Background: Uterine leiomyosarcoma (uLMS) is an aggressive soft tissue sarcoma that accounts for about 1−2% of uterine malignant tumors. It is associated with poor prognosis, and the 5-year overall survival rate is about 60−70%, even in patients at FIGO stage I of the disease. We aimed to evaluate the clinical features and outcomes of patients diagnosed with uLMS after they underwent total laparoscopic hysterectomy (TLH) for presumed benign fibroids.

Methods: We retrospectively reviewed our records of presumed benign fibroid surgeries between the years 2001 and 2017.

Results: From a total of 11,242 patients treated for benign conditions, 8 patients (0.07 %) were diagnosed with uLMS after they underwent TLH. The mean±SD age was 54±7.4 years, the median tumor size was 89 mm (28−146 mm), and four patients were premenopausal. Seven patients were diagnosed with FIGO stage I disease (IA:1 IB:6) and 1 patient with stage 3A disease. We performed the conventional vaginal hand morcellation for extraction during TLH, except in 3 of the 8 cases where we used in-bag morcellation. Power morcellation was not used in any of the cases. As adjuvant therapy, 2 patients underwent oophorectomy, while 5 patients received docetaxel/gemcitabine (DG) therapy. Three cases of recurrence were observed over a median observation period of 34 months. The site of recurrence was localized, except for one lung multiple metastases case, and there was no peritoneal dissemination or vaginal cuff recurrence of uLMS.

Conclusion: Our data suggest that TLH with vaginal hand morcellation does not increase the risk of recurrence of unsuspected uterine sarcoma. However, measures should be taken to minimize the dissemination of occult malignancy. We suggest that in-bag hand morcellation may be a reliable method for safe tissue extraction.

Objective: To assess the feasibility and validity of sentinel node (SN) biopsy to determine whether pelvic lymph node dissection (PLND) in patients with early stage cervical cancer should be performed.

Materials and methods: Between January 2011 and May 2019, 28 cervical cancer patients with stage IA2 or IB1 were enrolled in this study. For identification of SN, technetium phytate, indocyanine green and/or 1% patent blue were administrated. If tumor tissue could not be pathologically identified in the excised SN, PLND was omitted. We call this called SN navigated surgery (SNNS). To validate the non-inferiority of SNNS in cases of recurrence in patients receiving SNNS compared with standard PLND, a C-language based computer program that estimates the required number of SNNS was developed.

Results: Total detection rate and bilateral detection rate of SN was 100% and 84.7%, respectively. At present, the median follow-up period is 36 months, and only one patient presented with lung metastasis as recurrence. To demonstrate non-inferiority, the computer simulated model showed that the required number of SNNS to be performed was 64 with a 5% error rate of cases with no recurrence in residual lymph nodes.

Conclusion: Data obtained in the present study by SN biopsy and SNNS were feasible and without complications. Our computer simulations demonstrated that at least 64 trials of no recurrence in patients of SNNS would be required to show non-inferiority.

Objective: The objective of this study was to verify the feasibility of laparoscopic hysterectomy in patients with stage IA1 cervical cancer.

Methods: The current study was based on the available data for 103 patients with stage IA1 cervical cancer who were admitted at the Hokkaido Cancer Center between January 2000 and December 2016. The distinct parameters for each patient, including the operation time, estimated blood loss, blood transfusion, recurrence, and survival were compared between the conization group (n=36) and the hysterectomy group (n=67). Within the hysterectomy group, the treatment outcomes were compared between the non-laparoscopic hysterectomy group (n=31) and the laparoscopic hysterectomy group (n=36).

Results: In the present study, there was only one patient with cancer recurrence who underwent cervical conization. The rate of cancer recurrence in the conization group was substantially higher than in the hysterectomy group (2.8% vs. 0%, P=0.18). The estimated blood loss in the laparoscopic hysterectomy group was significantly less in comparison with the non-laparoscopic group (213g vs. 46.5g, P=0.0017). The rate of patients who received blood transfusion in the laparoscopic hysterectomy group was higher than that in the non-laparoscopic group (9.7% vs. 0%, P=0.056).

Conclusion: Thus, it can be concurred that laparoscopic hysterectomy is a safe surgical procedure in patients with stage IA1 cervical cancer when performed by experienced surgeons at the tertiary centers.

Objective: Although there are many reports from foreign countries that laparoscopic surgery for endometrial cancer has a similar prognosis to open surgery, there are few reports from Japanese institutions. The aim of this study is to assess the oncologic outcome of laparoscopic surgery for endometrial cancer in a Japanese hospital.

