Objective: Though the efficacy of laparoscopic surgery including paraaortic lymph node dissection (PAN) for early-stage endometrial cancer patients was demonstrated in the LAP-2 study, the procedure has yet to be widely adopted in Japan. The purpose of this study was to confirm the validity of laparoscopic surgery for intermediate- and high-risk endometrial cancer patients in our hospital.

Methods: The clinical data of preclinical stage I and II endometrial cancer patients who underwent either laparoscopic surgery or laparotomy in our hospital between January 2013 and December 2018 were analyzed. There were 24 cases of laparoscopic surgery including PAN and 36 cases of laparotomy including PAN. Postoperative outcomes, disease-free survival, and sites of recurrence were retrospectively reviewed in this study.

Results: In the laparoscopic group, the hospitalization period was shorter (laparoscopy: 10 days vs. laparotomy: 15 days, p = 0.002), and the volume of intraoperative bleeding was smaller (laparoscopy: 158 ml vs. laparotomy: 901 ml, p < 0.001). On the other hand, there was no difference in the operation time (laparoscopy: 458 min vs. laparotomy: 433 min, p = 0.31) or in the number of lymph nodes harvested (laparoscopy: 58 vs. laparotomy: 66, p = 0.22).

  There were three major complication events (12.5%) in the laparoscopic group including one case of venous injury and two cases of compartment syndrome, whereas there were four major complication events (11.2%) in the laparotomy group, which included one case each of urinary tract injury and abdominal incisional hernia and two cases of ileus.

  There was no difference between the two groups in the interval of disease-free survival (p = 0.19). There were eight recurrences, three (12.5%) in the laparoscopic group and five (14.0%) in the laparotomy group. In the laparoscopic group, recurrence occurred in one patient in the lung, one in the vaginal stump, and one in the vaginal introitus. In the laparotomy group, recurrence occurred in two patients in the lung, two in the vaginal stump, and one each in the pelvic wall, vaginal wall, and lymph nodes. There was no difference between the two groups in terms of recurrence sites.

Conclusions: Compared to open surgery, laparoscopic surgery including PAN for early-stage endometrial cancer had no greater adverse effect and minimal invasiveness could be achieved in our hospital. Laparoscopic surgery is a useful alternative to laparotomy for early-stage endometrial cancer.

Objective: Perioperative outcomes in the first year of introducing robot-assisted hysterectomy (RAH) using the daVinci Xi surgical system were evaluated based on comparisons with conventional laparoscopic hysterectomy (CLH) for simple hysterectomies performed during the same period.

Methods: This was a retrospective study involving comparisons between 38 cases of RAH from June 2019 to April 2020 and 28 cases of CLH from August 2018 to April 2020. All cases involved simple hysterectomies performed by 4 doctors (1 endoscopic technique-certified medical doctor and 3 doctors with less than 10 years of experience).

Results: The characteristics of patients who underwent RAH and CLH were as follows, respectively: age, 47 vs 49 years (mean, p=0.62); body mass index, 23.4vs 22.9 kg/m² (mean, p=0.57); uterine weight, 152 and 175 g (median, p=0.39); manipulator use, 28 (73%) and 21 (75%) cases (frequency, p=0.90); and 0/4 cases with endometriotic adhesions with Douglas fossa closure, 0 and 4 cases (frequency, p=0.028). The total operation time (from skin incision to skin closure) was significantly shorter in RAH cases (mean difference, 29 minutes; p=0.048) than in CLH cases. There was no significant difference between the two groups in terms of blood loss and perioperative complications.

Conclusion: We safely introduced RAH by selecting appropriate cases in advance. In the future, it is necessary to study robot-assisted surgery so that it can be safely introduced in patients with large uterine weights and endometriotic adhesions.

Objective: To investigate the risk factors for postoperative nausea and vomiting (PONV) in patients receiving fentanyl-based intravenous patient-controlled analgesia (IV-PCA) after gynecologic laparoscopy.

Methods: We retrospectively analyzed the data of 88 patients who underwent laparoscopic surgery and received postoperative fentanyl-based IV-PCA. Patient background characteristics and clinical variables were analyzed using univariate and multivariate analyses.

Results: In the univariate analysis, patient weight (<50 kg and> 50 kg) was found to be the dominant factor, and in the multivariate analysis, the amount of fentanyl used during surgery (<0.3 mg and> 0.3 mg) was the dominant factor.

Conclusions: This study showed that patient's body weight (>50 kg) and the amount of fentanyl used during surgery (0.3 mg or more) may be risk factors for the development of PONV in patients receiving fentanyl-based IV-PCA after gynecological laparoscopy.

  Port-site hernia (PSH) rarely complicates laparoscopic gynecological surgery. We perform approximately 200 laparoscopic surgeries annually at our facility; we report three cases of PSH that occurred after laparoscopic gynecological surgery over the past 4 years. PSH occurred in two patients after laparoscopic surgery for endometrial cancer and in one patient after total laparoscopic hysterectomy. These three cases represent 0.54% of all 558 laparoscopic surgeries performed at our facility between January 2016 and March 2019.

  We investigated patients' background, including age, body mass index, history of delivery, as well as surgical details, including operation time, estimated volume of blood loss, diameter of port site, and methods of wound closure. Two of the three patients were aged ≥65 years, and multiparity was the only factor common across all cases. The diameter of the port site at which PSH occurred was 12 mm in all patients, and fascial defects were closed using absorbable sutures. All patients developed small intestinal herniation. Hernia repair was performed via open surgery or the pushback method, or the hernia resolved spontaneously. PSH did not recur in any patient. Clinicians should consider the possibility of PSH after laparoscopic surgery.

　We investigated the role of an aggressive approach using dilation and curettage (D&C) prior to laparoscopic surgery to avoid unnecessary surgery in patients in whom ectopic pregnancy is indistinguishable from intrauterine miscarriage.

The study included 84 patients diagnosed with suspected ectopic pregnancy over 2 years from April 2017. D&C was performed prior to laparoscopic surgery in 21 of the 84 patients.

　The rate of change of serum human chorionic gonadotropin levels on the day following D&C was significantly higher in the ectopic pregnancy group than in the miscarriage group (10.9±18.4 vs. -53.1±12.5%, P<0.001).

　Aggressive D&C could be considered a useful approach to distinguish between ectopic pregnancy and miscarriage to avoid unnecessary laparoscopic surgery in these patients.

Study objectives: To compare the intermediate term follow-up outcomes of laparoscopic uterosacral ligament suspension (L-USLS) and laparoscopic sacral colpopexy (LSC) in patients with pelvic organ prolapse.

Methods: We retrospectively analyzed the data of 16 and 36 women who underwent L-USLS and LSC, respectively, between April 2017 and December 2019 and compared their age, body mass index, surgical time, blood loss, recurrent prolapse, and postoperative complication. Subjective recurrent prolapse was defined by the patient's bulge symptoms, and objective recurrent prolapse was defined as POP-Q (Pelvic Organ Prolapse Quantification) ≥2 in the dorsal lithotomy position with abdominal pressure.

