Objective: Intestinal obstruction and infertility are significant adverse effects related to the formation of postoperative adhesions after gynecological surgery. INTERCEED^® (Ethicon) and Seprafilm^® (Kaken Pharmaceutical Co., Ltd.) are widely used adsorbable-type adhesion barriers suited for open surgery. However, in December 2016, AdSpray^® (Terumo), a spray-type adhesion barrier that allows the insertion of a long nozzle through a trocar, became available for use in Japan. We studied the utility of AdSpray^® during laparoscopic surgeries.

Methods: We studied 37 patients who underwent a total laparoscopic hysterectomy at our hospital between April 2016 and August 2017. Patients were categorized into 2 groups to receive either AdSpray^® or INTERCEED^®. A retrospective intergroup comparison was performed based on the distribution/adhesion time, white blood cell count, and the C-reactive protein levels on day 1 postoperatively, and the number of days hospitalized after surgery.

Results: The AdSpray^® group showed a shorter distribution/adhesion time than the INTERCEED^® group (118 ± 25 s vs. 170 ± 61 s, respectively, p = 0.013). No significant differences were observed in terms of any other outcomes. Neither group showed perioperative complications.

Conclusion: The tip of the nozzle of AdSpray^® can be bent freely to allow passage through the trocar for distribution over uneven surfaces. Thus, AdSpray^® is easier and safer to use during laparoscopic surgeries than adsorbable-type adhesion barriers.

Objective: Laparoscopic surgery has the advantages of minimal invasiveness and aesthetics. Despite the increasing demand for gynecological laparoscopic surgeries, their use is not widespread in our local area. We attempted to promote safe laparoscopic surgeries.

Methods: We conducted three laparoscopic surgery seminars, with knot and suture training with a dry box (1st), knot and suture using pig stomach and heart (2nd), and surgical training using a pig (3rd). Invited lecturers were laparoscopic experts, with practical guidance from qualified gynecologists. Questionnaire-based surveys were also conducted.

Results: The number of participants were 39,32, and 19 (1st/2nd/3rd, respectively); approximately 50% were women. Participant backgrounds in the 1st, 2nd, and 3rd seminars were: 54% (20/37) had no experience as laparoscopic operators; 74% (17/23) were operators, of which 43% (6/14) had performed ≤10 laparoscopies; and 79% (15/19) were operators of which 87% (13/15) had performed ≥10 laparoscopies. The incentives to participate were "encouragement from a colleague" (68%, 82%, 47%) and "to improve skills" (41%, 88%, 84%). Knot and suture time was shortened in almost all participants after the 1st seminar (P<0.01). Understanding the importance of training with a dry box and an animal was emphasized. The seminar levels were deemed suitable. Almost all participants hoped to attend the next seminar.

Conclusion: Encouragement from colleagues was an important impetus to attend the seminars. The seminars motivated participants to practice and improve awareness about the importance of training. We intend to continue these attempts.

Objective: Laparoscopic surgery is recognized as a useful and minimally invasive strategy for treating uterine corpus cancer. Although obesity is a risk factor for uterine corpus cancer, laparoscopic surgery for obese patients with uterine corpus cancer is sometimes avoided owing to the associated complications and technical difficulties. The aim of this study was to evaluate the feasibility of laparoscopic surgery for obese patients with uterine corpus cancer.

Methods: The operation time, amount of blood loss, number of removed lymph nodes, and length of hospital stay were assessed retrospectively according to the patients' body mass index (BMI) values and the surgical methodology (open or laparoscopic surgery).

Results: Operation times for pelvic lymphadenectomy were not significantly different between the obese and non-obese groups. The operation times for cases involving pelvic and para-aortic lymphadenectomy were significantly longer in obese patients than in non-obese patients (p=0.0327 for laparoscopic surgery cases and p=0.0075 for open surgery cases). Although the amount of blood loss was significantly greater for obese patients than for non-obese patients in cases involving laparoscopic pelvic lymphadenectomy (p=0.0158), the average amount of blood loss was 151.4 g, which was not clinically important and was a significantly smaller amount than that in open surgery (p<0.0001). The number of resected lymph nodes and length of hospital stay were not significantly different between cases involving obese and non-obese patients. There were no recurrent cases in the laparoscopic group.

Conclusion: These findings suggest that laparoscopic surgery is feasible as a minimally invasive treatment for obese patients with uterine corpus cancer.

  Total laparoscopic hysterectomy (TLH) for uterine cervical myoma is quite challenging. As the ureter, bladder, and uterine artery and vein are deviated due to the myoma, the manipulation of the cervical ligament becomes atypical and risk of damage to the other organs increases. We report the strategy of TLH in a case of cervical myoma, in which it was difficult to insert the uterine manipulator.

