A uterine manipulator is a useful device that facilitates safe total laparoscopic hysterectomy (TLH). However, cervical stenosis may occasionally occur after cervical conization, particularly in postmenopausal women or in women who undergo deep cervical resection. The routine use of a uterine manipulator during TLH becomes impossible in such cases. We report safe and effective TLH for post-conization cervical stenosis; we have focused on the surgical technique based on intraoperative videos. Of the 27 patients who underwent TLH after cervical conization between November 2016 and June 2018 at our hospital, 11 patients developed post-conization cervical stenosis. Based on outpatient medical records, cervical stenosis was defined as difficulty with uterine probe insertion. In this study, routine insertion of a uterine manipulator was not possible in patients with cervical stenosis; however, laparoscopy guided uterine manipulator insertion was successful in 70% of patients. Despite the inability to insert the manipulator, we could successfully perform safe TLH using an additional port to pull the uterus.

Objective: Advanced energy devices are often used to perform laparoscopic surgery less invasively, with more safety and precision. This study aimed to compare the utility of LigaSure^TM with conventional bipolar techniques in laparoscopic salpingectomy for tubal pregnancy.

Methods: This retrospective study included the comparisons among 82 patients (57 with unruptured fallopian tubes; 25 with ruptured fallopian tubes) who had undergone laparoscopic salpingectomy using LigaSure^TM or conventional bipolar instruments from October 2009 to September 2018. Various perioperative parameters were evaluated from surgical videos and medical records, including total operative time from the skin incision to skin closure, the time from insertion of the energy device to the removal of the fallopian tube, intraoperative blood loss, and perioperative complications.

Results: The salpingectomy time was statistically shorter for LigaSure^TM (274 seconds) than with bipolar instruments (599 seconds; p=0.0012). In cases of both unruptured (50 cases of LigaSure^TM; seven of bipolar instruments) and ruptured (20 cases of LigaSure^TM; five of bipolar instruments) fallopian tubes, the salpingectomy time was significantly shorter with LigaSure^TM when compared with bipolar instruments (LigaSure^TM: 256 seconds vs. bipolar instruments: 570 seconds; p=0.006, and LigaSure^TM: 310 seconds vs. bipolar instruments: 609 seconds; p=0.003). The total operating time or intraoperative blood loss did not significantly differ between LigaSure^TM and bipolar instruments groups.

Conclusions: Salpingectomy using LigaSure^TM was comparable to conventional salpingectomy performed with bipolar and scissors forceps in terms of the total operating time and the amount of intraoperative bleeding; however, LigaSure^TM was effective in shortening the salpingectomy time during laparoscopic surgery.

　Laparoscopic cystectomy for mature cystic teratoma is widely performed, but there is no certainty about the risk of developing chemical peritonitis due to intraoperative spillage. We retrospectively reviewed 148 cases of laparoscopic ovarian cystectomy for mature cystic teratoma in five years (2016-2020) in our hospital. The intraoperative spillage rate was 76.3%, and the incidence of chemical peritonitis was 2.7%. In cases of intraoperative spillage, chemical peritonitis occurred more frequently in patients whose tumor contents spread to the upper abdomen, even after adequate washing. We conclude that it is important to prevent the leakage of tumor contents into the upper abdomen because it affects the development of chemical peritonitis.

Objective: Although laparoscopic ovarian drilling (LOD) has been widely used to induce ovulation in infertile women with polycystic ovarian syndrome (PCOS), predicting the clinical response to this treatment remains unclear in Japanese women. This study aimed to determine the clinical responses to LOD calculated as total thermal doses per ovarian unit volume.

Material and Methods: This retrospective study included 47 patients with anovulatory infertility due to PCOS, which was diagnosed by criteria from the Japanese Society of Obstetrics and Gynecology in 2007, and who underwent LOD between 2008 and 2017.

　This study evaluated the influence of patients’ pre-operative characteristics and the number of drillings (thermal doses) per ovarian unit volume (cm³) on ovulation, which occurred spontaneously or with up to 150 mg/day clomiphene citrate, after LOD. Multiple logistic regression analysis was used to identify independent predictors of ovulation after LOD.

Results: Thirty-eight patients (81%) had spontaneous or clomiphene citrate-induced ovulation after LOD.

　The luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio, serum anti-Müllerian hormone and testosterone concentrations, antral follicle counts, and ovarian volume were significantly decreased, whereas serum concentrations of FSH increased (P<0.05) following LOD.

　Multiple logistic regression analysis showed that a pre-operative LH/FSH ratio <1.5 and total drillings ≥1.8per ovarian unit volume (cm³) were independently associated with higher ovulation rates (P<0.05).

　There were no major adverse peri-operative effects, such as blood transfusion, extension of hospitalization, and insufficiency of ovarian function.

Conclusion: LOD may be performed effectively and safely by evaluation of pre-operative bio-markers and total thermal doses per ovarian unit volume.

　Peritoneal pregnancy is rare and represents approximately 1% of all ectopic pregnancies. We report six cases of peritoneal pregnancies that we encountered in our department. We investigated women diagnosed with peritoneal pregnancies between January 2015 and April 2019. Among the 100 women included in this study, we encountered the following types of ectopic pregnancies: fallopian tube pregnancy (77 cases), peritoneal pregnancy (six cases), interstitial pregnancy (seven cases), ovarian pregnancy (three cases), cervical pregnancy (one case), scar site pregnancy (four cases), and unknown pregnancy site (two cases). All six women with a peritoneal pregnancy underwent laparoscopic surgery with a favorable postoperative course. Ectopic pregnancy is often an emergency operation, and it is quite possible that a peritoneal pregnancy will be found during surgery. Even if it is an emergency operation, knowing how to deal with peritoneal pregnancy will lead to appropriate treatment. We report on the cases we experienced about peritoneal pregnancy.

