Introduction: Laparoscopic surgical training using cadavers is gradually increasing in Japan. In this study, we aimed to evaluate the usefulness of our cadaveric surgical training using questionnaires.

Materials and Methods: A laparoscopic surgical training was held in our department using a saturated salt solution-embalmed cadaver.

　The participants performed laparoscopic radical hysterectomy and para-aortic lymphadenectomy turn wise after checking the pelvic anatomy of blood vessels and nerves under the guidance of an educator. All the 13 participants completed the quantitative questionnaires on confidence of laparoscopic surgical skills and pelvic anatomical knowledge before and after training. The scores of each participant on each item were summed before and after training, and this score was defined as the self-confidence score.

Results: The self-confidence score for all the items increased after the training with the highest increase in the item “understanding of pelvic anatomy”. In a questionnaire that surveyed the overall usefulness of the training, the level of satisfaction with the training was very high; however, some participants did not feel that their skills had improved after the training.

Conclusions: The training on laparoscopic surgery using a cadaver was highly satisfactory to the participants. This training increased their confidence in understanding the pelvic anatomy. Although the training is still limited in Japan, it could be made more meaningful by focusing on deepening the anatomical knowledge of the participants.

Purpose: Following gynecologic surgery, postoperative adhesions commonly cause intestinal obstruction; therefore, the anti-adhesion materials used are of great importance. Currently, various anti-adhesion materials are used, including regenerated cellulose (Interceed, Johnson and Johnson, Ltd) and carboxymethylcellulose hyaluronate (Seprafilm, Kaken Pharmaceutical, Ltd).

　At our hospital, total laparoscopic hysterectomy (TLH) is performed using only 5 mm ports in four places (diamond placement) to reduce the wound pain and need for plastic surgery. The adhesion preventive material is placed intraperitoneally, which is sometimes difficult.

　Here, we demonstrate a new method for placing large-sized Interceed in the abdominal cavity, which we call the “Hakama” method. The purpose of this method is to reduce the placement and application time compared to the conventional method.

Methods: Twenty patients (10 treated with the Hakama method and 10 with the conventional method) who underwent TLH at our hospital between April 2018 and April 2019, were included in this study. To evaluate and compare both methods, the time to place the Interceed in the abdominal cavity and the time taken for it to adhere (time from placement to adhesion) were noted.

Results: The median (range) placement times were 16.5 s (12-35 s) and 24.5 s (13-34 s) and the application times (range) were 106.5 s (64-156 s) and 140.5 s (89-200 s) for the Hakama and conventional methods, respectively (p = 0.15 and 0.02; Fig. 2a and 2b, respectively,). Neither method resulted in damage to the large-sized Interceed.

Conclusion: We devised a new method for the intraperitoneal delivery of a large-sized Interceed in TLH using only 5 mm ports. The Hakama method requires only a simple incision and no other special materials or procedures. In addition, the procedure is relatively easy, and it is possible to quickly place the Interceed in the abdominal cavity with a single motion. Moreover, since the shape of the Interceed matches the open part of the retroperitoneum, the relative ease and convenience of attachment is enhanced. With this method, it is possible to use the anti-adhesion agent safely and quickly, while contributing to a shortened TLH operation time using only 5 mm ports.

Inguinal endometriosis, a rare and diagnostically challenging condition, is occasionally misdiagnosed by general surgeons as an inguinal hernia or a hydrocele of the canal of Nuck. In this study, we retrospectively investigated 23 patients with inguinal endometriosis diagnosed at our hospital between January 2006 and September 2021. Per our hospital policy, surgical treatment consists of resection from the round ligament to the inguinal lesion; notably, to date, no patient has shown recurrence with this approach. Individualized therapy (drug vs. surgical treatment) should be carefully selected based on the patient's condition.

Objective: Laparoscopic surgery is the standard care for early-stage endometrial cancer. We evaluated laparoscopic surgery for early-stage endometrial cancer in our hospital.

Methods: Thirty-nine endometrial cancer patients who underwent laparoscopic surgery in our institution during 2014-2021 were retrospectively examined. A staging laparotomy was performed when ascitic fluid cytology was positive. Operation time, blood loss, complications, and postoperative pathological diagnosis were analysed.

Results: The median patient age was 52 years (range:27-80 years), and the average body mass index was 22(range:16-30). The median operative time was 238 minutes(range:152-398), and the average blood loss was 105 mL (range:10-615 mL). Only one patient had a significant operative complication (bladder injury). Four patients had pathological stageⅡ or Ⅲ disease.

Conclusion: Laparoscopic surgery for early-stage endometrial cancer was performed safely in our institution.

Purpose: For many gynecologic surgeries, laparoscopy is well established and widely performed. In Japan, the gynecologic laparoscopy board certification program ensures surgical quality and safety. In our department, fellows experience many laparoscopic surgeries. To improve our laparoscopic educational program, we performed a questionnaire survey for laparoscopists and fellows to obtain detailed opinions.

Methods: A questionnaire survey was conducted for 26 laparoscopists and 29 fellows at the department of obstetrics and gynecology of Yokohama City University.

Results: A total of 44 out of 55 questionnaires were collected. Laparoscopists and fellows prioritized the experience in a high number of operative cases. Certified laparoscopists also considered the mental attitude as important. For improving surgical skills, fellows focused on technical trainings, whereas laparoscopists also indicated practical trainings, such as watching surgical procedures and videos.

Conclusion: To improve the educational program, obtaining and sharing opinions from laparoscopists and fellows is important.

Objective: The treatment strategy for ovarian tumors is often uncertain when a patient wishes to have children. Especially in the case of endometriotic cysts, although pre-assisted reproductive technology ovarian cystectomy does not improve the live birth rate, surgery may be selected considering the symptom and the infertility treatment course. In such cases, it is necessary to pay attention to selecting the hemostatic method for ovarian reserve. It has been reported that hemostasis with suture / hemostatic sealant has a smaller decrease in serum anti-Müllerian hormone (AMH) level than with bipolar coagulation. We focused on this method using a hemostatic sealant.

Methods: We used Oxidized Regenerated Cellulose Powder as a hemostatic method when performing laparoscopic ovarian cystectomy. Nine patients wishing to have babies were included. The serum AMH concentration was investigated before and 3 months after surgery.

Results: The average change in AMH before and after surgery was 97.3%, showing almost no decrease.

Conclusions: Using Oxidized Regenerated Cellulose Powder for hemostasis in laparoscopic ovarian cystectomy was shown to prevent a decrease in AMH level after surgery; this method could provide a sufficient protective effect on ovarian reserve.

Objective: Laparoscopic myomectomy (LM) is one of the most difficult surgical techniques. To complete LM safely, controlling intraoperative bleeding is important. In this study, we retrospectively investigated the relationships between size and location of uterine myomas and the amount of intraoperative blood loss during LM at our hospital.

