It has been suggested that laparoscopic surgery for adnexal masses during pregnancy has similar or better perinatal outcome compared to open surgery, and the advantages of laparoscopic surgery are similar for pregnant and nonpregnant women. Although there have been some reports on single-site laparoscopic surgery as minimal invasive surgery during pregnancy, disadvantages of single-site laparoscopic surgery include interference between forceps, difficulty in camera work, and difficulty in applying countertraction to the tissue, which requires high surgical skill and a long learning curve. We present some cases of two-port laparoscopic surgery for adnexal masses during pregnancy and evaluate its usefulness. We have experienced 10 cases of adnexal surgery during pregnancy between 2016 to 2021, all of which were performed as laparoscopic surgery, 7 by conventional 3-port and 3 by 2-port surgery. There were 8 standby and 2 emergency surgeries. The surgical procedures included cystectomy in 9 cases and adnexal torsion release in 1 case. All surgeries were performed between 10 and 15 weeksʼ gestation, with no perioperative complications, and all patients gave birth at full-term. The histological types of ovarian tumors were mature cystic teratoma in 7 cases and ovarian endometriotic cyst in 2 cases. The 2- and 3-port surgeries showed no significant differences in operative time, blood loss, or postoperative hospital stay. The 2-port surgery is feasible without compromising safety compared to conventional laparoscopic surgery, and may be applicable to more cases by more surgeons compared to the single-site surgery.

　Risk-reducing salpingo-oophorectomy (RRSO) is standard treatment among women with hereditary breast and ovarian cancer (HBOC). From August 2015 to March 2023, 67 women with HBOC were referred to the gynecologic department of our hospital to consider RRSO. Among them, 29 women selected to be observed and 38 selected to undergo RRSO. Age and rate of previous breast cancer histories were statistically low in observation group. Of those who underwent RRSO, 9 cases were laparotomy and 29 cases were laparoscopic surgery; no severe complication was shown in either group. For promotion of RRSO, we should continue to provide adequate explanation and safe, minimally invasive surgery.

Objective: This study aimed to determine whether the prognosis of the patients who underwent laparoscopic or robot-assisted surgery changes if the postoperative examination is performed by an attending or non-attending physician.

Methods: The medical records of 324 laparoscopic and robot-assisted surgeries performed at the hospital between January 1 and December 31, 2022, were reviewed retrospectively to determine the association between the physician who performed the postoperative examinations and post-discharge complications.

Results: The examinations were performed 2-3 days postoperatively by the attending physician in 281 cases (86％) and non-attending physician in 43 cases (14％). There were 23 post-discharge adverse events (7.1％). The adverse event rate were 18/281 (6.4％) and 5/43 (11％) in the attending and non-attending physician groups, respectively, with no significant differences (p＝0.231). Nineteen adverse events were judged to be surgery-related; 14/281 (4.9％) and 5/43 (11％) in the attending and non-attending physician groups, respectively, with no significant differences (p＝0.122). There were no post-discharge complications requiring re-hospitalization.

　Post-discharge complications were mostly grade 1 in the Clavien-Dindo classification, and none were grade ≥3. The incidence of post-discharge complications did not differ according to the physician who performed the examinations.

Conclusion: The results suggest that postoperative examinations may not necessarily have to be performed by the attending physician.

Purpose: The objective of this study was to evaluate changes in sexual function due to total laparoscopic hysterectomy (TLH) based on questionnaire surveys of patients.

Methods: The subjects were 30 premenopausal patients who underwent TLH at our hospital, consented to this study, and returned the questionnaires. The Female Sexual Function Index (FSFI) was used to evaluate sexual function before and after surgery. We compared the FSFI total score before and after surgery and the changes in each domain of sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction, and sexual pain.

Results: Postoperatively, the FSFI total score increased in 6 cases (20%), remained unchanged in 2 cases (7%), and decreased in 22 cases (73%), showing an overall significant decrease after surgery. Sexual arousal, vaginal lubrication, orgasm, and sexual pain were significantly reduced postoperatively. Sexual desire and sexual satisfaction decreased, but not significantly.

Conclusion: The FSFI score decreased after total laparoscopic hysterectomy. Since the number of cases was small, it is necessary to accumulate more cases and conduct further studies in the future.

