopic system to outcomes using the conventional 2-dimensinal (2D) laparoscopic system. From November 2014, when we began using the 3D laparoscopic system in our hospital, to December 2015, 47 TLHs were performed using the 3D laparoscopic system (3D-TLH) . The 3D-TLH outcomes were compared with the outcomes from 47 2D-TLHs performed just before the introduction of the 3D laparoscopic system.

Results: The 3D-TLH group had statistically significantly shorter mean operative time than the 2D-TLH group (119±20min. vs 137±20min.) , although the mean weight of resected uterus and the mean intraoperative blood loss were not statistically different. When we compared the outcomes for 20 cases in each group, using the same device in a short period of time, only mean operative time was statistically different between the 3D- and 2D-TLH groups. During the observation period, there was one occurrence of postoperative peritonitis in the 2D-TLH group and one occurrence of vagina cuff dehiscence in each group. The surgeon and surgical assistants did not report any symptoms that were attributable to the 3D imaging system such as dizziness, eyestrain, nausea, and headache.

Conclusion: The 3D laparoscopic system, which had been developed to account for the lack of depth perception, can be used safely and efficiently for TLH at our hospital.

Objective: To evaluate the results of hysteroscopic surgery after introducing in our hospital in July 2012.

Methods: For the period from July 2012 to December 2016, we examined the surgical results of all hysteroscopic myomectomies and cases with myomas having maximum diameters of 30 mm or more and protrusion rates of 50% or less. A gonadotropin-releasing hormone agonist was administered preoperatively in all cases. Monopolar or bipolar hysteroresectoscopes were selected as required. The boundary portion between the myoma and normal muscle layer was peeled off at the tip of the loop electrode and removed with placental forceps after sufficient detachment.

Results: A total of 364 hysteroscopic surgeries were performed (uterine fibroids: 235, endometrial polyps: 124, intrauterine synechiae: 3, endometrial cautery: 2).

  With the analysis for uterine submucosal fibroids alone, 94.9% of all cases involved complete resection during initial surgery. Even in cases with myomas having a maximum diameter of 30 mm or more, and a protrusion rate of 50% or less, 87.0% had been excised during initial surgery.

Conclusions: We consider our technique useful for treating large, less-protruding submucosal myomas, which are generally considered difficult surgical cases. As a result, the indications for hysteroscopic myomectomy may be expanded.

Objective: The objective of this clinical study was to compare intravenous patient-controlled analgesia (IV-PCA) with patient-controlled epidural analgesia (PCEA) after total laparoscopic hysterectomy (TLH).

Methods: A total of 21 patients subjected to TLH at our hospital from June to September 2015 were divided into two groups – those receiving IV-PCA (IV-PCA group) or those receiving PCEA (PCEA group).

The IV-PCA group received intravenous patient-controlled analgesia and the PCEA group received patient-controlled epidural analgesia. Post-operative pain was followed for 2 days and was evaluated using a visual analog scale (VAS) at rest and on ambulation. The frequency of analgesic use was also monitored.

Results: There were no significant differences between the two groups in terms of either the VAS score or analgesic use. However, the IV-PCA group had a higher VAS score than the PCEA group at ambulation six hours after the procedure. The side effects, mainly post-operative nausea and/or vomiting (PONV), were more frequent in the IV-PCA group.

Conclusion: Without exception, the analgesic effects were consistently inferior in the IV-PCA group after TLH.

Objective: To clarify the trends in outcomes of hysterectomies at our hospital.

Design: A retrospective analysis.

Setting: A city hospital.

Patients: Consecutive women who underwent hysterectomy for benign disease at our hospital from April 1, 2005 to March 31, 2016.

Interventions: hysterectomy±mono/bilateral salpingo-oophorectomy±vaginoplasty.

Main outcome measures: The operating time, intraoperative blood loss, uterine weight, length of hospital stay, and any surgical complications.

