Purpose: To verify the efficacy of the endometriosis fertility index (EFI) for predicting spontaneous pregnancy after surgery for endometriosis.

Methods: We retrospectively evaluated the predictive value of postoperative EFI for spontaneous pregnancy in 26 patients who underwent surgery for ovarian endometrioma in our institution between 2010 and 2016.

Results: The median EFI score in all patients was 7, and the rate of spontaneous pregnancy after surgery was 35%. The cut-off EFI score obtained from the receiver operating characteristic (ROC) curve was 8 (AUC, 0.79; sensitivity, 0.67; specificity, 0.82). Rate of spontaneous pregnancy with EFI scores ≤ 7 was significantly lower than that with EFI scores ≥ 8 (18% vs. 67%, P = 0.028). Infertility treatment with assisted reproductive technology (ART) increased pregnancy rates in the lower EFI score group.

Conclusion: We confirmed that the EFI was a reliable prediction tool for spontaneous pregnancy in patients with surgically treated endometriosis. In infertile patients with EFI scores ≤ 7, ART therapy should be recommended.

Objective: This study aimed to analyze the surgical outcomes of robotic-assisted surgery for early-stage endometrial cancer compared with those of laparoscopic surgery and laparotomy.

Methods: The clinical data and perioperative outcomes of stage IA endometrial cancer patients who underwent total hysterectomy, bilateral salpingo-oophrectomy, and pelvic lymphadenectomy by robotic-assisted surgery, laparoscopic surgery or laparotomy from January 2011 through December 2020 were reviewed and analyzed retrospectively.

Results: A total of 122 patients were eligible (robotic-assisted surgery, n=24; laparoscopic surgery, n=72; laparotomy, n=26). The median operation time for robotic-assisted surgery was longer than that for laparoscopic surgery and laparotomy (P < 0.0001). Robotic-assisted surgery resulted in less blood loss (P < 0.0001) and a shorter postoperative stay (P < 0.001) than laparotomy but was not different from laparoscopic surgery. There was no difference in the number of lymph nodes retrieved among the three groups. Three (17%) robotic-assisted surgeries, 6 (8%) laparoscopic surgeries, and 3 (12%) laparotomies resulted in perioperative complications (P=0.47). Two patients who underwent laparoscopic surgery developed recurrence.

Conclusions: Robotic-assisted surgery has similar surgical outcomes to laparoscopic surgery and offers a safe alternative in the surgical treatment of early-stage endometrial cancer, although the operative time may need to be shortened.

Objective: We investigated the effectiveness of switching cefazolin (CEZ) to cefmetazole (CMZ) for preoperative antimicrobial prophylaxis and the role of preoperative vaginal preparation using normal saline to reduce vaginal cuff infectious morbidity after total laparoscopic hysterectomy (TLH).

Methods: We retrospectively investigated 1476 patients who underwent TLH at our hospital between April 2010 and December 2020. The vaginal cuff infectious morbidity and the causative bacteria were analyzed. The CEZ group included 1095 women who received a preoperative intravenous drip injection of CEZ, the CMZ group included 221 women who received a preoperative intravenous drip injection of CMZ, and the vaginal cleaning group included 160 women who received a preoperative intravenous drip injection of CMZ and additionally underwent preoperative vaginal preparation using normal saline. We analyzed post-TLH data to determine the causative bacteria associated with vaginal cuff infection.

Results: Postoperative vaginal cuff infection occurred in 2.38%, 2.26%, and 1.25% of women in the CEZ, CMZ, and the vaginal cleaning groups, respectively. Intergroup comparison did not show a significant difference in vaginal cuff infectious morbidity. The causative bacteria associated with post-TLH vaginal cuff infection predominantly belonged to the Enterococcus species (10/38 cases).

Conclusion: Our study showed no significant intergroup difference in vaginal cuff infectious morbidity; however, further studies are warranted to conclusively establish the effectiveness of preoperative vaginal preparation using normal saline.

Objective: We aimed to evaluate the clinical and surgical results for unusual sites of ectopic pregnancy (U-EP) treated at Fukushima Red Cross Hospital.

Materials and Methods: We evaluated the incidence, clinical results, and surgical procedures of U-EP from January 2002 to June 2020. We discussed the current status of U-EP management based on the recent literatures.