  A 47-year–old woman (para 3 living 2), was referred to our hospital with a cervical myoma gradually increasing in size. On speculum examination, the uterine cervix was displaced posteriorly. Ultrasonography and Magnetic Resonance Imaging revealed a cervical myoma 9 cm in size. We planned TLH after Gonadotrophin-releasing hormone agonists therapy. We placed ureteral stents prior to surgery. Direct visualization of the abdominal cavity revealed that the cervical myoma was completely located in the anterior broad ligament of the uterus, and only the uterine body could be recognized. To lift the uterus, we used Vagi pipe^® and pulled the circular ligament and the cervical myoma with a Myoma Borer. On peeling off the bladder or making an incision on the vaginal wall we confirmed the vaginal fornix by Vagi pipe^® and sonde inserted through the Vagi pipe^® operation hole.

  Compared to the conventional method using a ribbon retractor, by using a combination of Vagi pipe^® and sonde, it is possible to simultaneously push up the uterus and identify the vaginal fornix. Moreover, it was possible to make an incision on the vaginal fornix without air leakage using Vagi pipe^®. The operation time was 150 minutes, and the bleeding volume was 400 g; the sample weight was 330 g.

  We predicted the technical difficulties in the surgery and implemented appropriate measures, such as the use of Vagi pipe^®, sonde and ureteral stents. We could, thus, safely perform TLH for uterine cervical myoma.

Objective: Minimally invasive surgery, such as laparoscopy, is used in many hospitals across Japan. However, this technique in not used to its full capacity, especially in local hospitals, such as those of the Nagano prefecture. Laparoscopic surgery was introduced in our hospital in 2008.

Predominantly, laparoscopic operations for benign ovarian tumors were performed until 2015. Since January 2016, a lead surgeon from another hospital has been regularly educating gynecologists at our hospital about laparoscopic surgery. We have also begun performing total laparoscopic hysterectomies (TLHs) and laparoscopic myomectomies (LMs), and the frequency of laparoscopic surgeries at our hospital has increased remarkably, from about 8 to 52 cases per year. We aspire to learn how to change the motivation of gynecologists and nurses through changing incentives before 2015 and after implementation of lead surgeon education in 2016.

Design: We prepared questionnaires about changes in laparoscopic surgery incentives for gynecologists and nurses before 2015 and after 2016.

Setting: This report analyzed the results of the questionnaire surveys from 5 gynecologists and 75 nurses. We compared the desire for laparoscopic surgery, preparation for the operation, and impression on the attitude of the doctors before 2015 and after 2016.

Primary Outcomes: Although we suspected that nurses may be frustrated by the long operation times, our analysis showed that nurses had a relatively good impression of the gynecologists. No serious problems were identified.

Results: Regular performance of laparoscopic surgeries with a lead surgeon allows good collaboration between co-medical partners.

Objective: Since 2014, we changed the surgical procedure for treatment of early stage endometrial cancer from modified radical hysterectomy (mRH) to total laparoscopic modified radical hysterectomy (TLmRH). When provided with training, even gynecologists with little experience in laparoscopic surgery can perform this procedure. In this study, we compared the results of laparoscopic surgery and laparotomy for treatment of endometrial cancer, further analyzed the results of laparoscopic surgery when performed by each surgeon.

Patients: Eighty-seven cases diagnosed with endometrial cancer stage IA before surgery were examined. Fifty-two TLmRH cases (group A), and 35 mRH cases (group B) were compared. Group A was classified into three groups (C: 16 cases, D: 18, E: 18, respectively) according to the number of total laparoscopic hysterectomy operations.

Results: In group A, the operation time was significantly longer, bleeding volume was lesser, and hospital stays were shorter than in group B. There was no recurrence in either group. Surgical results among the three groups (C, D, and E) were compared. The operation time for the cases in group E with a small number of surgeries was long and the complications tended to be more in number.

Conclusion: Subjects who underwent laparoscopic surgery showed reduced bleeding volume, shortened hospitalization period, and early recovery. On short-term observation, recurrence was not noted, and the same results as laparotomy surgery were obtained. However, complications associated with low proficiency level were recognized. In laparoscopic surgery, it is desirable not only to acquire the skills, but also undergo training before performing the surgery.

Objective: Atypical endometrial hyperplasia (AEMH) is a precancerous lesion of the endometrium, which is often treated with laparoscopic hysterectomy. However, we report some cases in which a postoperative diagnosis of endometrial cancer (EMC) was made although AEMH had been diagnosed preoperatively. In the present study, we retrospectively investigated the clinical features of EMC patients diagnosed with AEMH preoperatively.

Method: We retrospectively evaluated the characteristics (age, gravidity and parity, body mass index [BMI], menstrual history, medical history of diabetes, and family history of malignancy), blood test results (preoperative serum CA125 levels), and imaging study results (measurement of endometrial thickness by ultrasonography) of patients who had been diagnosed with AEMH preoperatively by total curettage of the endometrium and had undergone abdominal or laparoscopic hysterectomy between January 2008 and April 2017. These patients were postoperatively diagnosed with EMC or AEMH on the basis of their pathological findings. We investigated whether there were any differences in the preoperative findings between the EMC and AEMH groups.