Results: Data from 273 abdominal (ATH), 276 laparoscopic assisted (LAVH), 55 total laparoscopic (TLH), and 191 vaginal hysterectomies (VTH) were included. Laparoscopic approaches have increased in the past decade, and vaginal approaches have decreased. The VTH group had shorter operating times than the other procedures and less intraoperative blood loss than the ATH group or LAVH group. In the TLH group, intraoperative blood loss was significantly lower than the other procedures, but the median operating time was the longest. The ATH group had a significantly higher rate of large uteri and moderate to severe complications.

Conclusion: Our experience shows that we require extensive training for vaginal approach hysterectomies with the intent to decrease the operating time, blood loss, complications, and total cost of treatment, while noting that laparoscopic hysterectomy can be considered a standard procedure for benign disease.

Objective: To evaluate morcellation time and its complications between in-bag and open power morcellation during laparoscopic myomectomy (LM).

Design: Retrospective study

Setting: Takanohara Central Hospital, Nara, Japan.

Patient(s): This study subjects were comprised of 80 patients who underwent LM with power morcellation. The data were collected from 40 patients who underwent in-bag power morcellation of myomas between December 2015 and September 2016, and were compared with the data collected from 40 patients who underwent open power morcellation between February 2015 and August 2015.

Intervention(s): Comparison of the outcomes of the morcellation time and its complications between in-bag and open power morcellation groups.

Result(s): There were no significant differences in the mean myoma weight, intraoperative blood loss, and postoperative hospital stay between the two groups. The mean morcellation time of the in-bag power morcellation group was longer than that for the open power morcellation group (22 vs. 12 minutes; P=0.004). There were no severe intraoperative complications among the two groups. However, in one case the myoma specimen might have leaked out due to 5mm ligation hole of the bag, which was detached at a loose boundary at the time of pulling out the bag.

Conclusion: The mean morcellation time of the in-bag power morcellation group was 10 minutes longer than the open power morcellation group. However, the method of in-bag power morcellation can be very useful in preventing parasitic myomas and in minimizing the risk of inadvertent malignant tissue dissemination.

  The preservation of ovarian function during tumor removal is an important problem because ovarian endometrioma is most common in young women of reproductive age. The aim of this study was to evaluate the effect and value of hormonal treatment before laparoscopic surgery. Thirty patients scheduled to undergo laparoscopy for ovarian endometrioma from 2010 to 2013 were randomly assigned to three groups: the GnRH analog for preoperative treatment group (G group), dienogest for preoperative treatment group (D group), and no treatment group (non-T group). Operative time, total amount of bleeding, cystic wall peeling time, coagulation time, and number of primary follicles (assessed pathologically) were compared among the groups. There were no differences in the size of the endometrioma, revised American Society for Reproductive Medicine score, or amount of bleeding among the three groups. Operative time was shorter in the D group (44.6 min) compared to that in the G group (61.2 min) and non-T group (52.2 min). Coagulation time was shorted in the D group (34.3 s) than that in the G group (62.5 s) and non-T group (89.3 s). The number of follicles in the resected specimen was lower in the D group (0.8 follicles per microscopic field) than that in the G group (1.7 follicles per microscopic field) and non-T group (4.0 follicles per microscopic field). The use of dienogest for preoperative treatment facilitates minimally invasive surgery for ovarian endometrioma by shortening the coagulation time and reducing the number of primary follicles in the resected specimen.

  Interstitial ectopic pregnancy is rare but the frequency is increasing. It is important to diagnose and treat at an early stage to avoid massive hemorrhage due to rupture. We report a diagnostically challenging case of interstitial ectopic pregnancy associated with multiple myomas. A 34-year-old woman (gravida 0) was referred to our hospital because of possible ectopic pregnancy. She was pregnant by artificial insemination on the 36th day of her last menstrual period; however, a gestational sac (GS) was not seen in the uterine cavity and the serum human chorionic gonadotropin (hCG) level was 2,993 mIU/ml. Laparoscopic surgery was performed the same day. Intraoperative examination revealed that the uterus was enlarged by multiple myomas; the bilateral adnexa were normal in appearance. Villi were not observed intraperitoneally. Intrauterine curettage was performed, but only decidual tissue was histopathologically confirmed. Serum hCG increased to 2,555 mIU/ml 10 days after surgery, but a GS was still not observed. Enhanced computed tomography was performed because the pregnancy status was uncertain. An enhanced cystic mass was observed, suggesting a right interstitial ectopic pregnancy. Repeat laparoscopic surgery was performed. After local injection of vasopressin into the right fundus, the uterine wall was incised and villus-like tissue was confirmed in the interstitial portion of the right tube. We removed villi as much as possible and sutured the myometrium. Villi were confirmed histopathologically. Serum hCG promptly decreased and the postoperative course was uneventful.