Results: During the study, 245 cases of EP were treated surgically, including 24 cases of U-EP (9.8%). The subtypes of U-EP were as follows: 13 cases (5.3%) were interstitial pregnancies (IP), 7 cases (2.9%) were ovarian pregnancies (OP), and 4 cases (1.6%) were peritoneal pregnancies (PP). Laparoscopic surgery was the most common procedure (95.8%); only 1 case of IP was primarily treated with laparotomy. For IPs, serum human chorionic gonadotropin levels were higher than with tubal pregnancy and intraperitoneal bleeding were less than with other EP sites, but no cases with rupture were identified. As surgical procedures, cornual resection and cornuotomy were selected in 7 and 6 cases, respectively.

Conclusion: IP has been reported to be associated with a higher risk of massive intraperitoneal bleeding once it ruptures, and OP and PP have higher risk of intraperitoneal bleeding earlier during pregnancy. Earlier preoperative diagnosis and appropriate surgical intervention for EP are required, especially for U-EP, although the identification of U-EP implantation sites is difficult. As clinical evidence regarding medical and expectant treatment for U-EP are poor, strict management is important when these therapies are selected.

  Verbalized feedback on intracorporeal suturing and knot-tying movements was incorporated into our institute's assessments, and important aspects of the procedures were identified for future introduction in the training module.

  Seven valuers and six participants receiving training in laparoscopic surgery, blinded to each other, were recruited by a moderator who ensured fair assessments. Five courses of tasks and assessments were performed every 2 weeks for 3 months (April–June 2020). Tasks such as holding and handling the needle, and surgical and slip knot tying were performed with dry box training on a vaginal stump model. The moderator uploaded performance videos online, viewable by only participants and valuers, which the valuers assessed using a Google form, the Global Rating Scale, and verbalized free comments, including what could and could not be done and three focus areas, as feedback.

  We classified verbalized free comments into those on holding and handling the needle; pulling and cutting the thread; and general, surgical, and slip knot tying, among others. Most comments addressed surgical or slip knot tying. Valuers provided varying opinions on techniques, but all emphasized understanding the principle by training under direct vision, actively using the non-dominant hand, inter-hand coordination, holding the thread or tissue by the forceps tip, proper length adjustment of the short or long tail, and direction of pulling the thread.

  With verbalized assessments, we identified focus areas and issues initially observed in the suturing and knot-tying training; this is a potential index for training and should be introduced as such.

Objective: Laparoscopic video-based educational material helps in self-training of laparoscopists. However, its effectiveness in medical students remains unclear. During the COVID-19 pandemic, we stopped clinical training at our hospital and instead provided the abovementioned educational material. In this study, we clarified its effectiveness in medical students.

Methods: From July 2020 to May 2021, 87 fifth-grade medical students watched a 30-min video on total laparoscopic hysterectomy. Using the Likert scale, we interviewed the students about their impression of the material. We also asked whether it helped understand anatomy or surgical procedures and motivated students to study obstetrics and gynecology or surgery.

Results: The length and difficulty of the material were evaluated as "appropriate" by most of the students. Interest or aptitude of the material and helpfulness for learning pelvic anatomy or gynecological surgery both scored the highest. The second-best score was regarding the motivation to study obstetrics and gynecology or to join surgery. The impression of the length of the material correlated negatively with its aptitude. In contrast, the aptitude was positively correlated with helpfulness for understanding pelvic anatomy, surgery, or motivation for learning.

Conclusions: In this study, laparoscopic video-based educational material was favorably accepted by medical students. However, assessments of the strength and weakness of the material are needed for improving medical education after the COVID-19 pandemic.

  Uterine myomectomy is a procedure that is relatively prone to postoperative adhesion formation, which can cause infertility, chronic pelvic pain, and bowel obstruction. The sheet adhesion barriers, Interseed and Seprafilm, have been widely used to reduce such postoperative adhesions and have been effective to some extent. However, due to the characteristics of these sheet-based materials, a certain level of experience and skill is required to insert the barrier in the abdominal cavity and place it in the appropriate site. In contrast, Adspray is a spray-type barrier that is relatively easier to use than sheet-based barriers and has been reported to shorten the operation time. We have experienced 11 cases in which we were able to evaluate the anti-adhesion effects of Adspray after myomectomy. This study supports the effectiveness of Adspray to prevent adhesion.