Results: There was no difference in the surgical time (147.4±30.9 vs 150.9±31.4 min, P=0.82) and blood loss (28.1±53.3 vs 27.5±43.5mL, P=0.68) between the groups, and neither group developed postoperative complication, including mesh erosion and infection. During the median follow-up period of 22(3-33) and 13(6-28) months the L-USLS and LSC groups, respectively, subjective and objective recurrence rates were significantly higher in the L-USLS group than in the LSC group (56% vs 8%, P=0.016 and 56% vs 38%, P<0.001, respectively). Furthermore, the retreatment rate including reoperation and pessary was significantly higher in the L-USLS group than in the LSC group (19% vs 0%, P=0.039). Although cystocele was the most common recurrence, apical prolapse was also observed in 19% patients in the L-USLS group.

Conclusion: Although L-USLS was relatively easy and safe to perform, the L-USLS group had a high recurrence rate and similar complication rate and surgical time compare to the LSC group.

Objective: To evaluate the clinical effectiveness of falloposcopic tuboplasty assisted by hysteroscopy and X-ray fluoroscopy for tubal infertility.

Design: Retrospective cohort study

Setting: Infertility clinic

Patients: 110 patients with proximal tubal occlusion who were diagnosed by hysterosalphingography, either bilateral or unilateral, from March 2014 to October 2018.

Intervention: The patients were received falloposcopic tuboplasty without laparoscopic surgery. This surgery was assisted by hysteroscopy to set the FT catheter to the uterine cornu accurately and the tubal patency was evaluated by X-ray fluoroscopy during the procedures.

Main outcome: The medical records were reviewed retrospectively for the rate of success and complications. There were 35 cases of bilateral tubal obstruction and 75 cases of unilateral tubal obstruction. Of the 35 bilateral occlusion cases there were 33 cases (94.2%) with successful recanalization. 68 of 75 (90.7%) unilateral occlusion cases received successful recanalization. The rate of pregnancy after FT was 39.1% (43/110 cases), and the cumulative pregnancy rate was 83.3% at six months after FT. The only complication was tubal perforation in 17 cases (15.5%).

Conclusion: Falloposcopic tuboplasty assisted by hysteroscopy and X-ray fluoroscopy is an effective tool for tubal infertility patients.

Objectives: Natural orifice transluminal endoscopic surgery (NOTES) is an endoscopic technique that involves the passage of an endoscope through a natural orifice (the mouth, vagina, and anus, among others). Although NOTES is used for gastroenterological operations and gynecologists are familiar with this approach, transvaginal NOTES (vNOTES) is not described for gynecological procedures. We report our early experience in nine patients who underwent vNOTES using the GelPOINT^® V-Path device.

Methods: We investigated nine patients who underwent vNOTES for pelvic organ prolapse and/or ovarian cysts between January and April 2020. Patients were placed in the lithotomy position under general anesthesia for the vNOTES procedure. We used the GelPOINT^® V-Path platform, which included a GelSeal^® cap, the Alexis retractor, and three sleeves. The patients were placed in a 15-degree Trendelenburg position under pneumoperitoneum of 8 mmHg.

Results: The median operation time was 109 min (90–137 min), and the median estimated blood loss was 76 mL (50–150 mL). The vNOTES approach was useful to perform safe hysterectomy and/or salpingo-oophorectomy. Patients were discharged within 3 days postoperatively with minimal pain and no postoperative complications.

Conclusion: This is the first report that describes vNOTES in Japan; therefore, the indications and surgical procedure have not yet been conclusively established. Further accumulation of cases with data regarding long-term outcomes is essential; however, in our opinion, vNOTES is a novel approach that could be useful in clinical practice.

  Retroperitoneal ectopic pregnancy (REP) is rare. Laparoscopy is useful to diagnose a typical ectopic pregnancy and for removal of trophoblastic tissue. We report a case of REP diagnosed using exploratory laparoscopy. A 30-year-old, gravida 3 para 0 was admitted to our hospital with a history of 5 weeks' amenorrhea and suspected an ectopic pregnancy because of the empty uterus. Her obstetric history included a spontaneous abortion 8 years prior and laparoscopic left salpingectomy for a left tubal pregnancy, 6 years prior to presentation. She was completely asymptomatic and hemodynamically stable. Her serum human chorionic gonadotropin (hCG) level on admission was 3268 mIU/mL, which subsequently increased to 5654 mIU/mL, 2 days later. Transvaginal ultrasonography revealed a slightly edematous right fallopian tube. Exploratory laparoscopy was performed for suspected right tubal pregnancy; however, we did not detect any evidence of ectopic pregnancy. The serum hCG levels continued to increase postoperatively. Contrast-enhanced computed tomography performed to screen for trophoblastic disease revealed a ring-enhancing cystic mass in the left paraaortic region. Transabdominal ultrasonography revealed a gestational sac-like mass without a yolk sac and fetal heartbeat. We performed laparotomy and identified the gestational sac in the retroperitoneal space and removed all trophoblastic tissue. Diagnosis of REP is challenging on routine ultrasonography on routine evaluation. Exploratory laparoscopy is useful in the diagnosis of REP together with other imaging modalities to exclude other conditions.

OBJECTIVE: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare congenital abnormality of the female urogenital tract. We report a rare case of a laparoscopic unilateral hysterectomy in a patient with OHVIRA syndrome with complete unilateral obstruction and peritonitis.

CASE: A 14-year-old girl with an imperforate hymen was referred to our hospital for treatment of double uterus and right uterine enlargement. Her medical history reported right renal agenesis noted at age seven and menarche at the age of 12, and for one and a half years afterwards, her dysmenorrhea worsened. She has one cervix, a normal left uterus and a right uterus away from the vagina. In our first consultation, she was diagnosed with OHVIRA syndrome with complete unilateral obstruction and menstrual molimina. A magnetic resonance imaging (MRI) revealed right uterine congestion and a chocolate cyst of the right ovary. We decided upon surgery as a strategy for evaluation and treatment. Low dose estrogen-progestin (LEP) was used to reduce pain while she waited for surgery, but she underwent an emergency surgery at the diagnosis of peritonitis. Laparoscopic right hysterectomy and right ovarian cystectomy were performed and the left uterus was properly maintained. The postoperative diagnosis was same as the initial diagnosis.

CONCLUSION: Early diagnosis of OHVIRA syndrome with complete unilateral obstruction is important because a delay in treatment may result in pelvic adhesions and endometriosis due to menstrual reflux. In this case, laparoscopic surgery was useful for confirming the diagnosis and treatment.

Introduction: A unicornuate uterus with a noncommunicating rudimentary horn is a rare congenital uterine malformation that causes lower abdominal pain and dysmenorrhea due to endometriosis and uterine hematoma. We encountered a case of a unicornuate uterus with a noncommunicating rudimentary horn that was safely treated through laparoscopic removal of the rudimentary horn. The treatment strategy was determined following evaluation of preoperative 3D-reconstructed computed tomography (CT) images.

Case presentation: A 34-year-old patient's (gravida 1, para 1) past pregnancy history included an emergency caesarean section due to uncontrollable uterine contractions at 24 weeks of gestation. Her menstruation resumed, and at 10 months postpartum, she noted left lower abdominal pain. The patient was diagnosed with right unicornuate uterus with a noncommunicating rudimentary horn and accompanying dysmenorrhea. Surgical treatment was planned. Preoperatively, 3D-reconstructed CT images were acquired, and a defect in the left external iliac artery was confirmed. Due to the abnormal course of the left uterine artery, identification of the left ureter was delayed during the surgery. However, a careful surgery was possible due to the preoperative confirmation of the 3D-reconstructed CT, and laparoscopic removal of the left rudimentary horn and left salpingectomy were performed.