Methods: 219 patients who underwent LM at our hospital during the 4-year period from January 2017 to December 2020 were enrolled. The patients were classified into 137 intramuscular myoma group and 82 submucosal myoma group according to the location. We examined the maximum myoma diameter and blood loss, and the blood loss with and without preoperative GnRH analogue treatment.

Results: The maximum myoma diameter was positively correlated with the blood loss, but the number of myomas was not. The maximum myoma diameter tends to cause abnormal blood loss (bleed more than 500 ml) was more than 8.9 cm in the intramuscular myoma group, and more than 14.1 cm in the submucosal myoma group. Furthermore, there was a tendency to the preoperative GnRH analogue group to bleed approximately 40 ml more than the non-treated group compared by the same maximum myoma diameter.

Conclusion: It was not the number of myomas but the maximum myoma diameter that relates to the amount of blood loss in LM. Thus, if abnormal bleeding is predicted based on the maximum myoma diameter before surgery, explain the risks to the patient and also share the risks between operators may help to ensure safer LM.

Objective: After the increasing number of recent reports of hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES), we have introduced a novel procedure called vaginally-assisted NOTES hysterectomy (VANH). The objective of this study was to describe the VANH technique step-by-step, assess the technical feasibility of the procedure, and evaluate its initial surgical outcomes.

Methods: We retrospectively reviewed the perioperative outcomes in 20 patients with benign gynecologic disease who underwent VANH (n=10) or total laparoscopic hysterectomy (TLH; n=10) between February and November 2019 at our institution. Patient characteristics, operation time, blood loss, perioperative complications, and postoperative pain scores were compared between the two groups, as well as the amount of oral analgesia used in the first three postoperative days.

Results: There was no significant between-group difference in operation time or length of postoperative hospital stay. Mean estimated blood loss was significantly greater (198 mL vs. 18 mL, p=0.02) and the mean postoperative pain score was significantly lower in the VANH group than in the TLH group. The mean number of oral analgesics used was significantly lower in the VANH group (1.9 vs 3.5, p=0.01).

Conclusion: VANH could be safely introduced at our institution as an alternative approach for hysterectomy and have several benefits, including less postoperative pain and no visible scars. We anticipate that accumulation of more cases will allow us to improve our technique, consider expansion of the surgical indications for VANH, and introduce other vNOTES procedures.

Objective: Total laparoscopic hysterectomy (TLH) has gained widespread acceptance. Although using an intra-abdominal drain after laparoscopic surgery has been considered effective, there are no clear guidelines concerning it. We analyzed the cases of TLH in our hospital to see if drain placement could be omitted.

Methods: From April 2020 to March 2021, 79 patients underwent TLH in our hospital. While we placed intra-abdominal drains after TLH in 33 patients (drain group), we did not place the drains after TLH in 46 patients (non-drain group). Clinical background, operation time, bleeding volume, weight of the uterus, number of days until discharge, and postoperative complications were retrospectively analyzed.

Results: Three patients developed postoperative complications, of which 2 and 1 were from the drain and non-drain groups, respectively. One patient in the drain group underwent vaginal stump dehiscence whereas the other developed umbilical wound infection. Vaginal stump hematoma was observed in the patient from the non-drain group.

Conclusion: This study suggested that intra-abdominal drain placement after TLH could be omitted. Further studies are warranted to support omission of drains after TLH.

Introduction: Laparoscopic surgery is increasingly being performed for adnexal lesions during pregnancy and is usually performed between 12 and 16 weeks' gestation, although it may be attempted even after 16 weeks' gestation. However, a large-sized gravid uterus narrows the surgical field, and forceps manipulation is challenging.

Methods: We retrospectively investigated seven cases of adnexal laparoscopic surgeries performed after 16 weeks' gestation between 2009 and 2018 at our hospital.

Result: Elective and emergency operations were performed in one and six patients, respectively. Surgery was performed between 18 and 33 weeks' gestation. Postoperative diagnoses included teratoma in one, mucinous cystadenoma in one, torsion of serous cystadenoma in one, common ovarian torsion in three, and intraperitoneal adhesions in one patient. No premature birth was observed postoperatively.

Conclusion: There were some ideas for surgery so that laparoscopic surgery may be useful even after 16 weeks' gestation and for emergency surgery.

Objective: To investigate the clinical outcome of Transcervical Resection with laparoscopic uterine artery clipping in patients with placental polyp.

Design: Retrospective study

Setting: Single-institution case series

Patients: Nine patients with placental polyp who were admitted to the Teikyo University Chiba Medical Center between July 2014 and April 2021 were included.

Main Outcome: Prognosis and fertility

Results: Mean age of the patients was 26.2±1.3 years. Four of the previous pregnancies were first pregnancies and five were term pregnancies. The preceding mode of delivery included stillbirth in the middle of pregnancy in three cases and early abortion at 8 weeks of gestation in one case. Of the five cases that resulted in live births, two were cesarean sections. Mean time from delivery to diagnosis was 39.4±9.0 days. Postoperatively, all the patients passed without complications, such as re-bleeding or failure of removal, and treatment was completed. Natural menstruation occurred in an average of 64.5±4.7 days. As for postoperative fertility, two out of three patients, excluding the four patients who wish not to have a baby and the two patients who were difficult to follow, had live births. Additionally, one of the remaining patients is currently attempting to conceive a baby, and ovulation has been confirmed.

Conclusion: Laparoscopic uterine artery clipping for placental polyp is a useful skill for treating active vaginal bleeding and keeping fertility.

　Ovarian torsion is frequently found in benign cases of non-adhered ovarian tumors. When only a simple cyst without surface nodules is detected by preoperative ovarian imaging, we tend to classify the tumor as benign. We herein report a case of a simple ovarian cyst that presented as ovarian torsion and was found to be a high-grade serous carcinoma by laparoscopic adnexectomy in a postmenopausal woman.

Case: A 74-year-old woman (postmenopausal age: 55 years, gravida 1 para 1) was referred to our hospital because of a right ovarian tumor detected by abdominal computed tomography. Magnetic resonance imaging showed a 12-cm simple cyst, and no findings suggestive of malignancy, such as a nodule on the tumor surface, were detected. The levels of tumor markers were as follows: CA 125, 19 U/ml and CA19-9, 9.9 U/ml. A right ovarian laparoscopic adnexectomy was performed because the tumor was considered benign. Laparoscopic findings showed that the tumor was twisted twice around the ovary ligament and no adhesion or peritoneal dissemination to the surrounding organs were evidenced. Pathological examination revealed a high-grade serous carcinoma of the ovary. At a later date, we performed staging laparotomy and no carcinoma cells were found in the organs. Therefore, we classified the ovarian cancer as stage IA according to the International Federation of Gynecology and Obstetrics.

Conclusion: We reported a case of a simple ovarian tumor presenting as ovarian torsion detected as a carcinoma by laparoscopic adnexectomy in a postmenopausal woman. Ovarian torsion occurrence should be considered a risk factor for postoperative ovarian carcinoma.