  Ovarian clear cell borderline tumors are extremely rare, accounting for less than 1% of all borderline ovarian malignancies. The preoperative diagnosis of ovarian borderline malignancy is difficult in some cases, and although the number of cases diagnosed incidentally after laparoscopy is increasing, the optimal treatment for each histological type is unclear. In this case report, we describe a 65-year-old woman who was diagnosed with a cystic ovarian clear cell borderline malignancy without adenofibromatous components after laparoscopy. She presented at our hospital due to an abnormal medical examination, and an MRI revealed a polycystic lesion in the left appendage area. No obvious malignant findings were observed, and laparoscopic bilateral salpingo-oophorectomy was performed. The pathology was determined to be cystic ovarian clear cell borderline malignancy. No additional postoperative treatment was given, and the patient was carefully monitored and has not experienced postoperative recurrence for 1.5 years.

Case: A 16-year-old Japanese female adolescent presented with left-sided lower abdominal pain. Ultrasonography and magnetic resonance imaging revealed a left adnexal cyst (5 cm). Her history was unremarkable except for a sliding inguinal hernia attributable to inguinal herniorrhaphy.

  We report a case of tubal occlusion and ovarian atrophy secondary to fallopian tube and ovarian ligation associated with inguinal herniorrhaphy.

  A uterine artery pseudoaneurysm (UAP), which usually occurs after deliveries or miscarriages, is known to cause massive vaginal bleeding and may even be fatal in some cases. We report a rare case of UAP secondary to the use of a uterine manipulator during laparoscopic surgery.

  A 40-year-old woman presented with a right ovarian cyst and infertility and underwent uneventful laparoscopic ovarian cystectomy. She returned one month later with massive vaginal bleeding. Transvaginal ultrasonography revealed a cystic lesion (20 mm) with a pulsating blood flow near the uterine endometrium. We suspected UAP secondary to uterine manipulator-induced injury during the previous laparoscopic surgery, and she was referred to a tertiary center for further evaluation.

  Emergency angiography revealed UAP to the left of the uterus, and the patient underwent uterine artery embolism (UAE). Following UAE, the patient conceived via assisted reproductive technology and delivered transvaginally subsequently.

  A uterine manipulator is a common device used during gynecological laparoscopic surgery. We report UAP attributable to uterine manipulator-induced injury. Clinicians should be mindful that a uterine manipulator may injure the uterine endometrium with a consequent risk of UAP.

  We report a case of massive ovarian edema after laparoscopic resection of an ovarian mass with suspicion of a large ovarian tumor.

  The patient, aged 30 years, was suspected of having a right ovarian mass and presented to our hospital for the first time. The right ovary was enlarged to 50 × 41 mm and appeared to have follicles surrounding the mass. There was no elevation of tumor markers, and hormone tests showed luteinizing hormone (LH) levels > follicle-stimulating hormone (FSH) levels. There were no findings that indicated malignancy, and the patient was placed under observation. Subsequently, laparoscopic surgery was performed in 2 years later due to right lower abdominal pain. The right ovary was enlarged to 5 cm in size. An incision was made, a clear exudate was observed, and the center of the ovary was a soft yellowish-white edematous tissue. A biopsy with a diameter of 2 cm was performed at the center of the ovary. No neoplastic changes were observed on pathological diagnosis, and a diagnosis of massive ovarian edema was made. The final diagnosis was made after laparoscopic surgery with observation and biopsy. This case demonstrates the importance of laparoscopy in the diagnosis of ovarian disorders and preservation of ovarian function.

  Laparoscopic surgery is a minimally invasive approach and is therefore widely popular among gynecologists for both benign and malignant disease. Laparoscopic surgery for early endometrial cancer was covered by the National Health Insurance System in Japan in 2014, and is routinely performed nationwide since 2014.

  Several overseas studies have reported that the prognosis of laparoscopic surgery for endometrial cancer is similar to that observed with open surgery; however, few studies have discussed this subject in Japan.