Conclusion: In recent years, minimally invasive laparoscopic surgery has been a favorable choice for the removal of rudimentary horns. It is important to confirm the course of the uterine artery and ureter before surgery. In this case, 3D-reconstructed CT was effective for establishing treatment strategies.

Introduction: Unicornuate uterus with a rudimentary uterine horn is a rare Mullerian malformation which causes dysmenorrhea, infertility and perinatal complications. We report a case of a unicornuate uterus with a non-communicating rudimentary uterine horn and with adenomyosis.

Case: A 13-year-old nulligravid woman was referred to us with dysmenorrhea and severe pelvic pain. Abdominal computed tomography and pelvic magnetic resonance imaging suggested a unicornuate uterus with a left-sided rudimentary uterine horn on the right side of the pelvis. Hematometra in the rudimentary horn, left hematosalpinx, and left renal agenesis were also observed. Laparoscopy identified prominent inflammatory adhesions, with a swollen left fallopian tube adherent to the posterior wall of the left-sided rudimentary uterine horn. Moreover, the left ovary was swollen, and an endometriotic cyst was suspected. The rudimentary horn was removed along with the ipsilateral salpinx. The left fallopian tube and an endometrioma in the left ovary were also removed, and normal ovarian tissue was preserved. Histopathologic examination of the extracted rudimentary horn showed an area of adenomyosis, and the ovarian cyst revealed an endometriotic cyst. The final diagnosis was adenomyosis in a rudimentary uterine horn and left-ovarian endometriotic cyst.

Conclusion: Laparoscopic surgery is effective for treating a non-communicating rudimentary uterine horn. A uterine obstructive malformation, such as in this case causes severe dysmenorrhea; however, due to regular menstruation, diagnosis and intervention may be delayed. In cases of severe dysmenorrhea, it is important to carefully examine the possibility of such uterine malformations.

  A noncommunicating rudimentary uterine horn with functioning endometrium is a congenital Müllerian anomaly known to cause menorrhagia and abdominal pain. Here, we present two patients with a type 2b uterine anomaly (American Society for Reproductive Medicine classification) and successful laparoscopic resection of the rudimentary horn in each.

  Case 1. A 21-year-old female with a history of repeated clinic visits for menorrhagia was referred to our hospital due to findings showing an ovarian cystic tumor. CT and MRI results revealed an endometriotic cyst of the left ovary, left noncommunicating rudimentary uterine horn with functioning endometrium, and co-lateral renal agenesis. Laparoscopic resection of the rudimentary horn and left uterine adnexa was performed, after which the symptoms improved.

  Case 2. A 41-year-old female underwent a laparoscopic cystectomy of the right ovary at 28 years of age and her uterus was suspected to be bicornuate at that time. However, that operation was apparently ineffective for alleviation of menorrhagia, and the patient was referred to our hospital due to its persistence as well as suspicion of endometriosis. MRI revealed a right noncommunicating rudimentary uterine horn with functioning endometrium. Laparoscopic resection of the rudimentary horn and right uterine adnexa improved the symptoms.

　Peritoneal pregnancy is relatively rare and accounts for approximately 1% of all ectopic pregnancies. Accurately diagnosing peritoneal pregnancy before surgery is difficult; thus, gynecologists may encounter the disease accidentally.Many studies have reported that peritoneal pregnancy is preoperatively diagnosed as tubal pregnancy.

　The implantation sites varied in each case. In some cases, the implantation sites can be close to other organs such as the rectum, ureter, and bladder. Thus, it is important for operators to take measures to not injure the organs. Here, we report a case of peritoneal pregnancy implanted on the pouch of Douglas inside of the right uterosacral ligament. The gestational sac did not develop in the abdominal space but developed in the retroperitoneal space; thus, it should have been near the rectum. When laparoscopy was initiated, the positional relationship between the rectum and gestational sac was unclear. We inserted a reusable surgical probe (Rectal Sonde^®) into the rectum and moved it slowly and carefully and assessed the positional relationship. We safely removed the gestational sac. A reusable surgical probe for the rectum has been reported to be useful for laparoscopic adhesiolysis of the posterior cul-de-sac obliteration associated with endometriosis.

　We reported the usefulness of the probe in laparoscopic surgery to remove ectopic gestational sacs near the rectum.

　The safety of laparoscopic surgery for early stage ovarian cancer remains uncertain, and laparotomy is recommended. We examined a case in which laparoscopic surgery was performed before the first laparotomy for ovarian cancer unexpectedly, and ovarian cancer metastasis occurred at the port site and the circumference.

　A 48-year-old woman with left ovarian cancer was scheduled to undergo surgery, but acute cholecystitis developed, and an emergency laparoscopic cholecystectomy was performed.

　On the fifteenth postoperative day, because of acute abdomen and suspected ovarian tumor rupture, total hysterectomy, bilateral salpingo-oophorectomy, and omental biopsy laparotomy were performed. The postoperative pathological diagnosis was endometrial carcinoma with clear cell carcinoma, FIGO stage IC 2 (pT1c2pNXpM0).

　On the fifty-sixth day after laparotomy, a 10 mm sized tumor was found under the skin at the port site. Computed tomography (CT) revealed a mass in the right upper quadrant of the abdomen, a mass in the porta hepatis, the S4/5 region of the liver, and enlarged lymph nodes in the left external iliac region. It was considered that the ovarian cancer rapidly revived, and debulking surgery was performed. Recurrence of ovarian carcinoma was confirmed by pathological results, including a port-site mass.

　It is not a typical dissemination of ovarian cancer, and laparoscopic surgery might have resulted in metastasis. It should be prudent for the adaptation of laparoscopic surgery, even if it is an operation for a benign disease in a case, in which ovarian cancer is suspected.

  Along with the rise in kidney engraftment rates the number of women who are candidates for gynecologic laparoscopic surgery after a kidney transplantation has increased. Although kidney function may be maintained within operable range in these women, characteristic complications caused by the dislocation of the transplanted kidney and immunosuppression are risks for surgery. We report two cases of women with ovarian tumors, who underwent laparoscopic surgery following kidney transplantation. We performed laparoscopic bilateral adnexectomy for a 58-year-old postmenopausal woman with serous cystadenofibroma arising from both ovaries, and laparoscopic cystectomy for a 30-year-old woman with a left ovarian endometrial cyst. We adjusted the laparoscopic port placement to the location of the transplanted kidney, and administered perioperative immunosuppressive drugs and antibiotics in consultation with the renal transplantation specialists. Postsurgical hospital stay was 4 days and no complications were observed in both women. Minimally invasive surgery, such as laparoscopic surgery, is suitable for women after kidney transplantation because of better perioperative infection control. Considerations should be made for dislocations of transplanted kidneys and ureters, and it is critical for primary physicians to be familiar with immunosuppressive medications, their side effects

  Persistent ectopic pregnancy, a common complication of a salpingotomy for tubal pregnancies, is diagnosed by a secondary rise in serum human chorionic gonadotropin (hCG). However, it rarely occurs after a salpingectomy; therefore, the need for assessment of the hCG level after a salpingectomy is not widely recognized. The present report demonstrated the need for hCG follow-up assessment even after a salpingectomy.

