Objective: Myomectomy is the most popular treatment for women who wish to become pregnant in the future. Laparoscopic myomectomy (LM) has been increasingly performed and will probably continue to increase in popularity in the future. This study aimed to compare the perinatal outcomes after LM versus abdominal myomectomy (AM).

Methods: We studied women who had myomectomy before and without recurrence of myoma in the current pregnancy. We included 2387 deliveries performed in the Department of Obstetrics and Gynecology of Fukuoka University Hospital, Fukuoka, Japan from 2013 to 2017.

Results: Fifty-four women delivered after myomectomy. Thirteen women who had undergone LM and 15 who had undergone AM were compared after multiple pregnancies. Pregnancy with the complication of new myoma was excluded. Treatment with ritodrine for preterm labor was required more frequently in LM than in AM. However, there were no significant differences in perinatal outcomes including the rate of preterm delivery, a low Apgar score, and blood loss between patients who had LM and those who had AM. There was no uterine rupture or intrauterine fetal death.

Conclusion: LM requires treatment for preterm labor, but there is no difference in the rate of preterm delivery between LM and AM. There is also no significant difference in perinatal outcome between LM and AM, although careful consultation and follow-up are required.

Objective: To identify the risk factors involved in the conversion to laparotomy during total laparoscopic hysterectomy (TLH) for benign diseases.

Design: Retrospective comparative study

Setting: Kaizuka Municipal Hospital for gynecologic endoscopic surgery.

Patients: 453 patients who underwent TLH during the last four years of our performance of TLH.

Intervention: Total laparoscopic hysterectomy for benign disease. We compared patient characteristics(Age, Body Mass Index, history of abdominopelvic surgery, comorbidity of endometriosis), indications for hysterectomy, uterine width on Magnetic Resonance Imaging (MRI), operation time, blood loss, adhesion, uterine weight and complications between a failed and a successful group.

Main outcome measures: The rate of conversion to laparotomy was 1.9% (nine patients). There were no differences in patient age and BMI between the two groups. An independent risk factor for conversion was uterine width greater than 10 cm on MRI (p=0.0009). Operation time, blood loss and uterine weight were greater in the group with a uterine width that was greater than 10 cm on MRI. Adhesion, history of abdominopelvic surgery and comorbidity of endometriosis were not independent risk factors for conversion in this study. (p=0.0589, p=0.8503, p=0.5394).

Conclusion: Uterine width greater than 10 cm on MRI is a risk factor for conversion to laparotomy. Awareness of the risk factors for conversion to laparotomy is essential for better patient selection for TLH.

Objective: To determine the efficacy and safety of hysteroscopic surgery in women with infertility admitted to our hospital.

Design: Retrospective study.

Setting: Department of Obstetrics & Gynecology at a general hospital.

Patients: This study included 199 women with infertility who underwent hysteroscopic surgery for intrauterine lesions at our hospital between August 2012 and July 2017.

Intervention: Hysteroscopic surgery.

Main Results: The mean age of the women in this study was 36.5±4.2 years and 163 (81.9%) were nulliparous. Malignancy was detected postoperatively in 5 of the 199 (2.5%) women. One woman underwent an additional operation, whereas the other 4 received medroxyprogesterone acetate and continued with treatment for infertility. Notably, 70 of 122 (57.4%) women successfully conceived within a year of surgery; however, among these 70, miscarriage occurred in 10 women. Detailed obstetric data were available for 46 women with live births following surgery. Among these 46 women, 19 underwent a cesarean section. No detrimental effects were observed on reproductive and obstetric outcomes.

Conclusions: Hysteroscopic surgery was safely and effectively performed in women with infertility admitted to our hospital. Hysteroscopic surgery may contribute to successful treatment of infertility in women with intrauterine lesions.

　Although cytoreductive surgery can be the first choice of treatment for recurrent gynecologic malignancies (RGM), the effectiveness and safety of laparoscopic surgery for these tumors are still controversial. We conducted a retrospective study of cytoreductive surgery for RGM in a single institution. A total of 44 patients underwent RGM surgery on 57 occasions from 2011 to 2017. Laparoscopic surgery was performed for 10 cases, of which 6 cases were lymph node recurrence, 3 cases were peritoneal dissemination of ovarian cancer, and 1 case was central pelvic recurrence of uterine leiomyosarcoma.

　In almost all of these cases, the recurrence site was single and the mass volume was small enough (1.4 ± 0.6 cm) to extract from the peritoneal cavity through a trocar.

　In the laparoscopic surgery group, the operation time was short (157 ± 67.1 minutes), blood loss was small (55.5 ± 116 g), and length of stay was short (4.7 ± 1.5 days). Tumors were completely excised in all 10 laparoscopic cases, and there were no cases changed to laparotomy. During the postoperative observation period of 25.8 months on average, recurrence was observed in 4 cases but there were no deaths in the laparoscopic surgery group.

In the management of RGM, if the case is properly selected, laparoscopic surgery may be minimally invasive without compromising oncological prognosis.

Objective: To identify the factors associated with difficulty in performing laparoscopic gynecologic procedures, including hysterectomy, myomectomy, adnexectomy, and cystectomy.

Design: Retrospective study.

Setting: University hospital.

Patients: Six hundred and forty-four patients who underwent laparoscopic surgery for benign gynecologic pathologies at our institution in 2017.

Intervention: Laparoscopic surgery.

Main outcome measures: Factors associated with prolonged operative duration and intraoperative blood loss were reviewed. Patient factors were as follows: age, body mass index (BMI), history of vaginal delivery, history of laparotomy/laparoscopic surgery, adenomyosis/fibroid, uterine weight, diameter of the largest myoma, number of enucleated myoma, diameter of the ovarian cyst, type of the ovarian cyst (endometriotic cyst or others), unilateral/bilateral lesions, adnexal adhesion score, and presence of cul-de-sac obliteration.

Result: In hysterectomy, increased uterine weight, adnexal adhesion score, and a history of laparotomy significantly increased the operative duration and blood loss, while a history of vaginal delivery decreased operative duration. In myomectomy, larger diameter size of the myoma and greater number of enucleated myoma significantly increased operative duration and blood loss, and high BMI increased operative duration. In adnexectomy, adnexal adhesion score significantly increased operative duration and blood loss. In cystectomy, larger diameter size of the ovarian cyst, bilateral lesions, and a presence of cul-de-sac obliteration significantly increased operative duration and blood loss, and high BMI increased operative duration.

Conclusion: Understanding the factors associated with difficulty during laparoscopic gynecologic surgery could be helpful in appropriate case selection by the surgeons depending on their individual technical skills, while ensuring surgical safety.

Objective: The objective of this study was to assess the risk of recurrence of ovarian mature cystic teratoma (OMCT) and to evaluate the feasibility of ovarian-conserving surgery.

Methods: This retrospective clinical study investigated patients with OMCT who underwent laparoscopic surgery between January 2014 and March 2017.