　There are a few reports of torsion of paratubal cysts during pregnancy. We encountered a case wherein it was possible to spare the fallopian tubes in a patient with parabutal cyst torsion during early pregnancy; herein, we report our findings. A 32-year-old nulliparous woman became pregnant naturally and was receiving prenatal care from her previous doctor. At 13 weeks and 1 day of gestation, the patient experienced sudden pain in the lower left abdomen. A 6-cm mass was found in the left ovary on transabdominal ultrasonography, which matched the site of the abdominal pain; so the same diagnosis was established in this hospital, and we implemented experimental laparoscopic surgery. Observation of the abdominal cavity revealed a cystic tumor in the left mesosalpinx, and the patient was diagnosed with torsion of the paratubal cyst. Each fallopian tube was twisted once and turned dark red in color. Once the torsion was removed, the color rapidly improved, and there was no adhesion to the surrounding tissue or necrosis; therefore, it was considered possible to spare the fallopian tubes. The ligament was opened, and only the cyst was excised. The pregnancy progressed well, and the patient had a spontaneous cephalic delivery at 39 weeks and 5 days of gestation. The baby was male, weighing 3500 g and with an Apgar score of 9/10. Prompt laparoscopic surgery without hesitation is an effective treatment when uterine appendage torsion is suspected with acute abdominal pain, even during early pregnancy.

　Due to the precision and small size of laparoscopic devices, if part of the device is damaged and falls off, it can be highly difficult to recover. We report a case in which a part of bipolar forceps broke and fell off, but was retrieved through the effective use of fluoroscopy and a specimen retrieval bag.

　A 42-year-old Japanese woman with bilateral ovarian tumors and multiple myoma underwent laparoscopic cystectomy and myomectomy. Postoperative abdominal X-ray revealed a foreign body in the pelvic region. Although the site of damage to the surgical device was not identified, the part was considered to have fallen off during surgery and we attempted to retrieve it by laparoscopy. In consideration of movement of the foreign body depending on the posture, fluoroscopy was performed at a low head position. In addition, by photographing from two directions, the foreign body was easily identified at the suspected site in the pelvis. Furthermore, considering the possibility of breakage and reshedding of the foreign body during retrieval, it was placed in a bag and recovered safely.

　When searching for missing parts during laparoscopic surgery, it is important to identify them by fluoroscopy in the same operating position. Recovery by bagging was considered to be effective at preventing re-shedding.

　Mesothelial inclusion cysts（MICs）are benign lesions that arise from mesothelial cells and are particularly rare. They have been reported to be associated with a history of prior surgery or pelvic inflammation, especially in young females． We report a case of a 24-year-old, para 0 woman who had undergone abdominal left adnexectomy for a stage IC1(pT1c1N0M0) ovarian borderline malignant tumor five years prior, then presented with multiple cystic lesions in the abdomen during follow-up. A contrasted computed tomography scan was performed, and the results revealed a large number of cystic lesions in the abdominal cavity and retroperitoneal space.

　Given the possibility of peritoneal dissemination, laparoscopic tumor biopsy was performed. A small amount of yellowish ascites and a large number of cystic lesions up to 0.5 to 2 cm in size were scattered throughout the uterus, intestines, peritoneum, and diaphragm. Contrary to expectations, histology exhibited a diagnosis of a benign MIC.

　Surgical resection is the basic treatment for MICs．Even with cases of benign lesions, the recurrence rate after surgery is about 50%. It has been reported that anti-estrogen drugs and sclerotherapy may contribute to the treatment for recurrent tumors, but due to the lack of reports, standard treatment and management methods have yet to be established. Therefore, long-term follow-up is essential.

　Retroperitoneal neoplasms are relatively rare. We report two cases of retroperitoneal neoplasms diagnosed as ovarian tumors by preoperative imaging and approached by laparoscopic resection.

Case 1: A 31-year-old woman had lower abdominal pain. Pelvic MRI showed an ovarian tumor measuring approximately 7 cm. Intraoperative findings revealed normal-sized ovaries and a tumor measuring approximately 7 cm in the right hemipelvis, surrounded by the retroperitoneal. We could resect the tumor without puncture. Histopathology revealed an epidermoid cyst.

Case 2: A 56-year-old woman had hypermenorrhea. Pelvic MRI showed an ovarian tumor measuring approximately 7 cm. Intraoperative findings revealed normal-sized ovaries and a tumor measuring approximately 7 cm in the left hemipelvis, surrounded by the retroperitoneal. We could completely remove the tumor from the retroperitoneal space without any complications. Histopathology revealed a cellular schwannoma. Retroperitoneal teratomas are said that malignant change occurs in about 26%. Schwannomas are usually benign tumors; however, they have a few cases of malignant change and recurrence. Recently there are a lot of reports of retroperitoneal tumor in laparoscopic surgery. Laparoscopic surgery facilitates detailed observation, minimal invasion, and magnification, thus allowing faster postoperative recovery. In our cases, we could completely remove the masses without residual tumor. It is requirement that we should select appropriate procedure when intraoperative finding are retroperitoneal tumor thinking of malignant tumor.

　Cervico-isthmic pregnancy is rare and may potentially cause massive hemorrhage during pregnancy and delivery, resulting in a life-threatening situation. Here we report the case of cervico-isthmic pregnancy that was diagnosed with pathological examination after a laparoscopic hysterectomy. A 38-year-old multiparous woman was admitted to our hospital due to massive genital hemorrhage. A urinary pregnancy test was negative, and color Doppler ultrasonography showed vascular flow toward the intrauterine cavity at the lower uterine body. Blood transfusion and uterine arterial embolization were performed. Because the cervical and endometrial cytology were class 3 and 4, respectively, the patient chose laparoscopic hysterectomy for the diagnosis and curative treatment. The final diagnosis was cervico-isthmic pregnancy. It should be known that hemorrhage occurs without appearing gestation sac in utero in cervico-isthmic pregnancy. There are several treatments for cervico-isthmic pregnancy. It is important to choose the optimal treatment in consideration of patient’s background and the risk associated with each treatment.

　Major vascular injury during laparoscopic surgery is an uncommon but serious complication.

　An increase in the number and complexity of laparoscopic procedures has led to a corresponding increase in the risk of complications observed in clinical practice.