  A 28-year-old female patient was transferred to our hospital due to suspected ectopic pregnancy. She had slight tenderness in the lower abdomen, but her general condition was stable. Her hCG level was 2,551.0 mIU/ml. In the transvaginal ultrasound examination, gestational sac was not found in the uterus or adnexa. Laparoscopic surgery was performed for the suspected ectopic pregnancy. Ruptured pregnancy in the left tubal ampulla and slight hemorrhagic ascites were found intraoperatively, and a left salpingectomy was performed. The hCG decreased gradually, and she was discharged on postoperative day 5 without complications. Her hCG increased again to 445.9 mIU/ml at the follow-up examination on postoperative day 15. The uterus and adnexa were normal in transvaginal ultrasound. Based on these findings, persistent ectopic pregnancy was diagnosed, and administration of methotrexate 50 mg/m² was begun on postoperative day 18. Thereafter, the hCG decreased and normalized by postoperative day 43.

  In the present case, follow-up assessment of hCG after the salpingectomy led to early diagnosis of persistent ectopic pregnancy, indicating the need for follow-up assessment of hCG after a salpingectomy, especially in patients with spillage of trophoblast.

  Ovarian mature teratomas present various risks, such as acute abdomen, and hence surgery is the usual protocol. On the other hand, uterine lipoleiomyoma is a variant of uterine leiomyoma, and surgery is not always performed in postmenopausal cases. We report a case of postmenopausal uterine lipoleiomyoma, preoperatively diagnosed as ovarian mature teratoma, and treated surgically. A 71-year-old woman presented a 5.5-cm mass on the left dorsal side of the uterus that was fat suppressed on magnetic resonance imaging. The preoperative diagnosis was mature teratoma of the left ovary.

  Laparoscopic bilateral salpingo-oophorectomy was planned, but we changed the operative procedure to laparoscopic hysterectomy and bilateral salpingo-oophorectomy. This was because the mass was identified as a uterine mass as no swelling was observed in either ovary during surgery. Pathological examination of the excised specimen revealed lipoleiomyoma. It may be difficult to distinguish uterine lipoleiomyomas from ovarian mature teratomas when the lipoleiomyomas are subserosal. In this case, the tumor was presumed to have originated from the uterus based on the findings of the pelvic examination, and we were able to discuss the operative procedure options in advance. One of the merits of laparoscopic surgery in this case was that the burden of changing the surgical procedure was less than that with laparotomy; however, at the same time, preoperative exclusion of malignant disease was considered important. In the diagnosis of tumors containing fat, the differential diagnosis of lipoleiomyoma should be considered.

　Bowel endometriosis is one of the most severe forms of endometriosis and accounts for the highest incidence of endometriotic lesions at atypical sites. Although medical therapy is recommended as treatment for rectal endometriosis, surgical therapy is considered in patients with infertility. We report a case of rectal endometriosis with infertility in a patient who underwent laparoscopic rectal low anterior resection that was followed by spontaneous pregnancy.

　A 27-year-old nulligravida with infertility observed over 2 years after discontinuation of hormonal agent use was referred to our hospital with abdominal pain and melena that worsened during menstruation. Following detailed examination and investigations, she was diagnosed with bilateral ovarian endometriotic cysts and rectal endometriosis. We initiated infertility treatment, including assisted reproductive techniques; however, she could not conceive for a year. Laparoscopic rectal low anterior resection was performed owing to worsening endometriotic lesions and the development of intestinal stricture. Her postoperative course was uneventful, and she conceived spontaneously 2 months postoperatively with a vaginal delivery at term.

　Several recent studies have reported that surgical treatment for rectal endometriosis improves fertility. Following are the indications for surgical treatment for rectal endometriosis: (1) intestinal stenosis and melena, (2) pain refractory to conservative management, (3) lesions refractory to hormone therapy, (4) infertility and, (5) suspected malignancy. Laparoscopic intestinal resection could be considered a useful initial therapeutic approach, particularly in patients aged ≤35 years without uterine adenomyosis.

  Disseminated peritoneal leiomyomatosis (DPL) is a rare benign disease characterized by tumors derived from smooth muscles throughout the abdominal cavity. Iatrogenic DPL, a recently recognized entity, has been reported following laparoscopic procedures using the morcellation technique due to uterine myomas.

  A 31-year-old woman presented with a palpable mass in the left lower quadrant of the abdomen. Seven years prior, she had undergone laparoscopic myomectomy with power morcellation. Magnetic resonance imaging and computed tomography revealed a subcutaneous mass in the left iliac fossa below a previous laparoscopic trocar site, a uterine myoma, and multiple pelvic masses. After 6 months of administration of gonadotropin-releasing hormone agonists, she was offered laparoscopic tumor reduction surgery. During the laparoscopy, multiple tumors varying in size between 0.5 cm and 6.5 cm were found to be adherent to the upper abdominal wall, retroperitoneal pelvic cavity, and sacral uterine ligament. After laparoscopic resection of all the pelvic lesions, we excised a subcutaneous mass through a skin incision. Histopathological examination of multiple sections of the mass showed features compatible with those of a leiomyoma. Twenty-five months after the surgery, the patient delivered via cesarean section. On follow-up after 55 months, she was asymptomatic, with no clinical evidence of recurrence.

  The frequency of clinical encounters of iatrogenic DPL is considered to increase with an increase in the number of laparoscopic myomectomies and hysterectomies performed. Even for benign conditions, open power morcellation of the uterus may be associated with clinically significant dissemination of the disease. Myoma remnants should be carefully extracted, and confined morcellation should be considered.

  Laparoscopic myomectomy (LM) is currently widely used as surgical treatment for uterine fibroids; however, it may be technically challenging in some patients with cervical fibroids in whom laparotomy needs to be performed. Reportedly, preoperative uterine artery embolization and intraoperative cutting and ligation of the uterine artery reduce intraoperative bleeding during myomectomies. Notably, maintaining maximal uterine blood flow is necessary in patients who desire fertility preservation; unfortunately, currently, no such method is available.

  We describe two patients in whom LM was safely performed using a polyvinyl chloride Nelaton catheter for temporary intraoperative ligation and occlusion of the uterine artery. No major complications were observed intra- or postoperatively in either case. Laparoscopic surgery can be safely performed even in patients undergoing myomectomy for cervical fibroids if intraoperative bleeding is minimal and well controlled. Temporary ligation and occlusion of the uterine artery using a Nelaton catheter reduces intraoperative bleeding and is a simple, minimally invasive, inexpensive and effective strategy in such cases.

　We present a rare case of rupture of uterine pseudoaneurysm following laparoscopically assisted vaginal hysterectomy (LAVH). A 49-year-old gravida 4, para 4 experienced menorrhagia resulting in anemia. She was administered three doses of gonadotropin-releasing hormone agonists and subsequently underwent LAVH. She developed stomach ache on postoperative day 8, and abdominal computed tomography (CT) revealed hemoperitoneum. She was diagnosed with a ruptured pseudoaneurysm based on contrast-enhanced CT and underwent uterine artery embolization on the same day.