Results: Recurrence of OMCT was observed in 7 of 81 patients (8.6 %)—three patients (3.7%) showed ipsilateral recurrence, and four patients (4.9 %) showed recurrence in the contralateral ovary. Patients with recurrence (mean age 22.5 years [range 15–30 years]) were younger than those without recurrence (mean age 33.5 years [range 16–63 years]). No significant intergroup differences were observed in gravidity, parity, cyst size, intraoperative cyst rupture (cysts that did or did not rupture), number of cysts, and laterality.

Conclusion: The recurrence tendency of OMCT in adolescents and in patients in their early 20s was higher than that in older patients. Cystectomy should be considered in children and patients of reproductive age for conservation of the affected ovary. An initial adnexectomy may not obviate the risk of multiple subsequent surgeries because OMCT may recur in the contralateral ovary.

Objective: We compared the clinical outcomes of total laparoscopic radical hysterectomy (LRH) with abdominal radical hysterectomy (ARH) performed in women with cervical cancer.

Methods: Between November 2015 and February 2018, 19 women with cervical cancer (Stage IB1 or IIA1) underwent LRH, and 40 women with cervical cancer (Stage IB1 or IIA1) underwent ARH in our department. Patients' background, surgical outcomes, perioperative complications, and postoperative course were retrospectively compared between the groups. Statistical analysis was performed using the Student's t-test, Wilcoxon test, and the Fisher exact test.

Results: The operative time was significantly longer (587 vs. 422 min, p<0.0001) and estimated blood loss was significantly lesser (417 vs. 1077 mL, p<0.0001) in the LRH group. No statistically significant intergroup difference was observed in the number of lymph nodes removed, surgical margin, and perioperative complications. Median follow-up was 16 and 23 months, respectively, and recurrence occurred in 1 patient in each group.

Conclusion: Although this study included a limited number of patients and was a short-term study, LRH was safely performed in women with cervical cancer. Notably, no intergroup difference was observed in short-term outcomes. We will continue observation to determine the long-term prognosis in these women.

Objective: The aim of this study was to verify the validity of laparoscopic approach in Sentinel lymph node (SLN) mapping.

Design: This retrospective study was carried out using data for 118 patients with endometrial cancer who had undergone SLN mapping. Technetium colloid (Tc^99m) and/or indocyanine green (ICG) was injected into the uterine cervix and a gamma-detecting probe and/or photodynamic eye camera system was used intraoperatively to locate hot spots. SLN detection rate and incidence of complications were compared between open approach (O group, n=65) and laparoscopic approach (L group, n=53).

Results: Patients' median age was 60 years. One hundred and nine (92%) had FIGO Stage I disease. There was no difference in patients' age, BMI, FIGO stage, and histology between the two groups. SLN mapping with a combination of two tracers (Tc99m and ICG) was performed more frequently in the L group than in the O group (49% vs. 20%, P=0.0008). Successful bilateral or unilateral mapping occurred in 91 patients (77%) and 19 (16%), respectively. There was no difference in SLN detection rate between the two groups (P=0.73). However, perioperative complication rates were lower in the L group among both patients with back-up lymphadenectomies (10.0% vs. 20.4%, P=0.49) and those with no back-up lymphadenectomy (3.0% vs. 12.5%, P=0.25).

Conclusion: Laparoscopic approach might obtain a SLN detection ability equal to open approach without increasing the number of perioperative complication despite limitation of the present study.

Objective: Laparoscopic surgery has been performed in many facilities in Japan since 2014. The aim of this study was to evaluate the selection criteria of these cases for the treatment of endometrial cancer in our hospital, as well as to assess the complications and results of postoperative pathological diagnosis.

Methods: Fifty-four patients diagnosed with stage IA endometrioid carcinoma (G1-G2) with a small tumor diameter during preoperative evaluation underwent laparoscopic surgery in our hospital between 2014 and 2018. Operation time, bleeding volume, number of lymph nodes removed, complications, and postoperative pathological diagnosis were evaluated retrospectively.

Results: The median patient age was 56.5 years (range: 22-79 years), and the average BMI was 21.9 (range: 16.9-32.7). The median operation time was 217 minutes (range: 145-285 minutes), and the average volume of bleeding was 20 mL (range: 0-300 mL). The average number of lymph nodes removed was 17 (range: 1-42 lymph nodes). Postoperative complications were observed in 3 cases: a port site hernia, ileal and vaginal lymphatic leakage, and lymphocyst infection. A higher pathological grading occurred in 4 out of 54 cases following postoperative pathological assessment. No stage IVB cases were reported postoperatively.

Objective: Laparoscopic gynecological surgery is associated with a high incidence of PONV. In this study, we comparatively investigated the efficacy of combination therapy with dexamethasone plus droperidol versus no therapy in the prevention of PONV following laparoscopic gynecological surgery.

Design: In total, 122 patients who underwent laparoscopic gynecological surgery under general anesthesia at our institution from November 2017 to February 2018 were included in the study and assigned to two groups: the dexamethasone plus droperidol group (n=44) and the control group (n=78). Dexamethasone 6.6 mg was administered after the induction of anesthesia, and droperidol 1.25 mg was administered at the end of the surgery. The incidence of PONV and doses of administered rescue antiemetics were recorded on the first postoperative day.

Results: Combination therapy significantly reduced PONV compared with no therapy and required less rescue antiemetic treatment (P<0.05). No clinically important adverse effects were observed in either group.

Conclusion: Pretreatment with dexamethasone plus droperidol is more effective than no therapy in preventing PONV following laparoscopic gynecological surgery.

Objective: Laparoscopic gynecological surgeries are widely used in the treatment of uterine and ovarian diseases and has advantages in terms of postoperative early recovery and cosmetic sequelae over open abdominal surgery. However, postoperative pain is significant. We evaluated the efficacy of ultrasound-guided truncal peripheral nerve block, including rectus sheath and transversus abdominis block.

Methods: Two hundred and ninety-six patients who underwent laparoscopic gynecological surgeries for uterine and ovarian diseases at our institution from January 2012 to August 2014 were identified from the medical records and evaluated in a retrospective manner. The patients in group A received rectus sheath and transversus abdominis block combined with general anesthesia and those in group B received general anesthesia alone. The factors measured after surgery included the postoperative demand for postoperative additional analgesia and antiemetics.

Results: Postoperative demand for analgesics during the postoperative 48 hours was significantly decreased in group A (group A versus B: 1 versus 3; p<0.001) and for antiemetics was also statistically decreased in group A (13.3% versus 24.8%; p=0.01). The second analysis of the demand for postoperative analgesics for each surgery type (laparoscopic hysterectomy, ovarian surgery, and myomectomy) was also significantly decreased in group A. However, the demand for antiemetics was only statistically lower for laparoscopic ovarian surgeries when analyzing by surgery type.

