Objective: Robot-assisted surgery in the field of gynecology has been gaining popularity in recent years, particularly since 2018, when robot-assisted hysterectomy for uterine fibroids and uterine endometrial cancers was approved for insurance application in Japan. We reported results of the introduction of robot-assisted gynecological surgery in our institution.

Methods: We performed robotic-assisted surgery in 28 women with uterine fibroids or uterine endometrial cancers between February 2019 and April 2020, and perioperative characteristics (age, BMI, blood loss, required time for roll-in, docking and console, total operation time, and uterine weight) were investigated.

Results: Sixteen uterine fibroids and 12 uterine endometrial cancer cases were found. The average age was 47.0±3.9, 52.1±10.5 years, BMI was 24.9±5.2, 27.5±8.2, blood loss was 64.4±94.6, 10.8±20.2 g, total operation time was 154.5±32.5, and 168.7±66.5 minutes in uterine fibroids group and endometrioid cancer, respectively.

Conclusions: Robot-assisted gynecological surgery was safely performed at our institution. It is essential to accumulate more cases to evaluate the efficacy of robot-assisted gynecological surgery in the future.

Objective: The aims of this study were to clarify changes over time in surgery for benign gynecological disorders and to evaluate the perioperative complications of total laparoscopic hysterectomy (TLH).

Methods: This retrospective study included data of 262 patients who had undergone TLH for benign disease from January 2013 to December 2019. TLH was performed after determining on the basis of tumor markers and MRI that there was a low risk of malignant disease.

Results: Results: During the study period, 713 patients underwent abdominal hysterectomy for benign diseases, comprising abdominal hysterectomy in 432 patients, TLH in 262, and robotic-assisted surgery (RAS) in 19. From 2013 to 2015, TLH was performed on around 10% of patients; this percentage increased to around 50% from 2016. There were 12 perioperative complications in the 262 patients who had undergone TLH, comprising five intraoperative and seven postoperative complications. Perioperative complications comprised ureteral injury in two patients, bladder injury in two, and rectal injury in one. Postoperative complications comprised vaginal stump abscess in three patients, ureteral fistula in one, compartment syndrome in one, malignant hyperthermia in one, and open wound in one.

Conclusions: In this study, we investigated the complications of TLH. To achieve better outcomes of TLH, improvement in performance and safety of surgical procedures is important.

Objective: This study evaluated the advantages and disadvantages of the enhanced recovery after surgery (ERAS) clinical pathways and those traditionally used in the gynecological field for introducing the ERAS protocols in patients scheduled to undergo gynecological laparoscopy.

Methods: This was a prospective, randomized, controlled trial comprising women (18–75 years old) with benign gynecological disease who were scheduled to undergo laparoscopic surgery in June–September 2019. Patients who provided consent were randomly assigned to the traditional or ERAS group with the approval of the ethics committee of our hospital. A postoperative questionnaire and nursing and surgical records of the two groups were then evaluated.

Results: Consent was obtained from 191 patients (89 and 102 patients in the traditional and ERAS groups, respectively). The ERAS group reported shorter time for first postoperative defecation than the traditional group (p = 0.02). The number of physicians who had slight difficulty in performing surgical manipulation on ERAS group patients was significantly higher (p = 0.01). However, the ERAS protocols were successfully implemented in other settings.

Conclusion: Physicians had slight difficulty in performing surgical manipulation on ERAS group patients. However, since no periprocedural complications occurred, it can be assumed that laparoscopic surgery for benign disease was safely performed. Additionally, ERAS protocol in laparoscopic surgery enables the shortening of fasting period and duration of feeling queasy and relieves the patients from the discomfort associated with laxative use, making it more easily acceptable by the patients.

[Objective] We aimed to assess the safety and reliability of minimally invasive surgery (MIS) in the treatment of early-stage endometrial cancer.

[Method] This single-institute retrospective study compared clinical variables and disease-free survival (DFS) rates between an MIS group (38 cases) and a laparotomy group (71 cases) consisting of patients who were preoperatively diagnosed with clinical stage 1A, grade 1/2, endometrioid cancer and subsequently operated in our hospital between 2011 and 2019. The basic surgical procedures used were total hysterectomy, bilateral adnexectomy, and pelvic lymph node dissection.

[Results] The MIS group had a significantly longer operation time of 293 minutes versus the 224 minutes taken in the laparotomy group (median, p<0.01). Moreover, the MIS group had a significantly lower bleeding volume of 45 g compared with the laparotomy group, which was 303 g (median, p<0.01). The postoperative hospital stays were 8 and 12 days in the MIS and laparotomy groups, respectively (p<0.01). There were no significant differences in complications. There was no difference in terms of the DFS rates, which were 97% in both groups. Cox regression analyses showed that ovarian metastasis and high-grade histology were worse prognostic factors for DFS (p<0.001 and p=0.004, respectively).

[Conclusion] MIS was found to be a safe and reliable method for the treatment of early-stage endometrial cancer.

Objective: We aimed to evaluate the clinical and surgical results for ectopic pregnancy (EP) in patients with massive hemoperitoneum.

Materials and Methods: We evaluated the incidence, sites of implantation, clinical results, and surgical procedures of EP in patients with more than 500 ml of hemoperitoneum from January 2002 to September 2020 at Fukushima Red Cross Hospital.