　Clinicians should consider pseudoaneurysm rupture leading to hemoperitoneum among the differential diagnosis in women presenting with profuse vaginal bleeding as the primary symptom.

  We report a case of recurrent pseudomyxoma peritonei that was removed by laparoscopic surgery. A 61-year old woman complained of abdominal fullness. Computed tomography (CT) showed a giant tumor occupying the whole abdominal cavity with massive ascites. Pseudomyxoma was suspected based on aspiration of gelatinous ascites. The results of aspiration cytology also indicated pseudomyxoma peritonei. Cytoreductive surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + appendectomy + omentectomy + perinatology) was performed. Pathological examination showed that the tumor was derived from the right ovary. The appendix was intact. After primary surgery, monthly intraperitoneal chemotherapy with cisplatin (CDDP) was performed four times. However, tumor recurrence occurred in the pouch of Douglas 2 months after final intraperitoneal chemotherapy. This recurrent tumor measured 5 cm. There were no other recurrent tumors than that in the pouch of Douglas. Laparoscopic resection was deemed suitable for this localized and isolated recurrent tumor. We then resected the tumor by laparoscopic surgery. CDDP was administered as intraperitoneal chemotherapy at the end of this laparoscopic operation. After the laparoscopic operation with CDDP infusion, there has been no recurrence until the present. This report suggests that laparoscopic resection is useful for localized recurrence with low-grade malignancy as in this case.

　Total laparoscopic hysterectomy is increasingly being performed for uterine adenomyosis following widespread use of laparoscopic surgery in clinical practice. We report a case of postoperative endometrial cancer following total laparoscopic hysterectomy performed for uterine adenomyosis.

　A 45-year-old woman underwent total laparoscopic hysterectomy for dysmenorrhea. No abnormal bleeding or endometrial thickening was observed preoperatively; however, she was diagnosed with endometrioid adenocarcinoma based on postoperative histopathological examination.

　Studies in the available literature have reported that the rate of malignant transformation of uterine adenomyosis is the same as that observed in cases of ovarian chocolate cysts. Early detection of malignant transformation of uterine adenomyosis is challenging. Notably, laparoscopic surgery may result in dissemination of malignant cells; therefore, accurate preoperative diagnosis and careful management are important in these patients considering potential malignant transformation.

　Mature teratomas are benign tumors that usually affect young women and are commonly resected laparoscopically. We report two cases of chemical peritonitis that occurred after laparoscopic ovarian cystectomy performed for mature teratoma resection.

　Case 1: A 45-year-old woman underwent laparoscopic ovarian cystectomy for a mature teratoma. Intraoperatively, we observed tumor cell spillage into the abdominal cavity. The patient returned with lower abdominal pain a month postoperatively and underwent reoperation for suspected appendicitis. We detected intra-abdominal fat and hair remnants and performed peritoneal lavage. She was diagnosed with chemical peritonitis, and her symptoms improved after the procedure.

　Case 2: A 28-year-old woman underwent laparoscopic ovarian cystectomy for a mature teratoma with intraoperative tumor cell spillage into the abdominal cavity. She returned with lower abdominal pain a month postoperatively. Computed tomography revealed suspected peritonitis, and she was diagnosed with chemical peritonitis. Oral steroid administration led to improvement in symptoms.

　It is important to minimize intraoperative tumor cell spillage to prevent chemical peritonitis. Low-dose oral steroid administration may effectively prevent chemical peritonitis.

　The frequency of malignant transformation in endometriosis is rare; it is estimated to be less than 1%. Malignant transformation mainly occurs in the ovary and rarely in the extragonadal sites. Endometriosis-associated intestinal tumors (EAITs) represent the malignant transformation of gastrointestinal endometriosis; the prevalence of EAITs is 0.77% in Japan. Here, we present a case of endometrioid carcinoma of the rectum arising from rectal endometriosis that was treated by laparoscopic surgery.

　A 68-year-old woman presented with no symptoms but had a pelvic mass and was referred to our hospital. She had no history of endometriosis and hormone replacement therapy. Tissue biopsy revealed a poorly-differentiated adenocarcinoma, and the immunohistochemical studies showed cytokeratin7+, cytokeratin20-, and estrogen receptor+. Therefore, the tumor was suspected to be of gynecological origin and not primary colon origin. She underwent laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, and low anterior resection with D3 lymphadenectomy. There were no malignant findings in the uterus and ovaries. The tumor was located adjacent to the rectal wall; endometrial glands and stroma were present adjacent to the tumor. We diagnosed her with endometrioid carcinoma arising from endometriosis of the rectum. No metastatic lymph nodes were identified pathologically. The patient received adjuvant chemotherapy postoperatively and has been disease-free for 18 months since the surgery.

　The basic treatment for EAITs is surgery, and we could treat her through laparoscopy. Laparoscopy, a minimally invasive surgery, is another treatment option for EAITs.

[Case] A 50-year-old gravida 2, para 1 presented with multiple fibroids and a right ovarian tumor. Magnetic resonance imaging (MRI) revealed multiple uterine fibroids and a right ovarian tumor (4 cm) without any signs suggestive of malignancy. We performed total laparoscopic hysterectomy (TLH) after completion of 6 courses of gonadotropin-releasing hormone (GnRH) agonist therapy. Intraoperatively, we observed endometriosis around Douglas' pouch and the left adnexa; therefore, we performed simultaneous left salpingo-oophorectomy. The right ovary appeared normal in size. Postoperative histopathological examination revealed uterine fibroids and adenomyosis, and the left ovary showed no neoplastic lesions. Transvaginal ultrasonography performed at her 3-month postoperative follow-up revealed an enlarged right pelvic tumor (5 cm). MRI findings were suspicious for cancer, such as gastrointestinal stromal tumor. Therefore, a gastrointestinal surgeon performed concurrent laparotomy. The edematous pelvic tumor measured 9 cm in size with peripheral adhesions. We performed resection of the pelvic tumor and pelvic lymph node sampling (operation time 129 min, estimated blood loss 590 mL). Ascites fluid cytology evaluation showed negative results. Histopathological examination confirmed the diagnosis of ovarian endometrioid carcinoma G1. The patient received 6 courses of postoperative dose-dense paclitaxel-carboplatin therapy uneventfully, and no recurrence has occurred to date.

[Summary] Ovarian endometrioid carcinoma rarely shows rapid progression. Preoperative GnRH analogue administration might mask ovarian endometrioid cancer.

  Rectal injury is a serious complication of laparoscopic surgery and is associated with poor prognosis. We describe a patient who developed a pelvic abscess secondary to bacterial infection after a seromuscular rectal injury during laparoscopic surgery, who was successfully treated with drainage alone. Laparoscopic bilateral adnexectomy was performed for bilateral chocolate cysts; however, she developed fever and abdominal pain, 5 days postoperatively. Computed tomography revealed an intrapelvic abscess, and the intraoperative video recording led to a suspicion of rectal injury. Based on bacterial cultures of pus from the abscess, she was diagnosed with infection transmitted from the site of rectal injury. However, colonoscopy did not reveal any rectal mucosal injury. Therefore, we concluded that the injury was confined to the seromuscular layer. The abscess was successfully treated with drainage and antibiotics. Pelvic abscesses may occur secondary to seromuscular injuries without complete perforation of the rectal mucosa. Notably, drainage and antibacterial drugs are effective and emergency surgery is not required in patients without perforation. Colonoscopy may be useful to determine the treatment course.

