Laparoscopic cystectomy is widely performed for dermoid cysts. However, the total laparoscopic approach is associated with greater risk of intraoperative spillage (IOS). Although a few cases of chemical peritonitis (CP) have been reported following IOS, the association remains unclear. We conducted a retrospective study of spillage of dermoid cysts during laparoscopic cystectomy in a single institution. A total of 141 patients who underwent laparoscopic cystectomy for dermoid cysts at our institution between 2012 and 2016 were identified. Eighty patients (57%) developed IOS, and had a significantly longer operative time (60.0±25.7 min vs. 47.9±11.9 min, p<0.01) compared with patients who did not develop IOS. We did not observe significant differences in cyst diameter (6.8±2.4 cm vs. 6.1±1.4 cm, p=0.06), or in the rate of postoperative fever between the groups. No patients developed CP. We concluded that controlled IOS was not associated with postoperative complications, although further investigation is needed.

Objective: The objective of this clinical study was to compare abdominal field block to patient-controlled epidural analgesia (PCEA) after total laparoscopic hysterectomy (TLH).

Methods: Forty patients who underwent TLH at our hospital from July to September 2015 and from September 2016 to January 2017 were divided into two groups. The patients in group A received rectus sheath and transversus abdominis plane block, and those in group B received PCEA. Post-operative pain was followed for 2 days after surgery and evaluated using a visual analog scale (VAS) at rest and during activity. The frequency of analgesic use was also monitored.

Results: VAS scores at rest in group A were significantly higher than those in group B at 6 hours and 2 days after surgery.

VAS scores during activity in group A were significantly higher at all time points (6 hours, 1 day, and 2 days after surgery). However, there were no significant differences in VAS scores at rest between the two groups at 1 hour, 3 hours, and 1 day after surgery.

The patients in group A required significantly more analgesics than those in group B.

Conclusion: Abdominal field block after TLH seems less effective compared to PCEA, especially during activity after surgery.

Objective: Ectopic pregnancies (EP) commonly occur in the fallopian tube. As a result of improvements in technology and surgical techniques, laparoscopic surgery is a widely-utilized therapy in cases of EP in the fallopian tube, and also seems to be useful in cases of unusual EP. We aimed to evaluate the efficacy of laparoscopic surgery for unusual EP.

Method: We defined unusual EP as peritoneal pregnancy, ovarian pregnancy, and interstitial pregnancy. We experienced 165 cases of EP from April 2011 to March 2016. Among these cases, 105 cases underwent surgery. 85 cases occurred in a fallopian tube, and 20 cases occurred in an unusual site (peritoneal pregnancy n=5, ovarian pregnancy n=5, interstitial pregnancy n=10.). We retrospectively investigated the clinical features and analyzed treatment from the medical records of unusual EP at our hospital.

Results: Laparoscopic surgery was performed in two cases of peritoneal pregnancies (40%), five cases of ovarian pregnancies (100%), and three cases of interstitial pregnancies (30%). Although in eight cases with unusual EP there was a presentation with massive bleeding, laparoscopic surgery was tried in three of eight cases and completed without conversion to laparotomy. By undertaking intraoperative red blood cell salvage, we were able to could avoid homologous blood transfusion, except in one case.

Conclusion: EP requires emergency treatment, and the diagnosis of unusual EP is particularly difficult. Laparoscopy can facilitate correct diagnosis, results in less physical stress for the patient, and is effective in treatment.

Objective: To evaluate whether decreased abdominal air pressure and continuous administration of muscle relaxants may help relieve severe postoperative shoulder pain.

Design: Retrospective cohort study.

Settings: Single-center general hospital.

Patients: A total of 158 patients who had undergone laparoscopic gynecological surgery were included in the study. Patients were devided into three groups based on the surgical conditions used as follows: standard pneumoperitoneum pressure (10 mmHg) without muscle relaxants, standard pneumoperitoneum pressure with muscle relaxants, and low pneumoperitoneum pressure (eight mmHg) with muscle relaxants.

Interventions: Reduction of pneumoperitoneum pressure and continuous administration of muscle relaxants.