　Obstructed hemi-vagina and ipsilateral renal agenesis (OHVIRA) syndrome is a complex of Müllerian and Wolffian duct anomalies constituted by obstructed hemi-vagina that may form hematocolpos with ipsilateral renal anomaly and different degrees of didelphic uterine anomalies. Due to the obstructive anomalies of the reproductive tract, endometriosis of differing severities may be a common complication of OHVIRA syndrome. Here, we report three women with OHVIRA syndrome that showed different clinical courses and severities of pelvic endometriosis. This may suggest a relationship between the pathogenesis of endometriosis and asymmetrical obstructive Müllerian anomalies.

　Parasitic peritoneal leiomyomatosis (PL) and disseminated peritoneal leiomyomatosis (DPL) are rare medical conditions; however, cases have been widely reported in recent years. Case1: A 43-year-old woman presented at our hospital, eight years after a laparoscopic myomectomy, with anemia and a uterine tumor. Magnetic resonance imaging and computed tomography (CT) scans revealed a uterine mass, several other pelvic masses, and a subcutaneous mass in the umbilicus. Endometrial stromal sarcoma was suspected, and she underwent an open laparotomy to remove the masses. The pelvic tumors were found attached to the vesicouterine peritoneum. Upon rapid intraoperative pathological examination, the tumor appeared benign. She underwent total hysterectomy and tumor resection surgery. Histopathologic examination revealed that the masses were Estrogen Receptor- and Progesterone Receptors-positive leiomyomas. Case2: A 46-year-old woman presented at our hospital, about seven years after a total laparoscopic supracervical hysterectomy, with stomach pain. CT scans revealed a sigmoid colon mass. She underwent a laparoscopic tumor resection surgery. Histopathologic examination revealed that the mass was a leiomyoma. Efforts should be taken to prevent iatrogenic leiomyomas dissemination; whenever possible, tumor morcellation should be done in a containment bag. Considering each patient's history of gynecologic surgery, we believe these were rare cases of DPL following laparoscopic uterine myomectomy.

　To date, only 12 cases of mature cystic teratoma with sigmoid colon perforation have been reported in the literature. We report a rare case of mature cystic teratoma accompanied by sigmoid colon perforation treated using laparoscopic-assisted surgery. A 25-year-old woman (gravida 2 para 0) was admitted to our hospital for evaluation of a 2-week history of fever. Magnetic resonance imaging revealed a large cyst filled with fat, as well as free air in the pelvis. Laboratory investigations showed evidence of significant inflammation. Therefore, we suspected mature cystic teratoma concomitant with bowel perforation.

　Colonoscopy confirmed a sigmoid colon perforation, and we performed laparoscopic-assisted surgery.

　Histopathological evaluation confirmed diagnosis of a mature cystic teratoma without malignant transformation. Malignancy should be considered in the differential diagnosis, and an appropriate operative procedure should be selected in patients with ovarian cysts concomitant with bowel perforation.

　Levonorgestrel-intrauterine system (LNG-IUS) is mainly used for contraception. Recently, several studies reported cases in which an LNG-IUS partially perforated the uterine myometrium and migrated into the abdominal cavity. However, there have been no reports describing LNG-IUS migration from the myometrium into the abdominal cavity within a short period. Herein, we reported a laparoscopic removal of an LNG-IUS that migrated into the abdominal cavity within a short period.

Case: A 30-year-old woman (gravida, 3; para, 3) visited a clinic for LNG-IUS insertion for the purpose of contraception and improvement of dysmenorrhea at seven months postpartum. After five years, the doctor was unable to remove the LNG-IUS, and the patient was referred to our hospital. We attempted LNG-IUS removal under venous anesthesia, but it was unsuccessful. Ultrasound images showed LNG-IUS with partial myometrial perforation. We performed magnetic resonance imaging (MRI) after a 1-h procedure, and partial perforation was diagnosed. Two weeks later, we re-evaluated the MRI images because an abdominal computed tomography showed complete perforation. Upon the re-evaluation, we found that the previous MRI images actually showed complete perforation into the abdominal cavity. We thought that pulling the tail of the LNG-IUS in a state of partial perforation could lead to complete perforation due to uterine contraction. Under general anesthesia, the position of the LNG-IUS was determined on an abdominal X-ray. However, we successfully removed the LNG-IUS via laparoscopy.

Conclusion: Pulling the tail of an LNG-IUS in a state of partial perforation could lead to complete migration into the abdominal cavity. Abdominal X-ray tomography after induction of anesthesia was useful for determining the LNG-IUS location and facilitating its removal, laparoscopically.

Objective: To report a rare case of a urachal remnant cyst mimicking a benign ovarian cyst.

Case: A 50-year-old female was referred to our department because of a right ovarian tumor increasing in size. A pelvic examination revealed a 7 cm cystic tumor in the right adnexal region, and magnetic resonance imaging and computed tomography showed a 7 cm tumor without a solid component. Tumor markers were not elevated. We decided to perform laparoscopic surgery, and the port was inserted in a parallel fashion due to the tumor in the midline of the lower abdomen, which originated in the mural peritoneum and was connected to the bladder apex. The bilateral appendages were normal, and the cystoscopy showed normal bladder mucosa. The urologist resected the tumor under laparoscopic surgery. Postoperative pathological examination revealed no neoplastic findings in the epithelium, and the patient was diagnosed with a urachal remnant cyst.

Conclusion: We reported a case of a urachal remnant cyst that was difficult to distinguish from an ovarian tumor preoperatively. Although gynecologists rarely experience urachal disease, we were able to complete the laparoscopic surgery with the urologist.

　Laparoscopic sacrocolpopexy (LSC) is becoming a popular surgical method for patients with pelvic organ prolapse. It is associated with a lower rate of recurrence and higher rate of patient satisfaction. Dissecting the peritoneum on the promontory of the sacrum to expose the anterior longitudinal ligament is an essential part of this surgery. However, there are some cases in which we cannot perform this procedure due to anatomical anomalies. Laparoscopic lateral suspension (LLS) is another surgical procedure for patients with pelvic organ prolapse. It involves the anchoring and suspension of a mesh, without exposing the longitudinal ligament at the promontory of the sacrum. LSC was planned for a 74-year-old woman (gravida 2, para 2) with stage III pelvic organ prolapse. Preoperative magnetic resonance imaging showed that her right common iliac artery ran in front of the promontory of the sacrum, and it considered difficult to expose the anterior longitudinal ligament. The surgical method was changed from LSC to LLS with barbed suture for posterior colporrhaphy using V-Loc. The operation time was 5 hours and 37 minutes; there was little blood loss. She had an uneventful postoperative course with no recurrence at nine months after surgery. LLS with barbed suture for posterior colporrhaphy can be an effective alternative method when it is difficult to dissect the peritoneum on the promontory of the sacrum to expose the anterior longitudinal ligament in LSC.

Introduction: Interstitial pregnancies are rare. There have been sporadic reports of postoperative uterine scar rupture; precise frequency is unknown. Herein, we report a case where uterine rupture was observed during a cesarean section after surgery for interstitial ectopic pregnancy.