  Pseudo-renal failure is a rare condition with laboratory abnormalities mimicking acute kidney injury despite normal kidney function. When upper or lower urinary tract injury causes intraperitoneal urine leakage, reverse intraperitoneal urine dialysis leads to elevated levels of blood urea nitrogen and creatinine, hyperkalemia, and metabolic acidosis. We report a case of pseudo-renal failure with delayed bladder injury after total laparoscopic hysterectomy (TLH). A 52-year-old woman visited our hospital for treatment of multiple uterine myoma, for whom TLH was performed. After surgery, she had no urination desire and was made to urinate using urethral catheters as appropriate. After 3 days of surgery, laboratory findings showed elevated serum creatinine level. A urethral catheter was indwelled, the creatinine level improved. However, the creatinine level increased again after removal of the urethral catheter. Abdominal computed tomography (CT) showed presence of several ascites and cystoscopy showed a perforated bladder. After 6 days, bladder repair surgery was performed.

  Bladder injury is one of the complications to be avoided in TLH. If the uterus is large, the surgery is more difficult and the risk of bladder injury is higher. In this case, uterus was large and there was an anatomical change due to a broad ligament myoma. The bladder injury occurred when the bladder was detached from the lower uterine segment. In general, cystoscopy and CT cystography are useful for identifying bladder injury due to pelvic surgery. This case suggests that pseudo-renal failure is an indication of bladder injury after pelvic surgery.

Summary: We report a case of acute renal failure secondary to bilateral clot-induced ureteral obstruction, following prophylactic stent placement during laparoscopic radical hysterectomy (LRH). A 60-year-old patient with cervical adenocarcinoma stage IBI underwent LRH with prophylactic ureteral stent placement; the stent was removed postoperatively. Five days postoperatively, she developed acute renal failure secondary to blood clot-induced ureteral obstruction associated with urinary tract injury and anticoagulant therapy. She improved following cessation of anticoagulant therapy and ureteral stent re-insertion. Clinicians should be mindful that acute renal failure can occur secondary to blood clot-induced obstruction in patients who undergo prophylactic ureteral stenting.

  Port site hernia is one of the complications that occur following laparoscopic surgery, with a reported prevalence of approximately 0.5%. We report a case of hernia at a 5-mm port site in a 79-year-old woman who underwent laparoscopic bilateral salpingo-oophorectomy. She complained of reduced appetite and emesis on the fourth postoperative day. Contrast-enhanced computed tomography revealed intestinal obstruction at the port site, and emergency abdominal operation was required. Several causative factors of port site hernia were considered, such as advanced age, obesity, long-term history of steroid administration, and injury to the fascia during laparoscopic operation. It is important to evaluate the risk of port site hernia in terms of both patient as well as iatrogenic factors.

  We report a case of primary peritoneal pregnancy treated with laparoscopic surgery in a 24-year-old gravida 0 who was referred to our hospital with lower abdominal pain.

  Transvaginal ultrasonography did not reveal a gestational sac in the pelvis; however, a hyperechoic lesion suspicious for a pelvic hematoma was identified in the cul-de-sac. Her serum human chorionic gonadotropin (hCG) level was 6400 mIU/mL, and serum hemoglobin was 11.0 g/dL. Physical examination showed signs of peritoneal irritation.

  We performed laparoscopy, which revealed an unremarkable uterus, bilateral fallopian tubes, and bilateral ovaries. We collected 500 mL of blood from the abdominopelvic cavity, and evaluation revealed a peritoneal pregnancy with active bleeding. We removed the gestational tissue, and histopathological examination of the retrieved specimen confirmed villi. Her serum hCG level immediately decreased postoperatively. Finally, she was histopathologically diagnosed with a peritoneal pregnancy because syncytiotrophoblasts were observed adjacent to the peritoneum of the pouch of Douglas, following staining with collagen type IV, which is derived from the mesothelium.

  Torsion of normal adnexa is rare. Most patients present with nonspecific symptoms, and diagnosis is challenging; however, urgent treatment is essential for ovarian tissue preservation. We describe a patient in whom the intra-ovarian vascular resistance (RI) was used to diagnose adnexal torsion and facilitated prompt laparoscopic ovarian fixation.

  A 20-year-old woman was referred to our department with acute left-sided lower abdominal pain. Transvaginal ultrasonography revealed a mildly enlarged left ovary with torsion around its pedicle. On pulsed Doppler evaluation, the ovarian RI was as high as 0.94, and a notch at an early stage of dilatation was identified. Owing to persistent pain, we performed laparoscopy, which revealed torsion of the left adnexa around the ovarian ligament. We released the torsion because the left ovary was not necrotic.

  The left ovarian ligament was longer than the right; therefore, we fixed the ovary to the retroperitoneum to avoid the risk of recurrence. At the time of discharge, the ovarian RI decreased to 0.66, and the notch observed at an early stage of dilatation had disappeared.

  Ultrasonography, particularly pulsed Doppler evaluation, offers high diagnostic accuracy and is a common imaging modality used in clinical practice in recent years. We diagnosed this patient based on the high ovarian RI observed in this case. Clinicians should consider torsion of normal adnexa in the differential diagnosis in young women with abdominal pain of unknown etiology. The ovarian RI is a useful indicator to diagnose this condition.

  A 31-year-old woman was referred to our hospital for ectopic pregnancy. Transvaginal ultrasonography revealed a fetus in the right adnexal region (crown–rump length 7.1 mm with positive heartbeats). The gestational sac (GS) was implanted on the vesicouterine pouch near the right round ligament; however, no major bleeding was observed. Narrow band imaging (NBI) confirmed superficial neovascularization and avascular lesions. We performed subperitoneal injection of diluted vasopressin (0.2 U/mL) around the lesion, to prevent major bleeding, and excised the GS and villi using forceps, without any significant bleeding.

Conclusion: NBI-guided endoscopy can confirm the growth of vessels around the ectopic pregnancy, and injection of diluted vasopressin prevents severe bleeding and facilitates complete laparoscopic removal of the ectopic tissue.

　We report a case of an estrogen-producing Brenner tumor of the ovary. A 66-year-old woman presented with a pelvic tumor as revealed by computed tomography scan and was referred to our hospital by a local doctor.

　Magnetic resonance imaging revealed a 15-cm-sized solid and multilocular part mixed ovarian tumor with endometrial thickening. Her serum estradiol concentration was 31.6 pg/mL before treatment. We performed a bilateral salpingo-oophorectomy by laparoscopic-assisted surgery and endometrial curettage. The pathological examination of the left ovarian tumor revealed a mucinous and benign ovarian Brenner mixed tumor, with no evidence of malignancy in the endometrial tissue. Postoperatively, her estrogen level decreased to the post-menopausal level. Based on these results, the ovarian tumor was found to be estrogen-producing. The Brenner tumor is generally regarded as a non-estrogen-producing tumor; however, the Brenner tumor, as in this case, may produce estrogen. Therefore, it is necessary to consider changes in the endometrium due to estrogen in the diagnosis and treatment of Brenner tumors.