  We report a case of symptomatic lymphocele treated by laparoscopic marsupialization. A 68-year-old woman who had undergone retroperitoneal lymphadenectomy for ovarian cancer was diagnosed as having pelvic lymphocele. We conservatively treated the case with percutaneous puncture and sclerotherapy using povidone iodine, but were unsuccessful. We then performed laparoscopic marsupialization for the pelvic lymphocele, which proved to be effective as the patient had good recovery. Laparoscopic marsupialization is an effective and minimally invasive procedure to treat pelvic lymphocele in ovarian cancer patients who have undergone lymphadenectomy.

Introduction: Recently, the use of laparoscopic myomectomy (LM) is increasing. We found several case reports of uterine rupture in pregnancy after LM. Herein, we report a case of uterine rupture at 34 weeks of gestation prior to labor onset in a patient with a history of LM.

Case: A 43-year-old nulliparous woman conceived by cryopreserved embryo transfer after LM, thereby seven myomas were removed, including a 5-cm submucosal myoma in the posterior uterine wall. Antenatal follow-up at another clinic was uneventful until she presented with intense and abrupt abdominal pain and vomiting at 34 weeks of pregnancy. She was transferred to our hospital because of acute abdomen. Despite the presence of pain radiating from the uterus toward the epigastric region, ultrasonography revealed the intact anterior wall of her uterus. Within 2 hours, fetal bradycardia and fluid collection in the pouch of Morison were observed. Uterine rupture was suspected based on the myomectomy records attached to the referral letter, and emergency caesarian section was performed. The infant weighed 2032 g at birth, with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, and umbilical artery pH of 7.34. The infant was admitted to the neonatal intensive care unit because of the low birth weight. The ruptured left posterior uterine wall, matching the enucleated site, was repaired.

Discussion: The posterior location of the rupture made immediate diagnosis difficult. However, with the operative records, rupture was promptly suspected, urging for laparotomy. LM is a common procedure performed in women seeking for infertility treatment. Operatives notes on myomectomy are important in the consultation for early diagnosis of uterine rupture in pregnancy and shall not be spared for referral.

  Interstitial pregnancy is a rare and life-threatening condition. The most important facet of caring for women with interstitial pregnancy is early diagnosis. We report a case of interstitial pregnancy that was indistinguishable from normal intrauterine pregnancy. A 38-year-old woman, gravida 4 para 3, with a history of laparoscopic salpingectomy for ectopic pregnancy, felt a strong lower abdominal pain and visited our emergency department. The pregnancy test result was positive, and transvaginal ultrasonography revealed intrauterine pregnancy of 11 weeks with intrapelvic hemorrhage but without an adnexal mass. Two hours later, she felt severe upper abdominal pain. Urgent ultrasonography revealed increased intra-abdominal hemorrhage. Emergency laparoscopy was performed. We collected 1400 ml of blood in the abdominopelvic cavity and found that she had a left interstitial pregnancy with bleeding. We removed all gestational tissue and performed a cornuostomy. After the surgery, 4 blood units were transfused. Interstitial pregnancy was difficult to diagnose at 11 weeks of pregnancy. However, ultrasonography revealed intrauterine pregnancy with intrapelvic hemorrhage. Concomitant intrauterine and extrauterine pregnancies or interstitial pregnancy should be considered.

