Currently, laparoscopic surgery for early-stage uterine cancer is reimbursed by the National Health Insurance scheme; therefore, an increasing number of laparoscopic procedures are being performed in clinical practice. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) held discussions for evaluation of the surgical technique to ensure curative surgery. These discussions included members of the Committee for Surgery on Malignant Tumors and the Committee for the Endoscopic Surgical Skill Qualification System of JSGOE, and the results of the discussion and the process were made available to members at a special program at the 62nd Annual Meeting of the JSGOE. It was concluded that it was important to clarify eligibility for patients with uterine cancer and to be mindful of cancer cell spillage when applying for a qualified endoscopic gynecologist (laparoscopy/hysteroscopy), JSGOE. In our view, the surgical criteria and procedures will continue to evolve, following availability of further evidence. We expect that further discussions will be held in accordance with the times and environment and that safe and curative surgical procedures will become widely available.
Objective: Young gynecologists aim to acquire a certificate in laparoscopic surgery from the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE). However, there are no adequate training programs to support the certificate acquisition in the Department of Gynecology at Chiba University and 11 associated facilities (abbreviated as our facilities). This study aimed to investigate the experience of young physicians with performing laparoscopic surgeries, including total laparoscopic hysterectomy (TLH), in our facilities and self-training methods.
Methods: Using a web-based questionnaire, we surveyed 33 young physicians who are 3-10 years postgraduate in February 2022. Statistical analysis was performed using JMP Pro15 (SAS Institute, Cary, NC).
Results: Of 33 physicians, 27 were interested in acquiring the certificate. Although 14 physicians already had adequate experience in total abdominal hysterectomies (TAH), 24 physicians had no experience in TLH, and 9 physicians worked at facilities where TLH is not performed. Confidence levels in TAH were significantly higher than those in TLH (p<0.0001, Chi-square test). Further, 28 physicians recognized the importance of suturing practice, but 13 said they practice less than once a month. Ten physicians did not understand how to maintain their skills, while 16 wanted to train at other facilities.
Conclusion: Many young physicians in our facilities wished to get the JSGOE certificate but had few opportunities to perform TLH. It is necessary to increase opportunities for young physicians to experience TLH and establish a support system to help them acquire certification.
Objective: This study aimed to investigate the usefulness of intraoperative cell-free and concentrated ascites reinfusion therapy (CART) in patients undergoing diagnostic laparoscopic surgery of advanced ovarian or peritoneal cancer (AOPC) with massive ascites.
Methods: We retrospectively compared the background characteristics and post operative course between 11 patients with AOPC who underwent CART during diagnostic laparoscopic surgery (CART group) and 11 patients with AOPC who did not undergo intraoperative CART (non-CART group). The method of CART was as follows: Ascites was aspirated using a 12-French gauge catheter placed through a laparoscopic port; after the laparoscopic procedure, filtered and concentrated ascites was intravenously administered to the patients at a rate of 100 ml/h.
Results: The operation time was longer in the CART group than in the non-CART group (71 vs. 58 min, p=0.02). The CART group maintained adequate urine output without diuretics or albumin administration after surgery. The postoperative change in the serum albumin level was ±0.0 g/dl in the CART group and -0.7 g/dl in the non-CART group, and the difference between groups was statistically significant (p=0.02). One patient developed a fever during the reinfusion of ascites; however, no patient experienced any adverse effects or a delay in the start of adjuvant chemotherapy because of CART.
Conclusion: CART during diagnostic laparoscopic surgery is beneficial for the management of patients with AOPC.
Compartment syndrome due to prolonged lithotomy position and low head position is a known perioperative complication following robot-assisted pelvic surgery. We report a case of bilateral lower leg compartment syndrome (CS) after robot-assisted modified radical hysterectomy (RAMRH) for uterine cancer (UC) in a 55-year-old woman, which required two fasciotomies.
She had gravidity and parity of two and was obese with a body mass index of 39.3. She underwent RAMRH with bilateral salpingo-oophorectomy for UC. She was in lithotomy position and 25 degrees head-down for ４ h and 45 min during the operation. Postoperatively, pain and swelling in the right lower leg (RLL) and creatine kinase (CK) elevation (4,419 IU/l) were observed; therefore, CS was suspected. However, since the symptoms had temporarily improved, cooling and lower extremity elevation were performed conservatively. Thereafter, increased pain and pressure in the muscle compartment of RLL and further CK elevation (55,736 IU/l) were noted. Therefore, she was diagnosed with lower limb CS and emergency fasciotomy was performed. Additionally, 25 h after the surgery, pain and increased pressure in the muscle compartment of the left lower leg (LLL) were observed; thus, an emergency fasciotomy of LLL was performed. Postoperatively, no complications such as wound infection or necrosis were observed; hence the wound was closed with skin grafting on postoperative day 16.