Results: A total of 20 patients diagnosed with AEMH preoperatively underwent abdominal or laparoscopic hysterectomy (abdominal; n=7, laparoscopic; n=13). The number of patients diagnosed with AEMH (AEMH group) and EMC (EMC group) postoperatively were 11 (55.0%) and 9 (45.0%), respectively. All 9 patients in the EMC group were in FIGO stage IA and were diagnosed with endometrioid carcinoma, grade 1. No significant difference was observed in the evaluated findings between the AEMH and EMC groups.

Conclusion: As it is difficult to differentiate an EMC from an AEMH diagnosed preoperatively even after total curettage of the endometrium, it is necessary to consider the possibility of malignancy when we perform surgery for patients with AEMH.

  It is thought that the risk of ureteral injury is greater with total laparoscopic hysterectomy (TLH) than with abdominal surgery. Cystoscopy is sometimes useful to confirm a urinary system complication during TLH. We report a case of bilateral complete double renal pelvis and ureter. A 44 year-old woman was seen for treatment of uterine myoma. As she had hypermenorrhea and anemia due to a uterine myoma, we scheduled surgery. At the initial visit, she complained of hypermenorrhea and prolonged menstruation, and had a hemoglobin level of 8.9 g/dl. Transvaginal sonography and magnetic resonance imaging revealed a 60-mm uterine myoma. TLH was performed without difficulty. The operative time was 163 minutes and blood loss was 100 g. In this hospital, we examine the bladder using cystoscopy during surgery in all TLH cases, and also determine the presence of any urinary tract complications. In the present case, cystoscopy revealed a complete double ureteral orifice. This finding was also confirmed laparoscopically. With the diagnosis of a double ureter, we performed postoperative computed tomography, and identified a complete double renal pelvis and ureter with an ectopic ureterocele. The patient did not require treatment and is doing well after discharge. In general, we perform cystoscopy to identify urinary tract complications. However, urinary tract anomalies are sometimes incidentally found, and their identification can help to prevent complications.

  Surgery is used for acute abdomen due to endometriosis when antibiotic treatment is no longer effective, and adnexectomy may be necessary. We report a case in which laparoscopic drainage was used to control infection, with subsequent laparoscopic ovarian cystectomy in two-stage surgery, enabling organ-preserving management. A 34-year-old woman presented with abdominal pain for 1 day, and was found to have severe inflammation and a 7-cm pelvic cyst. Antibiotic treatment was administered for an infected endometrial cyst. As antibiotic treatment was not effective, we performed laparoscopic drainage, and the inflammatory reaction improved. Laparoscopic ovarian cystectomy was performed 3 months after the initial operation. The results suggest that a second-look surgery is useful for ovarian conservation because laparoscopic drainage is minimally invasive and effective.

  We report a case of uterine serosa pregnancy after in vitro fertilization. A 32-year-old woman, gravida 1 para 0, had abdominal pain. She was transferred to our hospital because of shock, which was judged by assessment of vital signs at a nearby clinic. The pregnancy test was positive, and computer tomography revealed an enhancing tumor in the uterine serosa; a large amount of blood was found in the peritoneal cavity. Emergency laparoscopy was performed. We collected 1400 ml of blood from the abdominopelvic cavity and found that she had a uterine serosa pregnancy with active bleeding. We removed the gestational tissue, but active bleeding remained at the excision margin of the uterine surface. We sutured the myometrium, which stopped the bleeding. Villi were confirmed histopathologically. After the surgery, serum hCG promptly decreased. If ectopic pregnancy is suspected, a peritoneal and or uterine serosa pregnancy should be considered.

  Bladder endometriosis is a rare pelvic dysfunction with painful urination and hematuria.

  We successfully managed two cases of bladder endometriosis by cystoscopy-assisted laparoscopic partial cystectomy.

Case 1: A 40-year-old woman presented with urodynia during menstruation for four years. Cystoscopy revealed a dark-red polypoid lesion on the posterior bladder wall. She underwent hormonal therapy with GnRH-agonist for six months followed by dienogest for a few months. She finally decided to undergo an operation because of poor improvement of symptoms. Incision line was determined using cystoscopy with a margin from both ureteral orifices and then laparoscopic partial cystectomy was performed. She was discharged after confirmation of no leakage by cystography at post-operative day 7.

Case 2: A 44-year-old woman was diagnosed with endometriosis at the age of 30 and had been taking low dose estrogen and progestin (LEP). She discontinued LEP owing to breast cancer and then started to feel pain during menstruation, urination, and defecation. Cystoscopy revealed a polypoid lesion on the posterior bladder wall. She underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and cystoscopy-assisted partial cystectomy. Her postoperative course was uneventful, and she was discharged at post-operative day 8. Altogether, this case report suggests that using cystoscopy to avoid unnecessary ureterovesicostomy and maintaining adequate distance from both ureteral orifices is useful to determine the incision line. Cooperation with urologists is necessary when performing surgery in patients with bladder endometriosis.

  Ectopic pregnancies account for approximately 1-2% of all pregnancies.