Case: Our 35-year-old patient has had six pregnancies and two deliveries. She was referred to our department with suspected ectopic pregnancy at 7 weeks of gestation. She was diagnosed with right-sided interstitial pregnancy and underwent laparoscopic salpingectomy and interstitial wedge resection. Operative time was 68 minutes; blood volume loss was 9 ml. She conceived spontaneously 18 months postoperatively and underwent elective cesarean section at 37 weeks of gestation. Intraoperatively, mild fundal compression was performed by the assistant during delivery. The newborn weighed 2,512 g; it had an Apgar score of 8/9 points and an umbilical artery pH of 7.233. When the uterus was elevated outside the abdominal cavity after delivery, complete uterine rupture was observed where previous surgery was performed, while the placenta had invaded the abdominal cavity. Uterine rupture was m using double-layer closure. Operative time was 89 minutes; blood volume loss was 607 ml. Postoperative course was uneventful for both mother and newborn.

Conclusion: Uterine rupture in pregnancies following surgery for tubal interstitial pregnancy and uterine rupture can also occur during a cesarean section; thus, it is advisable to avoid uterine fundal compression upon delivery, when possible. Additionally, the possibility of uterine rupture after a future pregnancy should be carefully considered during surgery for interstitial ectopic pregnancy.

　We have previously reported the usefulness of a needle laparoscopic surgery system that involves insertion of a port through the Douglas' pouch and use of an EndoPouch to facilitate cystectomy without leakage of the ovarian cyst contents.

　A 32-year-old woman (G0P0) with an unremarkable medical and surgical history visited a clinic for evaluation of lower abdominal pain and was referred to our hospital for management of a left ovarian cyst. Transvaginal ultrasonography and pelvic magnetic resonance imaging revealed a left ovarian cyst (6 cm in diameter) and several subserosal fibroids (up to 3 cm in size). A 5-mm optical trocar was inserted into the umbilical region, 3-mm ports into the left and right lower abdomen, and a 12-mm port into the Douglas' pouch. An EndoPouch was introduced via the port inserted into the Douglas' pouch, and the left ovarian cyst was carefully placed in it; we performed successful cystectomy without leakage of the cystic contents. The cyst wall, tumor contents, and a fibroid were placed into the EndoPouch and cautiously extracted from the Douglas' pouch.

　Histopathological evaluation confirmed diagnosis of a mature cystic teratoma and significantly degenerated leiomyoma. In this patient who denied a history of myomectomy and presented with multiple subserosal fibroids, we concluded that one of the subserosal fibroids was dislodged from the uterus and was implanted into the retroperitoneum via the bloodstream. This case report highlights that needle laparoscopic surgery was an effective and minimally invasive method for successful intra-abdominal tumor removal.

Introduction: The prognosis of ureteral endometriosis is good if proper treatment is applied, but lack of subjective symptoms often lead to poor treatment. The disease comprises as low as 0.1％ of all pelvic endometriosis and 10％ of urinary tract endometriosis. Therefore, both patients and doctors are usually unaware of the seriousness of the disease, and in some cases, patients do not seek medical attention although problems are noted during examinations. Even when medical attention is sought, treatment is delayed because of the lack of a proper diagnosis. In this report, we describe three cases in which unilateral renal function was impaired due to ureteral endometriosis.

Case 1: A 51-year-old woman was diagnosed with hydronephrosis at a checkup two years ago, but she had no symptoms and did not seek medical care. She visited her previous doctor for dysmenorrhea, irregular bleeding, and hematuria, and was referred to our hospital after CT and MRI scans revealed uterine fibroids, rectal endometriosis, and a left ureteral tumor. In addition to laparoscopic hysterectomy, bilateral adnexal resection, and low anterior resection, laparoscopic total left nephroureterectomy was performed.

Case 2: A 52-year-old woman was diagnosed with adenomyosis at another hospital more than 10 years ago, but the condition was difficult to treat because of poorly controlled hypertension. Graves'disease was diagnosed three months before her first visit, and preoperative examination showed abnormal renal function. CT showed left hydronephrosis, right nonfunctioning kidney, and uterine adenomyosis. She underwent the robot-assisted total hysterectomy, bilateral adnexal resection, and left vesicoureteral neoanastomosis.

Case 3: A 48-year-old woman visited her previous doctor because of abdominal pain and vomiting. MRI revealed multiple uterine fibroids and a left nonfunctioning kidney. Robot-assisted total hysterectomy, bilateral salpingo-oophorectomy, and left ureterolysis were performed.

Conclusion: Even in advanced cases of ureteral endometriosis, about half of the patients have few symptoms. Asymptomatic hydronephrosis should lead to a suspicion of ureteral endometriosis. It is also important to consider ureteral endometriosis even if adnexal lesions are not suspected.

Introduction: Pelvic inflammatory disease (PID) affects 4% of women, especially in younger age groups and occasionally, in patients with diabetes. We report a case of PID treated with laparoscopic surgery in a patient with uncontrolled type 2 diabetes mellitus.

Case: A 46-year-old nulliparous woman with diabetes visited our department for investigation and treatment of PID in year X-4. Bilateral adnexal hypertrophy was observed, and she was in remission with antibiotics. Subsequent recurrences were managed on an outpatient basis. In year X, the patient was hospitalized for antibiotic treatment because of severe recurrent PID. Blood tests showed elevated HbA1c (11.4%), prompting initiation of insulin. After 10 days, pre-prandial and 2 hour post-prandial blood glucose levels were controlled at 80-110 mg/dL and 140-180 mg/dL, respectively. However, no improvement in inflammatory response was observed; hence, surgical intervention was required. Emergency laparoscopy for left adnexal resection, right salpingectomy, and adhesion detachment was performed with an operation time of 3 hours and 23 minutes and an estimated blood loss of 400 mL. The patient was discharged 5 days post-operation.

Discussion: Around 60% of PID patients, with ≥ 10 cm adnexal abscess, require surgery. In patients with diabetes, it is crucial to maintain a perioperative blood glucose level of < 200 mg/dL to prevent complications. In addition, successful surgery is best achieved through the minimally invasive laparoscopic approach, which markedly reduces the risk of developing surgical site infections.