Main outcome: There were no differences in patient characteristics or surgical procedures among the three groups. However, low pneumoperitoneum pressure decreased the frequency of severe postoperative shoulder pain when compared to the application of standard pneumoperitoneum pressure (p= 0.001; odds ratio = 0.28; 95% confidence interval= 0.13–0.61).

Results: Low pneumoperitoneum pressure decreased the frequency of severe postoperative shoulder pain compared to the use of standard pneumoperitoneum pressure.

Conclusion: Reduction of pneumoperitoneum pressure reduces the frequency of severe postoperative shoulder pain after laparoscopic gynecological surgery.

Objective: We investigated the correlation between tumor diameter and the expression of tumor markers in ovarian mature cystic teratoma (MCT).

Methods: Thirty-two patients with MCT who were surgically treated at our hospital between January 2013 and March 2015 were included in this study. We investigated the correlation between tumor diameter and tumor marker expression (squamous cell carcinoma antigen [SCC], carcinoembryonic antigen [CEA], carbohydrate antigen [CA]125, and CA19-9).

Results: The median tumor diameter was 7.8 cm (range 5.0-16.0 cm). The median values of SCC, CEA, CA125, and CA19-9 were 1.25 ng/mL (range 0.6-3.5 ng/mL), 1.4 ng/mL (range 0.5-10.9 ng/mL), 16 U/mL (range 5.0-86.1 U/mL), and 34.6 U/mL (range 2.0-949.4 U/mL), respectively. The levels of SCC and CEA showed significant positive correlations with tumor diameter (respective correlation coefficients = 0.499 and 0.460), while the levels of CA19-9 and CA125 showed no significant correlation with the tumor diameter. We also encountered an example of malignant transformation of MCT during the study period. The tumor diameter in this case was 18.8 cm, and the preoperative level of SCC was 25 ng/mL, which is remarkably high, even considering the tumor diameter.

Conclusion: In this study, the levels of SCC and CEA showed significant positive correlations with tumor diameter. High preoperative SCC and CEA levels may suggest that the tumor diameter should be considered when planning laparoscopic surgery. On the other hand, in cases in which the tumor markers are remarkably high, preoperative evaluation for the possibility of malignancy may be necessary.

Objective: We investigated the clinical characteristics of patients with ruptured ovarian endometrioma and examined the role of serum D-dimer levels in ruptured and unruptured ovarian endometrioma.

Design: Retrospective and prospective study

Setting: Department of Gynecology of Saiseikai Nagasaki Hospital, Japan.

Patient(s): Women who had laparoscopic surgery for ovarian endometrioma from April 2009 to April 2017 were enrolled in the study. We classified these women into three groups: those with ruptured endometrioma (n=61), emergency surgery for unruptured ovarian endometrioma (n=13), and elective surgery for unruptured ovarian endometrioma (n=26).

Intervention(s): None

Main outcome measure(s): The clinical characteristics and serum D-dimer levels of women with ruptured and unruptured ovarian endometrioma were evaluated.

Result(s): In the ruptured group, the mean age was 33.8 years, mean ruptured cyst size was 6.4 cm, and rupture occurred on the right side in 27 patients and on the left side in 30 patients. Almost all patients had no definite trigger, and 30 patients (49%) had rupture during the menstrual period. We compared patients in the ruptured and unruptured groups; significant differences were observed in the rebound tenderness (79% vs. 42%,p<0.05), white blood cell count (10,536±4,412/µL vs. 7,269±2,650/µL, put p<0.05), and C-reactive protein level (4.0±5.4 mg/dL vs. 0.5±0.9 mg/dL, p<0.05). In the ruptured group, 55% of ovarian endometriomas were detected preoperatively by transvaginal ultrasonography and 74% by magnetic resonance imaging. We measured serum D-dimer levels in the ruptured group (n=24) and unruptured group with elective surgery (n=26). The mean serum D-dimer level (cut-off level is less than 1.0 μg/mL) was 2.2±1.9 μg/mL in the ruptured group, which was significantly higher than that in the unruptured group (put D-dimer value and p<0.05). In the ruptured group, 79% of patients showed higher serum D-dimer levels, and all patients in the unruptured group with elective surgery showed D-dimer values less than the cut-off levels.

