Objective: We evaluated the prevalence of intrauterine adhesion (IUA) and the effectiveness of placing FD-1 and Interceed in the uterine cavity to prevent IUA after laparoscopic myomectomy.

Design: We evaluated the following: a) the prevalence of IUA in our patient cohort, b) the association, if any, between IUA and the endometrial opening, and c) the effect of prophylactic methods used to prevent IUA in the endometrial opening (+) .

Setting and patients: In this study, a second-look hysteroscopy was performed on 149 women who had previously undergone a laparoscopic myomectomy at Tonan Hospital between 2007 and 2016.

Main outcome and results: The prevalence of IUA in the endometrial opening (-) and (+) group without applying the preventive measures against IUA, was 1.9% and 30.0%, respectively, with significant difference (P<0.01). Considering only the endometrial opening (+) group, the prevalence of IUA in the untreated group and the group that received preventive treatment against IUA was 30.0% and 5.6%, respectively, with significant difference (P<0.05). Additionally, in the endometrial opening (+) group, the prevalence of IUA in the no preventive treatment group, the FD-1 group, and the FD-1 + Interceed group was 30.0%, 0%, 6.5%, respectively, with significant difference between the no preventive treatment group and the FD-1 + Interceed group (P<0.05).

Conclusion: We found that IUA occurred after laparoscopic myomectomy; therefore this procedure has to be performed with care. The placement of FD-1 and Interceed in the uterine cavity was effective in preventing IUA occurrence.

Objectives: To investigate inflammatory responses after laparoscopic radical hysterectomy in Japanese women with early-stage cervical cancer.

Methods: Clinical data of patients with early-stage cervical cancer treated with laparoscopic radical hysterectomy, between January 2013 and June 2018, were collected and retrospectively reviewed. The patients were classified into 2 groups: normal (patients without postoperative complications) and complication (patients who experienced postoperative complications) groups. Their postoperative leukocyte/neutrophil counts and C-reactive protein (CRP) levels (inflammatory markers) were evaluated. Finally, we investigated the clinical utilities of the inflammatory markers to predict postoperative complications using receiver-operating characteristic (ROC) analysis.

Results: Fifty-three Japanese women underwent laparoscopic radical hysterectomy for early-stage cervical cancer. Postoperative complications occurred in 10 patients (18.9%). In the normal group, inflammatory markers peaked on postoperative day (POD) 1 and declined thereafter. Similarly, in the complication group, inflammatory markers peaked on POD 1 and declined on POD 3. However, they increased again thereafter, resulted in peaks on PODs 9–15. When the 2 groups were compared, inflammatory markers were significantly higher in the complication group than in the normal group. A leukocyte count >7280/μL, neutrophil count >6030/μL, or CRP level >0.4 mg/dL on POD 6 exhibited high sensitivities and specificities for the prediction of postoperative complications: leukocyte count (83.3%, 87.5%), neutrophil count (83.3%, 87.5%), or CRP level (100%, 56.3%), respectively. The negative predictive values of these markers were 93%, 93%, and 100%, respectively.

Conclusion: Inflammatory responses after laparoscopic radical hysterectomy in Japanese women with early-stage cervical cancer were evaluated. Leukocyte/neutrophil counts or CRP levels on POD 6 are useful to predict postoperative complications, allowing for safe and early discharge.

Objective: The aim of this study was to evaluate the feasibility of robotic radical hysterectomy (RRH) in patients with early stage cervical cancer.

Methods: This retrospective study was carried out using data for 166 patients with T1b1/2a1, N0 cervical cancer who underwent radical hysterectomy at Hokkaido Cancer Center from January 2010 to April 2018. Study outcomes including operation time, estimated blood loss (EBL), number of lymph nodes harvested, hospital stay, surgical morbidity, recurrence, and survival were compared between open radical hysterectomy (O group, n=134) and RRH (R group, n=32).

Results: There was no difference in age, body mass index, stage, histology, lymph node metastasis, and tumor diameter between the two group. RRH was significantly associated with longer operation time (268 min vs. 415 min, P < 00001), less EBL (492 cc vs. 30cc, P < 00001), shorter hospital stay (24 days vs. 10 days, P < 00001), and fewer number of lymph nodes harvested (42 vs. 18, P < 00001). RRH was marginally associated with fewer number of severe neurogenic bladder (49% vs, 31%, P = 0078). No severe neurogenic bladder was observed in the last eleven cases of RRH. At the time of this report, with a median follow-up of 22 months, only one patient recurred at her vaginal stump.

Conclusion: If RRH was strictly applied to cases of T1b1/2a1, N0 cervical cancer, it could be feasible in early stage cervical cancer. In addition, RRH might decrease occurrence of severe neurogenic bladder compared to open radical hysterectomy.

Objective: We analyzed the safety and feasibility of introducing robotic surgery for cervical cancer at our facility.

Design: We studied complications and outcomes of robotic surgery in our first 10 uterine cervical cancer cases.

Setting: Between June 2014 and April 2016, we performed robotic surgery on 10 cases.

Patients: All 10 had uterine cervical cancer IA1-IIA1.

Interventions: Operations for uterine cervical cancer were performed using a surgical robot (da Vinci Si Surgical System)

Main outcome: There were no intraoperative complications, but 1 case had grade 2 ulnar nerve injury, 2 grade 1 subcutaneous emphysema as postoperative complications. None of our cases experienced disease recurrence.