Materials and Methods: Patients who had undergone laparoscopic surgery for endometrial cancer between August 2012 and February 2016 in our hospital were retrospectively investigated with medical records. The patients whose post-operative follow-up period was less than 3 years were excluded. The over-all and disease-free survival rate of the patients were calculated, and the recurrent pattern of recurred patients were analyzed.

Results: Seventy-four cases were included in this study. Their median age was 55 years-old, and median follow-up period was 49 months. Lymphadenectomy was performed in 26 cases (35.1%), and adjuvant chemotherapy was given for 17 cases (23.0%). In the follow-up period, seven cases had recurrence. Lung was the most common site as the first recurrence of the patients. Estimated 5 years over-all and diseases-free survival of the 74 patients were 97.2% and 90.5%, respectively. Our survival rates were not inferior to those of previous reports.

Conclusion: The laparoscopic surgery for endometrial cancer has been performed with good prognosis in our hospital same as that in other institutions. It should be more widely spread for endometrial cancer patients also in Japan.

Objectives: Laparoscopic hysterectomy is currently performed in a large number of patients. We investigated the recurrence, disease-free survival (DFS), and overall survival rates of laparoscopic vs. abdominal hysterectomy for the treatment of early-stage endometrial cancer.

Methods: The study included 240 patients with stage IA endometrial cancer (endometrial adenocarcinoma, adenosquamous carcinoma, mucinous adenocarcinoma G1/G2) who underwent surgical treatment between 2007 and 2017. Laparoscopy was performed in 97 (laparoscopy group [L group]) and laparotomy in 143 patients (laparotomy group [O group]). We performed an intergroup comparison of recurrence, DFS, and overall survival rates.

Results: No intergroup differences were observed in recurrence (5.2% [L group] vs. 7.3% [O group]), DFS (90.3% [L group] vs. 94.1% [O group]), and overall survival rates (98.8% [L group] vs. 97.3% [O group]).

Conclusions: Long-term prognosis of laparoscopic surgery was not inferior to that of laparotomy for early-stage endometrial cancer.

  Ovarian pregnancy is a rare occurrence and accounts for 0.3% to 3.0% of all ectopic pregnancies. We report three cases of ovarian pregnancy diagnosed in our department. Three women treated for ovarian pregnancy from 2008 to 2018 were retrospectively identified and compared to 57 women who underwent tubal pregnancies during the same period. All cases were of spontaneous pregnancy and presented lower abdominal pain of varying intensity. Vaginal bleeding was observed in only one case among the three ovarian pregnancy cases but was detected in 70% of the tubal pregnancy cases. Transvaginal sonogram demonstrated hemoperitoneum in all three cases. These women underwent laparoscopic surgery and ruptured ovarian pregnancy was identified in all cases. There was no lesion of endometriosis or adhesion. The median estimated blood loss was significantly higher in women undergoing ovarian pregnancy than in those undergoing tubal pregnancy (330 mL vs. 80 mL, p=0.03). All three cases of ovarian pregnancy were diagnosed intraoperatively and the diagnosis was confirmed based on postoperative pathological findings. Wedge resection or enucleation was performed to remove ovarian pregnancy with laparoscopic surgery. Two of the three cases used bipolar devices and were closed with absorbable sutures to ensure hemostasis of the ovary. Laparoscopic surgery for ectopic pregnancy may be a basic procedure, but it sometimes requires suturing in a body cavity; the preoperative diagnosis of unusual ectopic pregnancy remains particularly difficult. We should keep in mind the possibility of unusual ectopic pregnancies in case of unclear implantation sites and perform early diagnostic laparoscopy to reduce the risk of complications such as rupturing, hemorrhagic shock, and maternal mortality.

Objective: The protocol for single-port laparoscopic cystectomy (LC) at our hospital includes the preliminary insertion of an isolation bag into the Douglas' fossa to minimize accidental intra-abdominal leakage and tumor cell dissemination secondary to intraoperative rupture of the tumor capsule. The on-bag cystectomy method was introduced in 2016 for cyst removal using an isolation bag. In this study, we retrospectively investigated the usefulness of this technique.

Methods: This study performed at the Saiseikai Senri Hospital between April 2017 and February 2019 included 18 patients who underwent single-port LC performed by a senior resident (with <1 year of experience in laparoscopic surgery). Statistical analysis was performed using the Mann-Whitney U test and the Fisher exact test to compare the operation time, washing time, and estimated blood loss between the conventional and the on-bag cystectomy methods (9 cases each).

Results: No statistically significant intergroup difference was observed in the operation time and the estimated blood loss; however, the cleaning time was significantly shorter in the on-bag cystectomy group. Subgroup analysis of cases revealed that compared with the conventional method, patients who underwent on-bag cystectomy showed a higher rate of left-sided tumors and tumors with a larger diameter and underwent a more technically challenging operation in several cases.