　Heterotopic pregnancy, defined as simultaneous intra- and extrauterine gestation is diagnostically challenging. The incidence rate of heterotopic pregnancy is 27-fold higher after assisted reproductive technology than after spontaneous conception; nevertheless, it is relatively rare (reported incidence rate 0.003％). We report a case of laparoscopically diagnosed heterotopic pregnancy. A 37-year-old primipara, who conceived after intrauterine insemination in conjunction with ovulation induction, was referred to our hospital for evaluation of abdominal pain at 6 weeks' gestation. Transvaginal ultrasonography revealed a viable intrauterine pregnancy and a left adnexal mass (3 cm) suggestive of hematoma or ectopic pregnancy. Laboratory test results showed total serum β-human chorionic gonadotrophin of 33,783 mIU/mL and serum hemoglobin (Hb) of 10.7 g/dL. Evaluation on the 2^nd day of hospitalization showed left adnexal mass enlargement to 5 cm with serum Hb level decreased to 8.5 g/dL. Magnetic resonance imaging (MRI) revealed a hematoma and a cystic area surrounding the left adnexa; however, the lesion was not definitively diagnosed. Transvaginal ultrasonography performed on the 9^th day of hospitalization revealed a gestational sac containing a yolk sac, surrounding the left adnexa, which led to a high index of clinical suspicion for heterotopic pregnancy. Laparoscopy revealed a distended left fallopian tube compatible with ectopic pregnancy; therefore, we performed left salpingectomy. Histopathological examination of the resected specimen showed villi within the left fallopian tube, which confirmed diagnosis of an ectopic pregnancy. The intrauterine pregnancy remained intact, and the patient delivered a healthy male neonate at term. MRI and ultrasonography may not definitively diagnose heterotopic pregnancy; however, laparoscopic surgery is a useful diagnostic and therapeutic approach for heterotopic pregnancy.

　A 26-year-old woman at 7 weeks and 4 days of gestation presented with atypical vaginal bleeding and mild abdominal pain. Transvaginal ultrasound revealed a free hypoechoic area of 10 mm in the pouch of Douglas and a 13-mm thick homogenous endometrium with no evidence of a gestational sac. A mass (46 × 38 mm) was detected outside of the uterine fundus. A T1-weighted MRI was performed, revealing a 4-cm mass between the left side of the fundus and the left ovary. Laboratory results indicated normal blood count values and a human chorionic gonadotropin (hCG) level of 4,393 mIU/ml. Because we suspected an ectopic pregnancy, we performed a laparoscopic exploration. An omental ectopic mass was detected 4 cm from the left fallopian tube. We performed a partial omentectomy using a laparoscopic approach to remove the omental mass. Pathological examination confirmed the diagnosis of an omental ectopic pregnancy with the presence of chorionic villi, blood clots, and adipose tissue. Post-operatively, the patient presented with decreased serum hCG levels and no surgery-related complications. We can use laparoscopy to successfully treat abdominal pregnancies, including rare cases of omental pregnancy.

　Rapid and better wound healing is an advantage of the laparoscopic approach compared with open surgery. The umbilicus is a preferred site for port placement considering safety and favorable cosmetic outcomes; however, postoperative management may be challenging owing to hypertrophic umbilical scars and keloids (abnormal scars).

　We report a case of abnormal umbilical scarring after total laparoscopic hysterectomy and estrogen replacement therapy (ERT) in a patient with obesity. A 46-year-old woman (body mass index 39.7 kg/m²) underwent surgery for uterine leiomyoma for management of hypermenorrhea. She experienced hot flashes 4 months later, and we initiated ERT. She presented with abnormal umbilical scarring that caused recurrent infections 26 months postoperatively, and underwent scar excision and umbilicoplasty. The patient is recurrence-free 17 months postoperatively. Obesity may have been a risk factor for abnormal scarring in this patient who received ERT. No study has reported an association between ERT and abnormal scarring; further studies are warranted to validate these findings.

　Owing to the widespread popularity of laparoscopic surgery, the number of patients with postoperative abnormal umbilical scarring is expected to increase. Abnormal scarring is attributable to chronic inflammation; therefore, it is important to reduce scar tension and maintain scar hygiene to prevent infections. Knowledge of risk factors can aid with prevention of abnormal scarring and enable prompt treatment. Individualization of port placement is important; umbilical port placement should be avoided in women with high aesthetic sensitivity for the umbilicus or in those with risk factors for abnormal umbilical scarring, such as obesity.

　Approximately 1,700 cases of renal transplantation are performed annually, and various diseases may occur due to long-term internal use of postoperative immunosuppressants. We experienced a case of cervical cancer, which is thought to be human papillomavirus (HPV)-related after a living kidney transplantation, underwent laparoscopic radical hysterectomy.

　A 42-year-old woman underwent living kidney transplantation at the age of 30 years. An increase of CA19-9 was recognized during the follow-up after transplantation. Cervical cytology detected squamous cell carcinoma (SCC); therefore the case was referred to our department. A diagnostic cone resection was performed, and a laparoscopic radical hysterectomy under the diagnosis of cervical cancer stage IB1, was performed. Luminescent ureter catheters were placed on both sides of the ureter, and a DJ stent was placed in the transplant ureter. The right post-peritoneal cavity was difficult to develop due to adhesion. On the left side, radical hysterectomy and pelvic lymph node dissection were performed (pT1bN0M0). Vulvar intra-epithelial neoplasia 3 (VIN3) developed 12 months after the operation and was removed.

　Following a renal transplantation procedure, close monitoring of the transplanted kidney and transplant ureter is required. Laparoscopic surgery and navigation with a luminescent ureteral catheter are useful methods for avoiding perioperative complications. In addition, in HPV-related cervical cancer, which is considered to be the effect of immunosuppressants, attention should be paid to other new lesions, and careful follow-up is important.

　The occurrence of black pigmentation in the peritoneal cavity is rare, and its rapid clinical diagnosis may be difficult. Here, we report a case with pigmented peritoneal deposits diagnosed via a histopathological examination at postoperative period. A 74-year-old woman was diagnosed with stage 2 pelvic organ prolapse on the POP-Q system, and planned to undergo a laparoscopic sacrocolpopexy. She had an obstetric history of two uncomplicated vaginal births, and a medical history of colon cancer. During the surgery, variously sized, irregularly shaped and partially swollen black pigments were observed mainly in the small pelvic cavity. Because malignant melanoma dissemination was suspected by macroscopic findings, sampling tissues were submitted to the rapid histopathological examination with frozen sections. However, the histopathological examination could not rule out malignancy because of the presence of cell nests similar to melanocytes with large nucleoli. Thereafter, to prevent the spread of the suspected cancer cells, the surgical procedure was switched to a vaginal approach. No malignant lesions were observed in a whole-body examination performed after the operation. Additionally, immunohistochemistry showed no evidence of malignancy or atypia in black pigmented tissues. When we checked the colon cancer operation records and pictures at 5 years ago, it was revealed that the black pigments were markings painted during this surgery. The present case serves as a reminder for differential diagnosis of black pigments in the abdominal cavity.

　A 47-year-old woman underwent living renal transplantation at the age of 41 and had been taking oral immunosuppressive drugs. She was diagnosed with intramural myoma and suspected of lobular endocervical glandular hyperplasia. Laparoscopic modified radical hysterectomy was planned. Before the operation, everolimus was changed to mycophenolate mofetil because of wound healing complications. Location of the transplanted pelvic kidney and ureter must be considered when performing laparoscopic hysterectomy in patients who had previously undergone renal transplantation. Computed tomography was performed to check the same for selection of the site for trocar insertion. When there is enough distance from transplanted ureter to internal iliac artery, laparoscopic hysterectomy can be performed safely. Considering the adhesion and hemorrhagic tendency of the anterior vesico-uterine ligament on the transplanted kidney side, hemostasis of the vaginal wall may be difficult. It may reduce the amount of bleeding when isolating the uterine artery. In this case, the renal artery of the transplanted kidney was anastomosed to the right internal iliac artery. It was considered safer to isolate and cut the right uterine artery on the peripheral side, away from the internal iliac artery. Although laparoscopic modified radical hysterectomy can be performed after renal transplantation, it is necessary to recognize that it may be difficult to cut off the anterior layer of the vesico-uterine ligament of the transplanted renal side.