Results: There were no intraoperative complications, but 1 case had grade 2 and 2 had grade1 postoperative complications. None of our patients had recurrent cervical cancer.

Conclusion: We were able to introduce robotic surgery for uterine cervical cancer without severe complications and no recurrences were detected during a 2-years follow-up period.

OBJECTIVE: Our aim was to compare the intra- and postoperative results of total laparoscopic hysterectomy with pelvic and paraaortic lymphadenectomy (TLH) and total abdominal hysterectomy with pelvic and paraaortic lymphadenectomy (TAH) in the surgical treatment of endometrial cancer at a single institute in Japan.

METHOD: Twenty TLHs and 20 TAHs for FIGO stage I-II endometrial cancer were performed between December 2015 and March 2018. The results were analyzed retrospectively by review of patients' medical records and operative reports.

RESULTS: Both groups had similar patient and tumor characteristics. One laparoscopic case was converted to laparotomy. The difference in the median operation time was not significant (431 vs 412.5 min, p=0.33), nor was the difference in the incidence of intraoperative complications (10.0 vs 15.0%, p=1.00). Treatment with TLH was generally superior to that with TAH with respect to blood loss (65 vs 1000 mL, p<0.001), bowel obstruction (0 vs 30%, p=0.02), and CRP value (5.2 vs 9.1 mg/dL, p<0.001). The number of pelvic and paraaortic lymph nodes removed was not significantly different between the two groups (68.1 vs 56.3, p=0.06). Similar trends were observed for comparisons of the intra- and postoperative results of TLH and TAH among cases where radical hysterectomies were not performed.

CONCLUSION: TLH was comparable to and not worse than TAH regarding the intra- and postoperative results in our study group. TLH for patients with FIGO stage I-II endometrial cancer may pose a safe and feasible alternative to TAH in surgical treatments of endometrial cancer.

Objective: This study verified the feasibility of the laparoscopic approach for sentinel lymph node (SLN) surgery in cervical cancer.

Design: We retrospectively reviewed data for 154 patients with cervical cancer who had undergone SLN mapping, with technetium colloid (Tc99m) and/or indocyanine green (ICG) injected into the uterine cervix and an intraoperative gamma-detecting probe and/or photodynamic eye camera system used to locate hot spots. We compared the SLN detection rate (unilateral or bilateral) and incidence of complications between open approach (O group n=108) and laparoscopic approach (L group, n=46).

Results: Patients' median age was 43 years; 143 (93%) had FIGO Stage I disease. Successful bilateral and unilateral mapping occurred in 117 (76%) and 26 (17%) patients, respectively. The two groups did not significantly differ in median patient age, BMI, histology, tumor diameter or use of the two kinds of tracers. Median number of harvested lymph nodes was significantly lower in the L group (40 vs. 25, P＝0.0003). The two groups did not significantly differ in SLN detection rates (P=0.98). The perioperative complication rate tended to be lower in the L group (21% vs. 11%, P=0.12). However, the laparoscopic approach was not confirmed as an independent risk factor for perioperative complication in our logistic regression analysis.

Conclusion: SLN detection by the laparoscopic approach could equal that of the open approach without increasing perioperative complications. However, its long-term effect on oncologic prognosis was not assessed due to the relatively short follow-up period in the present study.

Objective: To evaluate the preoperative factors associated with difficulty in performing total laparoscopic hysterectomy (TLH) and to develop a statistical model predicting surgical outcomes of TLH.

Methods: We retrospectively reviewed 240 patients who underwent TLH between January 2014 and March 2018. Preoperative magnetic resonance imaging (MRI) findings were evaluated in the analysis. Patient characteristics (age, body mass index [BMI], parity, and surgical history), preoperative MRI findings (uterine size and presence of an endometrioma), surgical outcomes (operative time, blood loss, pathologic uterine weight, transfusion, and conversion to laparotomy) were extracted from the medical records.

  Multiple regression analysis was performed to identify independent predictors of surgical outcomes.

Results: We examined 81 patients. The estimated uterine volume (length × width × depth × 0.52) and the presence of an endometrioma were independent risk factors for longer operative time and more blood loss. In this study, surgical history and increase in BMI were not associated with these outcomes.

Conclusion: Using preoperative MRI, the model developed in this study can predict the length of operative time and amount of blood loss associated with TLH.

Purpose: In total laparoscopic hysterectomy (TLH), the risk of postoperative complication of the vaginal stump is reportedly higher than that in total laparotomy. The procedure for TLH has been changed to incorporate a peritoneal suture to the conventional vaginal stump treatment since February 2016. We compared the vaginal stump infection rates before and after the procedure was modified.

Methods: From 2014 to 2017, we conducted 782 TLHs in our department. Among the patients, 430 who had no endometriosis, infectious diseases, and deficient medical records were included in the study. We had been using a single ligation to close vaginal stump and an adhesion inhibitor for peritoneal defects until January 2016 (non-suture group). Since February 2016, the procedure for TLH has been changed to incorporate a peritoneal suture to the conventional vaginal stump treatment (suture group). We analyzed the relationships among the postoperative C-reactive protein (CRP) levels and the rate of vaginal stump infection between the two groups.

Results: Among the 430 patients, peritoneal suture was performed in 247 patients. No significant differences in the CRP levels on post-operative days 1 and 3 were found between two groups. The CRP level after discharge tended to be higher in the non-suture group. Vaginal stump infection occurred 9 (4.9%) of the 183 patients in the non-suture group. And in the suture group, vaginal stump infection occurred 4 (1.6%) of the 247 patients.