Conclusion: Truncal peripheral nerve block in laparoscopic gynecological surgery is effective in reducing postoperative analgesia demand and preventing nausea and vomiting than general anesthesia alone. However, changes in the demand for antiemetics depends on surgery type.

Objective: The aim of this study was to clarify operative outcomes after laparoscopic surgery in patients with obesity diagnosed with early stage endometrial cancer.

Design: We retrospectively analyzed the medical records of 150 patients treated at our hospital between 2012 and 2016 to determine the prevalence of obesity and surgical outcomes. Patients were divided into the non-pelvic lymphadenectomy (PLN-) and pelvic lymphadenectomy (PLN+) groups. We compared surgical outcomes between patients with and without obesity in each group.

Results: We observed that 45 of the 150 patients were diagnosed with obesity (body mass index ≥25 kg/m²). No significant differences were observed in operative time, estimated blood loss, and duration of postoperative hospitalization between patients with and without obesity in the PLN- group. The operative time was longer (p=0.001) and the number of lymph nodes removed was higher (p=0.001) in patients with obesity in the PLN+ group. No significant differences were observed in estimated blood loss and the duration of postoperative hospitalization between patients with and without obesity in the PLN+ group. Intra- and postoperative complication rates were similar between patients with and without obesity (6.7% vs. 7.6%).

Conclusion: We conclude that laparoscopy can be safely performed for early stage endometrial cancer in patients with and without obesity.

  The patient was a 37-year-old woman with no history of pregnancy or laparotomy. She developed lower abdominal pain and nausea and was admitted to a local hospital with a diagnosis of acute gastroenteritis. However, she was found to have small bowel obstruction and an ovarian cyst on imaging studies and was referred to our department. A diagnosis of intestinal endometriosis was made on the basis of the results of transvaginal ultrasonography and magnetic resonance imaging. We performed laparoscopic bilateral ovarian endometriosis cystectomy and partial small bowel resection in collaboration with a gastrointestinal surgeon of our hospital. The patient had a favorable postoperative course and was discharged home on the 12th day after surgery.

  Among the less common and rare sites of endometriosis is intestinal endometriosis. The initial symptoms, occurrence patterns, and treatment methods of intestinal endometriosis differ considerably according to the sites of origin in the large and small intestines. Intestinal endometriosis is a benign disease and is usually treated with drug therapy; however, surgery is needed if patients present with intractable gastrointestinal symptoms or are strongly suspected to have an intestinal obstruction. This condition is a good indication for laparoscopic surgery in terms of its minimal invasiveness and advantage in preserving fertility.

  We report a case of laparoscopic resection of a cesarean scar pregnancy (CSP) in a 29-year-old Brazilian woman who had undergone 4 pregnancies and 4 deliveries (3 via cesarean section). She visited a local physician and was diagnosed with CSP at 7 weeks' gestation; however, because no changes were observed in a gestational sac, she was referred to our hospital. Transvaginal ultrasonography revealed a gestational sac measuring 25 mm attached to the cesarean scar, with thinning of the anterior myometrium and significant bleeding. After confirming that the gestational sac had protruded toward the urinary bladder, we performed laparoscopic resection of the scar pregnancy. We carefully separated the bladder from the site of the pregnancy. A 1:100 solution of vasopressin was locally injected at the site, and we used a monopolar device for incision and resection of the pregnancy tissue. After removal of the scar tissue, 2-layered suture closure of the myometrium was performed, and the site was closed. The operative time was 2 hours 29 min, and the estimated intraoperative blood loss was 5 mL. The patient showed an uneventful postoperative course, and she was discharged on the 4th day. Laparoscopic resection of a cesarean scar pregnancy is associated with a high success rate and is a useful treatment option with few complications. This option is particularly useful in women with a gestational sac located deep within the scar tissue (as was observed in our case). This minimally invasive technique prevents uterine rupture, bladder injury, and/or massive hemorrhage.

  Urinary retention is rare in women with uterine myoma. Although long-term urinary retention can cause irreversible injury to the urinary tract, no standard strategies have been established for optimal management of this complication. We present a case of uterine myoma associated with urinary retention in a woman who was successfully treated by laparoscopic hysterectomy performed during the subacute phase of this condition.

  A 43-year-old gravida 1, para 1 presented with urinary retention. Pelvic magnetic resonance imaging revealed a myoma located in the upper portion of the posterior uterine wall with a longer diameter of 11.5 cm. The uterine cervix and lower portion of the bladder were displaced anteriorly secondary to the tumor. These findings and the patient's history of her illness suggested that urinary retention was caused by the uterine myoma. Total laparoscopic hysterectomy was performed after 2 months of conservative management. Postoperatively, urination promptly improved without any disturbance of bladder function. Urinary retention caused by uterine myoma without any underlying illness should be considered an indication for surgical treatment.

  Paraneoplastic Limbic Encephalitis (PLE) is a kind of limbic encephalitis caused by remote effects of tumors. It is caused by immune reaction to antigens common in tumors and nerve tissue. We report a case which was suspected to be limbic encephalitis and in which the clinical symptoms improved after operation. The patient was a 69-year-old woman, G0P0, who suffered from depression and weight loss. She presented to the psychiatry department in another hospital and was then referred to the neurology department in our hospital because of acute cognitive dysfunction and higher brain dysfunction. Brain MRI showed mild ischemic changes without space-occupying lesion or cerebrovascular disease. Cerebrospinal fluid examination showed no evidence of infectious encephalitis. At this point, immune encephalitis was suspected and whole- body computer tomographic (CT) scan was performed. On CT scan, an ovarian cyst was found on the right side, so she was diagnosed with clinical paraneoplastic limbic encephalitis. After consultation with the gynecology department, we examined her serum N- Methyl-D-Aspartate (NMDA) receptor antibody and performed bilateral laparoscopic adnexectomy. Pathological examination suggested mature cystic teratoma in the right ovary and fibroma in the left ovary, however, the serum NMDA receptor antibody was negative. After the operation, her cognitive function and higher brain function improved immediately on postoperative day one. After six months, she became independent in everyday life. We, therefore, diagnosed this case as clinically paraneoplastic limbic encephalitis. In conclusion, when limbic encephalitis is suspected, the possibility of paraneoplastic limbic encephalitis should be considered and whole-body CT is strongly recommended. Surgical resection should be considered when ovarian cyst is found, even if NMDA receptor antibody is negative.