Conclusion: The on-bag cystectomy technique can be learned by beginners in laparoscopic surgery without significantly prolonging the operation time. This approach reduces the risk of tumor cell dissemination and chemical peritonitis by minimizing intra-abdominal leakage and spread of intracystic tumor contents.

Objective: We report robot-assisted laparoscopic simple total hysterectomy performed at our hospital for removal of benign tumors.

Design: We investigated the operation time, estimated blood loss, and console time in patients who underwent robot-assisted laparoscopic simple total hysterectomy.

Setting: This study was performed in patients who underwent robot-assisted laparoscopic simple total hysterectomy for removal of benign tumors between June 2018 and August 2019.

Patients: Benign tumors were diagnosed preoperatively in 50 patients.

Intervention: Benign tumors were removed using the da Vinci Si Surgical System.

Main outcome: We observed no intraoperative complications, and no patient required conversion to laparotomy. One patient developed significant postoperative genital bleeding.

Result: We performed laparoscopic simple total hysterectomy without any intraoperative complications.

Conclusion: In our view, laparoscopic simple total hysterectomy is safe and feasible.

  The number of total laparoscopic hysterectomy (TLH) is increasing due to advancements in technique, devices, and expansion of the indication of TLH. We have been performing this surgery for the treatment of benign uterine diseases since August 2017. In this study, we reported how we introduced the surgery at our hospital and evaluated the transition. We divided the procedure into 8 processes and recorded the durations and independence levels of each.

  TLH was successfully introduced in our hospital, and nine of ten cases were successful. There were no severe complications; however, there were cases that required a longer duration than expected, especially in an event of severe adhesion. Case selection is crucial when attempting to introduce a new surgical procedure safely.

Background and Objective: The number of laparoscopic surgeries being performed in Japan is increasing every year; however, few studies have investigated scarring at surgical wound sites. Silicone gel sheet application is increasingly being used to treat hypertrophic scars and keloids as a component of multidisciplinary treatment. We report effectiveness and safety of Silicone gel sheets (Lady Care 3^®) for post-laparoscopic hypertrophic scars.

Subjects and Methods: This study included 30 patients who underwent laparoscopic surgery between March 2017 and March 2018. In 15 patients, we applied Silicone gel sheets to the surgical wounds (umbilicus and lower abdomen) postoperatively for a period between one week and 6 months, and the remaining 15 patients were categorized as the Control group. Surgical wound assessment was performed using the Japan Scar Workshop (JSW) Scar Scale. Patient interviews and visual assessment of the wound site were performed prior to sheet application and at 3 months (post-3M) and 6 months postoperatively.

Results: Compared with the pre-application score, the post-3M JSW Scar Scale score was significantly lower in the Silicone group, indicating more rapid wound healing in the Silicone group than in the Control group. Three patients in the Silicone group reported mild itching; however, continued use of sheets was possible in all patients.

Conclusion: Compared with the Control group, the Silicone group showed significantly rapid and earlier postoperative improvement in their JSW Scar Scale scores. Additionally, no patient reported adverse events, suggesting that Silicone gel sheets are both safe and effective in this patient population.

Objective: We investigated the clinical outcomes of laparoscopic supracervical hysterectomy (LSH).

Methods: This study included 142 patients who underwent LSH between January 2016 and December 2019. Patient characteristics, operation time, estimated blood loss, weight of resected specimens, as well as intraoperative and postoperative complications were evaluated.

Results: The operation time in the LSH group was shorter than that in the total laparoscopic hysterectomy (TLH) group (110.5 [67–308] min vs. 141.0 [100-230] min, median [minimum-maximum time]). Moreover, complications in the LSH group were less severe and included the following: intraoperative sigmoid colon serosal injury (one patient [0.70%]), postoperative peritonitis (one patient [0.70%]), postoperative port site infection (two patients [1.41%]), and cervical stump hematoma (one patient [0.70%]).

Conclusion: Compared with TLH, LSH was associated with a shorter operation time. Intraoperative and postoperative complication rates were comparable with those reported by the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy TLH/LH statistics. LSH is a feasible treatment option for benign uterine diseases.

  A 60-year-old woman was admitted to our hospital for lower abdominal pain, nausea, and vomiting. Computed tomography showed a 56-mm monolocular ovarian tumor with ascites. We determined this to be a case of ovarian tumor rupture and conducted emergent laparoscopic surgery. We observed a right ovarian tumor and yellowish-green ascites. We resected the tumor and collected intratumoral fluid, which was serous transparent. Its properties were differed from the ascites, which were present at the start of surgery. We suspected gastrointestinal perforation of the small intestine, with a foreign body. We partially resected the small intestine, which revealed an incarcerated sea tangle roll and small intestinal perforation. The patient's postoperative course was good and she was eventually discharged.