Results: During the study, 250 patients with EP were treated surgically, including 36 (14.4%) with massive hemoperitoneum (≥500ml). The hemoperitoneum volume were as follows: 500~999 ml, 24 cases (9.6%); 1,000~1,999ml, 10 cases (4.0%); and ≥2,000ml, 2 patients (0.8%). Laparoscopic surgery was performed in all patients except in 1 with ovarian pregnancy who was preoperatively suspected of having ovarian bleeding at 5 weeks of gestation. Among 19 most recent cases in the present study, tubal ruptured occurred in 60% (100% in isthmus and 40% in ampulla). There were large variations in preoperative serum hCG level. Three of 8 patients (37.5%) with a hemoperitomeum volume over 1,500 ml had a shock index <1.

Conclusion: There was a poor relationship between hemoperitoneum and both preoperative vital signs and s-hCG level. Transvaginal and transabdominal ultrasonography examination may be the most useful tools for estimating hemoperitoneum volumes. Laparoscopic surgery is a useful and effective option when the patients are hemodynamically stabilized preoperatively and strictly monitored by senior anesthesiologist intraoperatively, then performed by surgeon with laparoscopic surgical skill and expertise, considering with risk factors such as obesity and severe adhesion. Salpingectomy is the treatment choice in patients with massive hemoperitoneum.

　The MorSafe™ is a type of collection bag to prevent tissue scattering when using a laparoscopic power morcellator for uterus or fibroma removal. The bag has two openings, one large, to contain the specimen and the morcellator, and one small (tail opening), for insertion of the scope. Having experienced some difficulty in inserting the scope through the tail opening, we decided to experiment with the use of forceps. We tried 2 methods, the first involves inserting forceps through the large opening into the tail, passing it through the navel from inside the bag, and using the forceps as a guide for the scope insertion. This proved tricky, with the approximate time from the bag insertion to start of morcellation being 20 minutes. The second method involves inserting forceps through the trocar into the tail opening first pulled out of the abdominal cavity, and used as a guide for trocar insertion. Once the trocar was in place the forceps were removed and replaced by the scope. Having performed the second technique on 8 cases, the average time to morcellation was 10 minutes. Also, by using forceps longer than the trocar, it was easier to keep the tail opening free from slack, thus minimizing resistance and blockage during the scope insertion process. The largest fibroid removed was 466 grams, and the S size bag, with a large opening measuring 125 mm in diameter, and a containment volume of 1600 mls, was sufficient for the procedures.

Objective: Insertion of the first trocar in laparoscopic surgery is associated with severe intestinal and vascular injuries; therefore, several techniques have been introduced to minimize complications. We retrospectively compared the open access technique (OAT) vs. direct optical access (DOA) to determine an easy and safe approach.

Method: We retrospectively reviewed records of patients who underwent laparoscopic surgery at two facilities (OAT was performed at one and DOA at the other) affiliated to our hospital between January 2018 and December 2018. We compared OAT and DOA with regard to the following parameters to determine the user-friendliness of each method: (1) time required for first trocar insertion and wound closure, (2) time required for first trocar insertion in patients with body mass index (BMI) >25 kg/m² and <25 kg/m², (3) time required for first trocar insertion based on the surgeon's experience (gynecological vs. non-gynecological specialists) and, (4) complications.

Results: The OAT and DOA groups included 104 and 142 patients, respectively. The mean times for first trocar insertion and wound closure were significantly shorter in the DOA group (p<0.01). No significant intergroup difference was observed in first trocar insertion time based on the BMI (OAT: p=0.588, DOA: p=0.216). The first trocar insertion time was significantly shorter in the OAT group when the procedure was performed by a specialist; however, no significant difference was observed in the DOA group (OAT: p=0.018, DOA: p=0.052). No complications occurred in either group during the study period.

Conclusion: DOA was technically easier than OAT; it was more effective in patients with mild obesity and was a simple technique that could be performed by less experienced surgeons and beginners.

  Between March 1991 and July 2019, we performed laparoscopic surgery for 836 ectopic pregnancies, including 13 abdominal pregnancies and one rare case of omental pregnancy. The mean gestational age at the time of treatment was 6 weeks and 5 days, and the mean maternal age was 28.4 years.

  The mean treatment-induced blood loss was 640 mL, and the mean preoperative serum human chorionic gonadotropin (hCG) level was 15,393 mIU/mL. The pouch of Douglas was the predominant site of abdominal pregnancy (n=9), followed by the vesicouterine peritoneum, Fallopian tube surfaces, posterior broad ligament, and the omentum. Laboratory investigations for serum chlamydia antibodies were performed in nine of 13 patients, and only one patient (11%) showed positive results. Coexistent pelvic endometriosis was observed in eight (8/13, 62%) patients, and we encountered the first case of an omental pregnancy, which represents a rare type of abdominal pregnancy. Transvaginal ultrasonography revealed a free hypoechoic area (10 mm) in the pouch of Douglas and thickened homogeneous endometrium without a gestational sac. A mass (46×38 mm) was detected outside the uterine fundus. T1-weighted magnetic resonance imaging revealed a mass (4 cm) showing a high-intensity signal between the left side of the fundus and the left ovary. Laparoscopy revealed an ectopic omental mass (4 cm) originating from the left fallopian tube and extending to the omentum, which was removed using laparoscopic partial omentectomy. Postoperatively, we observed a gradual decline in serum hCG levels in 11 of 13 (84.6%) patients, and two patients with persistent ectopic pregnancy received an intramuscular injection of methotrexate (50 mg). We observed no surgery induced complications. Six of seven women conceived postoperatively, one woman underwent an abortion, and the pregnancy progressed to a live birth in five women. Laparoscopy could successfully treat women with abdominal pregnancies, including a rare omental pregnancy, without any significant complications.