Conclusion: Peritoneal suture in TLH can be considered useful for preventing vaginal stump infection after surgery.

Objective: To evaluate the usefulness of diagnostic laparoscopy in patients with advanced ovarian cancer.

Methods: We retrospectively analyzed nine patients for whom primary debulking surgery was considered unfeasible. We evaluated whether laparoscopic procedure was adequate in making pathological diagnosis and intraabdominal assessment.

Results: Median age was 63 years (range, 47-79 years), and median operation time was 59 minutes (range, 43-103 minutes). All nine patients were pathologically diagnosed with high-grade serous carcinoma and were considered unfit to undergo primary debulking surgery. All patients received chemotherapy. Six patients underwent interval debulking surgery. Only one patient showed mild adhesions between the omentum and the abdominal wall.

Conclusion: Diagnostic laparoscopy is safe and feasible in advanced ovarian cancer patients.

Objective: Previous studies have reported an increased risk of vaginal cuff dehiscence following total laparoscopic hysterectomy (TLH) compared with that following total abdominal hysterectomy or vaginal hysterectomy. Although vaginal cuff dehiscence after TLH is rare, it often results in severe complications, and although the cause remains unknown, the use of energy devices in vaginal incision has been implicated. This study investigated whether reducing coagulation hemostasis decreases the risk of vaginal cuff dehiscence.

Methods: A total of 863 cases of TLH were analyzed from January 2016 to December 2017 at our hospital. We modified the method of hemostasis of vaginal cuff since January 2017. We followed different methods for hemostasis of the vaginal cuff between January and December 2016 (group A, complete hemostasis) and between January and December 2017 (group B, almost complete hemostasis, except in case of heavy hemorrhage). Group A included 352 cases, and group B included 511 cases. Vaginal dehiscence rates in the two groups were compared using the χ2 test.

Results: Vaginal cuff dehiscence was observed in four cases (1.1%) in group A and two cases (0.3%) in group B, which showed drastic reduction. However, no significant difference (p=0.2) was noted. Sexual intercourse was found to be the biggest trigger for the complication (50%).

Conclusions: Based on our results, we recommend that decreasing the vaginal cuff coagulation hemostasis can reduce vaginal cuff dehiscence following TLH.

Introduction: Myomas are a common disorder in women of reproductive age, affecting 20%–50% of the population. The relationship between myomas and infertility is still unclear, and the effect of myomectomy on reproductive outcomes is uncertain. We retrospectively investigated patients with infertility who had laparoscopic myomectomy (LM) in our hospital and discussed the impact of LM on reproductive outcomes.

Methods: A total of 54 patients with infertility who underwent LM in our hospital between January 2015 and September 2016 were analyzed. All patients received both preoperative and postoperative treatments for infertility, such as timed intercourse, intrauterine insemination (IUI), and assisted reproductive technology (ART).

Results: Mean age was 37.0 (29–44, median 39) years. Of 54 patients, 34 (63.0%) conceived after LM (timed intercourse = 10, IUI = 1, and ART = 23). Mean duration between the operation and pregnancy was 9.2 (4–24, median 8.5) months. Uterine cavity distortion did not have an influence on reproductive outcomes. All pregnant women delivered by cesarean section. No uterine rupture was observed.

Conclusion: LM may be offered to patients who do not become pregnant after infertility treatment.

  Tumors of the appendix are rare diseases and sometimes mimic a hydrosalpinx. Because, in females, the appendix is proximal to the uterus and an ovary, appendix disorders can be difficult to distinguish from hydrosalpinx, paraovarian cysts, and ovarian tumors by diagnostic imaging. We report on a 54 year-old post-menopausal female who presented with a growing cystic pelvic mass. The mass was in fact a low-grade appendiceal mucinous neoplasm that was misdiagnosed pre-operatively as a hydrosalpinx. Transvaginal ultrasonography and magnetic resonance imaging revealed an 88-mm cystic mass in the right adnexal region. CT findings did not indicate continuity between the tumor and the intestinal tract. Laparoscopic surgery was performed. Intraoperative observation revealed that the mass originated from the ileocecal valve, and she was diagnosed with an appendix tumor. The tumor was resected by a surgeon during laparoscopic assisted surgery. Laparoscopic surgery can be useful for differential diagnosis and treatment of adnexal and appendiceal tumors.

  To diagnose uterine myoma accurately, clinicians must often rule out malignant uterine tumors. However, this can be difficult to do preoperatively, as uterine sarcomas are commonly diagnosed through histopathological examination of surgical specimens. Here, we report three cases of preoperative transcervical uterine myometrial biopsy performed to exclude uterine malignancies. The preoperative biopsies and postoperative histopathological specimen examinations led to the same diagnosis. The results indicate that preoperative transcervical uterine myometrial biopsy is useful in the preoperative diagnosis of uterine myoma.