  Alimentary obstructions of the intestines are relatively rare and account for 0.3–1% of all intestinal obstructions. Intestinal obstructions due to sea tangle rolls account for 10–13% of alimentary bowel obstructions. This disease features acute stomach symptoms and can be difficult to diagnose. Because conservative treatment is often ineffective, and emergent surgery is often required, careful diagnosis is essential.

  Mesothelioma is a rare malignant tumor that occurs from the pleural and the peritoneal mesothelial cells. Well-differentiated papillary mesothelioma (WDPM) is a subtype of low-grade mesothelioma, the majority of which are asymptomatic and often discovered and diagnosed by chance during surgery. This time, we incidentally found spontaneous peritoneal uplift lesions and resected them using laparoscopic procedure when we performed a laparoscopic hysterectomy for the uterine fibroids. The pathological examination result was WDPM. We consider the significance of responding to incidental peritoneal lesions based on a rapid tissue examination during surgery and the technical key points of laparoscopic resection of peritoneal lesions.

  The efficacy of screening and risk-reducing salpigo-oophorectomy (RRSO) for women with BRCA1 or BRCA2 mutations has been widely reported. At our institution, women with these mutations consult with genetic counselors, and gynecologists then provide surveillance or RRSO. RRSO is performed laparoscopically for lower invasiveness and morbidity. We report a case of ovarian cancer detected by surveillance for hereditary breast and ovarian cancer. A 63-year-old woman who had undergone surgery 2 months previously for triple-negative breast cancer visited our department. Although an FDG-PET scan suggested an abnormality in her left ovary, general screening methods (such as transvaginal sonography or magnetic resonance imaging) did not detect it. She underwent a laparoscopic bilateral salpingo-oophorectomy. We found a small nodule on her left ovary, which was pathologically diagnosed as endometrioid carcinoma. Because staging laparotomy found no other lesion, this case was diagnosed as stage IA. This case indicates that conventional screening might miss early ovarian cancers. Diagnostic laparoscopy should be considered for women with BRCA mutations when any small ovarian abnormality is suggested.

  Myotonic dystrophy (MD) is an inherited autosomal dominant multi-systemic neuromuscular disease, and enhanced risk of neoplasms are reported. In perioperative management, respiratory and circulatory complications may occur, particularly under general anesthesia. We present a case of MD with a laparoscopic total hysterectomy (TLH) for endometrial atypical hyperplasia. We will discuss the differences in the perioperative course between the sisters, both of whom suffer from MD, after one sister's surgical treatment with a total abdominal hysterectomy (TAH) for endometrial cancer occurring at approximately the same time.

  Carcinoid is a neuroendocrine tumor that often originates in the gastrointestinal tract. The frequency of primary ovarian carcinoid is about 1.3%. There is a debate whether it should be considered a germline borderline malignant tumor and be treated according to ovarian cancer treatment guidelines or considered a neuroendocrine tumor (NET) and be treated according to gastrointestinal carcinoid guidelines. It most commonly occurs after menopause and coexists with mature cystic teratoma in about 60-76% of the cases. Here, we report a case of primary ovarian carcinoid with mature cystic teratoma found during pregnancy. A 25-year-old woman experienced pain in her lower right abdomen at 29 weeks of gestation and was referred to our hospital. She had no obstetrical abnormalities, and ultrasonography and magnetic resonance imaging revealed a 9 cm mature cystic teratoma in the Douglas fossa. There was no suspicion of malignancy, and the pain subsided naturally, so we decided to perform the surgery after vaginal delivery. She delivered the baby on the 40th week of pregnancy. Laparoscopic surgery was performed 6 months after the delivery. Since cystic teratomas were found on both ovaries, bilateral cystectomy was performed. The postoperative pathology indicated a small focal lesion (ovarian carcinoid tumor) in the right mature cystic teratoma. A right salpingo-oophorectomy was planned. Mature cystic teratomas could coexist with ovarian carcinoids even in young women, and it is necessary to investigate treatment methods after analysis of relevant gynecological cases.

Introduction: Prophylactic salpingectomy is increasingly being performed concurrently with hysterectomy to reduce the risk of future ovarian and fallopian tubal cancer. We report a case of left tubal cancer incidentally diagnosed during prophylactic salpingectomy at the time of total laparoscopic hysterectomy.

Case: A 50-year-old nullipara with menorrhagia was diagnosed with submucosal uterine myoma during a medical examination and presented to our hospital for further treatment. Uterine cytology showed negative results. Magnetic resonance imaging revealed a submucosal uterine myoma (3 cm), and the adnexa showed no abnormalities bilaterally.