Objective: Endometrial polyps are relatively common lesions. Although most of the endometrial polyps are benign, some of them are either malignant or premalignant lesions, like atypical endometrial hyperplasia (AEMH) or atypical polypoid adenomyoma. This study retrospectively examined postmenopausal patients who underwent hysteroscopic endometrial polypectomy, a population considered to include a relatively large number of cases for diagnostic purposes.

Methods: We retrospectively examined 21 cases of postmenopausal women who underwent transcervical resection at our institution between January 2016 and April 2020. The indications for surgery included irregular bleeding or discharge in symptomatic cases and polyps larger than 15 mm in asymptomatic cases.

Results: In all 21 cases, preoperative endometrial cytology or histology was benign, with no abnormal findings by hysteroscopy. Among these cases, two were endometrial adenocarcinoma (G1) cases and one was AEMH case. Both the patients with endometrial adenocarcinoma were obese with a body mass index of ≥30; and one of them had hypertension and diabetes, which are the risk factors for type 1 uterine cancer.

Conclusion: To treat postmenopausal endometrial polyps, removal of the polyps without remnants under hysteroscopy for diagnostic purposes in symptomatic cases with bleeding, asymptomatic cases with large polyp diameters, and cases with a background risk of uterine cancer was necessary, even if no abnormalities were revealed on hysteroscopic findings or pathological cytology and histology.

Objective: To evaluate the anti-adhesive effect of AdSpray^®.

Methods: This study included five patients who underwent second-look laparoscopy (SLL) after their initial laparoscopic surgery with AdSpray^® at our hospital between December 2017 and December 2018. The adhesion status was evaluated based on the findings of the initial surgery and SLL to determine the anti-adhesive effect. Adhesion was evaluated using the adhesion score of the revised American Society for Reproductive Medicine classification, which is used to classify the severity of endometriosis.

Results: Of the five patients, a case of myomectomy showed no adhesion at the SLL. Another patient who underwent ovarian tumor enucleation and myomectomy had high adhesion scores at both the initial surgery and SLL. The other three cases were for endometriosis with chocolate cysts. Although their adhesion scores decreased at SLL, adhesion re-formation or newly developed lesions were observed around the adnexa.

Conclusions: The results of this study revealed that the use of only anti-adhesive materials, such as AdSpray^®, might be insufficient to prevent adhesions, depending on the adhesion status at the initial surgery, procedural maneuvers, and disease.

Purpose: Although laparoscopy is a standard approach popularly used for a wide range of gynecological procedures, significant disparities exist across geographical areas, particularly in the remote islands of Japan. In this study, we investigated the current status of laparoscopy used for gynecological surgeries in hospitals across the remote islands of Japan.

Methods: Between May and July 2019, we performed a questionnaire survey to investigate the current status of gynecological laparoscopic surgery across 20 hospitals in 16 remote islands of Japan. We selected hospitals that employed at least one gynecologist who worked full-time.

Results: We received responses from 18 of 20 hospitals (90%); a single gynecologist worked full-time at 8 hospitals and at least two gynecologists worked at the other 10. Gynecological surgeries were performed at 12 hospitals, and of these, 6 hospitals performed laparoscopic surgeries. Notably, hysteroscopic surgeries were performed at only 2 hospitals.

No laparoscopic specialist certified by the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (specialist) worked at any hospital on a remote island; total laparoscopic hysterectomy under specialist guidance was performed only at 2 hospitals. Approximately two-thirds of the respondents surveyed at the hospitals were of the view that laparoscopic surgery should be performed even on remote islands.

Conclusions: We investigated the current status of gynecological laparoscopic surgery on remote islands of Japan and observed that not only gynecologists but even the residents of the islands were of the view that laparoscopic surgeries should be performed on these islands. Performing gynecological laparoscopic surgeries on the remote islands is challenging: however, it might be possible to introduce this technique in these geographical areas with appropriate specialist support.

Objective: To assess the feasibility and validity of laparoscopic sentinel node navigation surgery (SNNS) in patients that were preoperatively diagnosed with stage IA endometrial cancer.

Design: Between December 2012 and May 2020, 69 patients that were diagnosed preoperatively with stage IA endometrial cancer and underwent SNNS followed by hysterectomy after SN removal, were enrolled in this study. Clinical data of patients in whom we succeeded in diagnosing and identifying the sentinel node (SN), and those in whom we could not, were analyzed statistically, and the outcomes of patients with positive or recurrent SN were described in detail. To assess the degree of pedal edema, the lymphatic flow in the lower limb was evaluated with ICG lymphography using a fluorescent camera. To evaluate the validity of the introduction of SNNS in each facility, a computer simulation program was developed to determine whether the introduction of SNNS during a given number of SNNS was appropriate.

Results: The detection rate of SN was 94.2% and there were five cases of recurrence, however, no pelvic lymph node recurrence was observed. ICG lymphography findings revealed no abnormal dermal back flow was observed in the examined patients. Two probabilities that SNNS is worse than SN were computed on the basis of the newest recurrence rate of SNNS in a facility and that based on the statistical data. Comparing the probabilities could absorb stochastic fluctuations in the recurrence rate of SNNS.