　A 74-year-old woman with BMI of 40.4 visited our hospital with a complaint of vaginal bleeding. Histological examination of the endometrium revealed a grade 1 endometrial carcinoma. Pelvic contrast-enhanced MRI and contrast-enhanced CT showed no obvious myometrial invasion and three cm umbilical hernia, respectively. The preoperative diagnosis was endometrial cancer, stage IA equivalent. A four cm longitudinal incision was made in the right lower abdomen and the intraperitoneal area was observed using laparoscopy. The umbilical hernia was firmly adhered to the hernial orifice and comprised only the great omentum. A five mm camera port was then placed five cm to the right of the umbilicus under laparoscopic observation, and two additional ports were placed in the mid and left lower abdomen in a typical diamond configuration. Although it was difficult to obtain a regular view with a direct laparoscope due to interference between forceps, a total laparoscopic hysterectomy with bilateral adnexectomy was completed using to a flexible laparoscope. She was discharged on the fourth postoperative day. The FIGO stage for the endometrial cancer was stage IA, pT1aNxM0, endometrial carcinoma grade one. No postoperative therapy was administered as risk for recurrence was low. There was no evidence of tumor recurrence 14 months post-surgery. In cases of laparoscopic operation complicated by umbilical hernia, the usual umbilical approach is complicated. However, by placing the camera port on the right side of the umbilicus and using a flexible laparoscopy, it may be possible to perform a laparoscopic surgery, which was equally effective.

　A 57-year-old woman was admitted to our hospital with a pelvic mass and a left ovarian tumor. Twenty-one years ago, she had surgery for torsion of the right ovarian teratoma with salpingo-oophorectomy and appendectomy. Two years ago, a pelvic mass was found on magnetic resonance imaging (MRI), which was suspected to be a foreign body granuloma, but she complained of no symptoms, so she was instructed to follow up. However, a left ovarian tumor was additionally found during her annual medical checkup and she was referred to our hospital.

　Detailed ultrasonography, computed tomography (CT), and MRI revealed a tumor with calcification which was formed around a threaded matrix, and a left ovarian tumor with bilocular cysts. We diagnosed her with gauzeoma, a foreign body granuloma, and ovarian cystadenomas. Because there was a concern that the ovarian cyst would grow, we performed laparoscopic surgery to remove the tumor. When the left ovary was excised, we observed the sigmoid colon covering a mass in a curly manner. With the advice of a gastrointestinal surgeon, we detached the sigmoid colon from the tumor without damaging it and removed the tumor. The surgery took 130 minutes. The postoperative course was going well, and the final diagnosis was mucinous cystadenoma, mature cystic teratoma of the left ovary, and foreign body granuloma of the pelvis.

　This case of foreign body granuloma was almost asymptomatic for 21 years, and it was possible to make a preoperative diagnosis by CT and MRI. We were able to detach the sigmoid colon from the granuloma and remove it in a minimally invasive manner without any complications.

　Accidental rectal insertion of a vaginal delineator is an important cause of rectal injury during total laparoscopic hysterectomy (TLH). We report two cases of rectal or rectovaginal septum injury secondary to inaccurate Vagi-pipe insertion.

Case 1: A 70-year-old nullipara underwent TLH for pathological examination of endometrial thickening. Vaginal delineator placement could not be confirmed under direct vision at the time of creation of the anterior vaginal wall incision, and we immediately removed the device. Although the delineator was initially inserted into the vagina, the posterior vaginal wall was accidentally perforated and resulted in rectal injury. The rectal mucosa and vaginal wall were sutured transvaginally. The patient was discharged without any other complications, 14 days postoperatively.

Case 2: A 45-year-old virgin underwent TLH for treatment of leiomyoma after 3-month hormonal therapy. We detected a posterior vaginal wall wound at the time of creation of the anterior vaginal wall incision. Vagi-pipe insertion injured the posterior vaginal wall and resulted in placement of the device in the rectovaginal septum. The posterior vaginal wall showed two perforation sites, which were sutured transvaginally and laparoscopically. The patient was discharged without any other complications, 4 days postoperatively.

　We report two cases of complications associated with Vagi-pipe insertion. Women with a narrow vagina are at a high risk of vaginal wall injury during delineator insertion; therefore, extreme caution and alternative maneuvers are warranted in such cases.

　A 32-year-old woman (gravida 2, para 1) became pregnant after induced ovulation with human menopausal gonadotrophin and artificial insemination. At 5 weeks' gestation, she reported right lower abdominal pain and was diagnosed with ovarian hyperstimulation syndrome and transferred to this hospital. A gestational sac was present in the uterus, and ovarian tumors 11.6 × 5.6 cm on the right and 4.7 × 4.1 cm on the left were noted. The pain gradually decreased with analgesics and rest, and the patient was discharged a week later. Eighteen days later, she was transported by ambulance for right lower abdominal pain and readmitted. A fetus with a size consistent with 8 weeks' gestation and the fetal heart rate were noted. The right ovary, 12.9 × 7.3 cm in size, was located at the top of the uterus, and the region was extremely tender. She had signs of peritoneal irritation, but no increases in white blood cell count or C-reactive protein (CRP) level were noted and the patient was followed up with analgesics during the night. However, the pain was not alleviated by the next morning. Magnetic resonance imaging indicated torsion of the ovarian pedicle, so emergency laparoscopic surgery was performed because the CRP level continued to increase. The right adnexa was twisted about 720° and dark red. Blood flow in the right uterine tube was restored 30 min after untwisting and most of the ovary was necrotic; thus, most of it was removed. Her symptoms quickly disappeared after surgery. There were no signs of threatened abortion after discharge, and the patient gave birth vaginally at 38 weeks' gestation. In this case, the symptoms were conservatively relieved at the time of initial admission. No change in blood data at the time of relapse delayed the surgical intervention. As a result, it became difficult to preserve the affected ovary. To preserve the ovaries by releasing the torsion, if there are physical findings and diagnostic imaging findings suggestive of torsion, it is necessary to use diagnostic laparoscopy regardless of blood test findings and pregnancy duration.