  Total laparoscopic hysterectomy and bilateral salpingectomy were performed 7 months after her initial visit. Intraoperatively, no mass was identified in the bilateral adnexa. Postoperative histopathological examination revealed an endometrioid carcinoma (2 mm) in the left tubal fimbriae. Postoperative contrast-enhanced computed tomography revealed no lymphadenopathy or metastasis. Abdominal bilateral oophorectomy and partial omentectomy were performed 2.5 months after the initial operation.

  Lymphadenectomy was not performed owing to the diminutive size of the lesion without any clinical suspicion of lymphadenopathy or dissemination. Washing cytology specimens revealed negative results, and postoperative histopathological findings showed no residual tumor. The left tubal cancer was diagnosed as a stage IA lesion (the International Federation of Obstetrics and Gynecology 2014 classification); therefore, no postoperative therapy was required. She was recurrence-free 12 months after the second surgery.

Conclusion: Patients scheduled for hysterectomy to treat benign gynecological disease should be informed that concurrent bilateral salpingectomy may reduce the risk of future ovarian cancer.

Introduction: Long QT syndrome (LQTS) is divided into congenital and acquired LQTS. Acquired LQTS is induced by various factors and may lead to lethal arrhythmias. Some studies report that pneumoperitoneum can prolong the QT interval. A 49-year-old woman underwent total laparoscopic hysterosalpingectomy for myoma with no medical and family history.

  Her preoperative electrocardiography (ECG) was sinus rhythm and showed no abnormalities. When she entered the operating room, the QT interval on the ECG monitor was already prolonged; QTc 500 ms. After pneumoperitoneum, premature ventricular contractions (PVCs) were frequently observed, and QTc became 768 ms. Torsade de Pointes (TdP) occurred at 26, 27, and 71 minutes after beginning the operation, and each of them recovered spontaneously. Postoperative blood reports showed mild hypokalemia, K 3.2 mmol/l. Supplementary potassium was started, and monitoring using ECG was continued.

  After 3 hours, TdP recurred and developed into ventricular fibrillation. It persisted for about 2 minutes and recovered to normal sinus rhythm. At this point, K was 3.5 mmol/l and Mg was 2.0 mg/dl. Further, 20 mg of Mg was administered and a continuous lidocaine infusion was started. QTc on postoperative day (POD) 1 was 413 ms, and 24-hour Holter ECG showed only 2 PVCs and 9 supraventricular premature contractions. TdP did not recur, and she was discharged on POD 6.

Conclusion: In this case, hypokalemia resulted in acquired LQTS, pneumoperitoneum exacerbated it, and RonT premature contractions triggered TdP. More attention should be paid to prevent QTc interval prolongation and TdP during laparoscopic surgery, even when preoperative ECG findings are normal.

  We report a case of torsion of a subserosal leiomyoma necessitating distinction from ovarian hemorrhage.

  A 34-year-old woman presented to the emergency room of a hospital with acute abdominal pain for the past 3 months. Computerized tomography (CT) revealed an enlarged left ovary and ascites. She was diagnosed with ovarian hemorrhage, and was subsequently followed up. A magnetic resonance imaging (MRI) performed 2 months later, revealed a left hemorrhagic ovarian cyst leading to the suspicion of a persistent ovarian hemorrhage. Owing to an unrelieved chronic abdominal pain even after 3 months of onset, she was transferred to our hospital. Transvaginal ultrasonography showed normal ovaries bilaterally. A tumor of size 36 mm was detected to the left of the uterus, which accounted for tenderness. Surgery was recommended, for which the patient consented 4 months after the onset of symptoms. Laparoscopic surgery was performed; the tumor adhered to the left uterine adnexa and the uterus. However, no pedicle or vascular connection to the uterus was observed. Following adhesiolysis, the left ovary was confirmed to be normal and laparoscopic myomectomy was conducted. Histopathology revealed necrosis of the myoma. Based on the clinical course and intra-operative findings, torsion of the subserosal myoma was speculated and the myoma was detached from the uterus. In case of acute or chronic abdominal pain with myoma, laparoscopic surgery should be considered when imaging precludes accurate diagnosis.