Conclusion: The data obtained in this study were safe and feasible with no complications or pelvic recurrence. Comparing the two probabilities by the computer simulations helps us to judge whether SNNS is valid with a fewer number of SNNSs.

  Cesarean Scar Syndrome (CSS)is known to cause abnormal genital bleeding and dysmenorrhea, and has recently been reported to contribute to secondary infertility.

  The hypothesis is thought that pooled blood in a cesarean scar defect interrupts the implantation of the embryo. There are some reports that operative therapy is superior to conservative therapy when treating secondary infertility.

  Our case is a 40 year old woman who was gravidity three, parity one, whose previous pregnancy was an emergency cesarean section delivery. The previous baby died from complications due to the trisomy 13. The patient presented with secondary infertility and was introduced to our hospital by another clinic. Her Anti-Mullerian-Hormone (AMH) was 0.16ng/ml and her uterus had uterine myoma 7cm in diameter. So we performed laparoscopic myomectomy followed by Assisted Reproductive Technology (ART). After 2 cycles of IVF-ET, she couldn't get pregnant, so we treated her as a poor responder. Considering her age, we tried to store her ovum and embryo by cryopreservation.

  In addition, she complained of abnormal genital bleeding and we conducted Magnetic Resonance Imaging (MRI). The image showed that there was a clear cesarean scar defect at the lower segment of the uterus.

  Therefore, we suspected CSS and performed hysteroscopic ablation for the lesion. After the operation she got pregnant by the first cycle of ART.

  Detailed medical interview is important to suspect CSS, and hysteroscopic ablation is an effective method for secondary infertility due to CSS.

  A 33-year-old pregnant woman with type 1 diabetes underwent an emergency cesarean section (CS) because of chorioamnionitis at 40/1 weeks of gestation. She complained of lower abdominal pain and persistent fever postoperatively. Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed abscesses in the Douglas and bladder uterine fossae. Despite treatment with antibiotics, her symptoms, including fever, and laboratory tests did not improve. Hence, transvaginal ultrasound-guided drainage was attempted on postoperative day 15 but failed due to high viscosity of the pus and thus conservative management was pursued. However, on postoperative day 21, laparoscopic drainage was performed since the patient's condition was resistant to the conservative management. The abscess was found to extend from the pelvis to the upper abdomen. Adhesiolysis and

exhaustive pelvic cavity lavage were performed. The anterior uterine wall scar was repaired by endoscopic sutures and drains were placed. The postoperative course was unremarkable with complete recovery. A repeat MRI scan of the abdomen 5 months postoperatively showed complete resolution of the previously seen abscess. Abscess formation after CS is a rare but fatal complication. Nevertheless, a standardized treatment for post CS intra-abdominal abscess is not yet established and the treatment is decided on a case-by-case basis. Management includes laparotomy, ultrasound or CT-guided drainage, and conservative treatment for most patients. Laparoscopic drainage can be an effective treatment, especially if the pus is highly viscous and resistant to other treatments/modalities.

  An ectopic kidney is a congenital anomaly characterized by an abnormal location of the kidney. In this report, we describe total laparoscopic hysterectomy (TLH) in a patient with an ectopic kidney. A 42-year-old gravida 0 para 0 woman was referred to our hospital for management of uterine adenomyosis with persistent genital bleeding and low abdominal pain. Magnetic resonance imaging revealed uterine adenomyosis and a right ectopic kidney. Drip infusion pyelography revealed a short right ureter without any other urinary tract malformations. She underwent four-port TLH. A 12-mm navel port was placed using the open method, and a 5-mm port was placed on the right side of the lower abdomen with the help of laparoscopic forceps. The muscular layer of the bladder was accidentally injured but was successfully repaired using single-layer closure, and routine TLH was performed. The estimated blood loss was 50 mL, and the operation time was 111 min. A urinary catheter was placed for one week. No postoperative complications were observed, and the patient was discharged on the 7^th postoperative day.

  Detailed preoperative evaluation is warranted to confirm the location of the urinary tract prior to TLH in patients with an ectopic kidney.

  Vaginal leiomyoma is a rare tumor that is not continuous with the uterus. Few reports on the laparoscopic removal of vaginal leiomyoma have been published. Here, we report a case of vaginal leiomyoma removed laparoscopically after laparoscopic hysterectomy.

  A 53-year-old woman, G2P2, presented with dysuria and hysteroptosis. Multiple uterine fibroids and a 50–mm myoma-like mass, located between the bladder and anterior vaginal wall, were detected using transvaginal ultrasonography and magnetic resonance imaging. We diagnosed the patient with vaginal leiomyoma associated with multiple uterine fibroids and planned a subsequent laparoscopic hysterectomy with vaginal tumor resection. The procedure was initiated under general anesthesia and pneumoperitoneum, and 5-mm trocars were placed in a diamond shape at four locations on the lower abdomen. After hysterectomy, we confirmed the presence of a tumor protruding from the anterior vaginal wall into the vaginal cavity. The tumor was laparoscopically removed as one mass via a longitudinal incision in the mucosa of the vaginal anterior wall. The pathological diagnosis was angioleiomyoma without malignancy. The postoperative course was uneventful. Consequently, the symptoms improved with no complications or recurrence to date.

  In conclusion, we recommend laparoscopic removal of vaginal leiomyoma after laparoscopic hysterectomy as a treatment option for the surgical treatment of vaginal leiomyoma.