  We report a case of ovarian pregnancy with uterine penetration after in vitro fertilization following myomectomy. A 38-year-old woman underwent myomectomy about 1 year before the current pregnancy. On day 28 after in vitro fertilization and embryo transfer (IVF-ET), she was transferred to our hospital because of a suspicion of ectopic pregnancy. Transvaginal ultrasonography detected a mass inside her right ovary. Emergency laparoscopic surgery was performed. The adnexal adhesion was severe. After adhesiolysis, chorionic villi were found inside of the right ovary, and the endometrium was also taken from the same site. Penetration of the posterior uterine wall was confirmed and repaired. In addition, bilateral salpingectomy was performed. After the surgery, the defective part of the uterine endometrium and myometrium thinning were detected. Future pregnancy was considered high-risk of uterine rupture or ectopic pregnancy. Further repair of the thinning myometrium is needed before another pregnancy is permitted.

  A 36-year-old female with patient who has a history of surgical resection for mature teratoma by laparoscopic cystectomy about ten years ago, felt discomfort in her lower abdomen and presented visited to our hospital for further examination. From CT and MRI examination results, we found two kinds of tumors following; a) cystic tumors with wall calcification and fat content in the left ovary, b) small calcified tumors in the vesicouterine pouch and on the transverse colon. The tumor of the left ovary was extracted by laparoscopic cystectomy. During operation, we found that the calcified tumors in the vesicouterine pouch were teeth and suspected that the tumors resulted from peritoneal dissemination of the mature teratoma resected about ten years ago. We completely removed the tumors in the vesicouterine pouch but were unable to remove the tumor on the transverse colon because the omentum was well-grown. The tumor in the vesicouterine pouch was histologically diagnosed as a mature teratoma. In cases where the primary lesion is not malignant, the possibility remains of tumor dissemination in the abdominal cavity following tumor rupture during surgical resection. Therefore we must prevent such leakage of the teratoma contents in the abdominal cavity.

  To date, only 21 cases of mature cystic teratoma in Douglas' pouch that has no connection with adnexa or the alimentary canal have been reported. We report a rare case of extragonadal mature cystic teratoma. A 34-year-old woman, gravida 2 para 1, who had a history of laparoscopic cholecystectomy and cesarean section was referred to our department because of an ovarian cyst. Magnetic resonance imaging (MRI) revealed a 6-cm enhancing right ovarian mature cystic teratoma. We scheduled surgery, but it was delayed because she got pregnant. At 17 weeks of gestation, she was admitted to our hospital because of genital bleeding, high fever, and abdominal pain. Blood examination revealed a marked inflammation. The membranes ruptured right after admission, and the pregnancy resulted in abortion.

Two months later, we performed a laparoscopic surgery. A 6-cm tumor was found in Douglas' pouch and had no connection with right adnexa or the alimentary canal. The tumor had filmy adhesions to the pelvic peritoneum and posterior wall of the uterus. The left adnexa showed normal findings, but the right ovary was small, approximately 1 cm in diameter, and the right fallopian tube was blind-ended. Tumor adhesions were mild and detached from the surroundings, without feeding vessels. The tumor contained hair, adipose tissue, and calcification. Its histological features were consistent with the diagnosis of mature cystic teratoma with degeneration, although no follicles or ovarian interstitial cells were found.

Considering that the preoperative MRI findings showed the enhancing cyst wall and laparoscopic findings, the cyst was detached from the right ovary.

  Laparoendoscopic single-site surgery (LESS) has emerged as a minimally invasive surgery in the last few decades. As instruments are placed in-line during LESS, instrument crowding becomes a clinical problem; hence, advanced skills are needed to perform this procedure. However, this in-line placement can produce a new surgical strategy in cases in which it is difficult to perform multiport laparoscopic surgery. We present a case of a large ovarian tumor with adhesions between the tumor and abdominal wall. Since the adhesions surrounded the port site in the umbilicus, we could not observe the abdominal cavity using endoscopy. We inserted the instruments through the umbilical port and completed the dissection of adhesions. Finally, we performed a bilateral salpingo-oophorectomy (BSO) in LESS.