  Ovarian fibromas, the most common benign solid ovarian tumors, often occur unilaterally in postmenopausal women treated with laparoscopic salpingo-oophorectomy. Here, we report a rare case of unusual bilateral ovarian fibroma torsion in a young woman. A 38-year-old nulliparous woman presenting with an acute abdomen had a history of laparoscopic right partial ovarian resection for bilateral ovarian fibroma and cystectomy for a left ovarian chocolate cyst at 24 years of age. Magnetic resonance imaging showed bilateral solid adnexal masses with microcysts similar to the tumor seen 14 years prior, with the largest measuring 10 cm. We diagnosed torsion of re-enlarged ovarian tumors and performed emergency laparoscopic bilateral salpingo-oophorectomy rather than conservative surgery because it was difficult to macroscopically identify normal ovaries. For a young woman with bilateral fibroma, partial tumor excision may be selected to preserve ovarian function and fertility. In such cases, careful follow-up with informed consent is critical because the tumor may re-grow and subsequently twist.

　Incisional hernia was reported to occur in 11–25% of patients who underwent abdominal surgery. Surgical repair of incisional hernia is performed in patients complaining of pain, daily life restrictions, and strangulation hernia, using two surgical repair methods: simple closure without and with mesh repair. Recently, the mesh repair method has been recommended because of its lower recurrence rate.

　Identifying the location of the inserted mesh has not been established, and no report has specified the exact location of the inserted mesh on the abdominal wall and performed another surgery without damaging the mesh. Here, we report the first case with identified precise location of the inserted intraperitoneal onlay mesh for incisional hernia using transabdominal ultrasonography and who underwent laparoscopic surgery without puncturing the mesh.

  Pelvic abscess formation is a known postoperative complication in women undergoing surgery including lymph node dissection for gynecological malignancies. We describe a woman in whom computed tomography (CT)-guided drainage was difficult owing to widespread pelvic abscess formation after laparoscopic surgery for uterine endometrial cancer. A 56-year-old woman presented with a 2-month history of irregular genital bleeding. She was diagnosed with early stage endometrial cancer and underwent laparoscopic hysterectomy with bilateral oophorectomy and pelvic lymph node dissection. She developed lower abdominal pain and fever (≥38°C) on postoperative day 13. Contrast-enhanced abdominal CT revealed abscess formation between the vaginal stump and the right external iliac artery lesion. She underwent transvaginal drainage and was administered antibiotics; however, she showed persistent inflammation, and CT revealed a new abscess in the upper abdominal cavity. Laparoscopic drainage was performed 22 days after the first surgery, and port placement was performed in conjunction with the previous operation wound. The patient developed widespread abscesses in the external and internal side of the right iliac artery, as well as the vaginal stump and opened to wash with 3000 mL of saline. Postoperative subsidence of inflammation was observed. Surgical drainage is indicated for postoperative pelvic abscesses. Laparoscopic drainage is a useful minimally invasive method in such cases.

  Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy. The incidence of CSP is increasing with the growing rate of cesarean sections. Although several treatment options have been advocated, there is still no consensus regarding the management of CSP. We hereby report a case of CSP with a living fetus which was successfully treated by operative hysteroscopy without additional methods. The patient was a 32-year-old woman who underwent abdominal myomectomy followed by an elective cesarean section due to previous-uterine surgery. She was first diagnosed with CSP at 6 weeks of gestation by ultrasonography and magnetic resonance imaging. A living fetus was confirmed in the gestational sac located over the cesarean scar. We then elected to perform hysteroscopic resection because this CSP seemed to be of the endogenic type and the increase in blood flow around the gestational sac was still limited. To remove the gestational sac at the implantation site, we used a stripping technique with a roller electrode. This technique enabled us to pursue precise stripping of the gestational sac, as well as easy hemostasis of the surrounding vessels, which made it possible to treat CSP at a single time. As the CSP tissue was obtained intact, pathological analysis revealed a fetus, chorionic villi, and decidua, which clearly confirmed CSP.

  Smooth muscle tumors of uncertain malignant potential (STUMP) are rare; however, reports in the available literature describe recurrence and metastasis associated with these neoplasms. We report a case of STUMP that occurred after laparoscopic myomectomy in a patient diagnosed with a leiomyoma preoperatively.

  A 44-year-old woman developed menorrhagia at 35 years of age and underwent magnetic resonance imaging (MRI), which revealed a tumor (55 mm in size) at the bottom of the uterus, and we suspected cellular myoma. MRI revealed enlargement of the lesion when she was 38 years old; therefore, we performed laparoscopic myomectomy. The tumor showed degeneration and was carefully removed after morcellation. The patient was diagnosed with benign leiomyoma based on histopathological findings; therefore, outpatient management was discontinued 3 months postoperatively. An enlarging tumor was detected under the wound when the patient was 40 years old, for which she underwent thorough evaluation. Computed tomography revealed masses in the subcutaneous tissue and on the liver surface, and positron emission tomography revealed tracer uptake in these masses and in a part of the uterus. We diagnosed the patient with a benign leiomyoma and performed simple hysterectomy, bilateral adnexal surgery, and subcutaneous and intraperitoneal tumor extirpation for diagnostic purposes because malignancy could not be excluded. We diagnosed STUMP based on histopathological findings of nuclear atypia and nuclear fission. The tumor was considered to have originated from the residual uterus and intraperitoneal dissemination. The residual masses disappeared postoperatively and did not recur.