  Gynecological leiomyomas most frequently occur in the uterus and rarely in the vaginal wall. We report a case of vaginal leiomyoma in a 35-year-old woman who presented with significant genital bleeding as a rare presentation of this tumor. Physical examination showed a bleeding mass (10 mm) at the posterior vaginal vault. Gauze compression was applied for 3 days to control bleeding. Transvaginal ultrasonography and contrast-enhanced magnetic resonance imaging revealed a tumor protruding into the pouch of Douglas, which led to a high index of clinical suspicion for a mesenchymal tumor or Schnitzler metastasis from a gastrointestinal malignant tumor. Although a vaginal biopsy could not definitively diagnose the lesion, a malignant tumor could not be excluded, and we performed laparoscopic total tumor resection. Histopathological examination revealed a leiomyoma. She has shown no recurrence over 9 months since the surgery.

Massive bleeding secondary to a vaginal leiomyoma as observed in this patient is extremely rare, and preoperative diagnosis is challenging. Laparoscopic resection with vaginal assistance may be useful in patients in whom the vaginal approach alone is ineffective.

  Teratomas of the fallopian tube are rare, and most of them are diagnosed during surgery. Here, we have reported a case of mature cystic teratoma of the left fallopian tube that was diagnosed during laparoscopic surgery for an ovarian teratoma.

  A 32-year-old para 2 woman underwent surgery for a left ovarian teratoma. During laparoscopic surgery, a cystic tumor with fat tissues and hairs was found in the ampulla of the left fallopian tube. The tumor had penetrated into the fallopian tube lumen. After discussion with her husband, laparoscopic salpingectomy was performed. Pathological examination revealed a mature cystic teratoma of the left fallopian tube.

  Tubal teratomas are typically discovered during surgery. In such cases, a detailed explanation should be provided to the patient preoperatively.

Background : Laparoscopic surgery for a strangulated ovarian tumor that invades the Douglas' pouch is challenging during pregnancy owing to the enlarged uterus. We report a case of total laparoscopic cystectomy using a cervical balloon for a strangulated ovarian tumor (10 cm) that invaded the Douglas' pouch in a pregnant woman.

Case : A 27-year-old gravida 0, para 0 was referred to our hospital with a left adnexal mass during the sixth week of pregnancy. Transvaginal ultrasonography and pelvic magnetic resonance imaging revealed a cystic left adnexal mass (10 cm) with septation. Laboratory investigations revealed slightly elevated serum cancer antigen 125. The patient developed abdominal pain during the 14 th week of pregnancy, and ultrasonography revealed a persistent enlarged left ovarian tumor. Therefore, we performed laparoscopic surgery at 14 weeks 1 day of the pregnancy. Intraoperatively, we detected a gravid uterus corresponding to 14 gestational weeks in size and a left ovarian tumor (10 cm) that invaded the Douglas' pouch. We could not extract the ovarian tumor from the Douglas' pouch into the pelvic cavity; therefore, a cervical balloon was inserted into Douglas' pouch followed by inflation of the balloon using 120 mL of water to lift the tumor into the pelvic cavity. The patient underwent successful cystectomy, and her postoperative course was uneventful. Histopathological evaluation confirmed the diagnosis of a "large solitary luteinized follicle cyst" , and the pregnancy continued without any issues postoperatively.

Conclusion : Our surgical technique does not require special equipment and could be useful in clinical practice.

Introduction: The incidence of endometrial cancer (EC) in women of reproductive age is increasing. Recently, the effectiveness of transcervical resection (TCR) for diagnosis and evaluation of therapeutic effects was demonstrated.

Case presentation: Case 1 was a 41-year-old woman who had undergone sterile treatment for years and was referred to a general hospital with complaints of increasing amount of menstruation. An endometrial biopsy and magnetic resonance imaging revealed that she had EC with an estimated stage of IB according to the International Federation of Gynecology and Obstetrics criteria. Although a laparotomy with total abdominal hysterectomy was recommended, the patient did not agree to the treatment option. She then visited our hospital for an alternative option and underwent TCR, which confirmed the diagnosis. Since deep myometrial invasion was restricted in TCR, a fertility-sparing treatment was performed. Case 2 was a 25-year-old woman who presented to a nearby hospital with atypical genital bleeding. Histological diagnosis based on an endometrial biopsy suggested endometrial carcinosarcoma. Although a hysterectomy was recommended, the patient did not agree to this treatment option. She was referred to our hospital, and she underwent TCR. The histological diagnosis was changed to endometrial adenocarcinoma G1 based on the biopsy obtained using TCR. A fertility-sparing treatment was performed, and complete remission was achieved.

Conclusion: Using TCR for diagnosis can drastically change the course of treatment in some cases. It is important to be prudent when diagnosing EC in young patients. Since TCR allows for the resection of only visible tumorous lesions and leaves the normal endometrium undamaged, it should be considered more often for patients with EC.

  Transabdominal myomectomy for cervical myoma is challenging; however, a hysteroscopic approach is easier and less invasive. We describe two patients treated with this approach.

Case 1: A 34-year-old, gravida 2 para 2 presented with a myoma (90 mm) that originated from the posterior wall of the uterus immediately below the external uterine ostium. An incision was made at the 3 o'clock position, and the myoma was dissected under direct vision. The remnant myoma tissue was excised hysteroscopically; the operation time was 25 min, and the myoma weighed 320 g.