  Massive ovarian edema is a rare, non-neoplastic tumour-like mass. Massive ovarian edema mostly affects young women of reproductive age, who face a fertility-threatening diagnosis and treatment. We report a case of bilateral massive ovarian edema in a 36-year-old woman presenting with abdominal pain, an abdominal mass and hemoperitoneum. This is the first report of massive ovarian edema accompanied by hemoperitoneum. Ultrasonography showed enlarged multicystic right and left ovaries measuring 158 x 75 mm and 87 x 85 mm, respectively. MRI demonstrated multiple large peripherally located follicles, stromal edema evident by markedly increased T2 signal intensity and weak gadolinium enhancement, and torsion of the left ovary. MRI was useful in the preoperative diagnosis of massive ovarian edema. The patient underwent laparoscopic conservative surgery. Although the left ovary appeared dark purple due to torsion of 540 degrees during the surgery, both ovaries presented a normal appearance on MRI three months after surgery. Minimally invasive surgical treatment is a preferable option for women suspected to have massive ovarian edema.

Objective: To report three cases of subserosal leiomyoma torsion at different phases (time from onset).

Design: Case report

Patients: Patients included a 45-year-old, a 38-year-old, and a 28-year-old woman

Interventions: Computed tomography, magnetic resonance imaging (MRI), and laparoscopic surgery

Results: Case 1: A 45-year-old female patient visited our hospital with a chief complaint of lower abdominal pain persisting for 3 days. Emergency laparoscopic surgery revealed a dark-red subserosal leiomyoma on the posterior uterine wall extending into the left posterior cornual region. The leiomyoma pedicle was twisted 180-degree clockwise.

Case 2: A 38-year-old female patient developed lower right abdominal pain persisting for 7 days, which was treated as appendicitis. MRI revealed a 6 × 5-cm subserosal leiomyoma without enhancement on the right side of the uterus. Emergency laparoscopic surgery revealed that the leiomyoma was adhered to the greater omentum; moreover, a mildly weak adhesion was detected on the right side of the abdominal wall. The leiomyoma pedicle was twisted 180-degree anticlockwise.

Case 3: A 28-year-old female patient with a leiomyoma was referred to our hospital for surgery owing to chronic abdominal pain and worsening dysmenorrhea. MRI with contrast enhancement revealed a 10-cm subserosal leiomyoma on the anterior uterine wall. Laparoscopic surgery indicated an ischemic leiomyoma with extensive and tight adherence to the greater omentum and retroperitoneum. The twisted subserosal leiomyoma pedicle had not been expected preoperatively.

Conclusion: A subserosal leiomyoma torsion developed extensive and tight adherence as time progressed from onset. Laparoscopic surgery is useful in not only the acute phase, but also in the chronic phase of pedunculated subserosal uterine leiomyoma torsion.

  As minimally-invasive surgery becomes more widespread, laparoscopic surgery is more frequently applied to gynecological oncologic surgery. Laparoscopic surgery has many advantages such as cosmetic benefits and early recovery after surgery. On the other hand, laparoscopic surgery increases the risk of changes in circulatory dynamics due to increased intraabdominal pressure with Trendelenburg positioning and increases the risk of nerve damage caused by lithotomy positioning. Therefore, it is important to pay more attention to laparoscopic surgery. As operating time is more likely to be longer in oncologic surgery, unexpected complications could take place.

  We have experienced some rare but severe complications, including well leg compartment syndrome (WLCS). We report two cases of WLCS post-laparoscopic gynecological oncologic surgery. Both patients were middle-aged women with low potential risk who presented with WLCS symptoms soon after surgery. However, we could not determine the need for fasciotomy because we had no determining factors. As a result, they both developed a neuromuscular disability and required long-term rehabilitation.

  It is important to acknowledge WLCS, its diagnosis, and treatment. The main risk factors of WLCS include long operation time, lithotomy position, obesity, hypotension, hypothermia, and hypovolemia. It has a poor outcome if not diagnosed and treated promptly. Clinical symptoms are the 5 P's (pain, paresthesia, paralysis, palpable swelling, and pulselessness). If the patient reports corresponding symptoms, it is important to measure the intramuscular compartment pressure (ICP). If the ICP rises above 30 mmHg, a fasciotomy is needed to avoid permanent sequelae.

Introduction: Early onset trocar site hernia usually develops within about 2 weeks postoperatively, and patients present with ileus-like symptoms including nausea and vomiting. This condition can require intestinal resection. We report 3 cases of trocar site hernia to find its risk factors, including a 5-mm trocar site hernia case.

Case 1: A 55-year-old woman underwent laparoscopic salpingo-oophorectomy and developed nausea on postoperative day (POD) 16. Computed tomography (CT) showed a 12-mm sized trocar site hernia. Urgent surgery revealed an incarcerated small bowel adhered to the anterior rectus sheath; however, no resection was required.

Case 2: A 45-year-old woman underwent total laparoscopic hysterectomy. She developed nausea, vomiting, and abdominal pain on POD 3. CT showed a 12-mm sized trocar site hernia in the lower abdomen. The small bowel was incarcerated in the fascial defect; however, no adhesions were identified, and the herniated small bowel could be repositioned into the intraperitoneal cavity.

Case 3: A 65-year-old woman underwent total laparoscopic modified radical hysterectomy. A 7-mm drain was inserted through the 5-mm trocar site into the lower abdomen intraoperatively and was removed on POD 3. The patient developed vomiting on POD 5. After fasting and fluid replacement, the vomiting ceased, but recurred on POD 10. CT revealed a trocar site hernia and significant adhesions between the small bowel and the abdominal oblique muscle fascia. A section of the small bowel was perforated during adhesiolysis and required resection.

Conclusion: Obesity, old age, and a multiparous status are patient-related risk factors for trocar site hernia. Surgeon-related factors include imperfect closure of fascia. Appropriate fascial closure is important. Urgent imaging is warranted in patients presenting with ileus-like symptoms to resolve the problem earlier.