  Although most ectopic pregnancies occur in the ampulla of the fallopian tube, ectopic pregnancy in the remnant tube after previous ipsilateral salpingectomy is also reported.

  We report a case of spontaneous ectopic pregnancy occurring in the remnant tube after previous ipsilateral adnexectomy.

  A history of adnexectomy or salpingectomy cannot exclude ectopic pregnancy on the ipsilateral side. Attention should be paid to the remnant tube so as to not miss an ectopic pregnancy after adnexal surgery.

Introduction: Ureteral injury is a complication to be avoided in total laparoscopic hysterectomy (TLH), while occlusion of the ureteral orifice has not been reported yet.

Case: A 47-year-old nulliparous woman underwent surgery for a 10-cm-diameter uterine fibroid after pseudomenopause therapy. TLH was performed in accordance with the protocols after myomectomy. The urinary tract up to the ureteral tunnel was examined. The fibroid was divided into two and transvaginally collected. After the vaginal stump was occluded, a cystoscopy was performed. However, as the right ureteral orifice presented edema, the orifice and urine outflow could not be confirmed. Although drip infusion pyelography (DIP) was performed, the right renal pelvis was not visualized. Therefore, the right ureteral orifice was retracted with a Nelaton catheter to perform retrograde urography, and the right ureteral orifice was visualized without flexion or extension. On the basis of the above-mentioned findings, occlusion of the right ureteral orifice due to edema was diagnosed and treated with placement of a DJ ureteral catheter in the right ureteral orifice.

Discussion: Causes of the ureteral injury were verified from surgical records and images. The images confirmed that the practitioner's finger was strongly retracting near the right ureteral orifice at the time of transvaginal collection of a large specimen under the condition of severe extension of the vaginal wall. The possibility of this procedure to cause temporary edema in the right ureteral orifice, which leads to occlusion, was indicated. A specimen should be subdivided for a dynamically reasonable transvaginal collection in the future.

Results: In TLH, complications in the urinary system may occur not only during the perioperative procedure but also at the time of specimen collection. Therefore, cystoscopy with intravenous indigo carmine dye will be an important screening tool to ensure the safety of TLH.

  We report a case of "gauzeoma" that was first diagnosed as subserous uterine myoma or left ovary fibroma with magnetic resonance imaging (MRI) before the surgery. Case presentation: A 67-year-old woman, gravida 2 para 2, who had a history of tubal ligation surgery at the age of 22 years and appendicitis surgery at the age of 30 years was referred to our department because of an abnormal tumor in her abdominal cavity. She had undergone an MRI examination when she had experienced abdominal pain about a month before the referral. MRI revealed an approximately 55-mm tumor that presented a low signal intensity in both T1- and T2-weighted images. We established a diagnosis of torsion of the subserous uterine myoma or left ovary fibroma, and performed a laparoscopic surgery. The tumor was covered by adipose tissue and adhered to the abdominal wall. We separated the tumor from the adhesion and then found gauze material in the tumor, which we diagnosed as "gauzeoma." The adhesion between the gauzeoma and the small intestine was so strong that we could not separate it without damaging the small intestine. We consequently performed a partial resection of the small intestine. Conclusion: Gauzeoma should be considered if a tumor presents a low signal intensity in both T1- and T2-weighted magnetic resonance images in patients with a history of abdominal surgery.

  We report a case of left mucinous borderline ovarian tumor and right ovarian and tubal absence. A 36-year-old patient felt discomfort in her lower abdomen and visited our hospital for further examination. Magnetic resonance imaging (MRI) revealed an approximately 16-cm multilocular tumor. The tumor of the right ovary was extracted via laparoscopically assisted cystectomy. Intraoperatively, we noticed the absent left adnexa. Pathological examination revealed that the right ovarian tumor was a mucinous borderline tumor. During the follow-up, no postoperative recurrence was observed. Two causes have been identified for congenital absence of unilateral ovary and fallopian tube, namely congenital developmental defect and torsion of the adnexa. The present case likely resulted from an asymptomatic torsion because of the absence of other genitourinary anomalies and the strong adherence of the left fallopian tube angle to the sigmoid colon despite that the patient had no surgical history.

Background: Adhesions occurring after laparoscopic surgery are observed to be more localized than those after open surgery. However, whether the increased use of laparoscopic surgery has translated into fewer adhesion-related postoperative complications remains unclear. Notably, focal adhesions may cause more severe complications. We report a case of strangulated small bowel obstruction (SBO) secondary to focal adhesions occurring after total laparoscopic hysterectomy (TLH).

Case: A 39-year-old woman without a history of abdominal surgery underwent TLH for the management of a leiomyoma. She had uncomplicated intra- and postoperative course and discharged on postoperative day (POD) 3. On POD 37, she was admitted to the hospital with sudden onset of abdominal pain. Based on contrast-enhanced computed tomography and arterial blood gas analysis that revealed metabolic acidosis, we clinically suspected strangulated SBO. Emergency exploratory laparoscopy was performed, and intraoperatively we identified strangulated SBO secondary to ileo-ileal adhesions. Laparoscopic adhesiolysis was performed. Intestinal resection was not indicated because the previously diminished blood flow recovered after adhesiolysis. She was discharged on POD 9 of her second hospitalization following an uneventful course.