Case 2: A 44-year-old, gravida 0 para 0 presented with a myoma (62 mm) that originated from the anterior cervical wall. Hysteroscopic myomectomy was performed after completion of three courses of pseudomenopausal therapy. The myoma was resected in a piecemeal fashion; the operation time was 84 min, and the myoma weighed 143 g.

Conclusions: We concluded that hysteroscopic removal of cervical myomas was easier than removal using transabdominal approaches.

  Here, we present a case of low-grade endometrial stromal sarcoma that was diagnosed after total laparoscopic hysterectomy was performed for the preoperative diagnosis of leiomyoma. A 49-year-old woman (gravida 1, para 1), who presented with the primary complaints of anemia and dizziness, was referred to our hospital. Based on ultrasound and magnetic resonance imaging findings, we diagnosed degenerated leiomyoma. We performed total laparoscopic hysterectomy and morcellation. Histopathological findings revealed a highly cellular neoplasm composed of round and spindle cells that had invaded the myometrium. Tumor cells were CD10 positive. This led to the diagnosis of low-grade endometrial stromal sarcoma. After informed consent was obtained, we performed laparoscopic bilateral salpingo-oophorectomy. Gross dissemination was not noted, and the peritoneal cytology was negative. Follow-up after 10 months was favorable.

  A pyomyoma, or suppurative leiomyoma, characterized by infarction- or infection-induced purulent changes in a leiomyoma is extremely rare; only approximately 50 cases have been reported in the available literature since 1945. We report a case of peritonitis due to a ruptured pyomyoma, successfully treated with emergency laparoscopic surgery.

  A 64-year-old postmenopausal gravida 0, para 0, with a history of uterine leiomyoma presented to our emergency department with fever and abdominal pain. On physical examination, she was febrile with mild nonspecific abdominal distention without rebound tenderness. Pelvic examination revealed an enlarged tender uterus. Laboratory investigations showed a significant increase in inflammatory markers, and computed tomography revealed an enlarged pelvic mass with calcification, a thick-walled cystic mass (12 cm), intestinal dilatation, and ascites. We performed emergency laparoscopy for suspected peritonitis secondary to a suppurative leiomyoma. Exploratory laparoscopy revealed massive purulent ascites and a ruptured pyomyoma. We performed laparoscopic myomectomy and lavage. The patient showed an uneventful recovery and was discharged 15 days postoperatively.

  Although laparoscopic management of peritonitis is challenging, this approach offers the advantages of direct observation and prevention of surgical site infection. In conclusion, immediate surgical intervention is warranted in patients with peritonitis secondary to a suspected pyomyoma. We consider laparoscopic approach is useful not only for diagnosis but also for surgical treatment.

  Preoperative diagnosis of small uterine endometrial lesions by endometrial curettage biopsy can be difficult because tissue from localized lesions may not be obtained by this procedure. We here report a case of atypical endometrial hyperplasia in an endometrial polyp that was not diagnosed by several endometrial curettage biopsies but was finally diagnosed by resectoscopic partial resection. A 54-year-old woman, gravida 2, para 2 was referred to our hospital because cervical cytology had shown atypical glandular cells-favoring neoplasia. Cervical and endometrial biopsies obtained in our hospital yielded only normal tissue and MRI examination showed no obvious abnormalities. Hysteroscopy revealed a polypoid lesion near the ostium of the left fallopian tube, prompting repeat endometrial curettage biopsy. However, it proved difficult to collect a sample from that polypoid lesion, which was therefore removed via a resectoscope. Histological examination of the specimen thus obtained resulted in a diagnosis of atypical endometrial hyperplasia in an endometrial polyp. Abdominal simple total hysterectomy and bilateral salpingo-oophorectomy was therefore performed. The final pathological diagnosis was also atypical endometrial hyperplasia. We therefore suggest that removal of specimens via a resectoscope may be a useful means of diagnosing endometrial lesions from which it is difficult to collect tissue by endometrial curettage.

  Most cystic lesions of the uterine cervix are benign; however, it is important to distinguish these from gastric-type adenocarcinoma, including minimal deviation adenocarcinoma. Although radical hysterectomy is the standard surgical procedure for cervical cancer, it is highly invasive and requires accurate preoperative diagnosis. We report two cases of gastric-type adenocarcinoma of the uterine cervix in patients who were preoperatively diagnosed with lobular endocervical glandular hyperplasia (LEGH) and underwent laparoscopic simple hysterectomy. These cases highlight the role of preoperative conization for cervical cystic lesions. Additionally, definitive diagnosis is difficult in patients with preoperative imaging findings showing LEGH; therefore, laparoscopic surgery should be carefully considered if malignancy cannot be ruled out. Gastric-type adenocarcinoma of the uterine cervix is rare, and a limited number of cases could be investigated at a single center; therefore, further multicenter large-scale studies are warranted to confirm our findings.

  Cesarean scar syndrome (CSS) is caused by a defect in a prior cesarean section scar. Patients with CSS have gynecologic symptoms such as post-menstrual brown discharge, pelvic pain, and secondary infertility. We report three cases of CSS that received successful surgical treatment. Two cases showed post-menstrual brown discharge and one case showed a history of secondary infertility for four years. Transvaginal ultrasonography and magnetic resonance imaging indicated the cesarean scar defect and blood pooling. In all cases, we performed surgical treatment. We could not identify the cesarean scar defect by laparoscopy only. In two cases, we performed combined hysteroscopic and laparoscopic study, and in one case, we cut the myometrium vertically to identify the defect. Immediately after surgery, the post-menstrual brown discharge disappeared, and the case with secondary infertility achieved pregnancy six months after surgery. In conclusion, using hysteroscope or cutting the myometrium vertically was useful for identifying the defect.