Case: A 38-year-old woman, gravida one, underwent cesarean delivery. She presented with irregular bleeding, and left ovary endometriotic cyst was suspected. The findings at the first visit showed a 38-mm large cyst in the bladder uterine cavity. Magnetic resonance imaging (MRI) showed a cyst with traffic with the uterus. She was diagnosed with uterine pseudo-diverticulum from a cesarean section scar, and repair was attempted under laparoscopy. Cysts were found under the bladder uterine cavity. Traffic with the uterus formed a 10-mm fistula, which was excised using an electric scalpel without leaving a fistula wall, and the muscular layer was sutured using absorbable thread. One month after surgery, thinning was not observed in the restoration site, but softening of the tissue was observed by MRI, and findings suspected of fistulas were confirmed by hysterosalpingogram (HSG). Two months later, reoperation was performed under laparoscopic and hysteroscopic assist. The periphery of the fistula was excised with a cold knife, and the muscular layer was sutured using absorbable thread. Postoperative HSG confirmed the disappearance of the diverticulum.

Conclusion: There is no established treatment method for uterine pseudo-diverticulum occurring in the cesarean section scar. However, laparoscopic repair was thought to be one of the options for patients desiring fertility. Hysteroscopic assist was important during restoration.

Objective: Spinal muscular atrophy (SMA) is a genetic disease affecting the part of the nervous system that controls voluntary muscle movement. Scoliosis in SMA most likely develops because of a lack of muscular support for the spinal column or because of muscular imbalance. We report a case of laparoscopic myomectomy in a patient with severe scoliosis and SMA. To our knowledge, no prior report has discussed the technical difficulties of laparoscopic myomectomy in the presence of SMA with severe scoliosis.

Patient: A 31-year-old woman was referred to our department for submucosal fibroma with severe anemia. She underwent laparoscopic myomectomy. Surgery was completed successfully without need for open conversion and without any complications.

Conclusions: In patients with severe scoliosis and SMA, vertebral and thoracic deformities can make intubation difficult and reduced lung capacity can cause intraoperative ventilation failure. Thus, such surgery needs to be planned in conjunction with the anesthesiology department. Laparoscopic myomectomy in a patient with severe scoliosis enables improved operative visibility and easier access to pelvic organs. We believe that in patients with less pelvic working space, a laparoscopic approach can increase the working space and improve orientation. In our opinion, severe scoliosis is not a contraindication to this procedure.

  As the indications for laparoscopic surgery expand, the number of complications specific to laparoscopic surgery and severe injuries, such as intestinal damage and ureteral injury have also increased. In our hospital, we use the Yellow Port Plus^® produced by AMCO as a 5-mm port, which is reusable. During total laparoscopic hysterectomy for uterine corpus cancer, we noticed a leakage of carbon dioxide gas from the port as the scissor forceps were removed. We checked the valve of that port and found it had been damaged. A part of the valve was found on the surface of the sigmoid colon just below the tip of the port, and we managed to salvage it. To our knowledge, valve injuries have never been reported. If this finding had been delayed, it would have been undetectable. We noticed the leakage of carbon dioxide gas and responded promptly, it was possible to avoid the contamination of a piece of valve in the body. Since rare contingent complications occur infrequently, it is very meaningful to share the knowledge of these complications with those that are not as experienced.

Introduction: Heterotopic pregnancies are rare, with an incidence of approximately 0.003% in a natural ovulation cycle. We report a case of combined ovarian and intrauterine pregnancies, in which laparoscopic surgery confirmed the diagnosis and enabled successful pregnancy.

Case Report: A 31-year-old nulliparous primigravida had received ovulation-inducing treatment, and pregnancy was successful. At 5 weeks of gestation, one gestational sac was found in the uterus, but at 6 weeks of gestation, a gestational-sac-like structure was found in the right adnexa, and the patient was referred to our hospital. Upon admission, her serum hCG level was 76,303 mIU/mL, and transvaginal ultrasonography revealed the presence of a gestational sac inside the uterus, a gestational-sac-like structure in contact with the right adnexa, and an echo-free space around the uterus. As intraperitoneal bleeding and heterotopic pregnancy were suspected, the risks and benefits of general anesthesia and laparoscopic surgery were explained to the patient, and an emergency laparoscopic surgery was performed.

  Her intraoperative findings revealed intraperitoneal bleeding and enlargement of the right adnexa, with a 9.3-cm gestational sac adhered to the surface. A diagnosis of ovarian pregnancy with concomitant intrauterine pregnancy was confirmed, and the gestational sac on the right adnexa was removed. The postoperative course was uneventful.

  A spontaneous vaginal delivery occurred at 39 weeks of gestation and resulted in a live birth.

Conclusions: We report a case of combined ovarian and intrauterine pregnancies. Pregnancy can be adequately continued with appropriate diagnosis and treatment, and laparoscopic surgery may be a useful treatment option.

Objective: Double inferior vena cava is a congenital venous anomaly with an incidence of 1-3%. Several patients with anomalies of the great vessels present with complications such as minor anomalies of blood vessels. A thorough understanding of the positional relationships and anatomical construction is essential to perform safe and effective surgery. At our hospital, as a matter of policy, preoperative three-dimensional computed tomography (3D-CT) is performed in all patients undergoing laparoscopic para-aortic lymphadenectomy (PAN) to confirm the presence of anomalies of the great vessels. We report PAN performed in 2 patients with a double inferior vena cava.