　Damages in the urinary system are complications to be avoided in total laparoscopic hysterectomy (TLH). In this case reported at this time, we were not aware of bladder injuries in the operative field but were able to recognize the damages with expansion of a closed urinary drainage bag. She was 48 years old with four pregnancies and two childbirths, and had a past health history of Caesarean section by longitudinal incision in the lower abdomen at ages 18 and 26, abdominal myomectomy at age 19, and surgery to remove the remaining gauze at the time of myomectomy. She visited the clinic with a menorrhagia, abnormal vaginal bleeding, and difficulty in urination as main complaints resulting in TLH with the diagnosis of multiple uterine myoma. Intraoperative findings presented omental adhesion to the abdominal wall in a wide range, and the anterior wall of the uterus strongly adhered to the abdominal wall as well. As a result, the bladder was sandwiched between the abdominal wall and uterine cervix, and the posterior wall of the bladder was further presenting adhesion to the anterior vessels of the right parametrium. Sudden expansion of the closed urinary drainage bag was pointed out by the anesthesiologist while the bladder adhesion was detached. When the detached surface of the bladder was confirmed, a small 8mm tear was discovered and repaired with a double-layer closure. While confirming the mucosal surface with cystoscopy, routine TLH continued to be performed. Cystography was performed on the eighth day after surgery, and no leak to the abdominal cavity was confirmed and she was released from the hospital.

　Bladder injuries are diagnosed with severe urinary hemorrhage and urine leakage to the abdominal cavity, while intraoperative cystoscopy is also considered as effective for diagnosis. However, intraoperative diagnosis is difficult if the damaged site is very small and delayed injuries due to heat damage may occur; therefore it is impossible to understand all bladder injuries with intraoperative cystoscopy. Under such limited circumstances, bladder injuries were successfully recognized with expansion of the closed urinary drainage bag in our case. For this reason, paying attention to expansion of the closed urinary drainage bag during surgery is considered as a simple and effective tool not to overlook bladder injuries. We hope to be able to catch complications in the future, while considering to temporarily increase the abdominal air pressure after detachment of bladder adhesion in the case of TLH to determine whether or not expansion of the closed urinary drainage bag can be a method to confirm bladder injuries.

Introduction: A placental polyp can cause massive bleeding at postpartum. Treatment methods for a placental polyp include uterine artery embolization and hysteroscopic resection.We report here a case in which a laparoscopic utero-ovarian anastomoses ligation was performed on a placental polyp that also supplies blood flow from the ovarian blood vessels.

Case: A 34-year-old woman, gravid 2 para 2, had a natural pregnancy with no abnormalities. She had her baby by vaginal delivery at 39 weeks of gestation. On the 16th day after she gave birth, she had sudden active genitalia bleeding. Ultrasound color Doppler and computed tomography examination revealed a tumor with abundant blood flow in the uterus, and she was diagnosed with a placental polyp. Her serum human chorionic gonadotropin (hCG) level was 3.3 mIU/mL. Uterine artery embolization was performed for hemostasis. Furthermore, there was blood flow from the ovarian artery to the mass; therefore, the ovarian artery was judged to be the blood vessel responsible for the bleed. Embolization of the ovarian artery can result in ovarian dysfunction and endometrial necrosis; therefore, ligation of the utero-ovarian anastomoses by laparoscopy was performed. After blocking the main blood flow to the placental polyp was removed by hysteroscopic resection.

Conclusion: If the ovarian artery is also the responsible blood vessel for the placental polyp, laparoscopic utero-ovarian anastomoses ligation will be also an option.

　Androgen insensitivity syndrome (AIS) is a 46,XY disorder of sex development. It is characterized by a female phenotype associated with resistance to the effects of androgens. Some cases of AIS require vaginoplasty; however, prophylactic gonadectomy is recommended because of the risk of gonadal germ cell malignancies.

　We present a case of complete AIS (CAIS) treated by laparoscopic gonadectomy. A 16-year-old phenotypical female who complained of primary amenorrhea was referred to our hospital. Physical examinations revealed the blind end of the vagina and female external genitalia. A magnetic resonance imaging scan showed bilateral pelvic masses, such as gonads, and the absence of a uterus. Hormonal examination revealed elevated serum testosterone (12.00 ng/mL). Her karyotype was 46,XY. Therefore, the patient was diagnosed with CAIS. She had no urination disorder, but an examination with an anesthetic revealed that the urinary meatus was abnormally located in front of the blind vagina. She underwent a laparoscopic gonadectomy. Both gonads showed testicular tissue and no malignancies.

　Laparoscopic surgery is minimally invasive compared with open surgery and is the first choice for gonadectomy. If vaginoplasty is needed, vaginal dilatation can damage the urethra; therefore, cooperation between other departments, such as the urology or plastic surgery department, is needed for safe vaginoplasty.

Objective: We report a case of ovarian hemorrhage that occurred in a woman who underwent laparoscopic surgery for oocyte aspiration for mature oocyte cryopreservation. Additionally, we have presented a literature review.

Design: Case report and literature review.

Patient(s): A 36-year-old woman.

Intervention(s): Ultrasonography, computed tomography, and laparoscopic surgery.

Main outcome, Measure(s): Availability of laparoscopic surgery to treat ovarian hemorrhage after oocyte aspiration.

Result: A 36-year-old woman underwent surgery for breast cancer followed by hormone and radiation therapy. She desired to undergo oocyte preservation for fertility preservation. She received ovulation-inducing hormone therapy and underwent transvaginal aspiration after which she developed ovarian hemorrhage necessitating emergency laparoscopic surgery. Intraoperatively, the left ovary was edematous, and bleeding from a large fissure of the ovary was detected. Bipolar coagulation could not control the bleeding, and we sutured the fissure of the ovary for satisfactory hemostasis. Following uneventful postoperative recovery, radiation therapy was initiated on postoperative day 28.

Conclusion: We report a case of ovarian hemorrhage after oocyte aspiration for mature oocyte cryopreservation. Currently, social oocyte cryopreservation is gaining widespread acceptance. Therefore, oocyte preservation is possible in women with cancer, as well as in women desirous of future pregnancy. Given this scenario, such complications are expected to increase. Laparoscopic surgery is a less invasive option to avoid such complications and facilitates prompt institution of treatment in women with cancer. The ovaries are highly fragile after stimulation, and bipolar coagulation alone cannot control bleeding. Thus, laparoscopically placed sutures are usually required in such cases.

　Anti-N-methyl-D-aspartate (NMDA)-receptor encephalitis is a paraneoplastic syndrome encountered by obstetricians and gynecologists. Anti-NMDA-receptor encephalitis is a limbic encephalitis commonly seen in young females who present with various symptoms including psychiatric disturbance, changes in consciousness, and involuntary movements. Ovarian teratoma is found in approximately half of all cases of anti-NMDA-receptor encephalitis, and early tumor removal is considered important. We experienced two cases of acute encephalitis. Upon examination, we suspected ovarian teratoma and performed laparoscopic surgery. In case 1, surgery was performed on day 143 after onset; however, postoperative improvement was slow. The patient (Case 1) was extubated on postoperative day 71 and was discharged on postoperative day 374. For another patient (Case 2), surgery was performed on day 24 after onset. The patient was extubated on postoperative day 23 and was discharged on postoperative day 67. Neither patients experienced recurrence of encephalitis; however, the case 2 patient continues to exhibit limb contracture as a disease sequelae. These cases reinforce the importance of early tumor resection.