  Although mature cystic teratoma is a common benign tumor, it is rarely found in an ectopic accessory ovary. Our patient was a 31-year-old woman in whom a right ovarian tumor had been suspected during an earlier pregnancy. Magnetic resonance imaging indicated a right ovarian mature cystic teratoma. Laparoscopy showed a tumor in the Douglas pouch. Her left adnexa and right tube were normal, but her right ovary, although in the proper position, was atrophied to the size of a fingertip, and was connected to a soybean-sized accessory ovary. The tumor in the Douglas pouch was also connected to the accessory ovary. The tumor had a knobby, hemispheric lesion on its surface, and filmy adhesions to the pelvic peritoneum and the colon. The tumor adhesions were delicate and detached from their surroundings, with no feeding structures. The tumor was pathologically diagnosed as a mature cystic teratoma. Because follicular cysts were found in the hemispheric area, it was classified as ovarian tissue. In conclusion, the tumor was diagnosed as a mature cystic teratoma arising in an ectopic accessory ovary.

Introduction: Multiple ectopic gestations are extremely rare. Multiple ectopic pregnancies occur less frequently than heterotopic gestations and may appear in a variety of locations and combinations. However, with the advent of assisted reproductive technologies (ART), the incidence appears to be rising. We encountered a case of simultaneous pregnancies in the cervix and the left fallopian tube after ART.

Case: Though the serum human chorionic gonadotropin (hCG) value of a 39-year-old female with two transferred embryos was 9,687 mIU/mL at 5 2/7 weeks of pregnancy, ultrasonography showed no gestational sac in her uterus. Three days later, when the serum hCG level reached 13,499 mIU/mL, ultrasonography revealed cysts in both the cervix and the left adnexa. Magnetic resonance imaging (MRI) showed simultaneous pregnancies in the cervix and the left fallopian tube. First, laparoscopic salpingectomy was performed for the left tubal pregnancy. The next day, the gestational sac in the cervix was expelled spontaneously with little blood loss. Villi were found pathologically in both the excised left fallopian tube and the tissue excreted from the cervix.

Conclusion: For multiple ectopic pregnancies at different sites that are difficult to treat at the same time, we propose promptly carrying out the treatment that can be reliably completed with a small physical burden on the patient. This facilitates the planning of the therapeutic strategy for the remaining ectopic pregnancy.

  Endometriotic cysts often develop in the ovaries, while endometriotic nodules commonly develop in extra-ovarian sites. Herein, we report a rare case of an endometriotic cyst occurring in the mesosalpinx, and immunohistological reviews of it's the pathogenesis. Magnetic resonance imaging of a 36-year-old multiparous female patient detected a 6 cm-large cyst in the right adnexal region. Likewise, a cystic tumor in the right mesosalpinx distant to the right fallopian tube and ovary, was detected via laparoscopy. On pathological examination, the inner surface of the cyst was lined with cuboidal epithelium and showed hemosiderin deposition and, thus, was diagnosed as an endometriotic cyst. Immunohistologically, it was positive for CD10 and vimentin, further supporting the diagnosis of endometriotic cyst. It was also positive for estrogen and progesterone receptors, indicative of a Müllerian-type epithelial character, and parts with positivity and negativity for the mesothelial marker calretinin were found. The calretinin-negative transition was considered to be due to a metaplastic process from peritoneal mesothelium to Müllerian-type epithelium. In conclusion, the coelomic metaplasia theory is possibly involved in the pathogenesis of endometriotic cysts located in the mesosalpinx. Detailed macroscopic findings via laparoscopy were also helpful in reaching this conclusion.

  Gartner's duct cysts often occur in the deep and anatomically inaccessible areas of the pelvis and are therefore difficult to diagnose and treat. We report a case of a Gartner's duct cyst that was diagnosed using laparoscopic biopsy and was treated with tetracycline sclerotherapy. A 43-year-old woman was referred to our hospital with lower urinary tract symptoms. Magnetic resonance imaging of the pelvis revealed a multilocular cystic tumor (40 mm×25 mm) between the bladder and the anterior vaginal wall. Image-guided transvaginal fine-needle aspiration was performed, and based on cytological evaluation of the tumor contents, we suspected adenocarcinoma and performed a laparoscopic biopsy for diagnostic confirmation. We used the technique of dissection of the vesicovaginal pouch toward the Aa point, similar to laparoscopic sacral colpopexy and designed an approach for access to the tumor at the anterior vaginal wall. Histopathological evaluation of the resected specimen showed that the tumor wall was covered with flat to cubical epithelium without evidence of malignancy. Immunohistochemical evaluation showed cells with immunopositivity for CK7 and immunonegativity for CK20 and MIB-1 levels <5%. Based on these findings, we confirmed the diagnosis of a Gartner's duct cyst. The cystic fluid re-accumulated after the laparoscopic biopsy, with recurrence of lower urinary tract symptoms. Tetracycline sclerotherapy was performed and led to cyst shrinkage with improvement in the patient's symptoms.