Objective: Heterotopic pregnancy is relatively rare and clinical features are nonspecific, the diagnosis is often delayed and can be fatal. We report 4 cases of heterotopic pregnancy.

Patients: Case1: A 27-year-old woman conceived naturally. At 6 weeks gestation, she visited a previous hospital for lower abdominal pain and a small amount of genital bleeding. She was referred to our institution for suspicion of heterotopic pregnancy. In emergency laparoscopic surgery, right salpingectomy was performed for a right tubal pregnancy.

  Case2: A 38-year-old woman conceived after artificial insemination with husband's semen (AIH) with use of clomiphene citrate. At 8 weeks gestation, she entered shock and was transported by ambulance to our institution. In emergency laparoscopic surgery, right salpingectomy was performed for a right tubal pregnancy.

  Case3: A 27-year-old woman conceived after AIH. At 9 weeks gestation, she was rushed to our institution for lower abdominal pain and a large amount of genital bleeding. In emergency laparoscopic surgery, right salpingectomy was performed for a right tubal pregnancy. Intrauterine pregnancy became a miscarriage at the same time.

  Case4: A 40-year-old woman conceived after AIH. She was diagnosed as a miscarriage at 6 weeks of pregnancy. After 1week, she was rushed to a previous hospital for lower abdominal pain. She was referred to our institution for suspicion of heterotopic pregnancy and hemorrhagic shock. In emergency laparoscopic surgery, right salpingectomy was performed for a right tubal pregnancy.

Conclusion: We should always be alert to the possibility of heterotopic pregnancy even in the natural ovulation cycles.

　Significant scar defects of the uterine myometrium occur in 4–9% of women who undergo cesarean delivery. Women with prolonged menstruation, abnormal uterine bleeding, and/or secondary infertility attributable to a significant cesarean scar defect are diagnosed with cesarean scar syndrome (CSS).

　The incidence of CSS is expected to increase in Japan owing to the increasing rates of cesarean delivery being observed in obstetric practice. We describe two patients with CSS, who underwent successful minimally invasive surgery using a combined laparoscopic and hysteroscopic approach.

　Case 1: A 35-year-old Japanese woman with a history of cesarean delivery necessitated by arrested labor presented with atypical genital bleeding. Transvaginal ultrasonography (US) and magnetic resonance imaging (MRI) revealed a severe cesarean scar defect, and she underwent combined laparoscopic and hysteroscopic repair for CSS. The entire length of the uterine diverticulum was laparoscopically resected. The light source provided by hysteroscopy was useful during laparoscopic surgery to accurately determine the site and extent of the uterine diverticulum. The incision was laparoscopically closed with absorbable sutures after trimming, and successful surgical repair was confirmed both hysteroscopically and laparoscopically.

　Case 2: A 32-year-old woman who presented with prolonged menstruation underwent US and MRI, which revealed a significant cesarean scar defect. She underwent combined laparoscopic and hysteroscopic repair for CSS, although the method employed differed slightly from that used in Case 1. This treatment led to symptom resolution in both patients. In conclusion, combined laparoscopy and hysteroscopy may be useful for repair of a post-cesarean delivery uterine diverticulum because the site and extent of the uterine diverticulum can be easily determined under hysteroscopic guidance.

Introduction: Adenomyosis of the uterus can potentially give rise to pathologic processes causing infertility. We report the case of one previously infertile woman who achieved pregnancy after hysteroscopic resection of an endometrial tumor, diagnosed histopathologically as adenomyoma.

Case: A 35-year-old woman with a history of infertility and an intra-uterine tumor visited our hospital for hysteroscopic resection. Despite receiving 9 cycles of ovulation-inducing medications and artificial insemination using her husband's sperms plus ovulation-inducing agents for 3 additional cycles, she failed to achieve pregnancy. She was diagnosed with a tumor of the endometrium and underwent dilation and curettage. However, she was still unable to achieve pregnancy after 2 cycles of artificial insemination, one with and one without ovulation-inducing agents. Subsequently, she was brought to our hospital. We suspected an atypical polypoidal adenomyoma or submucosal myoma of the uterus on hysteroscopy and proceeded to perform hysteroscopic resection. The histopathological diagnosis was intra-uterine adenomyoma. The patient achieved a natural pregnancy 2 months after the surgery. Her pregnancy was uncomplicated.

Conclusion: In our study, we present the case of a previously infertile woman who achieved a natural pregnancy after hysteroscopic resection of an endometrial tumor, diagnosed histopathologically as adenomyoma. Our case demonstrates the utility of hysteroscopy and hysteroscopic resection in the diagnosis and treatment of unexplained infertility.

　A 37-year old woman was diagnosed as early-stage endometrial cancer (G1 endometrioid carcinoma) during infertility treatment. The patient desired fertility preservation, and underwent fertility-preserving hormonal therapy. She became pregnant after successful cancer treatment and underwent cesarean section for breech presentation. During the surgery, it was observed that the placenta had adhered to the uterine wall, and it was removed manually. A postoperative examination revealed an intrauterine mass, which was diagnosed as retained products of conception (RPOC). Because active bleeding was not observed, conservative management was initiated. However, the lesion did not resolve. Therefore, we performed hysteroscopic surgery and endometrial curettage to evaluate the recurrence of endometrial cancer. A 2-cm white polypoid lesion was discovered in the uterus, and it was excised using a loop electrode. The resected margin was ischemic with little bleeding. The resected polypoid lesions were pathologically diagnosed as necrotic hyaline tissue, whereas that of the endometrial curettage lesion was endometrial hyperplasia. To determine the method and timing of treatment for RPOC, it is necessary to consider the presence or absence of active bleeding and individual characteristics of patients such as a history of endometrial cancer.

Introduction: Few reports have described retroperitoneal hematoma around the infundibulopelvic ligament originating as a complication of hysteroscopic surgery. We report a case of retroperitoneal hematoma around the infundibulopelvic ligament secondary to uterine perforation during hysteroscopic myomectomy.

Case presentation: A 43-year-old woman presented with menorrhagia and a submucosal fibroid. Magnetic resonance imaging revealed a submucosal fibroid (basal diameter 20 mm). Hysteroscopic myomectomy was performed and using a loop monopolar electrode, we excised a submucosal fibroid (20 cm) that originated from the bottom of the uterus.

  The peritoneal cavity could be visualized from within the uterus, and we diagnosed the patient with a uterine perforation for which we performed immediate laparoscopic repair under general anesthesia. Intraoperatively, we detected a perforation (5 mm in size) at the bottom of the uterus. We also identified a hematoma (3 cm) on the dorsal aspect of the broad ligament at the site of physiological adhesions with the sigmoid colon. We repaired the uterine perforation; however, the hematoma ruptured during intraoperative exploration. Bleeding was successfully controlled with compression. The retroperitoneal hematoma detected around the infundibulopelvic ligament could be attributed to compression injury caused by a Hegar dilator, head of hysteroscope, the laparoscopic port, or indirect injury from energy devices.

Conclusion: Laparoscopy or laparotomy is necessary for meticulous visualization of the abdominal cavity in cases of uterine perforation during hysteroscopic surgery.

　Undifferentiated endometrial carcinoma is rare and accounts for only 1–2% of all types of endometrial carcinoma. We report a case of undifferentiated endometrial carcinoma diagnosed with hysteroscopic resection.