  Careful preoperative evaluation, meticulous histopathological examination of the excised specimens, and postoperative follow-up are warranted in women with atypical leiomyomas that show low malignant potential preoperatively.

  Uterine cervix atresia and vaginal aplasia in a patient with functional endometrium is a rare mullerian anomaly; however, definitive surgical treatment for this condition remains unknown. A 20-year-old woman with a several-month history of recurrent lumbago was referred to our hospital with vaginal closing. Magnetic resonance imaging revealed hematometra, and we suspected cervical atresia and vaginal aplasia. We made an incision from the vaginal aspect to create a tunnel between the bladder and the rectum by blunt dissection. Exploratory laparoscopy revealed a normal-appearing uterine corpus. We approached the endometrial cavity through a series of transverse sections on the inferior aspect of the uterine body. The edges of the uterine cavity were anastomosed to the edges of the neovagina. At her 6-month follow-up, she reported that her menses were regular, and lumbago and severe dysmenorrhea had resolved.

  Appendiceal intussusception secondary to endometriosis is extremely rare. We report a case of left ovarian endometriosis with endometriosis-induced appendiceal intussusception in a 42-year-old woman presenting with rectal bleeding and left-sided abdominal pain. Colonoscopy revealed a cecal mass measuring 30 mm in diameter. Magnetic resonance imaging revealed extensive pelvic adhesions and a left-sided endometrioma measuring 20 mm in diameter. Laparoscopy revealed isolated appendiceal intussusception and deep infiltrating pelvic endometriosis. Laparoscopic ileocecal resection and left ovarian cystectomy were performed. Histopathological examination confirmed the diagnosis of ovarian endometriosis with endometriosis-induced appendiceal intussusception. Although rare, endometriosis-induced appendiceal intussusception should be considered in the differential diagnosis in women with endometriosis presenting with an appendiceal mass. Coordination between gynecologists and gastrointestinal surgeons is essential for an effective surgical approach to ensure optimal management.

  The patient was a 44-year-old woman (gravida 0, para 0). We performed a total laparoscopic hysterectomy for hypermenorrhea due to submucous leiomyoma. Pneumoperitoneum was created by using 10 mmHg CO₂. It was difficult to insert the trocar at the right lower abdominal point. End-tidal carbon dioxide (EtCO₂) increased gradually and was at 60 mmHg an hour after pneumoperitoneum was created. Upon investigation, a broad emphysema from the right lower jaw to the right femur was observed. This might be due to the inappropriate trocar insertion. We increased the frequency of ventilation throughout the procedure. The procedure lasted for two hours and two minutes. The emphysema improved from the right chest to the right lower abdomen at the third postoperative day and diminished at the fourth postoperative day. She was discharged at the seventh postoperative day. There are a few reports of severe ventilatory disorders because of subcutaneous emphysema due to laparoscopic surgery. Although subcutaneous emphysema often disappears spontaneously, transition to open surgery and intubation after surgery were needed in some cases. Although there is no obvious management of subcutaneous emphysema, transition to open surgery should be considered in case where EtCO₂ is increased even if we increased the frequency of ventilation.

  Laparoscopic sacrocolpopexy (LSC) is useful for pelvic organ prolapse as a laparoscopic mesh surgery, with a low incidence of recurrence of pelvic organ prolapse. Our hospital introduced LSC for patients with pelvic organ prolapse in 2018.

  Since then, we have encountered 2 cases of bladder injury in patients with a past history of total hysterectomy. The bladder injury occurred when the anterior vaginal wall was separated from the bladder in each case. Fortunately, the bladder injury could be repaired laparoscopically with no after-effects.

  Some reports have suggested that bladder injury may occur as a complication of LSC, but to date, there have been no Japanese reports of patients with a past history of total hysterectomy. Since medical facilities that have recently introduced LSC, such as our hospital, may have a high likelihood to treat similar patients, we report these two cases with a discussion based on the literature.

  We report a case of rectal injury due to accidental insertion of a vaginal delineator into the rectum during total laparoscopic hysterectomy.

  A 48-year-old nulligravid woman underwent laparoscopic hysterectomy because of excessive menstruation due to uterine fibroids. The uterine manipulator was removed before cutting the vaginal wall, and a vaginal delineator was inserted. Although there was some resistance to insertion, it was thought that the delineator was guided to the correct position under the laparoscope. We noticed accidental rectal insertion, and laparotomy was performed to repair the damaged rectum.