　In 2002, the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy established the certification system “qualified gynecologist of endoscopy (laparoscopy).” This certification acknowledges individuals possessing the skills to perform endoscopic surgeries safely and smoothly, and having the qualifications to lead in this field. The list of certified individuals is accessible on the society's website, with 1,345 technical physicians certified as of April 2022, constituting 28.6% of the 4,695 members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy.

　To attain the status of a qualified gynecologist in endoscopy (laparoscopy), applicants must successfully pass a video review conducted by two examiners. The Technical Certification Consensus Meeting takes place during the academic conference held by the society, aiming to standardize examination criteria, reduce discrepancies in pass/fail decisions between examiners, enhance the instructional skills of certified technical physicians, and provide guidance to new applicants.

　The 18th Technical Certification Consensus Meeting took place on September 16, 2023, during the 63rd Annual Meeting of the Japanese Society of Obstetrics and Gynecology Endoscopy. This paper presents the survey results from the Technical Certification Consensus Meeting, accompanied by insightful discussions.

Objective: Child-rearing physicians (ikudoku) often have difficulties in continuing surgical training because of career interruptions and time constraints. A two-month seminar was held to provide ikudoku with opportunities to learn about laparoscopic surgery, career development, and peer support, and to consider effective types of surgical training for ikudoku.

Method: The seminar was attended by 12 participants, including the lead author. For ligating practice in a dry box, the participants were given assignments to share their ligation videos and suggest improvements with each other. Lectures on career development for female physicians were also given, and participants were asked to present their own future visions. To evaluate the effectiveness of the seminar, we compared ligation times at the beginning and end of the seminar and conducted a questionnaire survey.

Results: The median ligation time significantly decreased from 66.5 to 29.5 seconds (p = 0.003). After attending the seminar, the participants spent more time practicing per day and practiced more frequently, and their training content became more diverse, including left-hand ligation, part-by-part practice, and time trials, compared with before the seminar. According to the questionnaire, the main reason for the reduction in ligation times was sustained motivation levels, which resulted in more practice time and changes in practice content.

Conclusions: These findings suggest that ikudoku can improve their ligation skills by maintaining their motivation, spending more time on self-improvement and training, and devising more diverse practice content. Providing such opportunities to ikudoku could be useful for surgical training.

Objective: Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is now widely spread as a minimally invasive surgery. We have performed vaginally assisted NOTES hysterectomy (VANH) since April, 2022. The aim of this study was to compare VANH and total laparoendoscopic hysterectomy (TLH), and discuss the safety and feasibility of this new surgical procedure.

Methods: We retrospectively reviewed perioperative outcomes in 163 patients who underwent VANH (n=66) or TLH (n=97) from April 2022 until March 2023 at our center. We measured baseline characteristics, surgical data, pain score (NRS) after surgery, and the amount of analgesics usage.

Results: No differences were shown in baseline characteristics between the two groups. Operation time was shorter in the VANH group, and estimated blood loss was smaller in the TLH group. The VANH group showed higher postoperative pain on Day 0 than the TLH group, but there was no difference after Day 1. White blood cell count did not differ between the two groups, while C-reactive protein was lower in the VANH group.

Conclusion: This surgery has the advantage of leaving no scars on the patient's body, but contrary to our expectation, higher postoperative pain on Day 0 and amount of blood loss were shown in the VANH group. Those problems need to be solved for further expansion of surgical indication.

Introduction: Previously, robotic-assisted laparoscopic total hysterectomy at our institution utilized three arms/four ports (one camera arm, two operating arms, and one assist port). To enhance efficiency, we transitioned to using four arms/five ports (one camera arm, three operating arms, and one assist port) in April 2023. This study aimed to assess the effect of the number of robotic arms on surgical outcomes.

Methods: We analyzed cases of robotic-assisted laparoscopic total hysterectomy procedures performed between July 2020 and February 2024, comparing patient data and surgical outcomes between the three-arm and four-arm groups.