Conclusion(s): In addition to routine measurement of conventional parameters, our findings further suggested the clinical usefulness of measuring D-dimer levels in distinguishing patients with ruptured and unruptured ovarian endometrioma.

Objective: We retrospectively investigated the feasibility of using pre-operative magnetic resonance imaging (MRI) findings to diagnose broad ligament myoma.

Design: We examined the presence of elongated uterine arteries, evidenced by MRI, in nine cases of broad ligament myoma among the 257 cases of hysterectomy or myomectomy for uterine myoma performed at our institution from April 2015 to November 2017.

Results: In five of seven cases (excluding two cases of myoma of 2.5-cm diameter, growing vertically) an elongation of the uterine artery around the myoma was detected using MRI.

Conclusion: Findings of elongation of the uterine artery surrounding the myoma via MRI was effective in diagnosing broad ligament myomas and may help to reduce the risk of operative complications.

Objective: Laparoscopic surgery has been proposed extensively as an alternative to laparotomy for the treatment of early endometrial cancer. The aim of this study was to evaluate the safety, complications, and oncological outcomes and to assess the feasibility of this procedure.

Methods: Twenty-eight patients diagnosed preoperatively with clinical stage IA, G1-G2 endometrial adenocarcinoma underwent laparoscopic surgeries between 2014 and 2016 at Osaka University Hospital by a single surgeon. Surgical procedures included hysterectomy, salpingo-oophorectomy and pelvic lymphadenectomy. Clinical outcomes were evaluated retrospectively.

Results: Except for 2 cases in which laparotomic para-aortic lymphadenectomy was performed, laparoscopic surgery was successful. The mean operation time of cases in which pelvic lymphadenectomy was performed was 264 minutes (range: 190-359 minutes), the mean amount of blood loss was 59 mL (range: 0-300 mL), and the mean number of lymph nodes removed was 21 (range: 3-44 lymph nodes removed). Complications were noted in 3 cases (cases 12-14) in which pelvic lymphadenectomy was performed. In case 12, postoperative bleeding from the left obturator artery was observed and hemostasis was achieved under interventional radiology. In case 13, bladder muscles were injured during the dissection of the left vesicouterine ligament and the injury was successfully repaired laparoscopically. In case 14, vaginal cuff abscess was observed and conservatively treated using antibiotics. No recurrences were observed in any case during the observation period.

Conclusion: Laparoscopic surgery is feasible for the treatment of early endometrial cancer; however, it appears that a well-designed learning curve is required for surgeons to acquire laparoscopic surgery skills. Once skills are acquired, surgeons can substitute laparoscopic for laparotomic procedures.

Background : Uterine malformations frequently coexist with an abnormality in the renal urinary tract system. We report a case of uterus bicornate unicollis in which ureteral injury during surgery was suspected but congenital unilateral renal aplasia was eventually diagnosed.

Case : A 42-year-old woman with uterus bicornate unicollis accompanied by uterine leiomyoma with anemia underwent total laparoscopic hysterectomy after administration of a GnRH agonist. Following the hysterectomy, cystoscopy was performed with intravenous injection of indigocarmine, and neither outflow of indigocarmine nor the right ureteral orifice was confirmed. We suspected a ureteral injury and checked the right ureter but did not observe an enlarged ureter or urine leakage into the abdominal cavity. We consulted a urologist, but the right ureteral orifice could still not be identified and the right kidney could not be identified by ultrasonography. After surgery, abdominal contrast-enhanced CT was performed, and the right kidney was not recognized. The patient's renal function was normal and her postoperative course was good. The patient had been diagnosed with uterus bicornate unicollis, but we did not evaluate the renal urinary tract system by a method such as drip infusion pyelography before surgery.

Conclusion : We reconfirmed the importance of carefully examine the renal urinary tract system before surgery in the cases with uterine malformations.