Background: Ovarian teratomas are commonly observed in women of reproductive age; however, omental teratomas are extremely rare. Omental teratomas are usually asymptomatic or can produce compressive symptoms. Here we report a case of a patient with omental teratoma treated with laparoscopic surgery.

Case presentation: A 74-year-old woman had 3 months' history of intermittent leg numbness. She visited an orthopedic hospital. Computed tomography (CT) was performed, and mass lesions were defined in her abdomen and pelvis; therefore, she was referred to our institution. Magnetic resonance imaging and contrast-enhanced CT was performed, and we considered these lesions to be a right ovarian cyst and an omental cyst. Laparoscopic surgery was performed. Intraoperatively, a right ovarian cyst of 8 cm and an omental cyst were diagnosed. Although her left ovary was normal in appearance, it was connected to the omental cyst with its pedicle. Those cysts adhered to the around tissue, small intestine, greater omentum, and abdominal wall. Bilateral salpingo-oophorectomy was performed. The cyst wall of the omental cyst was thick and calcified, mimicking an egg shell. The pathological diagnoses were right ovarian mature cystic teratoma (MCT) and greater omental MCT arising from the left ovary.

Conclusion: Although extragonadal teratomas in the abdominal cavity are extremely rare, gynecologists should be aware of them. The possibility of an autoamputated ovarian teratoma should be considered, and careful observations of intraperitoneal conditions should be made during surgery.

  We herein describe a case of cystic adenomyoma that was treated by transcervical resection. A 29-year-old female with hypermenorrhea presented with an intrauterine cyst measuring 4 cm in diameter on transvaginal ultrasonography and magnetic resonance imaging. Hysteroscopy showed the patient to have either a submucosal myoma or an endometrial polyp with a slightly hard surface. Transcervical resection was performed to remove the cyst, which was filled with chocolate-colored blood. The operative findings and a histopathologic examination confirmed the diagnosis of cystic adenomyoma of the uterus. At 7 months after undergoing resection, she became pregnant without using any reproduction therapy. To maintain the patient's fertility, transcervical resection may be a minimally invasive alternative for the treatment of cystic adenomyoma.

Objective: To report a case of inguinal hernia of a rudimentary uterus associated with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), successfully diagnosed and treated with laparoscopic surgery, and to present a review of the past literature

Design: Case report and literature review

Patient(s): A 49-year-old woman

Intervention(s): Ultrasound, computerized tomography, magnetic resonance imaging, hormone analysis, and laparoscopic surgery

Main outcome, Measure(s): Accuracy of diagnosis and laparoscopic resection of hernia contents

Result: Based on the sonographic and the corroborating MRI findings, a diagnosis of post-coloplasty MRKH and inguinal herniation of a right ovarian tumor was made. Laparoscopic surgery was performed for the resection of the hernia contents. Intraoperative observation revealed that the uterus was divided into two sections, left and right, in the pelvic cavity and the hernia content was not the right ovarian tumor, but the right uterus and adnexa.

  The herniated uterus and adnexa were successfully resected laparoscopically without any complication. Pathological examination revealed a uterus without a normal endometrium. The post-operative diagnosis, based on the intraoperative findings and pathological examination, was inguinal hernia of a right rudimentary uterus and adnexa with MRKH.

Conclusion: There are few reports of inguinal hernia of the uterus and adnexa. Even if the diagnosis of MRKH is made preoperatively, it is almost impossible to identify the hernia sac's contents. The laparoscopic approach is less invasive than the abdominal approach, has several advantages, and offers excellent results in the diagnosis and treatment of these disorders.