Results: The study included 110 three-arm and 47 four-arm cases. No significant differences were observed in age, BMI, or uterine weight between the groups. However, the three-arm group exhibited a significantly higher manipulator utilization rate (p < 0.01). Compared to the four-arm group, the three-arm group showed significantly shorter times for console setup, console completion, and total surgery (all p < 0.01). No significant differences were observed in the time from console completion to surgical completion time. Multiple regression analysis indicated that lower BMI and the usage of the three-arm intervention were associated with shorter console setup times, whereas lower uterine weight along with the three-arm intervention, were associated with shorter console and surgical times (all p < 0.01).

Discussion: Robotic-assisted laparoscopic total hysterectomy with three arms was found to be as efficient as that with four arms, potentially offering economic benefits through reduced instrument usage.

　The incidence of heterotopic pregnancy during natural conception is approximately 1 in 15,000 to 30,000 pregnancies (0.003%). This incidence increases to an estimated 1 in 670 pregnancies for those achieved through assisted reproductive technology, albeit with some variability in the literature. No precise statistics are available regarding the frequency of simultaneous intrauterine and ectopic pregnancies occurring during single embryo transfer and natural conception. However, international reports, including our own, have documented only seven such cases, which supports their extreme rarity. Our patient was a 31-year-old gravida 4 para 0 woman who underwent single embryo transfer using in vitro fertilization at another hospital. A fetal sac was confirmed in the uterus at 5 weeks and 1 day of gestation. At 6 weeks and 0 days of gestation, the patient presented to our hospital with worsening lower abdominal pain since 3 days previously. Diagnosing the condition was challenging; however, multiple transvaginal ultrasound examinations and detailed medical interviews suggested a heterotopic pregnancy. Using magnetic resonance imaging (MRI), we developed a precise surgical plan and performed laparoscopic partial ovarian resection. By preserving the corpus luteum in the left ovary and removing only the ectopic pregnancy tissue, the intrauterine pregnancy was sustained and resulted in a successful live birth. Although heterotopic pregnancy is rare in cases of single embryo transfer, it should be considered during examination. MRI is effective for both diagnostic assistance and surgical planning, and its use should be considered when necessary, even during the first trimester of pregnancy.

　In laparoscopic surgery, abdominal wall vascular injury could occur as a complication of trocar insertion, which can sometimes cause serious bleeding. We report a case of hemorrhagic shock due to trocar injury to recanalization of paraumbilical vein caused by cirrhosis of the liver. A 53-year-old woman, gravida 2 para 1, had a history of alcoholic liver disease. MRI revealed right adnexal abscess, for which we performed laparoscopic salpingo-oophorectomy. Intraoperatively we observed irregularities of the liver surface. Surgery was completed with drainage of the right adnexal abscess. After extubation, a sudden drop in blood pressure and tachycardia were observed, and the patient was in shock. Transabdominal ultrasonography revealed an abdominal wall hematoma at the port insertion site in the midline of the lower abdomen, and consequently she underwent additional operation for hemostasis. Hemorrhage from a torn paraumbilical vein was observed and ligated and achieved hemostasis. Postoperative contrast-enhanced CT revealed splenomegaly and patency of the paraumbilical vein, which together with the intraoperative findings led to the diagnosis of alcoholic cirrhosis and associated portal hypertension. Before surgery, it is important to evaluate the patient's medical history and perform preoperative imaging with attention to abdominal wall abnormalities. In laparoscopic surgery, bleeding from veins may be masked; therefore, confirmation of hemostasis should be carefully performed.

　We report a case of treatment of active bleeding from endometriotic lesion around the broad ligament of the uterus that occurred during hysteroscopic surgery. A 35-year-old woman, gravida 0, was diagnosed with submucosal myoma. Although she had also suffered from left 5 cm dia. ovarian endometriotic cyst, which had been shrunk by low-dose estrogen and progestin, only hysteroscopic myomectomy was performed. Surgical procedure performed was as follows: 1. Hysteroscopic myomectomy was performed, during which the fundus of uterus was inadvertently perforated. 2. A large amount of intraperitoneal bleeding was observed under laparoscopy. 3. We immediately repaired the perforation site; however, the intraperitoneal bleeding was not stopped. 4. Careful observation revealed active bleeding from the endometriotic lesion around the broad ligament of uterus, while no endometrioma was found in the area. 5. Bleeding was stopped by clipping the bleeding point with Vascular Clip (PL594R) and suturing the same point. The patient progressed favorably after the surgery without any complications such as massive rebleeding. Three months after the operation, she started to attempt to conceive. Active bleeding from endometriotic lesion around the broad ligament of uterus during hysteroscopic surgery is a rare complication. However, attention should be paid to it when the patient has a history of endometriosis.