  If urinary excretion cannot be confirmed by intraoperative cystoscopy, while rare, the possibility of kidney deficiency and other malformations should be considered.

Introduction: Cervical pregnancy is a rare form of ectopic pregnancy; it has an incidence of 1 in 10,000 to 95,000 pregnancies. Recently, preservation of fertility has become possible for this condition through various efforts of conservative treatment, including pharmacotherapy and uterine artery embolism. Nonetheless, a standard protocol has not been established to date. In this report, we present two cases of uterine cervical pregnancy successfully treated with total laparoscopic hysterectomy in our hospital.

Case 1 presented to our hospital due to continuous vaginal bleeding. Transvaginal ultrasonography and magnetic resonance imaging (MRI) findings showed a gestational sac of 15 mm in diameter in the cervical canal, and a cervical pregnancy was diagnosed. The serum human chorionic gonadotropin (hCG) level was 2063 mIU/mL; the pregnancy was unwanted. We performed total laparoscopic hysterectomy (TLH) for this patient. She was discharged on day 5 without any severe adverse effects.

Case 2 was referred to our hospital due to continuous genital bleeding following polypectomy. Transvaginal ultrasonography and MRI findings showed a gestational sac of 12 mm in diameter in the cervical canal, and a diagnosis of cervical pregnancy was made. The serum hCG level was 18,180 mIU/mL; the pregnancy was unwanted. We performed TLH on this patient. She was discharged on day 5 without any severe adverse effects.

Conclusion: It is suggested that TLH might be an effective treatment choice for patients with this form of ectopic pregnancy, and who desire pregnancy interruption, considering that the clinical stay is short and the procedure is safe with no severe side effects.

Objective: There are many opportunities to distinguish between an ovarian cyst, a paroophoritic cyst, and a hydrosalpinx via imaging studies. We report a case of low-grade appendiceal mucinous neoplasm preoperatively diagnosed as paroophoritic cyst or hydrosalpinx.

Case: The patient is a 25-year-old woman. Preliminary examination confirmed a 77×27 mm cystic lesion near the right ovary; thus, she was diagnosed with the right paroophoritic cyst or hydrosalpinx. Tumor markers were found normal. We performed laparoscopic surgery for further diagnosis and treatment. A clubbed cystic tumor was revealed, which involved the right fallopian tube twisted by 720 degrees. Upon the release of the twist, the cystic tumor reached the ileocecum. We diagnosed the tumor origin as the appendix. We ligated and cut the appendix root and collected it into the pouch to avoid leakage of the contents of the cystic tumor in the abdominal cavity. When the cystic tumor was opened, it was found to be filled with a yellow transparent jelly-like mucus. The histologic diagnosis was low-grade appendiceal mucinous neoplasm. The patient was continuously followed up at our clinic.

Conclusion: In case of leakage of the cyst contents during operation, mucinous tumors may cause pseudomyxoma peritonei, which disseminates into the intraperitoneal cavity. Using laparoscopic surgery, we diagnosed that the cystic tumor originated from the appendix and removed and treated it with minimally invasive methods. Furthermore, for a favorable prognosis, it is essential to monitor a cautious manipulation without rupture of the mucinous cystic tumor.

  Ectopic pregnancy is considered as a possible diagnosis in cases in which women experience acute abdominal pain and a urinary human chorionic gonadotropin (hCG) test produces a positive result. However, we present a case of ruptured ectopic pregnancy involving a negative urinary pregnancy test result. A 34-year-old nulliparous woman was admitted to the emergency room of our hospital due to the sudden onset of lower abdominal pain. Rebound pain in the lower abdomen was detected during a physical examination. Since transabdominal ultrasonography showed massive ascites, and a urinary pregnancy test produced a negative result, we performed a contrast-enhanced computed tomography scan and found a 5-cm right-sided ovarian cyst and extravasation around the left adnexa. We diagnosed the patient with left ovarian hemorrhaging and a right ovarian hemorrhagic luteal cyst. Two hours later, hemorrhagic shock occurred, and an emergency laparoscopic operation was carried out. We detected a swollen left fallopian tube, which had ruptured and was bleeding. We performed left salpingectomy. After the operation, the patient's preoperative serum sample was re-examined to re-assess her hCG level. As a result, her serum hCG level was found to be 23.3 mIU/ml. Pathological examinations showed a very small number of chorionic villi. The final diagnosis was ectopic pregnancy. The patient's postoperative course was uneventful. This case report illustrates the difficulty of diagnosing ectopic pregnancy. Clinicians should include ectopic pregnancy in the differential diagnoses for cases of acute abdominal pain involving women of reproductive age, regardless of the results of urinary pregnancy tests.