In this case, the patient was at risk for multiple CSs, due to prolonged surgery, lithotomy position, low head position, and high obesity. Preoperative risk assessment and appropriate intraoperative management are important to prevent CS.
We describe our experience and modifications regarding the surgeries conducted with the hysteroscopy called Integrated Bigatti Shaver (IBS®). The rigid shaving system consists of two hollow reusable metal tubes fitting to each other. The inner tube rotates within the outer tube. The rotating and oscillating movement of the inner blade of the shaving system cuts the tissue and allows aspiration of specimens for histology. A correct fluid balance is calculated to maintain optimal distension and visualization inside the uterine cavity. Normal saline solution used for irrigation is inexpensive and economical.
From March 2020, we have performed hysteroscopy with the IBS®. Unlike the conventional resectoscopy, the main advantage of the IBS® is that the tissue chips or adhesions were effectively removed without any thermal injury occurring on the endometrium. The thermal damage of healthy endometrium should be avoided in view of reproduction.
Further investigations are needed to determine its utility for patients whose fertility preservation is requested.
We report a case in which umbilical endometriosis was resected and the umbilicus was used as an insufflation port for laparoscopic right adnexectomy before umbilicoplasty.
A 47-year-old gravida-2 para-2 woman, with no significant surgical history, presented with umbilical pain coinciding with her menstrual cycle for the last two years. She consulted the Department of Dermatology in our hospital. She underwent a biopsy of an umbilical mass, which was diagnosed as endometriosis, and was referred to the Department of Gynecology. We decided to resect the umbilical endometriosis and perform umbilicoplasty. Furthermore, we conducted additional laparoscopic resection of any endometriosis lesions identified in the abdominal cavity. A 20-mm, clearly demarcated mass was resected from the umbilicus. A 12-mm balloon trocar was placed in the umbilicus. However, air leakage necessitated the use of LAP DISC miniⓇ to maintain abdominal insufflation. Intraperitoneal observation revealed that one-third of the right ovary was tightly adhered to the pelvic wall. Thus, a three-port laparoscopic right adnexectomy was performed. After adnexectomy, a plastic surgeon carried out umbilicoplasty during the same surgical intervention.
In a single surgery, the umbilical mass was excised, umbilicoplasty was performed, and a laparoscopic right adnexectomy was conducted in collaboration with a plastic surgeon. Patients with umbilical endometriosis may have concomitant ovarian endometriosis, even if no enlargement of the adnexa is identified preoperatively. Modifying the abdominal insufflation procedure can enable laparoscopic observation and lesion resection in addition to treatment of the umbilical lesion.
Background: Mature teratoma (MT) is the most common ovarian tumor, accounting for 10-20% of ovarian tumors. It is reported that 1-2% transform to malignancy, most transforming to squamous cell carcinoma. Squamous cell carcinoma found together with noninvasive squamous cell carcinoma in situ (CIS) is rarely reported, but it is even rarer that we find CIS alone, and standard treatment is not established. In this case, MT of the left ovary was diagnosed and laparoscopic cystectomy performed. Histological examination revealed CIS alone arising from MT.
Case: A 31-year-old G0P0 with no medical history visited our hospital for infertility treatment. An ovarian tumor measuring over 10 cm was found. She was diagnosed with MT of the left ovary by MRI and other preoperative examinations. She underwent laparoscopic left ovarian tumor cystectomy. Operative findings showed no adhesion, no peritoneal metastasis and normal ascitic fluid. The final diagnosis of the ovary was MT containing skin, hair and fat tissues, without immature elements. CIS was found in the partial stratified squamous epithelium. With informed consent, a left salpingo-oophorectomy and omentectomy were performed as a staging surgery. The patient conceived four months after the first operation, and delivered one year and one month after the first operation and was disease-free at the time of delivery.
Conclusion: CIS alone in ovarian MT is rare. To date, only around 10 cases have been reported, all diagnosed by postoperative pathology. For this reason, even if preoperative diagnosis is benign, we need to perform operations considering possibility of malignancy.