　Ehlers-Danlos syndrome (EDS) is a group of connective tissue disorders where patients have difficulty in tolerating invasive procedures. Advanced tests and genetic analyses on EDS patients have revealed that some subtypes and genetic mutations correspond to clinical subtypes and are not contraindicated for invasive therapies.

Case: We present the case of a 46-year-old para 2 woman (both vaginal delivery) with a history of coronary arterial dissection and aortic dissection (replacement surgery) and a familial history of arterial dissection. She was referred to our hospital because of severe dysmenorrhea. Pelvic examination, trans-vaginal ultrasonography, and magnetic resonance imaging revealed that she had a leiomyoma-like nodule that seemed to penetrate the uterine muscle of the left uterine fundus. We assessed the risk of uterine corpus rupture and considered the necessity and possibility of hysterectomy. We next performed genetic analysis for connective tissue disorders, and the result revealed an unreported mutation of Col3A1, which is associated with vascular EDS and aortic and arterial aneurysms, although the variant was not considered a pathological mutation according to the Polymorphism Phenotyping v2 (PolyPhen-2) score. We consulted the vascular surgeons who had performed her aortic replacement, and they confirmed that there was no problem of tissue fragility. Due to those findings, we decided to perform standard hysterectomy. Total laparoscopic hysterectomy (TLH) was performed because of its minimal invasiveness. There was no problem of tissue fragility.

Conclusion: We suspected that the woman had EDS, but a thorough preoperative evaluation with genetic analysis and previous surgical records enabled TLH to be safely performed. We recommend managing patients with rare diseases such as EDS on an individual basis.

  A post-operative intraperitoneal abscess is common complication, but antibiotics do not always work well for abscesses. We report a case of a vaginal stump abscess after a transvaginal hysterectomy (TVH) that was treated by laparoscopic drainage. A 43-year-old gravida 1 para 1 was referred to our hospital for evaluation of endometrial thickening. We diagnosed endometrial hyperplasia by dilation and curettage (D&C) and prescribed progesterone in the luteal phase of the cycle ; however, withdrawal bleeding did not occur. Because of risk thrombosis due to obesity and diabetes, she chose a TVH for definitive treatment. Post operatively, pelvic abscess and hematoma were diagnosed. We administered Ceftriaxone (CTRX), which relieved the inflammation, but the pelvic abscess did not decrease in size. After performing laparoscopic drainage, the infection resolved and here were no post-operative complications.

  A port site hernia is a rare complication, which occurs in 0.5% of patients after laparoscopic surgery. We report a case of a port site fallopian tube hernia, a complication that occurred due to the removal of an 8 mm intraperitoneal drain placed on the port wound.

  A 38-year-old non-parous woman, suffering from primary infertility, underwent a laparoscopic myomectomy for a uterine intramural leiomyoma (3.5 cm). Four ports (a 12 mm navel port for the camera, 5 mm ports for the left side and center of the lower abdomen, and a 12 mm right side port) were placed for the operation. The intraoperative course was smooth and 2 myomas (30 g) were removed. An intraperitoneal low-pressure suction drain (8 mm) was placed on the left side port wound. On the first postoperative day, the drain was removed smoothly through the port wound; however, the left fallopian tube was herniated. The patient was diagnosed with a port site fallopian tube hernia, which was repaired by pushback. Since the number of laparoscopic surgeries is on the rise, considerations must be made for rare complications like port site hernias.

CASE: A 68-year-old gravida 1, para 1 underwent computed tomography (CT) for the evaluation of ischemic enteritis. CT revealed enlarged right-sided pelvic lymph nodes measuring 25 mm and 12 mm. A malignant tumor was suspected based on positron emission tomography-CT and transvaginal cytology testing. Examination of the uterus did not reveal any findings suggestive of malignancy. Laparoscopic lymphadenectomy was performed to establish a conclusive diagnosis. The uterus and adnexa showed no abnormalities. Laparoscopic ultrasonography was useful for the evaluation of blood flow to the lymph nodes. The lymph node measuring 25 mm was located on the dorsal aspect of the right obturator nerve and showed adhesions with surrounding tissues. This lymph node (25 mm in size) was removed; however, the lymph node measuring 12 mm could not be identified and was not removed. Histopathological diagnosis of the resected lymph node showed squamous cell carcinoma (SCC). Postoperative review did not reveal any primary tumor. Histopathological examination of the resected lymph node confirmed metastatic SCC from an unknown primary carcinoma. The patient was treated with total pelvic radiation.

Conclusion: Laparoscopic lymphadenectomy is useful for histopathological diagnosis and postoperative decision-making regarding optimal treatment for deep-seated lesions such as pelvic lymph nodes. Notably, laparoscopic ultrasonography enables evaluation of blood flow, which is useful.

  Mature cystic teratoma and concomitant adult granulosa cell tumor (AGCT) of the ovary is a rare condition. We report a case of mature cystic teratoma and concomitant AGCT of the ovary, which was treated by laparoscopic surgery. A 64-year-old woman presented to our hospital with postmenopausal irregular vaginal bleeding. Imaging tests revealed endometrial thickness, as well as a left ovarian tumor measuring 6 cm in diameter. Preoperative investigations including endometrial tissue biopsy and imaging tests did not reveal any evidence of malignancy. We performed successful laparoscopic surgery with a meticulous technique to prevent ovarian tumor rupture. Histopathological examination of the resected specimen showed findings of AGCT and concomitant mature cystic teratoma. The tumor was localized only to the left adnexa without intraoperative tumor rupture; therefore, the patient was deemed suitable to undergo regular follow-up, which is currently ongoing without evidence of recurrent AGCT.

  A comprehensive literature search revealed 8 cases of AGCT and concomitant mature cystic teratoma of the ovary. Predicting AGCT based on preoperative imaging tests was difficult in all cases. However, approximately 50% of these women showed either irregular vaginal bleeding or increased endometrial thickness. Clinicians should consider a malignancy such as AGCT in the differential diagnosis in women presenting with irregular vaginal bleeding or evidence of increased endometrial thickness on imaging tests.

Objective: Several studies have reported an association between malignant tumors and thrombosis. We report a case of fallopian tube carcinoma diagnosed laparoscopically in a patient with pulmonary embolism.

Case presentation: A 71-year-old woman was diagnosed with pulmonary embolism on chest computed tomography (CT) that was performed for evaluation of inconclusive chest radiography findings. Although a small amount of ascitic fluid observed on CT was suspicious for malignancy, we could not conclusively diagnose this condition using several modalities such as CT, magnetic resonance imaging, and positron-emission tomography-CT of the upper and lower gastrointestinal tract. Therefore, we performed laparoscopy, and she was diagnosed with tubal cancer with peritoneal dissemination.

Conclusion: Laparoscopy is useful to diagnose the origin of malignant tumors.