Introduction: Osteogenesis imperfecta (OI) is a congenital disease with various degrees of connective tissue abnormalities in addition to easily fractured bones due to bone fragility, as well as progressive bone deformities. We report a case of left tubo-ovarian abscess (TOA) in a patient with OI treated with laparoscopic surgery.

Case: A 33 - year - old woman with OI type III visited our hospital complaining of pain on the left side of her umbilicus and slight fever. An abdominal computed tomography (CT) revealed that the uterus, uterine adnexa, and urinary bladder were displaced into the upper part of abdominal cavity due to her deformed small bony pelvis. Additionally, a TOA was noted in her left adnexa. Antibiotic treatment was initiated with resolution of symptoms, however, a recurrence was observed after one month. A laparoscopic surgery was performed after careful consideration of surgical positioning, anesthesia modalities, and potential complications with anesthesiologists and surgical nurses.

Conclusions: Various potential perioperative complications are present when performing surgery on patients with OI. Therefore, sufficient preoperative consideration is required. Laparoscopic surgery may offer a minimally invasive approach to patients with OI after careful preoperative consideration.

  We report three cases of women with inguinal endometriosis who were treated with conventional extracorporeal excision and laparoscopy. Case 1: A 38-year-old woman complained of a painful nodule in the left inguinal region. Magnetic resonance imaging (MRI) revealed a 2-cm fibrous tumor at the left inguinal region presumed to be an endometriotic lesion. We performed an extracorporeal tumor excision and laparoscopy. The patient had pelvic endometriosis. The left inguinal tumor was excised and endometriosis was confirmed histologically. Case 2: A 40-year-old woman with previous history of ovarian endometrioma cystectomy presented with left inguinal swelling and pain during menstruation. MRI revealed a 2-cm fibrous tumor in the left inguinal region presumed to be endometriosis. Extracorporeal tumor excision and laparoscopy were performed. Endometriosis was confirmed histologically. Her symptoms improved after surgery, but four months after the first procedure, she noticed recurrence of the left inguinal tumor. She underwent a re-excision of the tumor along with inguinal hernia surgery (protrusive approach, mesh plug procedure). Case 3: A 35-year-old woman with a painful right inguinal nodule, suspected to be endometriosis, was treated with extracorporeal tumor excision and laparoscopy. During surgery, in addition to the presence of pelvic endometriosis and peritoneal adhesion, right inguinal hernia was diagnosed and inguinal hernia surgery (Hybrid-TAPP; transabdominal pre-peritoneal approach procedure) was performed along with the excision of the right inguinal tumor by a general surgeon. After surgery, she was symptom free with the support of oral contraceptives. Inguinal endometriosis is rare, but may need appropriate surgical and medical interventions. We discuss the clinical management for inguinal endometriosis and the significance of laparoscopy in such cases.