Conclusion: Strangulated SBO secondary to focal adhesions is a need-to-know complication after laparoscopic surgery. Immediate diagnosis of bowel ischemia and surgical treatment are essential.

  Reportedly, total laparoscopic hysterectomy (TLH) is associated with a higher rate of postsurgical vaginal cuff dehiscence than abdominal surgery and laparoscopically assisted vaginal hysterectomy. We performed TLH in 322 patients. We report 2 cases of vaginal cuff dehiscence observed after TLH and discuss the preventive strategies in this context.

Case 1: A 48-year-old woman (2G1P) was diagnosed with cervical intraepithelial neoplasia stage III (CIN 3) and underwent TLH concomitant with bilateral salpingo-oophorectomy. We diagnosed her with vaginal cuff dehiscence 3 months postoperatively. We sutured the vaginal cuff via a vaginal approach and sutured the peritoneum laparoscopically. She reported no complications a year after this surgery.

Case 2: A 39-year-old woman (2G2P) was diagnosed with atypical endometrial hyperplasia and underwent TLH. We diagnosed her with vaginal cuff dehiscence 6 months postoperatively. Initially, we sutured the vaginal cuff via a vaginal approach and sutured the vaginal cuff and peritoneum laparoscopically. She reported no complications 18 months after this surgery.

  Following our observations in these 2 patients, we routinely suture the peritoneum following vaginal cuff closure in all our patients.

  Usually, it is observed that vaginal cuff dehiscence is associated with the use of powered devices during TLH. We emphasize that peritoneal suturing prevents vaginal cuff dehiscence.

Introduction: Power morcellator is useful as a surgical instrument for shredding a specimen during laparoscopic surgery; however, because this technology requires a widened porthole in the abdominal wall, we consider that it has scope for improvement in terms of esthetic outcome and perspective on pain. In addition, at the time of transvaginal removal of the shredded specimen, we often cannot have enough space to perform the removal because the vaginal cavity is narrow and deep; alternatively, it may be difficult to perform owing to the extremely large specimen present. We report here a case of transvaginal in- bag morcellation.

Methods: A single hospital observational study that involved patients who underwent laparoscopic hysterectomy was conducted. A folded isolation bag (3M Steri-Drape Isolation Bag) was introduced into the peritoneal cavity, and the specimen was placed in the bag. The mouth of the bag was guided to the vaginal stump and then exteriorized. A small-sized wound retractor, along with the bag, was set at the vaginal cavity, and the hole was covered with a sterile glove. A 5-mm trocar was inserted into the glove for the endoscope, and a morcellator was inserted into the cavity via the glove under observation. We performed transvaginal in- bag morcellation without spillage and dissemination of unwanted cells and tissues.

Conclusion: Transvaginal in-bag morcellation performed with our new technique requires neither a widened porthole nor lacerations of the vaginal wall and thus may prove beneficial for esthetic outcome and reducing pain.

  We experienced the case of Low-grade appendiceal mucinous neoplasm treated with laparoscopic management, which was originally diagnosed as a right cystic adnexal mass. The case involved an 81-year old woman had undergone a total abdominal hysterectomy for leiomyoma of the uterus when she was 48 years old. She was refered to our hospital after being diagnosed with a cystic lesion of the pelvis at a local internal medicine clinic, with a dull pain in her right lower abdomen. We suspected a right ovarian cyst, but no conclusive evidence was found, so we performed exploratory laparoscopic operation. We found that the uterus and both adnexa had been extracted, and the cyst was derived from appendix, so we performed appendectomy. We made the diagnosis of a Low-grade appendiceal mucinous neoplasm after pathological examination. Cystic disease in the female pelvis is common. The majority of cystic pelvic masses originate in the ovary, but some other pelvic organs mimic this anomaly. It is important to understand the relationship of the cyst with its anatomic location, to identify normal ovaries at imaging, and to compare the findings with a patient's clinical history to avoid misdiagnosis.