　Unicornuate uterus with a rudimentary horn represents a Müllerian duct anomaly. We describe three women aged 20, 18, and 23 years with a unicornuate uterus associated with a non-communicating rudimentary horn, who underwent successful laparoscopic surgery. Studies have reported a high incidence of endometriosis associated with this anomaly. Therefore, prevention of progressive endometriosis and rudimentary horn resection are recommended as treatment. We performed successful laparoscopic removal of a non-communicating rudimentary horn, ipsilateral fallopian tube, and endometriotic ovarian cyst in our patients who underwent uneventful laparoscopic surgeries, following preoperative imaging to accurately confirm the course of the uterine artery. We performed magnetic resonance angiography (MRA) and computed tomography angiography for preoperative evaluation. Preoperative confirmation of the course of the uterine artery is essential, and MRA is a particularly useful modality in such cases.

　Fallopian tube torsion secondary to an adnexal tumor presents with nonspecific symptoms, and preoperative diagnosis is challenging. We report two cases of hydrosalpinx and paraovarian cyst with accompanying fallopian tube torsion that clinically presented with recurrent mild lower abdominal pain.

Case 1: A 35-year-old woman presented with recurrent mild abdominal pain, one year prior to presentation. Evaluation revealed a right adnexal tumor (59 mm). Abdominal pain had resolved at the time of her visit, and she underwent periodic follow-up to monitor the tumor. She returned with recurrent abdominal pain, and magnetic resonance imaging (MRI) revealed chronic adnexal pedicle torsion. Therefore, she underwent laparoendoscopic single-site surgery (LESS). The right fallopian tube showed hydrosalpinx and was twisted eight times, which necessitated its resection.

Case 2: A 35-year-old woman reported a history of a left adnexal tumor (43 mm) for which she underwent follow-up, 3 years prior to presentation. She currently presented with recurrent mild lower abdominal pain before menstruation and defecation. MRI revealed a left adnexal tumor, and we performed LESS. We observed left fallopian tube torsion (twisted six times) together with a paraovarian cyst. Detorsion led to improved color and restoration of blood flow. The left paraovarian cyst was removed.

　An adnexal tumor that presents with recurrent mild abdominal pain is a useful diagnostic clue for suspected tubal torsion. Preoperative diagnosis based on imaging studies is challenging, and intraoperative observation is necessary for definitive diagnosis. For intraoperative observation, LESS is a useful diagnostic and therapeutic tool associated with favorable cosmetic results.

　Extragonadal teratomas are rare and account for only approximately 0.4% of all teratomas. The pathogenesis of extragonadal teratomas is controversial and poorly understood. We report a case of an ovarian mature teratoma, which was discovered during autoamputation into an omental teratoma.

　A 47-year-old woman was referred to our department for evaluation of a computed tomography documented infraumbilical tumor (10 cm), with a high index of clinical suspicion for a mature teratoma. Although we suspected an omental teratoma, tumor resection was considered necessary, and we performed laparoscopic surgery in consultation with a gastrointestinal surgeon. Intraoperatively, we detected an upper abdominal tumor covered with the omentum. The left ovary was missing from the pelvis, and the left fallopian tube was identified in the upper abdomen and showed torsion and was connected to the tumor. The left ovarian and suspensory ligaments were not identified. The lesion was diagnosed as a left ovarian tumor, and we performed partial resection of the omentum and left adnexa. Histopathological evaluation of the resected specimen revealed an ovarian component in the tumor, and we diagnosed a mature teratoma. Laparoscopic surgery with cautious port placement and positioning is a useful diagnostic and therapeutic option in such cases.

　Laparoscopic hysterectomy is widely performed in obese patients in Japan; however few studies have reported on laparoscopic surgery in patients with severe obesity (body mass index [BMI] > 35 kg/m²). Here, we share our experience of performing laparoscopic hysterectomy for endometrial carcinoma in a patient with severe obesity and a giant thyroid tumor. Our patient was a 69-year-old woman (height 151 cm, weight 104 kg [BMI 45 kg/m²]) with a history of hypertension, diabetes mellitus, and hyperlipidemia and appendectomy, who presented with endometrial cancer and a thyroid tumor. Endometrial biopsy findings revealed carcinosarcoma and magnetic resonance imaging showed an endometrial tumor without myometrial or cervical stromal invasion, with uterine adnexal metastasis. Computed tomography revealed a giant thyroid tumor in the left lobe (82 mm) with bronchial compression, but no lymphadenopathy. Fine needle aspiration cytology revealed a benign thyroid tumor. Because of severe obesity and a giant thyroid tumor, we performed laparoscopic hysterectomy and concomitant thyroidectomy. We initially performed thyroidectomy under general anesthesia using tracheal intubation (tube diameter: 6 mm) in the supine position, followed by laparoscopic hysterectomy using tracheal intubation (tube diameter: 7 mm) with the patient placed in the Trendelenburg position. After the surgery, the patient was admitted in the intensive care unit for only one day, and after an uneventful course, was discharged on day 5 postoperatively. Adjuvant chemotherapy for endometrial cancer was initiated at 1 month postoperatively. This report highlights that laparoscopic hysterectomy can reduce perioperative complications and enable prompt initiation of adjuvant chemotherapy in patients with severe obesity. Thus, obesity and comorbidities are not contraindications for laparoscopic surgery.

Introduction: The insertion of intrauterine devices (IUDs) is widely used as a reversible and highly effective contraceptive method. Uterine perforation is a rare but serious complication of IUDs.

Case: We experienced four cases in which uterine perforations were caused by IUDs and removed after laparoscopic identification of the perforation site.

Conclusion: Diagnostic laparoscopy is extremely useful in removing an IUD that has migrated into the abdominal cavity because it provides a full view of the intraperitoneal cavity. It is important to predict the degree of adhesion and the possibility of organ damage as much as possible in preoperative diagnostic imaging. Depending on the site of IUD migration, it is necessary to consider collaboration with gastroenterological surgeons and urologists.

　The peritoneum covering pelvic organs such as the uterine and ovarian ligaments and the pouch of Douglas is a common site of endometriosis, which is explained by the endometrial transplantation, peritoneal metaplasia, and the Müllerian remnant theories. The endometrial transplantation theory is widely accepted. We report a case of a retroperitoneal endometriotic cyst in a 44-year-old woman (gravida 4, para 2) who visited a local physician with a complaint of left lower abdominal pain and was referred to our hospital for further evaluation and treatment of a left ovarian tumor. Magnetic resonance imaging revealed a left ovarian endometriotic cyst measuring approximately 4.5 cm in size, and we performed laparoscopic left adnexectomy. Intraoperatively, the uterus appeared normal in size, and both ovaries were normal in appearance. We did not detect any endometriotic lesions in the peritoneum, in the uterine and ovarian ligaments, or in Douglas' pouch; however, a tumor (approximately 5 cm) was observed in the left broad ligament. The cyst had a thick wall, with dark brown and slightly viscous intracystic fluid. Histopathological findings were consistent with an endometriotic cyst, and the cyst wall showed fibrous tissue containing smooth muscle. Based on the classification of rectovaginal endometriosis proposed by Koninckx et al., the lesion was categorized as a Type III cyst, and metaplasia of Müllerian remnants was considered the likely pathogenetic contributor to the retroperitoneal cyst.