  Our facility introduced this surgery in 2014, and 50 surgeries were performed between April 2014 and December 2020. During the follow-up period, we observed recurrence, para-aortic lymph node metastasis, omental metastasis, and vaginal implantation metastasis in two patients. We report two cases of recurrence based on the previous literature. In this study, we investigated the clinical aspects of laparoscopic surgery for endometrial cancer at our hospital. Based on our observations in these two cases, we emphasize the importance of optimal patient selection and evaluation of laparoscopy for the surgical management of endometrial cancer. To achieve oncologic outcomes comparable with those of laparotomy, it is important to develop safe laparoscopic procedures to prevent cancer recurrence. The accumulation of more cases is warranted to refine the laparoscopic procedure.

  Interstitial pregnancy is a relatively rare condition that accounts for 2–4% of all ectopic pregnancies; specifically, interstitial pregnancy after ipsilateral salpingectomy accounts for 0.3–4.0% of all ectopic pregnancies. Its surgical treatment includes cornual wedge resection and cornuotomy. Careful selection of the surgical procedure is important considering reports of onset of persistent ectopic pregnancy (PEP) after surgery and uterine rupture in postoperative pregnancy. In this study, we report two cases of interstitial pregnancy after ipsilateral salpingectomy managed laparoscopically using two different techniques.

  In case 1, the patient who underwent cornual wedge resection was completely cured via surgical treatment alone; in case 2, the patient who underwent cornuotomy developed PEP and required additional treatment. Although cornual wedge resection is a more curative procedure, it yields an increased risk of uterine rupture during postoperative pregnancy. Cornuotomy is useful for patients wishing to preserve their fertility, as it preserves the myometrium and may reduce the risk of uterine rupture in the next pregnancy. Currently, the use of methotrexate therapy is recommended in addition to surgical treatment to prevent the development of PEP.

[Introduction] Fallopian tube torsion is a rare disease. We report a case of fallopian tube torsion in a young girl.

[Case] The patient was a 12-year-old girl. She had her first menstruation 4 months prior to presentation and did not have a history of sexual intercourse. On her visit to the emergency department, her chief complaint was left lower abdominal pain. Transrectal echography revealed a 3-pack mass approximately 37 mm in size in the left appendage area. Blood test analysis did not reveal any increases in inflammatory response and levels of tumor markers. As the patient reported no exacerbation of the abdominal pain, we deemed that emergency surgery was not necessary and followed up the patient. On the fourth day of hospitalization, still no exacerbation of the left lower abdominal pain occurred. Thus, ovarian torsion was suspected, and emergency surgery was planned for treatment and diagnostic purposes. The intraoperative findings showed that the left fallopian tube was twisted three times counterclockwise. On the basis of these findings, a diagnosis of left fallopian tube torsion was made. After the torsion was released, part of the fallopian tube was found to be necrotic; therefore, the left fallopian tube torsion was not released but, instead, was resected. The patient's postoperative course was uneventful. She was discharged from the hospital 4 days after the operation.

[Conclusion] Fallopian tube torsion is a rare disease. Definitive diagnosis takes time, and saving the fallopian tubes is difficult. From the aspect of fertility, the possibility of fallopian tube and ovarian pedicle twisting should be considered in young patients with acute abdomen, and early positive laparoscopic orientation is desired.

  Well differentiated papillary mesothelioma, WDPM is a benign rare tumor. The longterm prognosis and characteristics of the disease are still unclear. We report a case of unifocal WDPM, two-millimeter in the greatest dimension, which was incidentally found in the small bowel mesentery during laparoscopic surgery for endometrial cancer. The patient is a woman in her 40s with no history of pregnancy. She was on hemodialysis for chronic renal failure due to type 2 diabetes and was consulted for anemia due to menorrhagia. Endometrioid carcinoma grade1 of uterine endometria was diagnosed by performing a total endometrial scraping. There was no tumor found in endometrium lesion on MRI study, and CT showed negative lymphadenopathy and distant metastasis. Laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performe d. During operation, a small tumor was found on the small bowel mesentery during observation after hysterectomy and it was completely resected. Careful observation around the tumor was performed and no other tumors were found. The postoperative pathological diagnosis was endometrial carcinoma clinical stage IA, and WDPM for a small tumor on bowel. The patient is being followed up without any post treatment, and both endometrial cancer and WDPM have passed without recurrence. Complete resection of tumor, judicious sampling and immunohistochemistry, and careful histopathological diagnosis is necessary for WDPM. When mesentery tumor is accidentally found during laparoscopic surgery for gynecological diseases, careful resection would help us to detect small tumors such as WDPM.