  Massive ovarian edema (MOE) is a rare non-neoplastic condition, which was first described in 1969 as a tumor-like enlargement of the ovary, with interstitial edema. The edema is caused by partial intermittent torsion of the ovarian pedicle that interferes with the venous and lymphatic drainage of the ovary. MOE is common in young women, and it presents with acute abdominal pain. Adnexectomy is usually the treatment of choice for MOE. When choosing the method of treatment, techniques that preserve the fertility of the patients should be considered. We report a case of a 12-year-old girl who presented with MOE and acute pedicle torsion. Laparoscopy was performed and the patient was conservatively treated. Although magnetic resonance imaging performed 6 months after the surgery revealed that the ovary was atrophic, the patient experienced no thromboembolic complications, infection, or recurrence of adnexal torsion. This case demonstrates that conservative surgery could be considered to treat adnexal torsion caused by MOE.

  The case was a 34-year-old female. Upon consultation at an ER with pain in the right abdomen, abdominal computed tomography (CT) revealed fluid in the abdominal cavity, leading to consultation at the department of gynecology in view of ovarian hemorrhage. Leakage of the contrast agent was suspected near the left ovary as a result of contrast enhanced CT; however other reasons of intra-abdominal hemorrhage were suspected since she was not in the ovulatory phase and there was no sexual intercourse leading to surgical consultation. Although her vital signs were stable, decrease in hemoglobin was recognized and laparoscopic operation was performed to identify the source of intra-abdominal hemorrhage and to stop bleeding. As a result, ovarian hemorrhage was not recognized and the bleeding site was confirmed in the greater omentum; leading to diagnosis of idiopathic omental hemorrhage. Furthermore, extensive omental adhesion was confirmed due to previous operation of appendicitis accompanying peritonitis. This report suggests the possibility to detect leakage of the contract agent at an unexpected location in the case of intra-abdominal adhesion in consideration of the rare female case with idiopathic omental hemorrhage by adding some bibliographic consideration.

  Adjuvant pelvic irradiation will be often applied after cervical cancer operation, despite inducing permanent ovarian damage. For the preservation of ovarian function, ovarian transposition is usually operated in premenopausal women with early-stage cervical cancer. The development of ovarian cysts is the most frequent complication after ovarian transposition. However, the pressure symptom exerted by ovarian cysts is not a usual symptom of ovarian cysts which occur in transposed ovary. Here we report a rare case of ovarian cysts of transposed ovary, presenting symptoms identical to rare malignant psoas syndrome, which refers to pain induced by ipsilateral psoas major muscle involvement of malignant disease. And the symptom was probed to be induced by the lutein cyst after ovarian transposition and radical hysterectomy. The patient was a 43-year-old woman, gravida 1, para 1, who underwent radical hysterectomy and ovarian transposition for early cervical cancer in another hospital. Two years after the operation, bilateral ovarian cysts of transposed ovaries were pointed out. They were not considered as a recurrence as specific tumor markers were within the normal range and the up-take was not recognized in PET-CT. She stated to experience hip and pubic pain when the ovarian cysts were 5 cm. Due to difficulties controlling her pain, we performed a laparoscopic operation for the diagnosis. A swollen left ovary was observed on the iliopsoas in the retroperitoneal space. It was not twisted or ruptured. We performed left adnexectomy and adhesiolysis and her pain resolved after the operation. The pathologic diagnosis was a lutein cyst.

Objectives: Since the positive predictive value of endometrial biopsy for uterine corpus cancer without myometrial invasion is not high, early diagnosis is difficult. We report a case in which we diagnosed uterine corpus cancer by using hysteroscopic endometrial tissue biopsy 2 years after an initial visit.

Patient: A 61-year-old postmenopausal woman was referred for evaluation of positive endometrial cytology. Magnetic resonance imaging showed thickening of the endometrium, but repeated uterine curettage biopsies revealed no malignancy. We thought that collection of polypoid-like lesions would be difficult, and performed hysteroscopic endometrial tissue biopsy. Two endometrial polyps were excised, and through histopathological analysis of one polyp, we diagnosed endometrioid adenocarcinoma Grade 2. Radical surgery was performed for stage I A uterine corpus cancer, and the final diagnosis was uterine corpus cancer stage I A (pT1aN0M0), with endometrial adenocarcinoma Grade 2.