　An 86-year-old woman with a history of obesity, hypertension, and knee replacement surgery underwent laparoscopic surgery for early-stage endometrial carcinoma. The external iliac vein was injured during dissection secondary to unipolar electrosurgery. We immediately grasped and held the lacerated blood vessel for 10 min using two atraumatic grasping forceps to decrease the pulse pressure. The injured vessel was laparoscopically repaired using a 4-0 polyglactin suture. The patient did not experience any leg pain the following day; however, the right dorsalis pedis artery pulse was feeble, and she had a cold sensation and edema of the right lower extremity with intermittent claudication. Therefore, we suspected arterial embolism. The patient underwent thrombectomy and stent placement for diagnosis of right iliac artery thrombosis, which successfully restored adequate blood flow to the right lower extremity. She did not show recurrence or complications in the right lower extremity during follow-up.

　Arterial embolism in this patient was attributable to a crush injury of the artery as opposed to direct arterial trauma. Implementation of adequate protective measures is important to avoid intraoperative vascular injury. Moreover, early detection of symptoms is essential for prompt and appropriate treatment.

　Gliomatosis peritonei, a rare complication of ovarian teratomas, is characterized by mature glial tissue within the peritoneum. Gliomatosis peritonei has favorable prognosis, but pathological diagnosis is necessary. We report a case of gliomatosis peritonei detected using diagnostic laparoscopy for an intrapelvic tumor after surgery for an ovarian immature teratoma (grade 1). A 29-year-old (3 para) woman was referred to our hospital. She underwent surgery for a left ovarian tumor when she was 25 years of age within 15 weeks of her second pregnancy, and the pathological diagnosis was an ovarian immature teratoma (grade 1). She was not administered additional treatment because of her pregnancy and underwent routine follow-up. The pelvic mass was assessed on ultrasonography and magnetic resonance imaging during the follow-up period; she underwent a detailed examination and was referred to our hospital. We performed laparoscopic surgery and resected the pelvic mass in the peritoneum. The pelvic tumor mostly consisted of mature glial tissue and no immature cells on pathological examination, and we established a diagnosis of gliomatosis peritonei. After the surgery, her condition was favorable, and she continued to undergo routine follow-up. Laparoscopic surgery is useful for the pathological examination of pelvic masses after teratoma treatment and diagnosis of gliomatosis peritonei.

　Tocilizumab (TCZ) is a humanized anti-human IL-6 receptor monoclonal antibody that suppresses the signaling of IL-6, which is important for inflammation and immune activation. In Japan, the use of TCZ for treatment of rheumatoid arthritis (RA), Castleman's disease, juvenile idiopathic arteritis, and Takayasu's arteritis / giant cell arteritis, etc. has been approved. IL-6 inhibition of TCZ suppresses leukocyte infiltration into the inflamed area. In addition, when TCZ achieves an effective blood concentration, C-reactive protein (CRP) becomes negative regardless of clinical presentation. Inflammatory outcomes such as CRP and erythrocyte sedimentation rate may be significantly different from clinical symptoms. We report a case of pelvic abscess following a laparoscopic simple total hysterectomy and bilateral salpingectomy during TCZ administration, along with a review of literature.

　We report a case of massive retroperitoneal tumor that had to be removed laparoscopically.

　The patient was a 53-year-old woman who was admitted to our hospital with the chief complaint of abdominal discomfort. Transvaginal ultrasonography revealed multiple uterine fibroids and a giant intra-abdominal tumor. Magnetic resonance imaging (MRI) showed a retroperitoneal mass on the left side of the pelvis and a suspected uterine fibroid with hydropic degeneration. After discussing the treatment options with the patient, we performed laparoscopic surgery for the removal of the retroperitoneal mass was planned due of the patient's desire for surgical treatment with the patient's consent. Intraabdominal examination revealed a large, discontinuous retroperitoneal tumor that grew in the retroperitoneum adjacent to the uterus. After total laparoscopic hysterectomy, the left broad membrane was stretched, and the retroperitoneal tumor was carefully dissected and removed through an en-bloc procedure. The operation took 179 minutes, and the intraoperative bleeding was mild. Permanent pathology of the resected specimen indicated hydropic degeneration of the tumor and intravascular invasion. Immunostaining showed that the samples were positive for desmin and smooth muscle actin, but negative for CD10; the Ki-67 index was ≤1%. Based on these observations, leiomyoma was diagnosed. The patient experienced no intraoperative complications. The postoperative course was also unremarkable, and the patient was discharged from the hospital on the third postoperative day. During the follow-up examination, the patient did not exhibit any symptoms or signs of recurrence.

　We report a case of endometriosis associated ovarian carcinoma that could not be diagnosed using preoperative magnetic resonance imaging (MRI). A 29-year-old woman presented with a 3-year history of acute abdominal pain. MRI revealed a left-sided endometrial cyst measuring 4.5 cm, and she had a history of low-dose estrogen-progestin (LEP) therapy for a left ovarian endometrial cyst. The cyst showed a slight increase in size to 5 cm, 1 year after it was diagnosed; therefore, she underwent pelvic MRI, which did not reveal evidence of malignancy but only showed intracystic nodules, which were suspected to be clots. She continued to receive LEP therapy; however, transvaginal ultrasonography performed 2 years and 6 months after the detection of the cyst revealed an increase in the size of the cyst to 7 cm, and pelvic MRI performed at that time revealed an increase in the size of the nodules, which were suspected to be clots without any evidence of malignancy. Contrast-enhanced pelvic MRI performed 2 years and 10 months after initial diagnosis revealed further growth of both the cyst and nodules; therefore, she underwent surgery. The nodule was enlarged; however, we observed no contrast effect, and the position appeared to have shifted from the ventral to the dorsal aspect. Therefore, we speculated that the nodule was most likely a benign lesion, and performed laparoscopic left ovarian cystectomy. We did not observe any increase in tumor markers during the course of the study. Intraoperatively, the cyst ruptured; however, we could visualize a clear boundary between the cyst and the surrounding parenchyma, and the lesion was easily removed. We detected no abnormalities in the contralateral ovary or the pelvis. Histopathological evaluation of the resected specimen revealed clear cell carcinoma, and we performed, abdominal left adnexectomy and omental biopsy, 1 month after the initial operation. Clear cell carcinoma was not detected in the resected ovary, and she was administered 3 cycles of a combination of carboplatin plus paclitaxel. She has shown no recurrence over 4 months postoperatively.