  Postoperative brachial plexus injuries infrequently occur after laparoscopic surgery. We describe postoperative brachial plexus injuries after laparoscopic myomectomy (LM), with analysis of the cause and method of prevention. Case 1: a 30-year-old female with body mass index (BMI) 22.0 kg/m² underwent LM. During the procedure, the left upper limb was placed at her side and the right upper limb was abducted; both shoulders were fixed. The head was lowered a maximum of 20 degrees. She developed a right median nerve injury and weakness on right shoulder and elbow flexion after awakening. Electromyography diagnosed a brachial plexus injury and the patient started a rehabilitation program. Case 2: a 36-year-old female with BMI 17.4 kg/m² underwent LM. The position was the same as in case 1. She developed hypoesthesia involving the median, radial, and musculocutaneous nerves in the right hand, and weakness of right elbow flexion and finger movement after awakening. Electromyography diagnosed a brachial plexus injury and the patient started a rehabilitation program. These neurological injuries may have developed when the brachial plexus was sandwiched between the clavicle and first rib in abduction, with overextension due to the weight of the head. Compression of the thoracic outlet is prevented by fixing both upper limbs at the sides and avoiding overextension of the neck with the head fixed. Neurological injuries have not recurred since this positioning method was introduced.

OBJECTIVE: The National Comprehensive Cancer Network guidelines recommend that in patients presenting with an incidental finding of an invasive cancer (The International Federation of Gynecology and Obstetrics stage IA2-IIA) during a simple hysterectomy, the management strategy includes observation, radiation and/or concurrent chemoradiation therapy, or a radical parametrectomy (RP). However, an RP procedure is difficult to perform; therefore, it is not widely used in Japan. We report a patient who underwent laparoscopic RP (LRP) to treat stage IB1 cervical cancer after a simple vaginal hysterectomy, and we additionally present a literature review.

METHODS: Case report.

RESULTS: A 66-year-old woman, diagnosed with CIN3, was treated with a simple total vaginal hysterectomy. Histopathological findings revealed cervical cancer stage IB1 (squamous cell carcinoma, nonkeratinizing type, measuring 7 mm each in diameter and depth, with a negative surgical margin). All investigative tests were negative for residual tumor or metastasis. After the treatment options were explained to her, she opted for RP, and we performed LRP on the 58^th day after her first operation. Intraoperatively, the tumor demonstrated fibrous adhesions with the vesicouterine ligament. The operation time was 5.5 hours, estimated blood loss was 173 mL, and 45 pelvic lymph nodes were removed. Because she showed no histopathological evidence of malignant cells in the studied specimens, we decided to follow her up as an outpatient. No recurrence has been observed for 15 months since the LRP.

CONCLUSION: Reportedly, performing RP is considered a difficult procedure due to adhesions resulting from prior surgery. However, recent reports indicate that RP can be safely and effectively performed. We conclude that this operation might serve as an alternative treatment strategy for the management of Japanese patients showing this presentation.

  Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare congenital anomaly involving the Müllerian and Wolffian ducts. It is often classified based on the type of hemivagina and whether the vaginal septum is completely obstructed or small communications exist. We encountered the case of a 16-year-old female patient having a double uterus, left hemivagina, left kidney agenesis, and severe dysmenorrhea. At the time of laparoscopic surgery for her 9-cm left ovarian endometriosis, a hysteroscopy was performed to explore her vagina and uterus in more detail. The hysteroscopy was extremely useful to determine the precise type of hemivagina, which presented a small communication with the cervix of the right uterus, and to permit resection of the small communication using hysteroscopic forceps to relieve the dysmenorrhea.

  We report 2 patients with history of prior renal transplantation who underwent laparoscopic myomectomy or hysterectomy.

Case 1: A 43-year-old woman (gravida 0) underwent living related renal transplantation when she was 38 years old to treat chronic renal failure secondary to IgA nephropathy. She reported history of a uterine myoma, which had gradually enlarged to measure greater than the size of a newborn's head when she presented at the age of 43 years. Because of a sensation of lower abdominal fullness, she underwent laparoscopic myomectomy after receiving gonadotrophin releasing hormone (GnRH)-agonist therapy. A 3-port laparoscopic myomectomy was performed (an umbilical trocar and 2 parallel trocars on the patient's left side). The estimated blood loss was 500 mL, and the operation time was 224 min.

Case 2: A 45-year-old woman (gravida1 para 0) underwent living related renal transplantation when she was 43 years old to treat chronic renal failure secondary to vesicoureteral reflux. She reported history of uterine myomas and adenomyosis that had enlarged and presented with hypermenorrhea and dysmenorrhea. She underwent laparoscopic hysterectomy with the insertion of ureteral stents after receiving GnRH agonist therapy. A 4-port total laparoscopic hysterectomy was performed (an umbilical trocar and 3 lower quadrant trocars). The estimated blood loss was 690 mL, and the operation time was 217 min.