  Gynecologic postoperative infections are expected to be due to aerobic gram-positive and gram-negative bacteria, anaerobic bacteria, Klebsiella pneumoniae, Streptococcus, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. In this case, we unexpectedly experienced the case of a patient with postoperative infection with Mycoplasma hominis. Measurements of this bacteria can result in false negatives in routine bacterial culture tests, and effective antibiotics are limited. Because it is difficult to identify and could lead to delayed treatment and aggravation, we report this case along with a literature review in order to increase awareness of this bacterium. A 37-year-old woman with uterine leiomyoma and endometriosis underwent laparoscopic-assisted myomectomy and left cystectomy. The intraoperative antibiotic was cefmetazole sodium (CMZ). Beginning the night of postoperative day (POD) 2, she developed a fever of 38°C. On POD 3, the fever worsened. Blood cultures were collected, and CMZ administration was initiated. On POD 6, we decided that the dose was insufficient. We increased the dose of CMZ and added metronidazole. Abdominal computed tomography (CT) suggested the presence of an abscess around the uterus. On POD 7, a catheter was placed in the abscess under CT guidance. On POD 8, the fever did not improve. We collected blood cultures and changed the antibiotics to tazobactam. After that, the fever appeared to improve. However, it recurred on POD 12. On the night of POD 13, Mycoplasma hominis was identified in the abscess culture. On POD 14, we changed the antibiotics to clindamycin and levofloxacin. The fever rapidly reduced, and the C-reactive protein level became negative. On POD 20, she was discharged. Later, the same bacteria were identified from blood cultures.

Objective: Ureteral injury is a devastating complication in gynecologic surgery. The prevalence of ureteral injury is higher in laparoscopic surgery than in laparotomy. That is because, unlike in laparotomy, it is difficult to identify the ureter by tactile sense in laparoscopic surgery. It is also well known that the prevalence of ureteral injury becomes higher especially in malignant or severe endometrioma operation. Lighted ureteral stents help gynecologists recognize ureter visually. Lighted ureteral stent is inserted prior to the surgery. Infrared Illumination System (IRIS) is a new lighted ureteral stent, which does not inhibit the function of the ureter or generate heat because of using near infrared light. In this case, we used IRIS to protect the ureter during laparoscopic surgery of endometrial cancer of uterine corpus.

Patient: A 50-year-old woman with genital bleeding was referred to our hospital. She was diagnosed with stage IA endometrioid carcinoma of uterine corpus, Grade 1 and taken laparoscopic surgery with lymph node dissection. To protect the ureter, we inserted IRIS prior to the laparoscopy. It took only 4 minutes. During operation, we were able to identify the position of the ureter very easily because the lighted stents were clearly visible. No complications associated with the ureter occurred during the operation and the patient was discharged seven days after the operation.

Conclusion: Infrared illumination system is thought to be very useful to identify ureter and prevent ureter injury in gynecologic laparoscopy.

　We experienced a case of thermal injury caused by the continuous irradiation of non-contact light of a laparoscope during ovarian cystectomy. A burn hole was noticed at the end of operation, and the burn injury was about 1 cm in diameter and located at the right iliac crest. The injury was diagnosed as a third-degree burn and required plastic surgery for treatment. The video review confirmed that the cause was a non-contact continuous light beam of a laparoscope; the light was placed on the patient's body at the injury site during the abdominal procedure to pull out specimens through a trocar hole.

　In relation to this case, we carried out simulations on the temperature due to contact and non-contact Xenon and LED light beams used in laparoscopes. According to the results, we recommend that the intensity level of the light source unit should be set within 60% to prevent contact thermal injury due to the laparoscope's end and that the ends of the light cable and laparoscope should be kept 15 and 10 mm away, respectively, from the operation drape to prevent non-contact thermal injury.

　Furthermore, it is contraindicated to keep the laparoscope on the patient.

  A uterine manipulator is used during laparoscopic surgery for optimal visualization of the operative field posterior to the uterus. However, the use of a uterine manipulator requires the services of an additional operator during the surgery, and insertion of this device may be difficult in women without exposure to sexual activity. We introduced a device to lift the uterus by piercing the base of uterus with a straight needle from above the pubis. We used our uterus lifting technique in 10 women. Notably, the operation time and estimated blood loss were similar to those observed with conventional surgery, and the postoperative course was unremarkable in all women. We conclude that our technique of lifting the uterus enables optimal visualization of the operative field during laparoscopic surgery.

Objective: To report our experience with the management of two cases of chronic tubal pregnancy by laparoscopic surgery.

Case 1: A 37-year-old woman presented to our hospital with a small amount of genital bleeding at 10 weeks and 3 days of gestation, calculated from the date of her last menstrual period. Serum human chorionic gonadotropin level was elevated to 108.5 mIU/mL and transvaginal sonography (TVS) revealed a 52-mm diameter of irregularly shaped left periovarian mass. Magnetic resonance imaging (MRI) also showed a periovarian cystic mass with suspicion of an old hemorrhage. We performed laparoscopic left salpingectomy after the diagnosis of chronic left tubal pregnancy.

Case 2: A 31-year-old woman was referred to our hospital with suspected left tubal abortion at 16 weeks and 1 day of gestation. Both TVS and MRI revealed a left periovarian mass with a diameter of 40 mm. After the mass was diagnosed as chronic left tubal pregnancy under laparoscopic vision, left fallopian tube was preserved by salpingotomy. She achieved twin pregnancy by ovulation induction with clomiphene 7 months after laparoscopic surgery.

Conclusion: Although preoperative diagnosis of chronic tubal pregnancy is difficult, laparoscopic approach would be feasible, especially when salpingotomy would be performed for future fertility preservation.

Introduction: Prophylactic laparoscopic cervical cerclage is commonly performed in Western countries in women with prior failed transvaginal cervical cerclage or iatrogenic cervical shortening. However, this approach has not been reported in Japan. We report a case of laparoscopic cervical cerclage (LCC) in a non-pregnant woman.

Case: A 37-year-old woman who underwent a previous cesarean section underwent laparoscopic repair of a cesarean section scar (laparoscopic removal of scar tissue and resuturing) in x-2 for infertility secondary to cesarean scar syndrome. Extensive scar tissue resection causes cervical shortening and might predispose to miscarriage and premature delivery. Our patient conceived naturally in x-1; however, she developed rupture of membranes at week 17 and underwent a miscarriage. She once again conceived naturally 5 months later. She developed cervical shortening at week 13, and underwent transvaginal cervical cerclage at week 16. Premature rupture of membranes led to miscarriage at week 20. Following informed consent, we performed LCC during the non-pregnant state in x. She conceived after ovulation induction in x+1 and was hospitalized for cervical shortening at week 25. At week 31, she underwent emergency cesarean section following a high rupture of membranes. Currently, the infant is 10 months old without any developmental issues.