　Endocervicosis is defined as an abnormal proliferation of tissues that histologically appear similar to the cervical tissues in other organs. While endocervicosis is less prevalent, it is most often found in the bladder. Herein, we present a rare case of endocervicosis in the left fallopian tube that was resected with total laparoscopic hysterectomy and prophylactic bilateral salpingectomy.

Case: A 47-year-old woman, gravida 3 para 1, with a history of abdominal myomectomy, experienced menorrhagia and iron deficiency-related anemia owing to adenomyosis and leiomyoma. Ultrasound and magnetic resonance imaging showed adenomyosis, leiomyoma, and normal bilateral ovaries. We decided to perform laparoscopic total hysterectomy based on the indication of adenomyosis with menorrhagia and prophylactic bilateral salpingectomy for ovarian cancer prevention after obtaining the patient's informed consent. A laparoscopic examination showed that the uterine corpus with adenomyosis had adhesions with the omentum, and the bilateral ovaries and fallopian tubes were grossly normal with no peritoneal lesions. The histopathological analysis showed that the uterine adenomyosis histologically appeared similar to the endocervical-type glands in the fimbria of the left fallopian tube. Therefore, endocervicosis was diagnosed.

Conclusion: We herein present an extremely rare case of endocervicosis of the fallopian tube that was resected with total laparoscopic hysterectomy.

　We report a case of asymptomatic ovarian abscesses developed from ovarian endometriosis in a woman with infertility. A 42-year-old married woman presented to our hospital on referral from an in vitro fertilization clinic for enucleation of uterine fibroids. Ovarian endometriotic cysts were also present, which could be considered a cause of infertility. Having undergone oocyte retrieval and embryo transfer several times, she had no evidence of pelvic infection. Laparoscopic myomectomy and left ovarian cystectomy were performed. During surgery, findings in the left adnexa suggested that the ovarian endometriotic cysts had developed chronic ovarian abscesses. Although fenestration and irrigation of the abscesses was performed, the patient had symptoms of severe inflammation after surgery. This case suggests that latent clinical deterioration may occur in patients with ovarian abscesses. Therefore, careful preoperative diagnosis and postoperative management are needed in patients who have undergone assisted reproductive techniques.

Rectal prolapse, which refers to extrusion of the full thickness of the rectal wall through the anal canal, significantly affects patients' quality of life. Laparoscopic ventral rectopexy has gained increasing acceptance as effective treatment for rectal prolapse. Currently, laparoscopic sacrocolpopexy is recognized as the gold standard treatment for pelvic organ prolapse, with good long-term success rates. Rectal prolapse with concomitant pelvic organ prolapse is not uncommon; sacrocolpopexy with concurrent rectopexy may be useful in such patients. We report two cases of pelvic organ prolapse with concomitant rectal prolapse in women who underwent laparoscopic ventral rectopexy combined with laparoscopic sacrocolpopexy. The estimated blood loss was <10 mL, and the operation time was 163 min and 218 min, respectively. No postoperative complications were observed, and patients were discharged on the 3^rd postoperative day. Laparoscopic sacrocolpopexy with concomitant ventral rectopexy is feasible and safe in patients with the aforementioned clinical presentation.

　Adnexal torsion in adolescents is not often associated with ovarian tumors when compared with that in adults. This is the case of adnexal torsion in a girl before menarche.

　A 13-year-old pre-menarche girl had a low-volume voice and experienced fast hair growth approximately 3 months before her visit. She had unbearable abdominal pain for the past 2 months. She presented at a previous hospital with bilateral polycystic ovaries and showed symptoms similar to those of polycystic ovary syndrome (PCOS). Abdominal echo and magnetic resonance imaging (MRI) showed swollen ovaries. After that, abdominal pain re-occurred, and a repeat MRI revealed that the swelling in the left ovary had increased, and it was edematous with no blood flow. Her pain had worsened, and she was hospitalized. Computed tomography revealed that her left ovary had grown to 8 cm, and the inside of the ovary was poorly deformed. Therefore, she was immediately transferred to our hospital for treatment. We suspected that her ovary had twisted, and left adnexal torsion was diagnosed on laparoscopy. Her left necrotic adnexa were then removed.

　A PCOS-like condition was diagnosed, based on ovarian pathology and the high testosterone level preoperatively.

　PCOS without tumors has the risk of causing ovary torsion. It is important to preserve the ovary function in adolescents. Therefore, when adnexal torsion is suspected, laparoscopy should be performed for diagnosis and treatment.

　Cancer of unknown primary (CUP) is metastatic cancer without a clinically detectable defined primary tumor site after an adequate diagnostic evaluation. It is well recognized that CUP incidence occupies 1-5% of all malignant epithelial tumors. Herein, we report a case of primary peritoneal carcinoma diagnosed as CUP revealed by laparoscopic surgery.

　A 74-year-old woman presenting with no symptoms, who had a past medical history of bilateral metachronal breast cancers and ascending colon cancer, and a family (her mother) history of breast cancer, was introduced to our facility. A new tumor located in the upper abdomen was detected on the follow-up computed tomography (CT) of the ascending colon cancer. Positron emission tomography/CT detected no other strong 2-deoxy-2 [18F] fluoro-D-deoxyglucose accumulation except in the upper abdominal tumor. A biopsy from the new tumor was performed, and the pathological diagnosis, including immunohistochemical analysis, revealed the possibility of serous carcinoma derived from the adnexa of the peritoneum. Gynecologic examinations revealed an increased serum cancer antigen 125 level; however, there were no clear abnormalities in the uterus and ovaries. After sufficient informed consent, the laparoscopic surgery was performed to resect the upper abdominal tumor, observe the abdominal cavity, and have bilateral salpingo-oophorectomy. There were no ascites and peritoneal lesions in the abdominal cavity. Although a small cyst in the left ovary was observed, there was no suspected malignancy on both adnexa. The upper abdominal tumor was completely removed, and laparoscopic surgery was performed for bilateral salpingo-oophorectomy. The pathological examinations revealed lymph node metastasis of serous carcinoma, and immunohistochemical examinations showed that ovarian cancer or peritoneal cancer was suspected as primary cancer.