  A 14-year-old female adolescent presented with sudden pain in the suprapubic region. She denied a history of pregnancy, childbirth, and sexual intercourse or any relevant medical history. She underwent medical examination at this hospital, and ultrasonography and computed tomography (CT) revealed a multilocular cystic tumor (13 cm) in the pelvis. She was diagnosed with left ovarian cystic tumor torsion, and underwent laparoscopic surgery. The cyst was punctured to ensure clear visualization of the operative field. We observed normal bilateral adnexal structures and identified a tumor that originated from the ileal mesentery. The cystic fluid was bloodstained, and her pain was attributed to intracystic hemorrhage within the mesentery. We performed only cystic drainage, and the patient's postoperative course was uneventful.

  Retrospective evaluation of the CT images revealed the superior mesenteric artery coursing through the cyst, and we diagnosed her with a possible mesenteric cyst.

  Unfortunately, we assumed that the cyst originated from the ovary, and puncture was performed before the site of the cyst could be confirmed.

  We emphasize that preoperative evaluation of imaging findings is essential in patients with a pelvic neoplasm, and clinicians should not conclude that the lesion is an ovarian tumor without considering a mesenteric cyst in the differential diagnosis.

  Parasitic leiomyoma is a rare manifestation of uterine leiomyoma that loses its adherence to the uterus to attach to other pelvic or intra-abdominal organs. Most reported tumors presented during laparoscopic myomectomy or hysterectomy.

  We report here a case of spontaneous parasitic leiomyoma with torsion in a 30-year-old woman with no previous surgeries. She was diagnosed with a subserosal leiomyoma during pregnancy. She reported pain during her second trimester because of the leiomyoma, which disappeared with conservative treatment, and she eventually delivered at full-term. After 2 years, she opted for surgical removal of the leiomyoma. Through preoperative transvaginal ultrasonography, we suggested the tumor to be ovarian in origin because it was located far from the uterus. Laparoscopy revealed the tumor to be separated from the uterus with a 720° torsion on the vesicouterine pouch.

  A postoperative histopathological examination diagnosed the tumor as a parasitic leiomyoma. There have only been 24 reports of spontaneous parasitic leiomyoma, and this is the first case with associated torsion in Japan. We believe that we have experienced an extremely rare case of leiomyoma.

  Laparoscopic surgery has become the standard of care for benign gynecologic conditions. We have performed more than 1300 laparoscopic surgeries since the introduction of the technique to our hospital in 2014 and have adopted the method for total laparoscopic hysterectomy (TLH), using the diamond port position and removing the morcellated uterus through the vagina. Although we have had no recognized ureteral injuries, two patients have unfortunately experienced bladder injury, with different causes, during TLH. Because bladder injury causes significant anxiety and stress for patients, we are reporting our two patients to highlight the importance of prevention and to advocate for a new strategy of prevention.

  Our first patient had a history of two prior cesarean deliveries and had severe adhesions between her bladder and anterior vaginal wall. During laparoscopy, we mistakenly identified the bladder as peritoneum, and we lacerated the bladder dome. To prevent this injury, we should have determined the location of the peritoneal incision by filling the bladder with saline, so as to reliably recognize the border between the bladder and the vaginal wall.

  Our second patient was a primiparous woman without a history of prior surgery. We suspected that she had a large uterus, with an estimated weight of over 500 g. During laparoscopy, the indwelling bladder catheter became obstructed, the bladder filled with urine, and we misidentified the reflection of the uterine peritoneum over the bladder as the broad ligament. Even though this patient did not have any adhesions, this misidentification resulted in a laceration to the bladder wall because of her large uterus. Fortunately, in both cases, the trigone of the bladder was not injured and we were able to repair the bladder injury laparoscopically. Neither patient experienced postoperative sequelae.