  Tuberculous peritonitis may cause ascites, peritoneal thickening, and elevation of CA125 levels. We report a case of tuberculous peritonitis diagnosed during exploratory laparoscopy. A 60-year-old woman complained of abdominal pain and distention, diarrhea, and fever for 2 months. Imaging studies, including positron emission tomography, showed peritoneal thickening with a fluorodeoxyglucose hotspot. Evaluation of ascites fluid, obtained via abdominocentesis, revealed an elevated lymphocyte count, elevated adenosine deaminase levels, and negative cytology. These findings were suggestive of tuberculous peritonitis; however, polymerase chain reaction and T-SPOT test results, which would have provided a definitive diagnosis, were negative. The patient was subsequently referred to our hospital and underwent exploratory laparoscopy. Her peritoneum was reddish and thickened, without evidence of disseminated cancer; both ovaries appeared normal. An ascites fluid sample was collected, and peritoneal biopsy was performed. A loop-mediated isothermal amplification assay (LAMP) of the ascites revealed the presence of Mycobacterium tuberculosis. Finally, we confirmed the diagnosis of tuberculous peritonitis. The pathological examination of the peritoneal biopsies also supported the diagnosis. Treatment with ethambutol, rifampicin, isoniazid, and pyrazinamide was initiated immediately. The patient recovered smoothly with the treatment, which was continued for 6 months. Tuberculous peritonitis was diagnosed during exploratory laparoscopy, allowing immediate initiation of the appropriate treatment. Tuberculous peritonitis is a rare disease, and its symptoms and clinical findings are often similar to those of malignancy. For accurate and immediate diagnosis, exploratory laparoscopy and LAMP examination can be candidates for the most effective diagnostic tools.

  Total laparoscopic ovarian cystectomy (TLC) is a common gynecological laparoscopic procedure and is often performed by a novice to this technique. We report a case of reoperation due to abdominal bleeding the day after TLC.

  A 26-year-old woman, gravida 2 para 2, presented with a 5 cm left ovarian cyst, presumed to be benign. TLC was performed. The next day, the patient's hemoglobin level decreased to 7.7 g/dL, and transabdominal ultrasonography revealed abdominal bleeding from the pelvic cavity to the Morrison's pouch. Laparoscopy was repeated, and suturing was performed to stop bleeding from the left ovary. Abdominal blood loss was 1300 mL. The postoperative course was uneventful, and the patient was discharged after 4 days without extra blood transfusion. Pathological diagnosis was mucinous cystadenoma.

  Excluding cases of endometrial cyst, the probability of postoperative bleeding and hematoma after TLC was reported to be 0.15% in the 2014–2015 adverse events research of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy. We considered the reason for this reoperation from two viewpoints: the technique of ovarian cystectomy and the property of laparoscopic surgery.

  Preoperative diagnosis mainly including presumptive pathological diagnosis on adnexal tumors has various issues such as differentiation from tumors of other adjacent organs. We experienced a case of appendix tumor after diagnosis as right ovarian cyst at this time. Further, this case had a very rare condition with a simultaneous appendix tumor of low-grade appendiceal mucinous tumor and appendiceal carcinoid tumor, and is reported by adding bibliographic consideration.

  This case was a 24-year-old female with no experience of sexual intercourse. CT identified a 6cm-long cyst in the pelvis at the time of admission for Campylobacter enteritis; therefore she was referred to the department of gynecology with the diagnosis of a right ovarian cyst. A normal right ovary was confirmed as a result of MRI, leading to diagnosis of relatively frequent right ovarian cyst. However, transrectal ultrasound tomography presented a layered echo image that was different from echo images common to paraovarian cysts. Since the diameter of the tumor also increased, laparoscopic operation was performed, leading to the finding of appendix tumor.

  Only six cases of simultaneous appendix tumor including this case were confirmed in Japan, and this is the first case reported by a gynecologist. When this case was verified on the basis of literature of appendix tumor that was preoperatively diagnosed as ovarian tumor, the layered echo image from ultrasound tomography seems to reflect high viscosity of the content solution, and does not match the tumor image of a clear boundary with a low signal in T1 weighted imaging and a high signal in T2 weighted imaging of MRI. This difference is important to differential diagnosis and can be helpful for diagnosis. If layered echo images are visualized in the process of preoperative examination of adnexal tumors, appendix tumor needs to be remembered for differential diagnosis although frequency is low.

Introduction: Port-site hernia (PSH), a complication of laparoscopic surgery, is extremely rare in obstetrics and gynecology. We report a case of hernia at a 5-mm port site used for drain placement after laparoscopic surgery.

Case presentation: A 46-year-old woman (gravida two, para two) with a giant right ovarian tumor underwent laparoscopic right adnexectomy lasting 99 min with minor blood loss. She recovered and was discharged 4 days postoperatively. However, an adult granulosa cell tumor was diagnosed, and 41 days postoperatively she underwent another operation comprising laparoscopic hysterectomy, left adnexectomy, omentectomy, and pelvic lymphadenectomy, lasting 305 min (blood loss: 98 mL). Drain placement was through a left lower abdominal 5-mm port site, with removal 1 day postoperatively. She remained stable after resuming oral intake and was discharged 6 days postoperatively. She visited our department 8 days postoperatively with a chief complaint of left lower abdominal pain, where a lump was observed. Contrast-enhanced computed tomography revealed intestinal obstruction from the port site, leading to a diagnosis of PSH requiring emergency surgery. The port site scar was incised and extended an additional 5 cm. Intestinal obstruction with no ischemic change was confirmed. After hernia reduction, the peritoneum and fascia were closed. She recovered and was discharged 7 days postoperatively.

Conclusion: Drain placement through the port scar was possible causative factor of PSH. Sufficient measures to prevent PSH are crucial even for a 5-mm port site in high-risk patients.