　However, the abdominal washing cytological diagnosis was negative, and no malignant tumors in bilateral adnexa were detected in the search for detailed pathological examinations. These findings concluded that the final diagnosis was primary peritoneal cancer, and the chemotherapy was performed according to stage III of ovarian cancer. This case suggested that laparoscopic surgery helped diagnose CUP because this method could minimize physical and mental damages.

　The increasing rates of cesarean section are accompanied by a corresponding increase in the complications associated with the operation, including cesarean scar syndrome (CSS). CSS refers to a clinical presentation of abnormal genital bleeding, pelvic pain, and/or infertility in a woman with cesarean-induced isthmocele. CSS is associated with the risk of serious complications such as uterine rupture and preterm delivery; however, CSS is not widely known.

　Case: A 29-year-old woman with a history of cesarean delivery presented with secondary infertility in addition to abnormal uterine bleeding after cesarean section.

　We diagnosed the patient with CSS based on transvaginal ultrasonography and magnetic resonance imaging, which revealed cesarean-induced isthmocele with scar thickness of 2 mm.

　She underwent hysteroscopy assisted laparoscopic repair for CSS and conceived spontaneously during the first cycle of our permission to get pregnant, 6 months postoperatively. The patient was at a high risk of uterine rupture and preterm delivery of a monochorionic diamniotic twin pregnancy.

　Eventually, she underwent elective cesarean section and delivered two healthy female neonates (birth weight 2500 g and 2735 g) at 38 weeks' gestation.

　Uterine artery pseudoaneurysms frequently rupture and cause a hemorrhage. Such a pseudoaneurysm is a potential complication of vascular injury resulting from inflammation, trauma, or surgery, but it rarely happens after an ectopic pregnancy. Many cases have been treated by transcatheter uterine arterial embolization (UAE) or disappeared spontaneously, but there is no report of a case treated by laparoscopic surgery. We successfully treated a patient with a uterine artery pseudoaneurysm that occurred after conservative treatment for an interstitial pregnancy by performing laparoscopic surgery.

　A 40-year-old woman was referred to our hospital for a suspected incomplete abortion and vaginal hemorrhage; we diagnosed an interstitial pregnancy. After she was administered methotrexate, her hCG value decreased and the pregnancy part got smaller. We diagnosed a uterine artery pseudoaneurysm based on the results of contrast enhanced computed tomography (CECT), which revealed a pooling of contrast medium in the interstitial part. On the same day as the CECT examination, we performed UAE, but it could not stop the hemorrhage completely. We performed laparoscopic surgery 1 week later. The blood vessels from the omentum, the left ovarian artery, and the right side of uterus flowed into the swollen interstitial part. We sealed the blood vessels, cut off the uterine artery pseudoaneurysm, and sewed muscle layer.

　Although uterine artery pseudoaneurysms have been successfully treated by UAE, in the present case, the hemorrhage could not be stopped by UAE because of the many collateral vessels. In similar cases, laparoscopic surgery could be the most effective treatment.

　Laparoscopic surgery requires reliance on visual information, and there are several points to be aware of when performing such surgery. Intestinal injury is a serious complication of endoscopic surgery, delayed detection of which can have a fatal course due to generalized peritonitis. We report a case of pelvic abscess caused by perforation of the appendix after surgery.

　A 50-year-old woman underwent laparoscopic total hysterectomy, bilateral adnexal resection, and pelvic lymph node dissection for stage IA equivalent endometrial cancer (grade 1) (surgical duration: 292 minutes, bleeding volume: small amount). Five days postoperatively, she had right lower abdominal pain and fever, and an increased inflammatory response. Contrast-enhanced CT examination revealed a poor contrast-enhanced abscess in the right pelvis and appendix, leading to the suspicion of perforation. When we tried a trial laparotomy, her appendix was necrotic and had collapsed into the cavity created by the surgical dissection, forming an abscess. We performed appendectomy and lavage drainage.

　We were able to confirm a case report of direct damage to the appendix during laparoscopic surgery, but not a report of perforation of the appendix due to appendicular artery injury. Looking back at the surgical video, it was possible that the appendicular artery was amputated by monopolar (cut mode) electrocautery during fat amputation while expanding the broad membrane. It is important to remember that the appendicular artery might not bleed when electrocauterized, and to understand the three-dimensional anatomy of the ileocecal region when dissecting retroperitoneum.

　Aggressive angiomyxoma (AAM) is a benign mesenchymal neoplasm arising in the pelvis, perineum, and vaginal wall of premenopausal women. Its recurrence rate reaches approximately 50%, and it is treated with combined surgical resection and gonadotropin-releasing hormone (GnRH) agonists. Laparoscopic surgery is superior to laparotomy in terms of accessibility and a detailed and magnified view of the surgical field. Learning the anatomy of the less familiar Retzius space may be useful for gynecologists.

　A 46-year-old G2P2 presented with an incidental finding of a pelvic mass on computed tomography. Magnetic resonance imaging revealed a 3.5-cm spindle-shaped mass between the left pubic bone and the bladder with clear demarcations from the vagina and bladder. Preoperative diagnosis suggested AAM located in the Retzius space. Because resection using a single approach from the perineal region was considered difficult, we performed laparoscopic resection with visualization of the Retzius space from the abdominal cavity, which revealed a pedunculated mass arising from the left internal obturator muscle. Because of unclear borders, we dissected the mass while observing the inside of the bladder with a cystoscope. The mass was resected, placed in a retrieval bag, and retrieved from the umbilicus. The final pathological diagnosis was AAM and prophylactic GnRH agonists were administered. No regrowth occurred in 2 years and 4 months postoperatively.

　The Retzius space between the pubic bone and bladder, also known as the retropubic space or prevesical space, is often visualized during urological surgeries. During laparotomy, the pubic bone blocks the Retzius space. Contrastingly, laparoscopy allows less invasive and safer resection of AAM arising from the left internal obturator muscle. Laparoscopic surgery for benign tumors in the Retzius space may be a feasible option as minimally invasive procedure.