  Both patients presented with early ovarian cancer, and staging surgery including PAN was performed. The double inferior vena cava was identified on preoperative 3D-CT. Transperitoneal PAN was performed in both patients. No other concomitant anomaly was observed. Although a careful operation was required with regard to several points, no massive bleeding necessitating blood transfusion or complications occurred, and surgery could be safely performed.

Conclusion: A transperitoneal approach provides better intraoperative orientation than a retroperitoneal approach, because with this approach, the left inferior vena cava is unlikely to interfere with the operation. Therefore, preoperative 3D-CT may be useful to select the optimal approach for PAN.

Introduction: Leiomyomas of the round ligament of the uterus are rare. Two-thirds of these lesions originate from the extraperitoneal end of the round ligament and may be misdiagnosed as inguinal tumors that are operated by general surgeons. We report a case of a leiomyoma originating from the round ligament of the uterus, which was preoperatively diagnosed as a left ovarian tumor.

  A 51-year-old woman presented to our hospital with the chief complaints of hypermenorrhea.

  Plain pelvic magnetic resonance imaging showed multiple leiomyomas including a submucosal uterine leiomyoma, which was presumed to be the cause of hypermenorrhea. Additionally, a mass measuring 6 cm in size was identified on the left side of the pelvis. The mass was suspected to be a left ovarian tumor; thus, we planned laparoscopic surgery for the ovarian tumor and hysteroscopic myomectomy. The mass originated from the left-sided round ligament of the uterus, and the intact left ovary was observed posterior to the tumor. The tumor border was indistinguishable from the proper ligament of the left ovary; thus, we performed ablation of the left ovary. We cut the left-sided round ligament of the uterus and the suspensory ligament of the left ovary to avoid injury to the ureter. Thereafter, we cut the round ligament of the uterus and the proper ligament of the left ovary, and the tumor was removed. Histopathological examination revealed that the tumor was a leiomyoma.

Conclusion: Intrapelvic leiomyomas of the round ligament of the uterus are often asymptomatic; however, in a few patients, emergency surgery may be warranted for suspected torsion of an ovarian tumor. A normal ovary with a leiomyoma of the round ligament of the uterus can be identified by the course of the vessels feeding the leiomyoma. However, in this case preoperative diagnosis was difficult. It is necessary to carefully observe the course of the feeding vessels intraoperatively and cut the supporting tissue, ensuring that the ureter is not injured.

  Ovarian carcinoids represent 0.1% of all ovarian cancers. We report a case of primary ovarian carcinoid with a mature cystic teratoma diagnosed after laparoscopic surgery. A 32-year-old woman presented with secondary amenorrhea. Pregnancy test was negative. Ultrasonography and magnetic resonance imaging revealed a mature cystic teratoma measuring 7 cm in the right ovary. We performed a laparoscopic right ovarian cystectomy. The pathological examination revealed that most of the tumor was a mature cystic teratoma, including a small focal lesion of a trabecular carcinoid tumor. Therefore, a laparoscopic right salpingo-oophorectomy was performed, and the postoperative pathology indicated no tumor tissue. The prognosis of ovarian carcinoids is favorable; however, careful postoperative follow-up is important because recurrence may happen in a small number of cases.

Objective: To assess the efficacy of careful surgical technique and intrauterine balloon tamponade in preventing abnormal bleeding in hysteroscopic surgery for placental polyps

Design: Retrospective study

Setting: Single-institution case series

Patients: Patients with placental polyps who underwent hysteroscopic surgery

Intervention: Hysteroscopic resection with intrauterine balloon tamponade

Main outcome: Perioperative surgical complications including abnormal bleeding

  A total of 8 patients were treated using hysteroscopy. The mean patient age was 40.1 years (range: 34-44 years), the median diameter of the placental polyp was 23 mm (range: 7-46 mm), and the median surgical time was 32 min (range: 10-65 min). Hysteroresectoscopes with 22 or 26 Fr diameters were used to carefully cauterize individual blood vessels at the base of placental polyps with a flat-type loop electrode. Two cases required temporary compression hemostasis with an intrauterine balloon during the intraoperative period because of increased bleeding. Although 2 cases experienced 100 g and 80 g of blood loss, the other 6 cases did not have abnormal bleeding during the perioperative period when treated with intrauterine balloon tamponade for a day after hysteroscopic surgery.

Conclusion: Placental polyps can be safely treated by hysteroscopic resection through careful surgical technique and intra- and/or postoperative application of intrauterine balloon tamponade.

  Vaginal leiomyomas are rare, and their etiology is unclear. Their symptoms and methods of surgical removal differ depending on the location and size. When adjacent to the vagina or urethra, they can be difficult to distinguish from paraurethral leiomyomas. Here, we report our experience using bladder suspension during laparoscopic removal of a vaginal leiomyoma.

  The patient was a 43-year-old woman, parity 2, who was examined for frequent urination and difficulty in urination. A 6-cm tumor was observed on the anterior vaginal wall. Eversion and extraction of the tumor outside the vagina were difficult, and therefore laparoscopic surgery was planned. To remove the vaginal wall tumor, which extended deep into the pelvis, a straight needle with nylon thread attached was used to pierce the bladder and suspended it by fixing it to the abdominal wall, which created adequate field of view and working space. Traction could not be applied because of the fragility of the myoma tissue, and the manipulations to detach the tumor were difficult due to indistinct boundaries with the vaginal wall and surrounding tissue. Nevertheless, complete enucleation was accomplished laparoscopically.