Calcification of uterine myoma is not rare. However, due to the hardness of calcified myomas, sometimes it is difficult to extract the myoma from the pelvic cavity during a total laparoscopic hysterectomy (TLH). We present a case of a patient with a large uterine calcified myoma who underwent TLH. A 52-year-old virgin woman was diagnosed with multiple large uterine myomas with a maximal size of 120 mm by magnetic resonance imaging. An abdominal X-ray examination identified one of the myomas as calcified. The patient underwent TLH. Even though we tried to extract the uterus and myomas by in-bag morcellation, the calcified myoma was not morcellated using a power morcellator. Then, after adding a small 40 mm incision to the main port site, orthopedic instruments were used to morcellate the calcified myoma safely. Uterine weight was 1163 g, operative time was 387 minutes and intraoperative blood loss was 325 ml.
If the calcified uterine myoma is too hard to be morcellated using gynecological surgical instruments, it is thought to be possible to morcellate the specimen using orthopedic instruments with great care.
Unicornuate uterus is a uterine malformation caused by Müllerian duct dysplasia and is classified according to the presence or absence of accessory horns, atrophic uterine remnant, and functional endometrium. Early diagnosis and treatment of rudimentary horn pregnancies are important because of the risk of serious perinatal complications involved.
Transperineal transmigration of sperm, the ovum, and fertilized ovum can occur in spontaneous pregnancies and is responsible for many occurrences of rudimentary horn pregnancies and adnexal tubal pregnancies in the rudimentary horn. Even in the absence of a functional endometrium, adnexal tubal pregnancies can result from extravasation, making it important to select a curative treatment aimed at recurrence prevention.
We described herein a case of repeated atrophic uterine interstitial pregnancy following conservative surgery which was able to be treated laparoscopically.
Herein, we present a case of bilateral ovarian tumors with symptoms of pelvic peritonitis, a disease difficult to diagnose. Intraoperative and pathological findings led to a diagnosis of omental panniculitis. However, due to a lack of knowledge about the disease, the patient was forced to undergo two surgeries and a lengthy hospital stay.
Mesenteric and omental panniculitis are considered nonspecific inflammatory diseases with unknown etiologies, with sporadic reports in the surgical field. Although this case is rare in the field of gynecology, we present the clinical course and imaging findings of this case, as well as a literature review that includes treatment methods.
We present a case of total laparoscopic hysterectomy (TLH) for a virgin patient with multiple large uterine myomas. Thirty-five-year-old primiparous patient was diagnosed with multiple large uterine myomas which size was maximum of 120 mm diameter by magnetic resonance imaging. The patient underwent TLH. We didn’t use the uterine manipulator to avoid the hymen and vaginal laceration, therefore, we only use Tsukahara uterine forceps instead of using uterine manipulator. Firstly, the myomectomy was performed during TLH to obtain good visibility of operative field and enough space of smooth manipulation of the instruments. Then, cervical amputation was conducted after treatment of uterine upper ligaments and uterine vessels, because large uterus could not be handled enough by Tsukahara uterine forceps. After cervical amputation, bilateral ureters were easily detected, and residual uterine cervix was removed safely. By using Tsukahara uterine forceps, and performing myomectomy and cervical amputation during TLH, we completed TLH in virgin case with multiple large uterine myomas without any complications.
Port-site metastasis (PSM) is specific and challenging complication that occurs after laparoscopic surgery for malignant tumor. Few cases of isolated PSM in patients with early-stage endometrial cancer have been reported; the management and prognosis in this patient population is poorly understood.
This report presents the case of a 64-year-old woman preoperatively diagnosed with stage IA endometrial cancer (endometrial carcinoma, G1), who performed total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Gross peritoneal dissemination was not observed in the abdominal cavity, and the postoperative pathological diagnosis was stage IA endometrial cancer (serous carcinoma). Cytodiagnosis of the ascites was positive. The patient underwent six courses of paclitaxel and carboplatin chemotherapy postoperatively. At 25 months postoperatively, she complained of a solid mass in her abdominal wall, and CT showed a 20-mm tumor under the skin at the 5-mm port site in the right lower quadrant of the abdomen. A partial abdominal wall resection involving the tumor and surrounding tissue was performed, and the tumor was completely removed. The pathological diagnosis was serous carcinoma, and the tumor was diagnosed as PSM. The patient preferred close monitoring instead of additional adjuvant chemotherapy. No recurrence was detected within 82 months from the initial surgery and 57 months from the PSM.
PSM of early-stage endometrial cancer is extremely rare, but not reached zero. Surgeons should take care to prevent PSM. Several causative factors of PSM and preventative methods were retrospectively considered in this patient.