　Ectopic pregnancy accounts for 1-2% of all pregnancies; however, cervical pregnancy is extremely rare and occurs in <1% of all cases of ectopic pregnancies. Reportedly, women with cervical pregnancy may occasionally develop significant hemorrhage during the early stage of pregnancy; bleeding is occasionally difficult to control owing to careless intracervical curettage, necessitating blood transfusion or total hysterectomy. Following the development of novel diagnostic imaging modalities in recent years, cervical pregnancy can be diagnosed at an early stage, and uteruspreserving conservative treatment is currently the common therapeutic approach used for this condition. However, to date, the definitive treatment protocol remains unclear, and individualized therapy is necessary. In this case, we performed two-step hysteroscopic surgery using a small-diameter hysteroscope and resectoscope for the management of cervical pregnancy in a woman in whom systemic administration of methotrexate did not induce spontaneous abortion. We report a case of successful management of cervical pregnancy without hysterectomy and massive bleeding. Smalldiameter hysteroscopy can be performed without cervical dilation (which increases the risk of bleeding) and enables accurate visualization of target lesions, as well as the use of various instruments including scissors, grasping forceps, and bipolar electrodes necessary for the operative procedure. The resectoscope provides a clear view of the surgical field and ensures adequate hemostasis. We conclude that a two-step technique facilitates safer surgery owing to the advantages offered by the aforementioned instruments.

　Lymphangioleiomyomatosis (LAM) is a rare disease in which multiple cysts are formed mainly in the lungs and symptoms such as dyspnea, bloody sputum, and chyle effusion appear. We experienced a case of endometrial cancer with a para-aortic mass that was initially suspected to be due to metastasis. However, after resection by retroperitoneoscopic surgery, the mass was diagnosed as LAM and fertility-sparing therapy was started.

[Case] The patient was a 28-year-old woman (0G0P) who consulted a nearby doctor for abnormal genital bleeding, and was diagnosed with endometrioid carcinoma G1. CT showed a mass in the para-aortic region and a 6-cm left ovarian mass. MRI showed no obvious myometrial invasion, and the left ovarian cystic mass was suspected to be a mature cyst teratoma. The tumor in the para-aortic region was hyperintense on T2-weighted images and had a high ADC on diffusion-weighted images. These findings are atypical for lymph node metastasis. Since the patient was young, she requested fertility-preserving therapy, but the possibility of lymph node metastasis of endometrial cancer could not be ruled out. Therefore, we decided to remove the para-aortic mass using a retroperitoneoscopic approach. The patient was discharged on postoperative day 4 without complications. Histopathological examination indicated that the para-aortic mass was due to LAM and endometrial cancer was diagnosed as stage IA, after which MPA treatment was started.

[Discussion] Diagnosis of para-aortic tumors is difficult by imaging, and pathological examination is required. Retroperitoneoscopic resection of a para-aortic tumor is beneficial because it allows diagnosis with minimal invasiveness.

　We report a case of recurrent massive ovarian edema (MOE) manifesting as acute abdomen. At the first onset, we presumed MOE with torsion because of the immense pain in the patient's right adnexa. We considered that the torsion was spontaneously released at the time of laparoscopic surgery. During the conservative follow-up, the right ovary returned to its normal size, and the pain disappeared. After 3 years, MOE recurred and manifested as acute abdomen. The corresponding pain was relieved, and the ovarian volume was reduced by the prescribed analgesics. The magnetic resonance images of the first and second MOE were similar, so we retrospectively considered that the ovary was not twisted in both instances.

　In about half of the MOE cases, the ovary does not twist. The assumption that MOE occurs on the basis of lymphatic or vascular circulatory disorders of the ovary supports that MOE should manifest as acute abdomen even in the absence of adnexal torsion.

　Patients experiencing ovarian torsion should be surgically treated promptly to preserve their ovarian function. However, they can avoid unnecessary surgical intervention if we consider that the ovaries in some MOE cases with severe abdominal pain do not twist and that their symptoms disappear spontaneously.

　Inguinal endometriosis is rare and accounts for 0.3% to 0.6% of all cases of endometriosis. Although a few studies have described drug therapy for this condition, inguinal endometriosis is primarily treated surgically. We report a case of inguinal endometriosis in a patient who presented with a mass and menstruation-associated pain in the inguinal region. Dienogest administered as pharmacotherapy was ineffective, necessitating surgical management. The inguinal mass was percutaneously removed along with the round ligament after laparoscopic resection of the round ligament. Dienogest was administered postoperatively, and no recurrence was observed during follow-up. We present a case of inguinal endometriosis, together with a literature review on the surgical treatment of inguinal endometriosis with laparoscopy in Japan.

　A uterine manipulator is frequently used as a complementary factor for operation during laparoscopic myomectomy in the field of gynecology. However, the influence of a balloon in the uterine manipulator has not been reported in the past and sufficient information on such influence has not been provided. This was a 41-year-old case with no pregnancy or childbirth, referred to by the previous doctor for the purpose of operation for a unilocular cyst of the left ovary and multiple uterine myoma. Laparoscopic myomectomy and laparoscopic extraction of a cyst of the left ovary were performed while using a uterine manipulator, and upon myoma enucleation, a measure to reduce bleeding was taken with 100-fold dilution of vasopressin. Sterile physiological saline was injected in the balloon at the distal end of the tip of the uterine manipulator until piezoresistance was felt. Occult bleeding occurred from the needle’s eye due to needle handling at the site of myoma enucleation on the bottom; therefore, resuture was performed, and tissue adhesion and closure sheets for biological tissues were also adhered. As a result, rebleeding was not confirmed after passing the time period when vasopressin efficacy was assumed to wear off. After removing the uterine manipulator, however, rebleeding was recognized from the muscular layer at the site of myoma enucleation on the bottom; therefore, suture by needle handling was added for arrest of bleeding. Complication of postoperative intraperitoneal hemorrhage was successfully avoided with the opportunity of hemostasis at this time. In consideration of operation history, however, the state of the fully inflated balloon in the uterine manipulator may be indicating stress on and closure of blood vessels within the uterine muscular wall, partially contributing to measures to suppress bleeding. When a balloon is depressurized, therefore, it is important to run a final check on the state of the site of myoma enucleation as it is, without immediately removing the uterine manipulator. While the issue of perioperative bleeding is often emphasized as a complication during laparoscopic myomectomy, a bleeding pattern that occurs due to its removal immediately prior to the end of surgery exists in the case of using a uterine manipulator. I would like to propose that sharing the astriction ability of a uterine manipulator could help avoiding a pitfall of complications.