  The patient exhibited no postoperative complications, indicating that bladder suspension is a safe and useful method that could be applied to a variety of deep pelvic surgeries.

  Here, we present a rare case of ovarian chocolate cyst rupture in an adolescent female. A 14-year-old female presented with severe abdominal pain. Imaging, including ultrasonography and computed tomography, detected a cystic tumor of the right ovary. Laparoscopic surgery removed part of the right ovary including the ruptured cyst, and identified several intraperitoneal adhesions. According to the revised American Society of Reproductive Medicine classification, it was graded 42 points (focal score: ovary 20; adhesion score: 16, tube 8) and stage IV. The pathological study after laparoscopic surgery revealed endometriotic cyst of the right ovary. The patient is presently doing well with a course of low-dose oral contraceptive medication. Although ovarian endometriotic cysts are frequently encountered in adults, it should be noted that these lesions also occasionally occur in adolescents.

  Well leg compartment syndrome (WLCS) is a rare but potentially devastating complication that is seen after gynecological, urological, and colorectal operations. We report a case of a 31-year-old woman presenting with right lower limb WLCS after laparoscopic myomectomy. The operation was performed in the lithotomy position combined with the Levitator and Trendelenburg positions and the duration of the procedure was approximately 6 hours. Both legs were attached with elastic stockings and intermittent pneumatic compression applied for prevention of deep vein thrombosis.

Hemodynamic parameters of the patient were stable during the procedure. The Trendelenburg position was suspended, with the aim of preventing WLCS, for 5 minutes and 50 minutes at about 3 hours and 4 hours, respectively, from the beginning of the operation.

  Immediately after the operation, the patient complained of right crural pain, yet serum creatine phosphokinase (CPK) was detected to be within the normal range (100 IU/L). The following morning, on examination, we observed foot drop, paresthesia, swelling of the right calf, and an increased CPK (5316 IU/L). Three-dimensional computed tomography (3D CT) revealed the right lower limb muscle to be swollen and edematous in the posterior compartment. Acute arterial occlusion or deep vein thrombosis was not found. Fortunately, the patient did not need to undergo fasciotomy as the foot drop recovered after 3 months.

  WLCS is believed to be a life-threatening iatrogenic complication following surgery in the lithotomy position. As a result of this clinical experience, we have decided not to use elastic stockings, to mobilize the legs every 2 hours, and to take the supine position without Trendelenburg for 10 minutes at 3.5 hours from the beginning of the operation in this position. Moreover, to prevent irreversible damage, 3D CT angiography should not be delayed if WLCS is clinically suspected even in cases in which CPK is within the normal range.

  Although torsion of a normal ovary is rare in young women, preservation of ovarian function is an important treatment goal, especially when the ovary may be affected by severe congestion or necrosis. We report 2 cases in which ovarian torsion with apparent necrosis was successfully treated with laparoscopic detorsion.

Case 1: An 18-year-old woman visited our hospital complaining of acute lower abdominal pain. Laparoscopic surgery was performed for suspected ovarian torsion. The left ovary was enlarged at 6 cm in diameter, with torsion of 360 degrees. Although the affected ovary appeared necrotic with purple discoloration, we only performed detorsion. The rescued ovary was 3 cm in diameter 28 days later, and ovulation was detected 5 months later.

Case 2: A 41-year-old woman was scheduled for in vitro fertilization with embryo transfer. Six days after ovum retrieval, she visited our hospital complaining of acute lower abdominal pain. We performed laparoscopic surgery for suspected ovarian torsion. The left ovary was enlarged, with torsion of 360 degrees. Although the ovary appeared necrotic, we only performed detorsion. The affected ovary returned to normal size 14 days later and ovulation was detected 2 months later.

  These cases suggested that laparoscopic detorsion may be an important option for the treatment of torsion in a normal ovary with necrotic appearance to preserve ovarian function.

  With population aging, the number of patients with pelvic genital prolapse is increasing. As a surgical technique for pelvic genital prolapse, laparoscopic sacrocolpopexy (LSC) is now covered by insurance in Japan. The cervix remains as an anchoring point for fixing the mesh in LSC. We encountered a case of cervical adenocarcinoma arising from the remaining cervix after LSC surgery. The patient was a 68-year-old woman who underwent laparoscopic supracervical hysterectomy and LSC for pelvic organ prolapse. After 1 year, the cervical cancer test led to the diagnosis of cervical adenocarcinoma. Preoperative magnetic resonance imaging did not show a mass lesion. The patient underwent a simple trachelectomy with pelvic lymph node dissection because of adhesion. This case demonstrates that postoperative screening after LSC is important to detect cervical cancer early.

Objective: Interstitial pregnancies account for 2–4% of all ectopic pregnancies and its incidence is increasing because of the rise in sexually transmitted diseases and assisted reproductive technology. Interstitial pregnancy after ipsilateral salpingectomy is a rare condition with potentially serious consequences.

In this study, we report a case of a patient with interstitial pregnancy who conceived naturally following ipsilateral salpingectomy.