Benign multicystic mesothelioma of the peritoneum (BMMP) is an uncommon benign tumor that arises from the peritoneum in women of reproductive age. Associated risk factors include endometriosis, pelvic inflammatory disease, and previous abdominal surgery. However, etiopathogenesis is still unknown. The preoperative diagnosis of BMMP is challenging and is confirmed by pathology.
We report a case of a 22-year-old woman with no medical history who presented with abdominal pain at her one-month checkup after a vaginal delivery a month prior. Contrast-enhanced magnetic resonance imaging showed a multifocal tumor on the ventral side of the uterus. Diagnostic laparoscopy revealed multiple cysts adherent to the peritoneum and omentum. BMMP was diagnosed based on the pathology report, and follow-up did not reveal any recurrence for nine months.
The prognosis for BMMP is excellent, despite the high recurrence rate of 50%. Although there is no standard algorithm for the treatment, surgery is considered the primary treatment because of its high recurrence rate after the resection. Long-term follow-up is necessary, and diagnostic laparoscopy is useful given the high recurrence rate.
The severe pain and discomfort of deep endometriosis are caused not only by local inflammation-associated peripheral neuralgia, but also by pain modulation of the central nervous system due to reflex contraction of pelvic organs responding to slight stimuli, correlates with the density of nerve fibers in the lesion. A 46-year-old woman with severe chronic pelvic pain, low back pain, and gastrointestinal symptoms underwent laparoscopic surgery. Preoperative blood tests and imaging studies have not revealed the cause of her pain for 10 years. During the operation, adhesions in the rectovaginal space were systematically dissected for dyspareunia and defecation pain, and the sacral uterine ligament and peri uterine tissue were excised while preserving the inferior abdominal nerve for dysmenorrhea and back pain. Pathologically, a nodular lesion removed from the rectovaginal cavity was found to have endometrial glands, inflammatory cells, smooth muscle, and numerous nerve fibers, leading to the diagnosis of deep endometriosis. A nodular lesion of the right sacral uterine ligament and posterior wall of the uterus, which was removed as a cause of right lower back pain, revealed no endometrial glands but had numerous nerve fibers. Postoperatively, her pain was almost completely resolved. We were able to diagnose and treat an undiagnosed deep endometriosis with severe chronic pelvic pain by laparoscopic surgery. Pathological examination revealed extensive nerve fibers in addition to endometrial glands, suggesting that the severe chronic pain was associated with these extensive nerve fibers. We believe this case will serve as a reference for future treatment of deep endometriosis.
A 26-year-old pregnant woman was referred to our hospital for examination of a right adnexal mass. Transvaginal ultrasound revealed a cystic tumor (approximately 8×7 cm) arising from the right adnexa. MRI revealed a suspected benign simple cyst of right ovary without any sign of nodules. We performed laparoscopic right ovarian cystectomy at 14 weeks and ６ days of gestational age (GA) to excise the tumor. The fluid inside appeared yellowish and mucinous, and the surface of the resected cyst was rough. Pathological diagnosis of the resected right ovarian cyst was right ovarian sero-mucinous borderline tumor. We recommended right adnexectomy and partial omentectomy as a secondary surgery. She consented, and laparoscopic right adnexectomy and partial omentectomy were performed at 16 weeks and ２ days GA with no operative complications. She was discharged ６ days after the operation. There was no evidence of residual tumor or metastasis. Her pregnancy course was generally good until emergency c-section surgery was performed because of placental abruption at 36 weeks and ２ days of GA. There has been no evidence of recurrence or metastasis until now.
Intramural pregnancy is a rare type of ectopic pregnancy, and early diagnosis is difficult. We herein report a case in which interstitial pregnancy was suspected during laparoscopy, but intramural pregnancy was eventually diagnosed. We also report another case of intramural pregnancy diagnosed a few months later that was suspected before operation.
The first patient was a 38-year-old woman who conceived by in vitro fertilization. After spontaneous abortion and D&C, she became pregnant naturally. Transvaginal ultrasonography was performed, but no obvious gestational sac was visualized. The plasma beta human chorionic gonadotropin (hCG) level was 1,373 mIU/ml. We did not discover the pregnant lesion at diagnostic laparoscopy, but pelvic magnetic resonance imaging after the operation revealed a gestational sac in the uterine myometrium. With methotrexate therapy, the patient's hCG level steadily decreased.