  In our preparation for both of these patients, we recognized that the risk for bladder injury is influenced by a history of previous cesarean deliveries, the total number of vaginal deliveries, a high body mass index, and the presence of endometriosis. However, none of these factors were involved in our second patient. We propose that the risk for bladder injury is also influenced by visual misidentification on the surgeon's part. We suggest that surgeons should prepare to reduce the volume of the uterus and to verify the location of the bladder during every TLH procedure to avoid misidentification. We also suggest that surgeons should prepare patients for autologous blood transfusion and that they should closely monitor the urinary catheter system for air bubbles and hematuria so that bladder injury can be detected in real time, to avoid postoperative sequelae.

Introduction: Interstitial pregnancy is a rare subtype of ectopic pregnancy.

Case: Our patient was a 35-year-old woman with a history of bilateral salpingectomy for hydrosalpinx prior to ART. ART was carried out in the clinic, and pregnancy was confirmed. At 5 weeks and 6 days of gestation, the patient presented to the clinic with genital bleeding and lower abdominal pain. The gestational sac and yolk sac were found in the interstitial region of the right fallopian tube, and the patient was referred to our hospital for management. There were no abnormal vital signs, and the blood human chorionic gonadotropin (hCG) level was 5,598 mIU/mL. Magnetic resonance imaging revealed a 16 mm cystic mass in the right interstitial region. Since there were no ruptures and the patient's condition were stable, methotrexate was administered systemically. On 11 days at for MTX administration, the patient's blood hCG levels decreased, but abdominal pain worsened. Sonography and computed tomography showed intra-abdominal bleeding due to rupture. The patient was diagnosed with ruptured interstitial pregnancy, and emergency laparoscopic surgery was performed. We observed a large amount of blood in the pelvis, persistent bleeding from the right uterine horn to the interstitial region of the fallopian tube, and surrounding hematoma. The villi of the stromal oviducts were removed, and the affected area was sutured.

Conclusion: Ectopic pregnancy of the remaining fallopian tubes should be considered, even after salpingo-oophorectomy has been performed.

  A septate uterus is an important cause of infertility and recurrent pregnancy loss. Implantation failure is attributable to inadequate blood flow through the septum, and surgical procedures are effective in such cases. Reportedly, septoplasty can improve reproductive outcomes in women with a septate uterus. Conventional laparotomy (the Tompkins operation) and hysteroscopic septoplasty are the common surgical approaches used in clinical practice.

  Laparotomy is highly invasive and is associated with the risk of uterine rupture during pregnancy and necessitates cesarean delivery. Less invasive hysteroscopic operations are increasingly being performed in recent years. Intraoperatively, it is important to ensure that the residual septum measures < 1 cm; however, this is difficult to confirm during hysteroscopic procedures. Studies have reported that intraoperative hysterosalpingography is useful to evaluate the septum; however, this procedure is challenging and is associated with the risk of radiation exposure. We report a case of a septate uterus in a woman with a history of two miscarriages, who underwent hysteroscopic septoplasty under three-dimensional ultrasonographic guidance.

  A 43-year old woman presented with severe anemia due to myomas and received oral iron supplementation. Three months later, after the recovery of severe anemia from Hb 4.2 g/dl to13.5 g/dl, was confirmed(Hb 13.5g/dl), we performed a total laparoscopic hysterectomy. Three days after operation, the patient had altered mental functioning and seizure. The FLAIR MR imaging revealed high signal intensity in the bilateral occipital lobes, and the patient was diagnosed as PRES. We immediately injected Nicardipine intravenously to lower the systolic blood pressure below 120mmHg. No seizures occurred after the administration of Nicardipine. Four days later, the high signal seen in FLAIR MR imaging significantly diminished. A follow up MR imaging in three months revealed the disappearance of the lesion. PRES is typically characterized by symptoms of headache, altered mental functioning, seizure, and visual impairment. FLAIR MR imaging is especially beneficial in diagnosing PRES. Patients with PRES often show high signal intensity in the occipital, temporal and parietal lobes. There are many known factors associated with PRES such as hypertension, immunosuppressive drug therapy for neoplasm or organ transplantation and more. In the field of obstetrics and gynecology, eclampsia, hypertensive disorders of pregnancy and the treatment of severe anemia are associated with PRES. Notably, the treatment of severe anemia due to myomas could induce PRES at any point of time. There have been reports of PRES seen a few days after transfusion, a few months after oral iron supplementation, and even a year after treatment. Although PRES is a rare disease, it is essential to keep PRES in mind when patients suddenly present with neurological symptoms during and after the treatment of severe anemia due to myomas, regardless of the route of administration.