Objective: One of the complications associated with port insertion in laparoscopic surgery is abdominal wall vascular injury. To prevent this, it is common practice to check the abdominal wall vessels using the transmitted light of the laparoscope. In this report, we describe a case of massive bleeding due to abdominal wall vessel injury despite such efforts and was discovered by laparoscopy.

Case: The patient was a 40-year-old woman, gravida 1 para 0, who came to our hospital because of abnormal uterine bleeding and dysmenorrhea. Uterine fibroids of 5 cm and 3 cm were found, and laparoscopic myomectomy was performed to treat her symptoms. After the surgery, pain, pallor, and anemia appeared. Contrast-enhanced computed tomography (CT) was performed, and the patient was diagnosed with abdominal wall vascular injury near the port wound in the left lower abdomen. Laparoscopic hemostasis and blood transfusion were performed, and the patient was discharged on the 9^th postoperative day.

Conclusion: Although the frequency of abdominal wall vascular injuries is decreasing, there is still no reliable method of prevention, and it is a complication that requires constant attention. In postoperative management, attention tends to focus on the more frequent complications, but it is necessary to share experience with complications so that even infrequent complications can be dealt with promptly.

　Drawing outlines of the lesion and the uterus on the abdominal wall were helpful in appropriately placing trocars and completing laparoscopic salpingectomy for fallopian tube torsion at 34 weeks of gestation.

Case: A 34-year-old primipara underwent an exploratory laparoscopy for right lower abdominal pain. We drew an outline of the lesion and the uterus on the patient's abdominal wall using ultrasonography. The marking showed that the operative field was limited to a narrow area in the right-upper abdomen. After comparison of the distance from the upper edge of the operative field to the drawn lesion with the length of the forceps, laparoscopic surgery was deemed to be feasible.

　The first trocar was placed at the point where a tangential line of the outer uterine margin passing through the lesion intersected with the midline of the abdominal wall. The second trocar was placed under the rib arch on the right anterior axillary line, and the third trocar was placed between them. A 10-mm, 30° viewing angle laparoscope was used as the camera to avoid interference with the forceps. The twisted and necrotic right fallopian tube was removed with a walnut-sized para-ovarian cyst. The postoperative course was uneventful, and the patient delivered a healthy baby at full term.

Conclusion: Drawing the lesion and the outline of the uterus on the abdominal wall was helpful in determining the most appropriate trocar position during laparoscopy in the third trimester of pregnancy.

　Peritoneal pregnancies are rare, accounting for approximately 1% of ectopic pregnancies and 0.01% of all pregnancies. This report discusses two cases initially diagnosed as tubal ectopic pregnancies, which upon laparoscopic surgery, were identified as peritoneal pregnancies. Case 1 involved a 29-year-old woman, gravida 0, who was referred to our hospital due to suspected ectopic pregnancy. Serum hCG level was 2,255 mIU/ml. Transvaginal ultrasonographic examination did not detect a gestational sac in the uterus, but identified a hematoma around the right ovary. Diagnosis indicated a right tubal ectopic pregnancy, leading to laparoscopy. Approximately 52 ml of blood and a gestational sac were observed on the uterine serosal surface. Complete removal of gestational tissue and villi resulted in her smooth recovery. Case 2 involved a 43-year-old pregnant woman post in vitro fertilization, gravida 1 para 0, referred to our hospital with a serum hCG level of 2,289 mIU/ml. Transvaginal ultrasonography revealed a gestational sac in the right fallopian tube but not in the uterus. Laparoscopy indicated little blood in pelvis and uncovered a gestational sac and clot on the vesicouterine pouch. Resection of these tissues and villi revealed a peritoneal pregnancy. Preoperative diagnosis of peritoneal pregnancy remained challenging in both the cases, underscoring the diagnostic and therapeutic utility of laparoscopic surgery in such instances.