Discussion: We report successful LCC during the non-pregnant state in a woman who delivered a preterm but otherwise healthy neonate. LCC during the non-pregnant state might be an effective strategy in women with failed transvaginal cervical cerclage during pregnancy.

Objective: Both abdominal pregnancy and heterotopic pregnancy are rare, and rupture in ectopic pregnancy can be fatal. We report successful laparoscopic surgery for an abdominal pregnancy in a case of spontaneous heterotopic pregnancy.

Case: The patient was a 29-year-old woman, G1P0. She had undergone intrauterine curettage for inevitable abortion at 6 weeks of pregnancy in another hospital. Pathological findings indicated villi in the uterine contents. She presented at our hospital with acute abdominal pain 3 weeks after the operation. Transvaginal ultrasound confirmed massive bleeding in both the pouch of Douglas and vesicouterine pouch. We suspected rupture of ectopic pregnancy, as the serous human chorionic gonadotropin (hCG) level was still high. We performed laparoscopic surgery that revealed abdominal pregnancy at fundus of uterus. Complete removal of the pregnancy site was performed through laparoscopic surgery, and the serous hCG level decreased after the operation. Pathological findings indicated villi in the pregnancy site below the uterus. The serous hCG level was in the normal range 56 days after the surgery.

Conclusion: Given that both abdominal pregnancy and heterotopic pregnancy can be fatal, careful examination is vital in the early stages of pregnancy. Although laparoscopic surgery for abdominal pregnancy is a treatment option, this should be changed to laparotomy when there is uncontrolled bleeding from the pregnancy site. Chemotherapy and embolization may also be an option for abdominal pregnancy when complete removal of the pregnancy site is difficult.

  The etiology of acute abdominal pain during pregnancy is multifactorial including pregnancy condition, obstetrical complications, gastrointestinal and/or genitourinary conditions, and several other causes. Delayed diagnosis and treatment can increase the risk of maternal and fetal morbidity and mortality; therefore, prompt evaluation is warranted.

Case: The patient presented with a right ovarian cyst at the 9^th week of gestation. She was admitted to our hospital with sudden onset of abdominal pain at the gestational age of 19 weeks. Physical examination showed right-sided abdominal tenderness. Ultrasonography revealed that the area of tenderness corresponded to the area over the right ovarian cyst. Therefore, we suspected ovarian tumor torsion or appendicitis. Two-port laparoscopic right ovarian cystectomy was performed; however, ovarian torsion was not identified, and appendicitis was suspected. Simultaneous laparoscopic appendectomy was performed using the same port positions. Diagnosis of appendicitis during pregnancy is challenging. In addition to ovarian torsion, appendicitis and other conditions should be suspected in pregnant women with right-sided abdominal pain with concomitant right-sided ovarian cysts. Laparoscopy is useful to diagnose acute abdomen, and diagnostic laparoscopy is warranted even in pregnant women, if clinically indicated.

  Congenital cervical atresia is an extremely rare condition that is often accompanied with vaginal agenesis and uterine malformations; therefore, its management remains controversial. Here, we present the case of a 17-year-old female with primary amenorrhea. After examination and investigation, she was diagnosed with isolated congenital cervical atresia. We conducted laparoscopic assisted reconstruction. After harvesting a portion of the peritoneum in the pelvis, we laparoscopically incised the anterior wall of the uterus to confirm uterine cavity definitely and transvaginally punctured the uterine cervix from external os to internal os using a needle. Next, we dilated the uterine cervix and lined the peritoneal graft by using a pigtail catheter at the reconstructed cervical canal for early epithelization and restenosis prevention. Thereafter, we inserted the levonorgestrel-releasing intrauterine system to prevent postoperative intrauterine adhesion and immediate menstruation. However, the patient needed to undergo surgery again to remove this system because of perforation in the uterine cavity.

  Consequently, the patient experienced spontaneous regular menstruation for 30 months. Although a longer follow-up is needed to monitor for restenosis, this case shows that laparoscopically assisted surgery and autologous peritoneum are safe and effective for treating congenital cervical atresia.

Introduction: Radical trachelectomy is preferred to radical hysterectomy in cases where the patient wants to preserve fertility. This is the first case report of fallopian tube prolapse after abdominal radical trachelectomy.

Case presentation: A 34-year-old woman underwent cervical conization for carcinoma in situ, in which minimally invasive carcinoma was suspected. The pathological findings revealed a squamous cell carcinoma (stageIB1). Abdominal radical trachelectomy was performed to preserve her fertility. Six months after the trachelectomy, speculum examination revealed a papillary tumor with a diameter of 1.5 cm at the vaginal vault. Tumor biopsy showed no evidence of malignancy. Lower abdominal pain was caused by pulling tumor with forceps. MRI revealed a tumor with a diameter of 2.5 cm on the left side of the cervix. We could not deny the possibility of cancer recurrence. Given these findings, she was suspected to have a fallopian tube prolapse into the vaginal vault or a relapse of the carcinoma. Diagnostic laparoscopy revealed that the vaginal tumor was causing prolapse of the left fallopian tube, Left salpingectomy was performed. Although the left fallopian tube and ovary were covered with a tissue film, the left fallopian tube was completely resected laparoscopically. The pathological findings of the resected tube showed no evidence of malignancy.

Conclusion: An appropriate operative management, such as keeping distance between the oviduct and anastomotic site, is necessary to prevent the prolapse of fallopian tubes into the vagina.

　Omental pregnancy is a subtype of abdominal pregnancy, which accounts for <1% of all ectopic pregnancies. Definitive diagnosis is challenging due to its rarity and difficulty in localizing its implantation site. Here, we describe the case of a 20-year-old nulliparous woman with omental pregnancy, referred to our hospital due to acute abdominal pain and high serum human chorionic gonadotropin levels. The gestational sac was not detected on a pelvic ultrasound examination. Abdominal contrast enhanced computerized tomography (CT) revealed an intra-abdominal hemorrhage and a 3-cm mass in the omentum. Diagnostic laparoscopy confirmed the omentum as the implantation site, following which complete resection of the lesion was performed. Histopathological analysis confirmed the diagnosis of omental pregnancy. Her postoperative course was uneventful. Our findings suggest that CT and laparoscopy are useful when the implantation site could not be visualized via ultrasonography in ectopic pregnancy. In addition, we discuss the association between emergency contraception and ectopic pregnancies.