  Acute lower limb compartment syndrome may develop after pelvic surgery performed in the lithotomy position. Accurate diagnosis is based on clinical suspicion, and postoperative leg pain may serve as a red flag sign of this condition. Early diagnosis and treatment improve prognosis; therefore, prompt intervention is important in patients showing a high index of clinical suspicion for this syndrome. We report a case of bilateral acute lower limb compartment syndrome in a 43-year-old woman, following total laparoscopic hysterectomy with bilateral salpingo-oophorectomy.

  The operative time was 5 hours and 10 min in this patient who was placed in the lithotomy position with a head-down tilt. The total intraoperative blood loss was 75 g, and the patient's blood pressure was low throughout the operation. We suspected this condition based on bilateral calf swelling/pain, and the patient underwent blood tests and contrast-enhanced computed tomography, which revealed bilateral lower limb muscle ischemia, and we diagnosed the patient with lower limb compartment syndrome and performed emergency fasciotomy. The patient was discharged on postoperative day 25 and has shown good recovery without any complications. Even mild postoperative leg pain may be an early sign of acute lower limb compartment syndrome; therefore, early identification of high-risk patients and close 24-hour postoperative monitoring are warranted in such cases.

  Massive ovarian edema (MOE) is a non-neoplastic tumor-like mass, which was first reported in 1969. However, MOE is not extensively recognized even among gynecologists. Herein, we report a case of MOE that could be diagnosed and managed by laparoscopic surgery. A 23-year-old woman presenting right lower abdominal pain visited our hospital. Ultrasonography showed an enlarged right ovary and ascites. MRI showed multiple small cysts located peripherally and stromal edema with a marked increase in T2 signal intensity. The patient was diagnosed with torsion of the right ovarian mass, and underwent laparoscopic surgery. Pathological evaluation of a biopsy revealed no neoplastic findings, and the ovary was preserved. The hormonal levels of LH and FSH showed polycystic ovarian syndrome (PCOS). Based on these findings, the final diagnosis was MOE with PCOS. Three months after surgery, the right ovary showed a normal appearance on MRI. This case demonstrates that laparoscopic surgery is useful for the treatment of MOE.

  Chlamydial pelvic peritonitis presents with high levels of CA125, massive ascites and inflammatory changes in the peritoneum, and is sometimes difficult to differentiate from carcinomatous peritonitis. We report a case of chlamydial pelvic peritonitis, diagnosed by laparoscopy, mimicking carcinomatous peritonitis due to fallopian tube cancer. A 22-year-old primipara woman with a history of artificial abortion five months before was referred for a massive ascites effusion. Her CA125 was elevated at 532 U/ml, and pelvic MRI showed a left fallopian tube edema with wall thickening and nodules, and suspected peritoneal and great omentum thickening. A CT scan revealed some enlarged lymph nodes around the pararenal aorta. Cervical chlamydia real-time PCR was positive, and chlamydial pelvic peritonitis was suspected, but carcinomatous peritonitis could not be ruled out, so a laparoscopy was performed. The pelvis was filled with bloody ascites, and fibrous adhesions were found around the uterine adnexa and on the surface of the liver. A mass was found in the left fallopian tube. Rapid ascetic fluid cytology revealed atypical cells that were highly suggestive of malignancy, so a left salpingectomy, bilateral ovarian cyst enucleation, peritoneal biopsy and adhesiolysis were performed. Postoperative pathological examination indicated an atypical oviductal epithelium, but there was no destructive proliferation or invasion indicative of inflammatory changes. After surgery, azithromycin was administered. The ascites disappeared, peritoneal thickening and lymph node enlargement improved, and CA125 became negative. Laparoscopy is a minimally invasive and reliable method of tissue sampling, and is useful in differentiating carcinomatous peritonitis from other type of peritonitis.