Background: Endometrial ablation is a widely accepted conservative surgical approach for women with abnormal uterine bleeding. However, data on late-onset endometrial ablation failure are scarce. Endometrial cancer, particularly after endometrial ablation for adenomyosis, is unknown.

Case: A 53-year-old Japanese woman had microwave endometrial ablation for heavy menstrual bleeding caused by adenomyosis after excluding uterine malignancy. Prior ablation a hysterectomy was discussed because medical management had been unsuccessful. However, she elected to preserve the uterus and underwent a hysteroscopic endometrial resection and microwave endometrial ablation. Based on histopathological findings, initially, adenomyosis was diagnosed. Sixteen months after ablation, the patient presented with sudden-onset leg pain and was diagnosed with deep vein thrombosis (DVT), pulmonary embolism (PE), multiple brain infarctions, and enlargement of the uterus. As uterine malignancy was highly suspected, abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic/aortic lymphadenectomy were performed. Histopathological analysis revealed endometrioid endometrial carcinoma grade 1 with a clear cell carcinoma component. However, later diagnosis by computed tomography showed FIGO Stage IVB presenting with isolated supraclavicular lymph node metastases. We reviewed past pathological examinations, and found atypical endometrial hyperplasia in the hysteroscopic endometrial resection specimen. Chemotherapy with paclitaxel and carboplatin was administered, which showed complete remission for 7 years.

Conclusion: Endometriosis and adenomyosis are associated with an increased risk of endometrial cancer; however, endometrial cancer following endometrial ablation may be difficult to diagnose. Further studies with patient selection and long-term surveillance are necessary to determine the safety and efficacy of endometrial ablation.

　Superficial myofibroblastoma is a very rare benign mesenchymal tumor that develops in the cervix, vagina, and vulva. We report a case of superficial myofibroblastoma that was diagnosed following laparoscopic surgery for a vaginal tumor arising from the posterior fornix. The patient was a woman in her 40s (gravida 0). A flexible vaginal tumor with a smooth surface was observed arising from the posterior fornix. Magnetic resonance imaging revealed a neoplastic lesion with no signs of malignancy. We performed total laparoscopic hysterectomy and vaginal tumor resection because of the presence of multiple uterine fibroids. We made an incision in the vaginal wall on the vulva side of the tumor and removed it together with the uterus without breaking the tumor. Histopathological examination revealed superficial myofibroblastoma. The tumor was difficult to diagnose based on clinical symptoms and imaging findings. The differential diagnosis included tumors with poorer prognosis, such as aggressive angiomyxoma; thus, surgery with the aim of complete resection was required. Complete resection was possible by laparoscopically removing the uterus and tumor.

　A 40-year-old G0P0 presented with uterine leiomyomas and underwent total laparoscopic hysterectomy and bilateral salpingectomy for management of worsening hypermenorrhea. Intraperitoneal findings included an endometriotic lesion (approximately 1 cm) in the peritoneum of the Douglas pouch and partial adhesion. The vaginal canal was incised, and the uterus was transected and removed after transvaginal morcellation. Histopathological examination of the resected specimen revealed uterine leiomyoma without salpingeal abnormalities or endometriotic lesions. The patient observed monthly genital bleeding, 2 and 5 months postoperatively; however, no apparent clinical abnormalities were detected. She experienced similar genital bleeding accompanied by periumbilical pain, 9 months postoperatively. Colposcopy revealed several red endometriosis-like lesions involving the vaginal stump, and the patient was diagnosed with vaginal stump endometriosis. Oral dienogest administration initiated at 11 months postoperatively was continued as maintenance therapy, and the patient's symptoms nearly resolved 5 months later.

　Preoperative diagnosis of small lesions in the Douglas pouch is challenging in patients in whom imaging does not reveal endometriosis in any other region. Endometriotic lesions may remain in the vaginal stump, even in the absence of uterine or adnexal endometriosis, and such lesions may occur even in patients with mild pelvic endometriosis. Vaginal stump endometriosis should be considered in the differential diagnosis in women with periodic genital bleeding or abdominal pain after total laparoscopic hysterectomy. Detailed patient interviews and physical evaluation within a wide area are necessary. Vaginal stump endometriosis can be histopathologically diagnosed based on biopsy specimen evaluation, and dienogest therapy is useful for symptom relief.

Objective: Since laparoscopic surgery has more limitations than laparotomy; thus, it needs more ingenuity. Herein, we will examine and report the ideas we use for laparoscopic myomectomy at our hospital.

Methods: First, set the abdominal wall lift, after which the first trocar will be inserted for the 5.5 mm camera, as the optical method. After inserting all the trocars, the pneumoperitoneum pressure should be 12 mmHg for observation of the abdominal cavity, and be kept at 5 mmHg during the surgical procedure. A 3-cm skin incision will be made on the pubis attached with a lap disc mini for inserting and removing needles, threads, and fibroids. Fibroids will be kept inside with a thread attached to it to prevent lost. Since the fibroids must be manually cut into small pieces by a scalpel, a tube, which is cut off from a syringe, will be used to prevent abdominal wall damage. Seprafilm will be used for the myomectomy wound with a special tube to be inserted for all cases.

Discussion: It will be safe not to damage the gastrointestinal tract by using abdominal wall lift first. A tube cut off from a syringe made it easier to carry out the fibroid resection. The seprafilm was certainly placed by using a special tube.

Conclusion: Laparoscopic myomectomy will be performed safely by using various ingenuities from the beginning to the end of the operation. Additionally, the time and cost of the operation will be reduced.

Objective: To describe the laparoscopic surgical procedure for the removal of endometriotic lesions in the median part of pelvis and the efficacy of the procedure on pain relief.

Design: Retrospective observational study

Setting: A regional medical care support hospital

Patients: A total of 639 patients underwent laparoscopic surgery for the removal of endometriotic lesions from 2005 to 2016.

Interventions: A trapezoidal incision was made in the median pelvic peritoneum, and the fibrotic lesion was resected from the posterior vaginal fornix and retrocervical region.

Main outcome and measures: Pain symptoms were assessed using a 10-cm visual analogue scale (VAS). Recurrence was diagnosed when a patient complained of pelvic pain 100 days after the surgery.

Results: The endometriotic lesions were localized in the medial part of the pelvis. The lesions were resected through a trapezoidal incision in the pelvic peritoneum. Complications including vaginal lacerations and burns were observed in 18 cases, without any serious organ injury. Dysmenorrhea improved from 6.3 ± 2.6 (mean ± SD) to 1.4 ± 2.1, and chronic pelvic pain improved from 3.7 ± 3.0 to 0.2 ± 0.9. In 84.6% of the cases, the VAS level of dysmenorrhea decreased to less than 4 and that of chronic pelvic pain to less than 2 after the surgery. Recurrence of pain was observed in 26.5% of the cases.

Conclusions: Laparoscopic removal of endometriotic lesions from the posterior vaginal fornix and retrocervical region using a trapezoidal incision in the median pelvic peritoneum is feasible without significant complications and is effective in reducing pelvic pain.