  The muscles of the anus relax under anesthesia, and even a vaginal delineator, which is difficult to insert without anesthesia, can be guided into the rectum easier than into the narrow vagina. Furthermore, it is difficult for the surgeon to detect incorrect insertion in laparoscopic view.

Case report: We report about a patient who underwent robot-assisted laparoscopic hysterectomy (RALH) after laser iridotomy (LI) for corner angle closure.

Case: The patient was a 50-year-old woman who was gravida 2, para 1 and experienced menopause at 47 years of age. She was diagnosed with atypical endometrial hyperplasia with total curettage of the endometrium. An ophthalmologist suspected bilateral corner angle closure so that LI is needed before robot-assisted surgery in order to prevent postoperative visual loss. RALH and bilateral salpingo-oophorectomy (BSO) were performed two weeks after bilateral laser peripheral iridotomy. The patient had no complications during and after surgery. Hence, LI before RALH may be an option to prevent postoperative visual loss in patients with corner angle closure.

  Robot-assisted hysterectomy for early endometrial cancer and benign gynecologic diseases has been covered by the public health insurance system in Japan since April 2018, and the number of cases has steadily increased. However, few reports exist of robot-assisted hysterectomy in severely obese Japanese women [body mass index (BMI) >50]. Herein, we report a case of robot-assisted hysterectomy followed by left adnexectomy for atypical endometrial hyperplasia and left ovarian teratoma in a Japanese woman with a BMI of 50.8. A 43-year-old nulliparous woman with a height of 161.2 cm and body weight of 132 kg was referred to our facility for the treatment of abnormal uterine bleeding. Endometrial biopsy revealed atypical endometrial hyperplasia, and magnetic resonance imaging revealed endometrial thickness of 23 mm and a left ovarian teratoma of 7 cm. Since the patient was unlikely to undergo a successful future pregnancy, we performed a robot-assisted hysterectomy, left adnexectomy, and right salpingectomy using the da Vinci Xi surgical system. We set four ports at the height of the umbilics, all of which were made along skin striae, and added an assistant port at a point 8 cm above and 8 cm lateral to the umbilics. The excised uterus and left ovary were vaginally removed without morcellation. No complications have occurred, and the four wounds were hidden by abdominal fat; therefore, the patient was satisfied with the surgical outcome. In conclusion, robot-assisted hysterectomy is well tolerated in severely obese Japanese women, and the inconspicuous wounds are cosmetically acceptable.

Objective: To assess the effects of the laparoscopically assisted myomectomy (LAM) procedure that we added to a previously reported technique for diffuse uterine leiomyomatosis.

Methods: In the previous technique, a longitudinal dissection was made at the midline of the uterus, and then the uterine wall was divided into two from the dissection site to effectively enucleate the myomas near the endometrium. We performed this technique after clipping the uterine artery temporarily under laparoscopy to reduce blood loss. Moreover, we did not use an energy device for enucleation near the endometrium to prevent heat damage.

Results: We performed this operation in two patients, with blood losses of 693 and 180 g and operation times of 334 and 327 minutes, respectively. Their intraoperative and postoperative courses were uneventful. One patient gave birth to a healthy baby. The other patient showed an improvement for hypermenorrhea.

Conclusion: The procedure we added to the previous technique was safe and effective. Further studies involving more patients are needed to examine pregnancy or menstrual outcomes.

Objective: Laparoscopic myomectomy is the operative method for fertility preservation. Precise sutures are important to ensure the safety of postoperative pregnancy and delivery. To acquire suturing and ligation techniques, a dry box is often used. However, it is different from real surgery. We report the results of using a three-dimensional (3D) model made from materials such as real objects for training.

Methods: Bio-Texture Modeling^® technology by FASOTEC Corporation is already applied to other fields. We collaborated with FASOTEC and produced a 3D model uterus that is constituted of a myoma and the myometrium.

Results: We used a 3D model to dissect the myoma and the myometrium and sutured them. Subsequently, we could evaluate our suturing techniques by making sure whether there is dead space. Furthermore, we could reuse this model by cutting the sutures multiple times. Additionally, since this model reproduces the real texture of hardness and viscosity by Bio-Texture Modeling^®, it is worthwhile to simulate in-bag morcellation.

Conclusions: Laboratory animal training is used as a method of laparoscopic surgery simulation. Although it is good for training in dissection, vessel ligation, hemostasis, and internal genitalia, the model is not similar to humans. Furthermore, there are many problems, such as animal protection and high costs. Considering these disadvantages, it is useful to train with a 3D model in a dry lab for laparoscopic myomectomy.