Patient: A 26-year-old woman gravida 3 para 1 with a history of laparoscopic right salpingectomy for ectopic pregnancy had lower abdominal pain and vaginal bleeding. Transvaginal ultrasonography revealed intrapelvic hemorrhage and no gestational sac in the uterine cavity. The human chorionic gonadotropin level in the blood was 3,674 mIU/mL. After admission, she felt severe lower abdominal pain. We suspected abortion of intrauterine pregnancy or ectopic pregnancy. Intrauterine curettage and emergency laparoscopic surgery were performed on the same day. Approximately 650 mL of blood in the abdominopelvic cavity was obtained, and right interstitial pregnancy with bleeding was observed. We removed all gestational tissue and performed laparoscopic right interstitial wedge resection.

Conclusion: The remaining fallopian tube following salpingectomy carries the risk of interstitial pregnancy. In addition, ipsilateral interstitial pregnancy should be considered in a natural conception setting after salpingectomy because of isthmic tubal pregnancy.

Case report: We report a case involving primary uterine serosal pregnancy treated via laparoscopic surgery. A 35-year-old woman with suspected ectopic pregnancy was referred to our hospital. We were unable to detect a gestational sac in the uterus or implantation site by imaging. Her urine human chorionic gonadotropin (hCG) level was 18,835 mIU/mL. Exploratory laparoscopy was performed to examine her abdominal cavity. Both of her fallopian tubes were normal. We found a gestational sac on the uterine serosal surface. Vasopressin was injected into the myometrium to reduce bleeding, and the part was dissected with minimal bleeding using monopolar and bipolar forceps. A pathological examination revealed the presence of chorionic villi and trophoblastic cells. Her postoperative course was good, and the patient was discharged on the fourth postoperative day. Overall, laparoscopic surgery was useful for the early diagnosis and treatment of peritoneal pregnancy.

Objective: Laparoscopic surgery is cosmetically superior to laparotomy. Recently, single-site laparoscopic surgery (SSL) is being performed in clinical practice because it requires a small incision. However, owing to the technical difficulty in performing this procedure, it is performed in gynecology departments only at a few hospitals. Forceps interfere with the charge-coupled device camera used during SSL (single-site laparoscopic surgery) owing to the restricted surgical field available in such cases. The SSL operation is more difficult than multi-port laparoscopic surgery owing to technical obstacles. We report the efficacy of the scope holder system (ViKY EP system™, Endocontrol, La Tronche, France) used during SSL in such technically difficult cases.

Case presentation: A 22-year-old pregnant woman was diagnosed with a left ovarian tumor. She underwent SSL after delivery. The surgery was performed by a single surgeon using the ViKY EP system™.

Conclusion: The ViKY EP system™ may be a safe to reduce operator stress during operations.

  During laparoscopic surgery, the thinnest part of the umbilicus is longitudinally incised to insert a trocar because this is the easiest route of access into the abdominal cavity. Following longitudinal incision of the bottom of the umbilicus, a deformation of the navel may become noticeable. This type of deformation is not observed when using a conventional incision, along the lower edge of the umbilicus. Deformation of the umbilicus is thought to be caused by a reduction in subcutaneous space due to suturing of the deep tissue and the turning-over skin at the time of incision becoming less invaded. It is also conceivable that contracture of the scar, in which the longitudinal wound at the bottom of the umbilicus shortens with the passage of time, causes the bulge in the umbilicus to stand out. If Z-plasty is used to perform umbilical closure in order to prevent scar contracture, it becomes easier for the skin at the edge of the wound to penetrate into the deeper portion of the wound. It is believed that the wound will not shrink following Z-plasty, even with the passage of time, thereby decreasing the incidence of deformation of the umbilicus.

  Therefore, umbilical wound closure was performed using Z-plasty and patient satisfaction was evaluated 6 months after the operation. Of 102 patients questioned, 7.8 % responded that the shape of the umbilicus was improved following surgery, while 12.7 % acknowledged that there was some deformation of the navel. When the responses from patients who had undergone wound closure using Z-plasty were compared with those who had experienced the conventional wound closure method, umbilical wound closure using Z-plasty appeared to be useful for preventing deformity of the navel.

Introduction: Uterine cystic adenomyosis is a rare proliferative disease in which the endometrial tissue focally repeats hemorrhage in the myometrium and forms cystic lesions. We report a case of uterine cervical cystic adenomyosis for which we performed total laparoscopic hysterectomy (TLH) with two techniques to avoid urinary tract injury.

Case: The patient was a 45-year-old woman with G0 who had two times of surgery for endometriosis. A local doctor diagnosed uterine cervical cystic adenomyosis about 30 mm in diameter and followed her up. Due to the worsening dysmenorrhea and the enlarging cystic lesion, she was referred to our hospital for treatment. Pelvic MRI showed uterine cervical adenomyosis about 35 mm in diameter and diffuse adenomyosis of the uterine body. TLH was performed because of the worsening dysmenorrhea due to uterine adenomyosis. Anatomical change due to a cervical tumor and severe adhesions because of endometriosis were expected; hence, we carried out two techniques. Firstly, urinary catheters were preoperatively placed, secondary, we injected air into the bladder when the uterus and the bladder were detached, then, TLH was safely completed while monitoring the bladder wall. Histopathology showed endometrial glands in the cervical myometrium, and uterine cervical cystic adenomyosis was diagnosed. Her symptoms have improved, and no recurrence after surgery has been observed.

Discussion: Cystic adenomyosis is rarer in the cervix than in the uterine body. There is no report about TLH for uterine cervical cystic adenomyosis. A difficult surgery was expected due to a cervical tumor and endometriosis, but the urinary tract injury was avoided using two techniques, and the surgery was safely completed.