Objective: Endometrioid borderline ovarian tumor accounts for 0.2％ of all ovarian epithelial tumors, and 63％ of them are associated with endometriosis. In this report, we present a case of an infertile woman with ovarian endometrioma, which was diagnosed as an endometrioid borderline tumor postoperatively.

Case: The patient was a 37-year-old infertile woman with an ovarian cyst. Pelvic magnetic resonance imaging showed a 65-mm ovarian cyst with high signal on T1-weighted imaging and low signal on T2-weighted imaging. Serum CA125 and CA19-9 levels were 17.3 U/mL and 778 U/mL, respectively. We performed laparoscopic cystectomy with a diagnosis of ovarian endometrioma. A 6-cm-sized left ovarian endometrioma was removed, and superficial endometriotic lesions on the pelvic peritoneum and right adnexa were ablated. The score on the revised American Society for Reproductive Medicine classification was 33 points. The histopathological examination revealed that the ovarian cyst was an endometrioid borderline tumor. We discussed the treatment plan with the patient and decided to try to achieve pregnancy as soon as possible instead of performing additional surgery. The patient is currently undergoing assisted reproduction.

Conclusion: We encountered a case of an infertile woman with an endometrioid borderline ovarian tumor who wished to bear a child. Endometrioid borderline tumors are rare, and few reports have described assisted reproduction for patients with this tumor; these patients have lower pregnancy rates than those with other histologic types of ovarian borderline tumor. More studies are required to determine the safety and efficacy of assisted reproductive technology in infertile patients with endometrioid borderline ovarian tumors.

　Vaginal cuff dehiscence is a rare complication of total hysterectomy.　It occurs more frequently after laparoscopic or robotic hysterectomy than after abdominal or vaginal hysterectomy.

　A 39-year-old woman underwent robot-assisted radical hysterectomy for stage IB１ cervical cancer. The total operative time was ４ hours 51 minutes, the estimated blood loss was 100 mL, and there were no intraoperative complications. Three months later, the patient presented with sudden abdominal pain after intercourse. On examination, separation of the vaginal cuff and prolapse of the small intestine from the same site were observed, and emergency surgery was performed. The vaginal cuff was completely separated and repaired through laparoscopic surgery. The prolapsed small intestine was returned to the abdominal cavity with only mild erythema. The abdominal cavity was thoroughly cleaned, and vaginal end was sutured with a single nodule suture, and the same area was sutured transvaginally with a single nodule suture, resulting in a two-layer suture. The patient was discharged from the hospital after a good postoperative course.

　Post-hysterectomy vaginal cuff dehiscence is a rare but serious complication. As the use of robot-assisted hysterectomy becomes more widespread, it is necessary to accumulate cases and investigate methods to prevent and repair vaginal cuff dehiscence.

　Robotic surgery for the treatment of patients with early-stage endometrial cancer has been covered by National Health Insurance in Japan from April 2018. Since then, robotic surgeries have become more common, and at present, it is possible to perform robotic surgeries in many institutions in Japan. However, there are no consensus criteria at present regarding the optimal surgical method (i.e., robotic surgery or laparoscopic surgery) for early-stage endometrial cancer patients. In general, for obese patients, robotic surgery is considered to be more favorable than laparoscopic surgery, owing to its operability and ability to secure a clear surgical field. We here report a case of an early-stage endometrial cancer patient with morbid obesity (BMI=54.19 kg/m²) who was successfully treated by robotic-assisted total hysterectomy and bilateral salpingo-oophorectomy at our institute.

　Endometrial stromal sarcoma, a rare disease, accounts for approximately 0.2％ of all types of uterine malignancies. The disease may be difficult to differentiate from the benign one using preoperative imaging and histological diagnosis. We report a case of a patient who underwent robot-assisted surgery for uterine adenomyosis and was diagnosed with low-grade endometrial stromal sarcoma. She underwent additional laparoscopic surgery using the initial surgical wound. A 45-year-old gravida 4, para 2 was referred because of excessive menstruation caused by uterine adenomyosis. Ultrasound and magnetic resonance imaging revealed uterine adenomyosis and a 5-cm right endometrioid ovarian cyst. Cytology did not reveal any suspicious findings for malignant disease. Hormone therapy was initiated, but bleeding and anemia were observed. Hence, robotic surgery was performed. Robot-assisted laparoscopic hysterectomy, right adnexectomy, and left tubectomy were performed using the da Vinci Xi system. The patient was discharged without any postoperative problems.

　Pathological examination revealed low-grade endometrial stromal sarcoma, FIGO pT1a, NX, M0, stage IA. Based on the pathological diagnosis, laparoscopic removal of the left ovary was decided. The same wound as the initial surgery was used for the operation. No malignant findings were observed in the removed ovaries. When additional laparoscopic surgery was required after robot-assisted surgery, laparoscopic surgery using the previous wound was thought to be a safe option.

　We report two cases of recurrence after laparoscopic sacrocolpopexy for pelvic organ prolapse, in which the mesh was fixed only to the cervix; the reoperation was performed with robotic assistance.

　In both the cases, recurrence was observed residual cervical prolapse of POP-Q stage III and II at the age of 61, respectively. They were repaired by the modified French method that widely covers the vaginal wall with the assistance of a robot. The modified French style uses a single mesh for the anterior vaginal wall and sutures the posterior vaginal wall. Intraoperative findings and postoperative pathological examination revealed that the cause of recurrence was not detachment of the mesh but elongation of the cervical fixation. There have been no previous reports of this condition and caution should be exercised regarding the indications for mesh fixation only to the cervix.