Introduction: Chronic pelvic pain affects about 10-40% of women presenting to a physician. The gynecological factors responsible for chronic pelvic pain include endometriosis, pelvic congestion syndrome (PCS), ovarian tumors. We experienced a case of PCS who had a complaint of chronic pelvic pain which was relieved after laparoscopic surgery.

Case: A 30-year-old primigravida woman complained of sudden onset of lower abdominal pain and low back pain. Imaging studies did not reveal any organic disease of uterus or ovaries, however, it was suggestive of left ovarian vascular congestion. Therefore, it was inferred that PCS was the cause of chronic pelvic pain. A laparoscopic resection of pelvic peritoneum was performed which resulted in remarkable disappearance of pelvic pain.

Conclusion: Resection of the pelvic peritoneum is considered to provide pain relief through resection of sensory afferent nerves that cause visceral pain, and it effectively provides pain relief regardless of the cause of pelvic pain.

Objective: To assess safe, accurate, and fertility-preserving treatment of cervical pregnancy (CP).

Design: We present two case reports and a literature review.

Patients: We evaluated a 39- and a 40-year-old woman in this study.

Interventions: Two patients underwent hysteroresectoscopic resection after systemic methotrexate (MTX) therapy.

Results: Case 1: The patient was referred to our hospital with suspected ectopic pregnancy at 6 weeks of gestation. Transvaginal ultrasonography (TVS) showed no gestational sac (GS) in the uterine body or the cervix; however, a power Doppler study showed hypervascularity of the cervix. She reported copious vaginal bleeding, and we inserted a Foley catheter in the cervical canal. Her serum human chorionic gonadotropin (hCG) level was 7634 mIU/mL. We anticipated a threatened abortion of the GS implanted in the cervical canal, and we initiated the systemic administration of MTX. Hysteroresectoscopic resection of the GS was performed 13 days after admission. All products of conception were completely removed, and she showed an uneventful postoperative course.

Case 2: The patient underwent consultation at 5 weeks 1 day of gestation for suspected CP. TVS demonstrated a GS measuring 8.3 mm in the cervical canal with no cardiac fetal activity, and the patient's serum hCG level was 5549 mIU/mL. We initiated the systemic administration of MTX, and hysteroresectoscopic resection of the GS was performed 12 days after admission. The patient showed an uneventful postoperative course.

Conclusion: Hysteroscopy provides direct visualization of the uterine cavity; thus, complete resection of the GS could be successfully performed in the 2 patients described in this report. We emphasize that hysteroresectoscopy is a safe, accurate, and fertility-preserving treatment.

  Congenital anomalies of the uterus can result from developmental disorders of the Müllerian ducts. The precise incidence of congenital uterine malformations remains unclear, but the reported incidence is 4-5% of the general female population and it might be higher among patients with infertility or repeated miscarriages. Failure to resorb septa between the Müllerian ducts leads to the formation of a septate uterus, which, when combined with cervical duplication and a longitudinal vaginal septum, represents a rare congenital malformation. Although infertility is associated with uterine malformations, only a few reports have described endometrial neoplasia arising in patients with congenital uterine malformations.

  Endometrial polyps are caused by the localized overgrowth of endometrial glands and stoma through the uterine cavity, and they are associated with postmenopausal bleeding, infertility, and menorrhagia. The prevalence of malignancy with endometrial polyps is 0.52-3.5%. Risk factors for malignancy within polyps include ageing, obesity, arterial hypertension, postmenopausal period, and tamoxifen, which is a nonsteroidal anti-estrogenic agent that is a popular adjunctive therapy for women with breast cancer. Several reports over the past decade have indicated an increase in the incidence of endometrial abnormalities ranging from polyps to endometrial cancer in women undergoing treatment with tamoxifen.

  We describe a giant endometrial polyp in a complete septate uterus with longitudinal vaginal septum in an 81-year-old patient with breast cancer who had been treated with tamoxifen for 3 years and 7 months.

  An obstructed hemiuterus is very rare, and causes dysmenorrhea, infertility and perinatal complications. Here, we describe two patients with obstructed hemiuterus that was managed by laparoscopic surgery. Case 1: A 27-year-old nulliparous woman presented with drug-resistant dysmenorrhea, chronic pelvic pain and hypermenorrhea. Magnetic resonance imaging (MRI) revealed a right unicornuate uterus continuing to the uterine cervix and vagina, a rudimentary left uterine horn and bilateral ovarian cysts. Hysterosalpingography revealed a right uterine horn with a solitary patent tube. Laparoscopic resection of the left rudimentary horn and bilateral ovarian cystectomy proceeded. Postoperatively, she can control dysmenorrhea with low-dose estrogen-progestin. Case 2: A 35-year-old nulliparous woman, presented with dysmenorrhea and infertility problems. Computed tomography (CT) and MRI revealed a left unicornuate uterus with myoma, a rudimentary left uterine horn and left renal agenesis. Hysterosalpingography revealed a left uterine horn with a solitary patent tube. Laparoscopic resection of the right rudimentary horn and myomectomy proceeded. Postoperatively, she remains free of dysmenorrhea. We noted the four points, during laparoscopic surgery. First, we clarified the anatomical construction by first conduction division of adhesion, ovarian cystectomy and myomectomy. Secondly, the difference in the connection state between the unicornuate uterus and the rudimentary uterine horn. Third, whether the affected uterine artery flows into the rudimentary uterine horn. Fourth, after conducting uterine body amputation, we could accurately grasp the cutting plane line of cervical using pelvic examination finger. Our findings suggest that laparoscopic surgery is effective for treating dysmenorrhea associated with a non-communicating rudimentary uterine horn.