  A laparoscopic approach, specifically a bladder-vaginal detachment procedure performed via laparoscopic sacral colpopexy is useful to treat pelvic floor cystic tumors. Tetracycline sclerotherapy may be useful for conservative management of Gartner's duct cysts or recurrence.

CASE: A 41-year-old gravida 1, para 1 presented with dysmenorrhea and anemia. Magnetic resonance imaging revealed a left-sided endometriotic cyst (45 mm) and a submucosal uterine fibroid (48 mm). She underwent hysteroscopic myomectomy and laparoscopic adnexal resection, following 3-month pseudomenopausal therapy.

  Hysteroscopic surgery involved fragmentation and removal of the myoma, which weighed 67 g. Subsequently, we performed laparoscopic surgery, and intraoperatively we observed intra-abdominal bleeding that extended to the liver surface. The source of bleeding was identified as the ruptured broad ligament. We performed left adnexal resection after satisfactory hemostasis was achieved. The estimated intraperitoneal hemorrhage was 900 mL. Transabdominal ultrasonography performed upon completion of hysteroscopic surgery could not identify the source of intra-abdominal bleeding. However, subsequent immediate laparoscopic surgery successfully detected the bleeding source. Hysteroscopic myomectomy should be performed cautiously in patients with endometriosis.

  Intrathoracic endometriosis is a rare and atypical site of endometriosis. A large number of cases of intrathoracic endometriosis are being reported in recent times, owing to an increase in the incidence of endometriosis.

  We report a case of hemopneumothorax secondary to intrathoracic endometriosis, following laparoscopic surgery.

  A 49-year-old woman who underwent laparoscopic cholecystectomy for gallstones at another hospital developed significant right-sided pleural effusion, along with right-sided pulmonary collapse and pneumothorax on postoperative day 3, and hemopneumothorax was suspected in this case. We performed thoracoscopic surgery to confirm the diagnosis. Intraoperatively, we observed no clear evidence of intrathoracic bullae; however, we detected several small brittle ruptured pleural vessels and hemorrhage from these vessels. Furthermore, we observed endometrial deposits in the diaphragm, and a biopsy of the resected tissue confirmed diaphragmatic endometriosis. We speculated that the gas used to establish pneumoperitoneum passed through the diaphragmatic defect caused by intrathoracic endometriosis, leading to pneumothorax, which resulted in rupture of the brittle intrathoracic vessels and consequent hemopneumothorax.

  Hemopneumothorax following laparoscopic surgery is rare. However, intrathoracic endometriosis increases the risk of hemopneumothorax, as observed in our patient. Prediction of intrathoracic endometriosis prior to its development is challenging.

  Various surgical instruments are routinely used for laparoscopic surgery, which represents a minimally invasive approach. However, retrieval of broken pieces of instruments/foreign bodies lodged in the abdominal cavity is challenging. We report a case of emergency laparoscopic surgery for a ruptured ovarian cyst in a patient who presented with a postoperative pelvic abscess in whom we identified a broken piece of a needle holder that was retrieved following reoperation 11 months after the initial surgery. The patient was referred to our department after computed tomography revealed a pelvic mass (9 cm in length). She underwent emergency laparoscopic-assisted ovarian cystectomy for a ruptured left ovarian endometrial cyst. Intraoperatively, the suture needle and thread could not be grasped, and the instruments were replaced. Postoperatively, the patient developed a pelvic abscess and was treated with antimicrobial agents. Magnetic resonance imaging performed on the 12^th postoperative day revealed a metal artifact, which led to the identification of a 1 mm-sized defect and remnants of a laparoscopic needle holder. The patient was asymptomatic and refused surgical retrieval of these items and was therefore observed. The foreign body was laparoscopically retrieved, 11 months postoperatively because it appeared to be immobile within the pelvis. Laparoscopic instruments are fragile. X-ray fluoroscopy and magnets are useful to retrieve small metal fragments.

  Barbed sutures are widely used to suture the myometrium in cases of cesarean delivery and myomectomy, as well as to suture the vaginal stump in hysterectomy. Although barbed sutures facilitate rapid and accurate tissue approximation, protrusion of the cut end of the suture into the abdominal cavity and subsequent entanglement in the intestinal tract or mesentery can cause bowel obstruction or volvulus. We report a case of strangulated ileus after laparoscopic myomectomy using barbed sutures. We ligated the cut end of the barbed suture using another suture and cut it as short as possible. The patient has shown no complications postoperatively. We report our novel suturing method, which could be useful clinically in such cases.

  Precise clinical differentiation between lobular endocervical hyperplasia (LEGH) and mucinous carcinoma, including the gastric type, in women with multi-cystic lesions in the uterine cervix is important. However, tissue sampling is difficult when the lesions are located near the internal os. We report the effectiveness of hysteroscopic transcervical resection (TCR) in the diagnosis of LEGH located at the internal os. A 35-year-old Japanese woman with clinical LEGH was followed-up at our hospital. After 3 years of follow-up, she required pathological examination because the lesion increased in size, which suggested malignant transformation. We performed TCR for biopsy because the LEGH lesion was located at the internal os and conization biopsy was considered difficult. Hysteroscopic observation revealed a blue bulging area in the post cervical wall near the internal os, and tissue samples were taken from the lesion by TCR. Pathologically, lobular proliferation of cervical glands with positive HIK1083 and PAS reactions was observed, confirming the diagnosis of LEGH. Cervical biopsy using TCR may be effective for the pathological diagnosis of LEGH located near the internal os.