　A 33-year-old gravida 0 para 0 woman presented to our hospital with lower abdominal pain continuing for an hour. A hard tumor with tenderness on the right side of the uterus was found in pelvic examination. Transvaginal ultrasound revealed an ovarian tumor. It was 8 cm in diameter, solid, smooth-marginated and isodense. There was neither blood flow in color Doppler, nor ascites around the tumor. Tumor markers were not elevated. We suspected benign ovarian tumor such as fibroma. The patient hoped to preserve her ovaries. We performed laparoscopic ovarian tumorectomy and used MorSafe™ for morcellation and extraction of the tumor. We completed tumorectomy with no damage of MorSafe™. The ovarian tumor was 172 g, and the pathological diagnosis was fibroma with no malignancy. Laparoscopic ovarian tumorectomy is widely performed in cases of benign ovarian tumor, especially in young women. Gynecologists have an issue with extracting resected tumor, but there is no established method. Morcellation is an option to extract the resected tumor without further invasion, but there is a concern that power morcellation in abdominal cavity can spread the tumor. MorSafe™ is a new device that prevents the tumor from scattering. Some cases of morcellation in uterine leiomyoma with this device have been reported but there is no report of morcellation with MorSafe™ for an ovarian tumor. With this device, we performed a safe morcellation in a case of ovarian fibroma. Morcellation with MorSafe™ was a useful method to extract solid ovarian tumor.

Introduction: Postoperative abdominal X-ray is helpful for examining for remains in the abdominal cavity. We mistook radiopaque material for a surgical instrument in a comparison of pre- and postoperative X-rays.

Case 1: A 48-year-old woman with uterine myoma underwent total laparoscopic hysterectomy (TLH). The postoperative abdominal X-ray revealed a high-intensity shadow in the pelvis, whereas the X-ray taken 15 days preoperatively did not. We were concerned that a surgical instrument was left during surgery. The patient's family said that she had undergone an upper gastrointestinal examination 6 days preoperatively. We thus determined that barium had remained in the appendix.

Case 2: A 46-year-old woman with uterine adenomyosis underwent TLH. A postoperative abdominal X-ray revealed a clip-like shadow in the pelvis, but we had not used any clips during surgery. Because no shadow was visible in the abdominal X-ray taken 1 day preoperatively, we were concerned that a surgical tool remained within the abdominal cavity. When we reexamined her pelvis, a surgical assistant found the shadow of a clip in another X-ray taken before surgery. The shadow of the clip was located behind the iliac bone on the first X-ray image. The patient had undergone a laparoscopic appendectomy at 25 years of age, and we concluded that the clip within her abdomen was used during that surgery.

Conclusion: We reaffirmed the importance of taking a detailed preoperative history of examinations, surgeries, and surgical procedures.

　Pregnancy in the rudimentary uterine horn is an extremely rare condition (incidence: from 1:76,000 to 1:150,000). We report a case of rudimentary horn pregnancy that was treated with laparoscopic surgery. A 21-year-old primigravida female visited a clinic complaining of abnormal genital bleeding, and a left tubal pregnancy was suspected. Therefore she was referred to our hospital. Transvaginal ultrasonography showed an empty uterine cavity and a gestational sac, which exhibited a live fetal shadow, in a left adnexal lesion. Her serum human chorionic gonadotropin level was 21,557 mIU/ml. We suspected a left tubal pregnancy and performed emergency laparoscopic surgery. During a pelvic evaluation, we found that the rudimentary horn was connected to the right unicornuate uterus and left fallopian tube, which was dark red in color and thumb tip-sized. We diagnosed the patient with a rudimentary horn pregnancy. We removed the left rudimentary horn and left fallopian tube. A histopathological examination showed villi and fetal components in the rudimentary horn, which were surrounded by smooth muscle. The patient's postoperative course was uneventful, and she was discharged on the 3rd postoperative day.

　Since rudimentary horn pregnancies can cause uterine rupture and induce massive bleeding, which can lead to maternal death, we need to treat this rare condition carefully.

Objective: The aim of this study was to evaluate the usefulness of hysteroscopic endometrial ablation for adenomyosis with hypermenorrhea.

Design: Retrospective analysis

Setting: Tokyo Metropolitan Health and Hospitals Corporation, Ohkubo Hospital, Japan

Method(s): From January 2011 to December 2017, 14 women with hypermenorrhea underwent hysteroscopic endometrial ablation for adenomyosis. Surgical outcomes and complications were evaluated. In our method, the endometrium and a part of the myometrium lining the uterus (approximately 5 mm in depth) were resected.

Result(s): All patients had decreased bleeding. Four patients had amenorrhea (28.6%) and 10 patients had menorrhea (71.4%). The recurrence of hypermenorrhea and major complications were not reported. Three patients with dysmenorrhea needed additional treatments but were relieved by hormonal therapy and were able to avoid hysterectomy.

Conclusion(s): Hysteroscopic endometrial ablation for adenomyosis is an effective and safe procedure that can reduce the hysterectomy rate.

Introduction: The myoma pseudocapsule (MPC) is a metaplastic connective tissue formed by the displacement of the normal muscle layer by a uterine myoma; it plays an important role in wound healing throughout the body. However, few studies have specifically addressed the procedures for its preservation in laparoscopic myomectomy(LM). We have devised a procedure, termed as "MPC accurately conserved LM " (Mac-LM), for myoma enucleation and suturing that conserves the MPC.

Patients and Methods: Muscle layer recovery in patients who underwent Mac-LM was evaluated 3 months postoperatively via contrast-enhanced magnetic resonance imaging (MRI).We compared blood loss and suturing time between eight patients with interstitial myoma who underwent Mac-LM and eight patients who underwent conventional LM. Mac-LM was performed in the following manner: (1) A dilute vasopressin solution with indigo carmine was injected into the MPC layer. (2) Enucleation was performed to conserve the stained MPC. (3) After confirming the absence of bleeding from the MPC, a single-layer suture was inserted in the muscle layer alone without lifting the bottom.

Results: MRI of the Mac-LM patients, performed 3 months postoperatively, did not reveal any contrast defects or thinning of the muscle layer. Blood loss was 101 mL and 250 mL, and the suturing time was 13 min and 28 min for the Mac-LM and conventional LM groups, respectively.

Discussion: Staining to visualize the MPC reduced injury during enucleation, while decreasing blood loss. There were no problems with muscle recovery

Conclusions: Mac-LM may be a useful therapeutic procedure for interstitial myoma.

　In Japan, laparoscopic sacral colpopexy (LSC) is performed often, and its efficacy has become well known over the past several years. But sometimes, technical difficulty arises with this procedure, especially in obese patients. In Europe, laparoscopic pectopexy has been developing, as a new technique for apical prolapse.

　A 69-year old woman, gravid 4 para 2, came to our hospital with uterine prolapse. She had a pelvic organ prolapse quantification (POP-Q) of stage IV. Her body mass index (BMI) was 28.8 kg/m² and she had a history of two previous intra-pelvic surgeries. As securing the anchor point at the sacral promontory was a great concern, we decided to perform laparoscopic pectopexy.

　After laparoscopic supracervical hysterectomy, successful fixation of mesh to the ilio-pectineal ligaments on either side of the pelvis was achieved. The cervical stump was then elevated without any complication. This is the first report in Japan, of laparoscopic pectopexy, for treating pelvic organ prolapse.