Conclusion: For uterine corpus cancer with suspected polypoid lesions and difficulty in diagnosis with uterine curettage, hysteroscopic endometrial biopsy can be useful.

  Ovarian torsion in pediatric patients is rare. We had a case of left ovarian torsion in a 10-year-old girl who underwent laparoscopic left salpingo-oophorectomy because the ovary looked necrotic. The pathological diagnosis was mature cystic teratoma with extensive bleeding and absence of viable ovarian tissue on microscopic inspection. The symptom was nonspecific, considering that acute lower abdominal pain in most infants is caused by digestive diseases. Thus, differential diagnosis would have been difficult if ovarian torsion had not been considered at the initial diagnosis. Gynecological disorders should be considered in cases of acute stomach symptom in girls. In addition, infants and adults have anatomical differences, and the anatomical knowledge of the infant pelvis is necessary when performing surgeries.

  We present a case of pelvic organ prolapse associated with chronic pelvic pain, which was successfully treated with laparoscopic surgery. The patient was 64 years old (gravida 2, para 2). She underwent total abdominal hysterectomy and right adnexectomy for a hydatidiform mole at the age of 43. Ten years later, she sensed that the suture thread in the vaginal stump had broken off inside her lower abdomen. Pelvic pain then developed. Six months later, she developed pelvic organ prolapse and the pelvic pain increased. She first came to our department 20 years after hysterectomy. Pelvic Organ Prolapse Quantification was used to diagnose a stage II vaginal cystocele and vaginal vault prolapse. She had tenderness on the left side of the vaginal stump, as well as a urinary disorder. Therefore, we performed laparoscopic surgery to identify the cause of pain. There were dense adhesions between the left adnexa and pelvic peritoneum. Furthermore, the threads of the vaginal stump were pulled tense. After left adnexectomy and resection of suture threads adherent to the pelvic peritoneum, her symptoms were markedly improved. She is doing well without recurrence 17 months after surgery. In cases of pelvic organ prolapse with unusual pelvic pain, a laparoscopic approach is effective.

  Fallopian tube torsion is a rare gynecological cause of acute abdominal pain. Fallopian tube torsion is known to occur during the reproductive age. We experienced four cases of fallopian tube torsion over 3 years, with three of the four cases occurring in nulligravida young women. We discuss the clinical features of our four cases and the problems of fallopian tube torsion in young women. They were referred to our hospital with acute abdominal pain, where emergency laparoscopic surgery was used to diagnose and treat the fallopian tube torsion. Three cases were isolated fallopian tube torsion, while one case was accompanied by a para-ovarian tumor. Although the degree of pain varied, abdominal pain and swollen tubes were observed in all cases. According to reports in Japan, many cases have occurred in their 10s to 30s.

  In particular, diagnosis is often delayed for young women who are yet to experience sexual intercourse because they often go to other departments and internal examination is difficult. Since early treatment is indispensable for the preservation of the fallopian tubes, it is important to consider fallopian tube torsion in cases of abdominal pain accompanying enlargement of the adnexal area.

Since the average lifetime of Japanese women is 87 years old recently, the gynecologic surgeons will face the elderly patients who need to be performed operation. We report a case of laparoscopic salpingo-oophorectomy for huge ovarian tumor in an elderly patient. A 100-year-old woman, gravida 3 para 3, caught a cold and visited emergency department. The chest - abdominal CT revealed huge pelvic mass, and she was referred to our hospital. MRI showed a multiple cystic ovarian mass without solid part. We evaluated her cognitive function and surgical risk with Comprehensive Geriatric Assessment and E-PASS scoring system. Laparoscopic salpingo-oophorectomy was performed under the general anesthesia. During the operation her vital sign was stable. Two days after operation she discharged without any problems. Our treatment decision for surgical intervention was based on the patient's general condition rather than her chronological age.