  In both patients, immunosuppressants and steroid were continued perioperatively, and acetaminophen was used for postoperative pain control. Intraoperatively, pneumoperitoneum was established to a pressure of 8–10 mmHg, and urine volume was maintained perioperatively. Both patients were discharged from the hospital on postoperative days 5 and 6, respectively.

Objective: We encountered two cases of rare pelvic cysts diagnosed after laparoscopic cystectomy.

Case report: Case 1 was of a 73-year-old woman with a cyst measuring 4.7 cm, detected by transvaginal ultrasonography and MRI. We diagnosed a potential ovarian cyst and conducted laparoscopic surgery, finding the cyst in the mesenteric ligament and resecting it. Histopathologically, the cystic wall consisted of fibrous tissue lacking epithelium. Immunohistochemical analysis showed positive staining for calretinin, leading to diagnosis of a mesenteric pseudocyst. Case 2 was of a 57-year-old woman with a 14.3 cm serous cyst in her pelvis, detected by abdominal MRI. On the basis of a preoperative diagnosis of an ovarian cyst, we conducted laparoscopic surgery, finding a retroperitoneal cyst and resecting it. Histopathologically, the cyst was lined by benign papillary epithelium. Immunohistochemical analysis showed positive staining for estrogen receptors, progesterone receptors, and CA 125. It was diagnosed as a retroperitoneal Müllerian cyst.

Conclusion: It is important to consider the possibility of a rare pelvic cyst whenever a patient is diagnosed with an ovarian cyst.

Background

  Parasitic myoma is an extrauterine leiomyoma that develops because of feeding of nutrients by vessels from organs other than those of the uterus. Recently, laparoscopic myomectomy has become popular. However, incidences of iatrogenic parasitic myoma have also been reported. In this case, uterine myoma recurred after laparoscopic myomectomy and disseminated lesions were found in the peritoneal cavity with suspected uterine sarcoma.

  Retained placenta, a partial retention of placental tissue after abortion or delivery, may cause massive hemorrhage. When it is removed surgically with uterine preservation, uterine artery embolization is often performed beforehand to reduce the amount of bleeding during operation. However, the risk of postoperative obstetrical complications is concerning due to the extended amount of time with blood flow blocked in the uterine artery. A 37-year-old woman, gravid 5 para 3, came to our hospital on the 35^th postpartum day because of bloody vaginal discharge after artificial abortion at 19 weeks of gestation by gemeprost vaginal suppository. An intrauterine mass with abundant blood flow was observed by ultrasound. The elevated level of serum human chorionic gonadotropin (HCG) was 26.9 mIU/ml, and was indicative of retained placenta. Hysteroscopic resection after temporal laparoscopic uterine artery clipping was performed for the removal of retained placenta without any complications. We report here this minimally invasive procedure for the treatment of retained placenta and discuss its efficacy, usefulness and safety.

  We report a case of an ectopic pregnancy removed via laparoscopic surgery in a patient undergoing therapy for ovarian hyperstimulation syndrome (OHSS). A 36-year-old woman, with a history of egg retrieval after ovulation induction with human menopausal gonadotropin and human chorionic gonadotropin (hCG), was referred to our hospital because of abdominal pain and bloating. Ultrasound examination showed an 8-9 cm bilateral adnexal mass and subphrenic ascites. She was diagnosed with moderate OHSS. Despite conservative therapy, symptoms did not improve and the bilateral adnexal mass did not decrease in size. Serum hCG level was 6339 mIU/ml. Ultrasound examination did not detect a gestational sac in the uterus. Magnetic resonance imaging indicated a cystic mass in the peritoneal cavity. We strongly suspected ectopic pregnancy in the abdominal cavity. Laparoscopic surgery and intrauterine curettage were performed. The histopathological diagnosis was peritoneal pregnancy. Symptoms disappeared and serum hCG levels decreased. We believe that the peritoneal pregnancy caused OHSS. Even if there is a period when of pregnancy failure via assisted reproductive technology, ectopic pregnancy should be considered. Pregnancy should be confirmed and egg retrieval performed before initiating medical treatment in patients with OHSS.