Objective: This study aimed to report the experiences and problems associated with surgical training using a cadaver.

Materials and Methods: A surgical technique training was held in our department using a cadaver, which was embalmed using Thiel's method once a year since 2014. In consideration of the widespread introduction of laparoscopic surgery, we set up the first laparoscopic booth in addition to laparotomy training in 2016. The Thiel's method was used to treat the corpse.

Result: The Thiel's method, which preserves the texture of the corpse as close to the living body as possible compared with the conventional embalming method, leads to good operability. Manual operation with radical hysterectomy and exteriorization of the blood vessels/nerves in the deep pelvis could be performed with an almost similar protocol as in the actual operation. However, as bleeding did not occur, tension reduced and the procedure was not performed with as much care and precision. During laparoscopic training, in addition to the confirmation of the anatomy, performing the surgical procedure becomes easier. Thus, among the doctors who perform laparoscopic radical hysterectomy, the timing to change from manual operation to professional laparoscopy is difficult. Due to the limitation in the number of donations and time constraints, setting goals according to the experience of the laparoscopic surgeon with malignant tumor surgeries and to devise measures such as changing of operators for each technique should be considered.

Conclusion: Laparoscopic training using a cadaver treated with Thiel's method was thought to be useful for practical training and anatomical learning.

Objectives: To propose two different methods to dissect the posterior vaginal wall in laparoscopic sacrocolpopexies and confirm the efficacy and safety of these methods.

Design: Retrospective observational study.

Setting: Single urogynecology center in Chiba prefecture.

Patients: Fifty-five patients who underwent laparoscopic sacrocolpopexies with posterior dissections, which were performed by a single surgeon, between January 2017 and December 2017 were enrolled in this study.

Intervention: Either of the two different posterior dissection methods, that is, the rectovaginal or pararectal approach, was used according to dissection difficulty.

Primary Outcomes: Perioperative complications, operating time required for dissection, and postoperative defecation symptoms two months after surgery.

Results: The rectovaginal and pararectal dissection methods were used in 26 and 29 patients, respectively. Severe pelvic organ prolapse and adhesion between the posterior vaginal wall and rectum were frequently observed in the patients treated using the pararectal approach. The rectovaginal approach required significantly less operating time than did the pararectal approach. No perioperative complications, including rectal injury, vaginal injury, and mesh exposure, were observed. There were no significant differences in postoperative defecation symptoms, except for pain, between the two groups.

Conclusion: The two different posterior dissection methods, used on the basis of dissection difficulty, are effective and safe for efficient dissections.

  Postoperative adhesions can cause complications such as chronic pelvic pain, ileus, and infertility. However, the frequency of these adhesions has been found to decrease with the use of anti-adhesion materials, such as adhesion barriers. An adhesion barrier (Seprafilm^®, Kaken Pharmaceutical, Tokyo) is a fragile film that is susceptible to damage by external forces. Thus, for laparoscopic surgery, it is necessary to devise a technique for careful insertion and adherence in the abdominal cavity.

  There are many reported techniques for the use of this film in laparoscopic surgery. For example, the Cylinder-Roll technique, which involves loading a film into a cartridge of a Sterilized Lap Sponge (TroX^® II-D type, Osaki Medical, Aichi) and inserting it into the abdominal cavity using a 5-mm-diameter trocar. However, the Cylinder-Roll technique has two problems: loading the film into the cartridge and picking up the film with forceps after insertion into the abdominal cavity.

  To overcome these problems, we devised a technique in which the film is bent into a cylindrical shape so that the cross-section of the film is S-shaped upon loading it into the cartridge. The cylindrical shape makes loading of the film into the cartridge easy, and the S-shaped cross-section enables insertion and adherence while gripping the film with forceps.

  This report includes 30 cases of total laparoscopic hysterectomy performed at the Showa University Hospital and Showa University Northern Yokohama Hospital between April 2016 and March 2017. A total of 120 sheets of Seprafilm^® quarter packs were used; 111 sheets were accurately pasted, and the success rate was 92.5%.

  The Cylinder-Roll technique is an inexpensive and safe method. Through our modification of this technique, Seprafilm^® can be placed more easily, quickly, and accurately in the abdominal cavity and can be applied onto the target site. Thus, the modified S-type Cylinder-Roll technique is considered useful.