  Mature cystic teratomas derived from extragonadal lesions are rare. We report a case of extragonadal mature cystic teratoma (EMCT) in the pouch of Douglas (POD), which was predicted preoperatively and successfully resected by performing laparoscoic surgery. A 35-year-old woman was incidentally diagnosed with a mass measuring 6 cm in diameter in the right pelvis on ultrasonographic examination. Magnetic resonance imaging (MRI) findings were suggestive of mature cystic teratoma. Both normal ovaries were found adjacent to the mass. We considered the possibility of EMCT, and performed laparoscopic surgery.

  Intraoperatively, the cyst was found in the POD and both ovaries appeared normal. There were violin string-like adhesions between the cyst wall and the back of the uterus, right ovary, and serosa of the rectum. We dissected the adhesions with the rectum with the help of a gastroenterological surgeon, and dissected the other adhesions easily ourselves. The patient had an uneventful postoperative course and was discharged on the fourth post-operative day. Pathological examination of the resected mass revealed the mass to be EMCT.

  Only approximately 20 cases of EMCTs in POD have been reported till date. There are several hypotheses to explain their etiopathogenesis. We hypothesize that auto-amputation could be the mechanism that resulted in EMCT in this case. Though EMCTs are rare, we should consider performing detailed preoperative evaluations with EMCT as a differential diagnosis. Subsequently, we can plan an appropriate surgical approach beforehand, and perform laparoscopic surgery safely.

  A 44-year-old woman who had no history of tuberculosis was referred to our hospital because of lower abdominal pain and ascites. Blood tests revealed an elevated CA125 level (326 U/mL), and enhanced computed tomography detected thickened peritoneum and enhanced peritoneal nodules. While microbiologic testing and cytologic examination of ascites were negative, the T-SPOT^®.TB test was positive. Diagnostic laparoscopy was conducted, revealing tiny nodular lesions on the peritoneal surfaces. Pathological examinations showed granuloma and Langhans giant cells with caseous necrosis; however, no signs of malignancy were observed. After administering a combination drug regimen using isoniazid, rifampicin, pyrazinamide, and ethambutol, she had been on a good clinical course. Tuberculous peritonitis (TBP) is one of the types of extra-pulmonary tuberculosis. Although early diagnosis is known to improve patients' prognosis, it is still difficult to obtain due to the non-specificity of symptoms. A number of reports already revealed that laboratory tests such as tumor marker show similar results with carcinomatous peritonitis. Detecting Mycobacterium tuberculosis is the gold standard for diagnosis, but this detection is difficult in routine practice because of the low detection rate. Auxiliary tests such as radiography, immunological test, and laparoscopy are usually conducted. Laparoscopic surgery is the most common method for early diagnosis, detection of localization of infection, and differentiation from carcinomatous peritonitis. As the long-term treatment is necessary for TBP, confirming other diseases requiring uncomplicated treatment is important.

Objective: We are currently testing a simplified and safe laparoscopic hysterectomy procedure in our clinical practice that is technically similar to laparotomy. The present study aimed to evaluate the feasibility of this modified total laparoscopic hysterectomy (TLH) method, which uses the RUMI II Colpotomiser System and without requiring separation of the ureter and uterine artery for laparoscopic surgeons under training.

Methods: During the procedure, uterine vessels and ureters are not skeletonized, the vaginal vault is identified using a colpotomy cup, and retrograde dissection is performed from the anterior vaginal wall. We used statistical analysis to evaluate operative time, parity, body mass index (BMI), blood loss, and surgery-related complications by Student's t-test.

Results: We have performed 11 TLH procedures applying the above method, excluding cases of severe adhesion, since 2016. Compared with the traditional TLH method, average operating time was significantly shorter using the new method. There was no significant difference between the two groups with regards to parity, BMI, or blood loss. No complications have occurred postoperatively since 2016; whereas, one vesicovaginal fistula occurred in the 18 TLH performed before 2016.

Conclusion: This simplified TLH procedure may be a safe and effective alternative for laparoscopic beginners as it is similar to that of abdominal hysterectomy. Furthermore, the exclusion of complicated tissue peeling reduces operator stress and surgery-related complications.