　Using robotic-assistance, it was possible to isolate the mesh that was strongly adherent to the surrounding tissue and to excise the mesh from the anterior longitudinal ligament on L5-S1. The highly flexible robotic arm enables accurate incision and detachment of the mesh, which are difficult with a laparoscope, suggesting its usefulness during reoperation.

Introduction

　To prevent cutting the ureter during laparoscopic total hysterectomy (TLH), it is important to identify the point where the ureter intersects with the uterine artery (the entrance to the ureteral tunnel) and determine the height of the cut of the basal ligament. To do this, it is necessary to first identify the ureter. There are three approaches to ureteral passivation: anterior, lateral, and posterior. In order to compensate for the disadvantages of each approach and to optimize safety, we have developed a method that combines the anterior and posterior approaches of laparoscopic total hysterectomy (hereinafter referred to as the anterior-posterior approach)

Method

　In the anterior approach, a cavity is created between the lateral umbilical ligament and the ureter (neobladder lateral cavity). From there, the rectal cavity of Okabayashi could be created and the ureter could be passivated, but in some cases, detachment is difficult. Therefore, once the neobladder lateral cavity has been liberated by the anterior approach, we switch to the posterior approach.

　This approach facilitates ureteral fluoroscopy from the posterior lobe of the broad mesentery as the lateral lumen of the neobladder has been created. This aids the identification of the ureter and the creation of the lateral rectal lumen in a safe and efficient manner.

Results

　The anterior-posterior approach is a safe and efficient method of visualizing and identifying ureteral passages in patients with TLH.

Conclusion

　In TLH, the lateral approach allows the identification of the ureter cephalad to the ovary and as well as that of the site of intersection of the uterine artery and the ureter while isolating the ureter caudally, thus facilitating a better and clearer visualization of the peritoneum. However, the lateral approach is thought to increase the risk of ovarian torsion after TLH. Moreover, it is often difficult to identify the ureter by the posterior approach in cases with high amount of fatty tissue or adhesions in the retroperitoneum. The anterior-posterior approach can compensate for the limitations of the lateral and posterior approaches and potentially help reduce the risk of ureteral injury in cases of TLH.

Purpose

　Rectosigmoid colon injury is one of the complications of total laparoscopic hysterectomy (TLH). During TLH, when incising the vaginal wall, a blind incision into the posterior vaginal wall may have to be made, depending on the position of the camera port. If the rectum/sigmoid colon, which should be elevated outside the pelvis, is present in the pouch of Douglas, the risk of rectosigmoid colon injury increases.

　We report a surgical strategy to prevent rectosigmoid colon injury in patients suspected of pouch of Douglas adhesions preoperatively or intraoperatively at our institution.

Methods

　First, we incise the supporting tissue to expose the entire cervical fascia, and insert a vaginal pipe when an incision of the vaginal wall is possible. Next, we incise the ventral vaginal wall and insert the forceps through the hole of the vaginal pipe. Finally, we grasp the cervix at 12 o'clock with the forceps and lift the entire uterus ventrally.

　This makes a space between the pouch of Douglas and the posterior vaginal wall, which enable us to treat the posterior vaginal wall while maintaining the distance from the rectum/sigmoid colon. Using this method, we can securely lift the entire uterus from the vaginal side to the cranial, thus creating sufficient work space between the posterior uterus and the rectum even in cases with pouch of Douglas adhesions.

Results

　We completed the operations safely without any damage due to this ingenuity.

Conclusion

　Using this technique, we have been able to prevent rectosigmoid colon injury in cases with pouch of Douglas adhesions at our institution.

　We hope that this report will encourage more laparoscopists to use this method in cases with pouch of Douglas adhesions observed before or during surgery.

　In this report, we report a case of bilateral ovarian torsion due to severe ovarian hyperstimulation syndrome (OHSS) at five weeks gestational age for a triplet gestation at a nearby clinic. A 24-year-old woman became pregnant by timed sexual intercourse after follicle stimulation with gonadotropin but developed severe OHSS. She was referred and admitted to our hospital the same day. On the ninth day of hospitalization, she experienced acute abdominal pain and was diagnosed with ovarian torsion. Laparoscopic findings revealed bilateral ovarian torsion and extremely fragile and hemorrhagic ovaries. Aspiration was performed on the ovarian cysts for volume reduction, which made it easier to perform detorsion without causing accidental bleeding. The postoperative course was uneventful.

　Therefore, we concluded that the laparoscopic aspiration of ovarian cysts may be considered in the case of ovarian torsion by OHSS during pregnancy.

Objective: We describe our initial experience with laparoscopic surgery for endometrial cancer using trocar insertion into the posterior vaginal fornix.

Methods: This retrospective study included 22 women with clinical stage IA endometrial cancer, who underwent laparoscopic surgery at our hospital between April 2018 and December 2020. We avoid the use of uterine manipulators at our hospital to minimize the risk of cancer cell dissemination and prefer natural orifice transluminal endoscopic surgery, which involves insertion of trocars into the posterior vaginal fornix to achieve uterine traction. We recorded the operation time, estimated blood loss, number of extirpated lymph nodes, surgery-induced complications, and safety of trocar insertion into the posterior vaginal fornix.

Results: All 22 women underwent bilateral salpingo-oophorectomy; pelvic lymphadenectomy was performed in 16 women. The median operation time was 218.5 (range 166-299) min in women who underwent additional pelvic lymphadenectomy and 109 (range 93-153) min in women who did not undergo pelvic lymphadenectomy. The median estimated blood loss was 50 (range 5-280) mL in operations with additional pelvic lymphadenectomy and 12.5 (range 5-27) mL in operations without pelvic lymphadenectomy. The median number of lymph nodes resected in the pelvic lymphadenectomy group was 23.5. All procedures were successfully performed without additional transabdominal trocar insertion. No intraoperative complications occurred, and no patient required conversion to laparotomy.

Conclusion: Laparoscopic surgery for endometrial cancer with trocar insertion into the posterior vaginal fornix was safe with regard to short-term outcomes.