　The patient presented with hypermenorrhea and abnormal genital bleeding, and transvaginal ultrasonography revealed a simple polyp-like lesion with a smooth surface.

　Initial endometrial cytology findings showed lymphocytic infiltration without any evidence of malignancy. Hysterofiberscopy revealed a massive tumor that protruded into the uterine cavity. This mass showed a smooth surface without any bleeding or necrosis, and endometrial cancer was ruled out. We performed hysteroscopic endometrial resection, and histopathological examination of the resected specimen confirmed a diagnosis of undifferentiated endometrial carcinoma. The patient underwent hysterectomy, and no residual lesions were observed.

　Preoperative diagnosis of undifferentiated endometrial carcinoma is challenging as observed in our case. Cytological evaluation did not reveal proliferation of any atypical endometrial cells. The tumor showed a smooth surface without any bleeding or necrotic changes. We considered them to be morphological features of undifferentiated endometrial carcinoma.

Introduction: An endometrial polyp is a benign clinical finding, but distinguishing a polyp from a malignancy, such as endometrial cancer, can be difficult¹⁾ . We report three cases of endometrial cancer, the endometrial cytology was negative, but the definitive diagnosis was established hysteroscopic appearance.

Case 1-3: Three women were referred to our hospital for evaluation of an endometrial polyp or endometrial thickening. Every endometrial cytology was negative. We performed a hysteroscopy and suspected endometrial cancer based on nodular or papillary or polypoid tumor with abnormal surface vessels for each patient. We performed a hysteroscopic biopsy of the mass and an endometrial curettage to each patient. Every pathologic diagnosis were endometrioid carcinoma (G1/G2).

Conclusion: For an in utero mass which does not lead to a diagnosis based on images and examinations, such as a MRI of the uterus, hysteroscopy can facilitate the diagnosis.

　Fallopian tube torsion is a relatively rare disease and is said to occur in 1 in every 1.5 million women. Sometimes, it is difficult to decide whether to preserve the tube over time after the disease onset. We report a case in which blood flow was evaluated after untwisting of tube by using intraoperative indocyanine green (ICG) fluorescence. A 25-year-old woman was admitted to our hospital for acute abdomen, and laparoscopic surgery was performed because computed tomography (CT) revealed a suspected torsion of the adnexa. A right paratubular cyst was observed, which was in a twisted state. After untwisting, the recovery of blood flow was confirmed by the ICG fluorescence method. The operation was completed by excision of the cyst. Thus, the ICG fluorescence method could be used to confirm the recovery of blood flow after the release of torsion.

Introduction: Ovarian auto-amputation is extremely rare and is most commonly attributed to chronic adnexal torsion and subsequent devascularization that precipitate infarction and necrosis. We describe a woman (Jehovah's witness) who presented with an inflamed abdominal cyst, which was diagnosed as an auto-amputated endometrial ovarian cyst, following laparoscopic surgery.

Case presentation: A 45-year-old Jehovah's witness was referred to our hospital with acute abdominal pain. She had complained of dysmenorrhea prior to referral. Laboratory data revealed evidence of severe inflammation (white blood cell count 12400 cells/μL, C-reactive protein 17.4 mg/dL).

  MRI revealed a cystic pelvic tumor with features of a benign ovarian cyst. She received intravenous antibiotics with resolution of inflammation following this conservative therapy after which we performed laparoscopic surgery for removal of the pelvic mass. Intraoperatively, we performed careful adhesiolysis followed by meticulous exploration of the pelvic cavity. We performed cystectomy and left adnexectomy with insertion of multiple drains into the peritoneal cavity.

Discussion: Based on the laparoscopic and histopathological findings, the patient was diagnosed with chemical panperitonitis associated with a wandering ovarian endometrial cyst.

Conclusion: We report successful but significantly challenging laparoscopic intervention for a wandering ovarian endometrial cyst in a woman with chemical peritonitis.

Introduction: A discussion that uses surgical videos in a real conference room is called a Video Conference (VC) in Japan. Although VC is a useful tool in the education of laparoscopic surgery, it is difficult to hold VCs frequently between some facilities. An Online Surgical Video Discussion (OSVD) is the idea of holding VCs through the internet. We launched OSVDs in 2017 and report on the efficacy thereof.

Methods: OSVD is approved by Institutional Review Board of Nagano Red Cross Hospital. OSVDs are held via You Tube™ Live. We conducted a questionnaire to investigate the perceived efficacy of OSVD.

Results: We performed OSVDs 22 times from September 2017 to November 2019. There were 27 participants that completed the questionnaire. More than 70% of them thought that they had become more motivated, their frequency of watching surgical videos had increased, and OSVD was a good opportunity to learn from other facilities. All of the participants answered that OSVD would improve their surgical skills. In addition, more certified doctors participated in OSVDs than in VCs (OSVD 38.8%; VC 12.0%).

Discussion: OSVD provides a valuable opportunity for furthering laparoscopic surgery education. Participants can discuss surgical videos without actually getting together physically, for free, and without any conflict of interest. Moreover, OSVDs may contribute to reducing disparities in laparoscopic surgery between regions and facilities, and thereby lead to a standardization of surgical skills.

  Following expansion of the surgical indications for laparoscopic surgery, even a large uterus can be removed via laparoscopic hysterectomy. Morcellation involves fragmentation of the uterus into smaller pieces for easier specimen extraction. However, morcellation may cause iatrogenic complications associated with intra-abdominal fragmentation and dissemination of an occult malignancy and benign gynecological disease. Vaginal morcellation is associated with the risk of vaginal injury, as well as injury to the surrounding viscera. We investigated the role of the Alexis Contained Extraction System for vaginal morcellation and removal of a large uterus. This device minimizes the risk of visceral injury and prevents dissemination of potentially malignant tissue and benign gynecological disease. The Alexis Contained Extraction System is particularly useful in patients in whom optimal exposure of the surgical field is challenging, such as in women with a narrow vaginal vault, in those with vaginal wall relaxation, and in patients with a high body mass index. This device reduces the risk of vaginal lacerations, tears, and bruising caused by sharp-edged retractors. We conclude that the Alexis Contained Extraction System is useful during laparoscopic hysterectomy for safe vaginal morcellation and removal of a large uterus.

  Total laparoscopic hysterectomy (TLH) is the standard treatment for benign gynecological diseases. We introduced a senior residents' training program to equip these clinicians with skills to perform safe TLH. Residents developed their own training box and trained themselves. We evaluated residents' progress with technical skills and compared the training methods at least once a month. As part of their training, residents performed laparoscopic surgery in a sequential manner as follows: ovarian cystectomy and salpingo-oophorectomy, followed by surgery for complicated endometriosis to learn the operative strategy in such cases, and finally TLH. TLH involved the insertion of a ureteral stent and uterine manipulator with a colpotomy cup to secure an optimal field of view and to prevent ureteral complications. Ureters were freed from the retroperitoneum. and were closely observed intraoperatively. The uterine artery was cauterized and cut only in close proximity to the manipulator cup. Residents could reconfirm the surgical steps of an abdominal hysterectomy because the operative method used to perform an abdominal hysterectomy was the same as that used for TLH. The aforementioned sequential approach and use of specific equipment helped residents to develop surgical skills to perform safe TLH.