The second patient was a 36-year-old woman who conceived by artificial insemination. Ultrasound examination did not detect a fetal sac in the uterus at ６ weeks of gestation. Three days later, another ultrasound examination led us to suspect intramural pregnancy. Laparoscopic surgery was performed, and the ectopic pregnancy was resected. Histological examination confirmed chorionic villi within normal uterine muscular layer. Serum hCG levels promptly decreased to undetectable levels after the operation.
We report two cases of intramural pregnancy that were successfully treated with pharmacotherapy or laparoscopic surgery.
Diagnostic laparoscopic surgery (lapDx) is a minimally invasive procedure that allows tissue collection and management for the definitive and genetic diagnoses of advanced ovarian cancer. We report four patients with advanced ovarian cancer who underwent lapDx from April, 2020 to July, 2022.
The mean age of the patients was 52 years (range: 47-59), and all of them were diagnosed with high-grade serous carcinomas. The mean serum CA125 level at initial diagnosis was 2,227 U/mL (range: 927-4,130). The mean time from initial consultation to laparoscopic surgery was 11 days (range: 5-15), and chemotherapy was initiated in a mean time of 7 days (range: 6-8) postoperatively. The average operative time was 89 min (range: 65-117), and only minimal bleeding was noted. Biopsy sites were unilateral or bilateral adnexa and omentum. Three patients gave consent for HRD testing, and two tested positive. The other one tested positive for gBRCA mutation. Three patients with preoperative pleural effusion required pleural drainage before chemotherapy, and no serious postoperative complications were noted. Three patients underwent interval debulking surgery after three courses of chemotherapy, leading to complete removal. Currently, one patient is continuing chemotherapy, two patients are alive with no recurrence, and the last patient is alive with recurrent disease.
LapDX was performed on four patients where chemotherapy was promptly done postsurgery. The pathological specimens allowed genetic diagnosis. LapDx is a useful option for patients with advanced ovarian cancer if initial complete removal is considered difficult.
Ichthyosis uteri is a rare condition where an extensive portion of the surface endometrium is replaced by stratified squamous epithelium. Although ichthyosis uteri is considered a benign disease, it has recently been associated with malignant tumors. Here we report a case of ichthyosis uteri complicated by endometrioid carcinoma.
A 58 years old female patient visited her previous physician with a chief complaint of irregular bleeding. Endometrial cytology revealed atypical cells derived from squamous metaplasia. The patient was referred to our hospital for a detailed examination. The results of the endometrial histological examination revealed a squamous cell component. A similar result was obtained upon examining the endometrial scraping samples. Based on these findings, the patient was diagnosed with ichthyosis uteri.
It is reported that ichthyosis uteri is often associated with malignancy; therefore, a contrast-enhanced magnetic resonance imaging was performed. A 3 cm large mass protruding from the posterior wall of the uterus was observed with high signal on diffusion-weighted images. A preoperative diagnosis of stage IA uterine cancer was suspected. An extended total laparoscopic hysterectomy and bilateral adnexectomy were performed.
Histopathological examination revealed ichthyosis uteri with extensive superficial coverage of the squamous epithelium and a deep internal endometrioid carcinoma. The carcinoma was diagnosed with stage IA uterine cancer and G1 endometrioid carcinoma with vascular invasion.
Squamous cell and verrucous carcinomas have frequently been reported as uterine carcinomas arising in the setting of ichthyosis uteri. Here we report a rare case of endometrioid carcinoma associated with ichthyosis uteri and perform a literature review.
Uterine pseudoaneurysm is a potentially fatal complication that can occur after non-traumatic delivery/abortion and surgical procedures such as cesarean section and myomectomy. We encountered a case of pseudoaneurysm after hysteroscopic myomectomy, necessitating hysterectomy due to massive hemorrhage. A 40-year-old woman was referred to our institution with hypermenorrhea caused by submucous leiomyoma. The leiomyoma was resected with hysteroscopic surgery, which revealed a FIGO type 3 leiomyoma. A transvaginal ultrasonography at the routine follow-up visit after 14 days revealed a hypoechoic structure with a diameter of 2 cm in the uterine cavity. Color Doppler ultrasonography revealed pulsatile flow within the hypoechoic area. Thus, a pseudoaneurysm was suspected. She presented with excessive vaginal bleeding the same night. Contrast-enhanced computed tomography confirmed the rupture of the pseudoaneurysm. She was treated with hysterectomy.
Hysteroscopic surgery can cause pseudoaneurysm that can be diagnosed early using Color Doppler ultrasonography. Pseudoaneurysm should be suspected if a hypoechoic cystic lesion is present at the myomectomy site after hysteroscopic surgery.