  Rudimentary horn pregnancy (RHP) is a rare disease, the frequency of which is reported as 1/76,000 to 1/150,000 of pregnancies. The preoperative diagnosis is reportedly difficult, and the diagnostic yield is 16%. Some RHP cases are determined during the operation for ectopic pregnancy diagnosed, preoperatively, as tubal pregnancy. We present a case of RHP diagnosed by ultrasound and treated with laparoscopic surgery. A 35-year-old woman (gravida: 2, para: 1) presented to our department with suspected ectopic pregnancy at 6-weeks gestation.

  Vaginal ultrasound revealed a gestational sac covered with a thick myometrium on the left side of the uterus and a fetal heart beat within. Communication between the endometrium of the uterus and the gestational sac was undetected. Magnetic resonance imaging (MRI) showed the same findings as those of ultrasonography and a diagnosis of pregnancy with non-communicating rudimentary horn was established. On laparoscopy, we resected the rudimentary uterine horn including the fetus. This case demonstrates that laparoscopic resection of pregnant rudimentary horn is safe and feasible in the surgical management of unruptured RHP.

Introduction: Gynecologic laparoscopy often involves making the first puncture in the umbilicus. However, such punctures may injure organs in patients with large uterus or ovaries reaching the umbilicus, or the omentum or intestine adhering to the umbilicus in patients with previous abdominal surgery. To avoid such complications, we make the first puncture at Lee-Huang point for giant tumors and Palmer's point when umbilical adhesion is suspected.

Technique: [Lee-Huang point] In cases with giant tumor, the first puncture is made at Lee-Huang point, the midpoint between the umbilicus and xiphoid process. Making the first puncture at Lee-Huang point and using it as the camera port. It helps avoid organ injury and ensure an intraoperative visual field.

[Palmer's point] In cases with suspected umbilical adhesion, the first puncture is made at Palmer's point, 3 cm below the costal margin on the midclavicular line.

Discussion: We make the first puncture at Lee-Huang point or Palmer's point in case with high risk, such as giant tumor or adhering. Guidelines from the Society of Obstetricians and Gynaecologists of Canada state that in patients with suspected umbilical adhesion, open entry increases the risk of small intestine perforation; therefore, a Palmer's point approach is recommended.

Conclusion: We can perform the operation with making the first puncture at Lee-Huang point and Palmer's points without the associated complications.

  Because a large tumor within the broad ligament sometimes alters the anatomical position of the ureter, vessels, and bladder, surgeons should be particularly attentive during surgical procedures.

  We report a case of a large paratubal cyst within the broad ligament in a pregnant woman treated with laparoscopic surgery.

  A 25-year-old gravida 0 woman presented with 6 weeks of amenorrhea. On ultrasonographic examination, we diagnosed a normal pregnancy and detected a simple cyst of 116 × 96 mm in the right adnexa. To prevent torsion or rupture during pregnancy, the patient underwent a laparoscopic procedure with two 5-mm ports and two 12-mm ports in the standard diamond position for cystectomy. We found a large paratubal cyst located in the retroperitoneum space. We cut the surface of the broad ligament and exteriorized the cyst wall, then punctured and aspirated the cystic fluid (800 mL). Next, we separated the adhesion between the cyst wall and the broad ligament carefully, and resected the cyst. The procedure was conducted in 104 minutes with no intraoperative complications. The patient had an uneventful post-operative course and was discharged on the fourth post-operative day. The patient delivered a healthy girl at 41+3 gestational weeks.

  As it is difficult to manipulate the uterus in surgical procedures during pregnancy, a more effective method should be devised to allow better visualization of the surgical site especially in pregnant patients. This will allow performing laparoscopic surgery safely for large tumors within the broad ligament even in pregnancy.