　The incidence of uterine malformations in the general female population is estimated to be 3.8% to 6.7%. From the 8^th week of gestation, the oviduct, uterus, and upper vagina are formed by the differentiation of the Müllerian ducts, but a cessation of differentiation during this process results in uterine malformations. The uterine morphology is classified into duplicated uterus, bicornuate uterus, septate uterus, and so on, starting from the condition resulting from the earliest differentiation arrest. In this report, we describe a case in which a patient was diagnosed with a single cervical bicornuate uterus at the time of pregnancy and delivery and underwent total laparoscopic hysterectomy for excessive menstruation and anemia due to submucosal fibroids.

　The prevalence of ovarian tumor torsion in women under 20 years old is estimated to be 4.9 /10,0000 cases, and the premenarcheal case is even less. We experienced a case in which an 11-year-old girl before menarche presented with a complaint of lower abdominal pain, which led to the diagnosis of ovarian tumor stem torsion combined with imperforate hymen. Ovarian tumor cystectomy combined with laparoscopic surgery and perforation of hymen were performed. Pathology result was ovarian mature teratoma. Normal menstruation was observed one month after the surgery. When examining premenarcheal pediatrics with lower abdominal pain, it is important to identify rare diseases such as imperforate hymen by taking a detailed history and performing a general medical examination.

　Vulvar cancer is a relatively rare gynecologic malignancy, and the primary treatment for this neoplasm is complete surgical excision. This case report details a 73-year-old patient who underwent complete surgery assisted laparoscopic pelvic exenteration (PE) for vulvar cancer. The patient presented with physical activity difficulties, and clinical examination revealed a bulky vulvar tumor with perineal bleeding and severe anemia. Diagnostic imaging showed a 15 cm vulvar tumor within the pelvis, involving the pubis, upper two-thirds of the urethra, upper two-thirds of the vagina, and the anus, without distant metastasis.The laparoscopic PE procedure which the patient underwent included radical vulvectomy, partial adductor muscle excision, pubic resection, bilateral pelvic and inguinal lymph node dissection, ileal conduit urinary diversion, sigmoid colostomy, and flap reconstruction. The final diagnosis was vulvar cancer (adenoid cystic carcinoma, pT３N０M０, FIGO stage IVA).

　Tubal torsion is a rare disease. We report a case of fallopian tubal torsion caused by an endometriotic cyst growing in the fallopian tube, which was difficult to diagnose. The patient was 14 years old and had never had sexual intercourse. She presented to her primary care physician with sudden onset of abdominal pain, and a right-sided functional ovarian cyst was suspected based on transabdominal ultrasonography and computed tomography. She was referred to our outpatient clinic for surgery. Contrast-enhanced pelvic magnetic resonance imaging (MRI) revealed a 10-cm tumor on the right side of the uterus, which was suspected to be a right ovarian hemorrhagic cyst or right ovarian cyst stalk torsion. One month after the onset of symptoms, the patient was prepared for laparoscopic ovarian cyst enucleation for right ovarian cyst torsion as a standby procedure. There were extensive adhesions in the peritoneal cavity due to inflammation. After removing the adhesions and exposing the tumor, the epidermis was incised and the cyst was enucleated. The cyst ruptured during the procedure. The fluid was dark red and serous. Further dissection of the adhesion revealed a normal right ovary. The enlarged mass was diagnosed as a tumor of the twisted right fallopian tube. The right ovary was preserved and the right fallopian tube was removed. Final pathology revealed that the tumor in the right fallopian tube was an endometriotic cyst. The patient had a good postoperative course.

　Intrauterine devices (IUDs) are useful for contraception, but in rare cases perforate uterus and migrate into the abdominal cavity. We report a case of ectopic IUD removal by single-incision laparoscopic surgery (SILS). The patient was a 46-year-old woman, gravida 2, para 2, who had an IUD inserted for contraception four years previously. She visited for a replacement IUD but the doctor could not find her original IUD in the uterus by ultrasound. Abdominal X-ray revealed that the IUD had migrated into the abdominal cavity. She was referred to our hospital to remove the ectopic IUD. Pelvic 3D-CT determined the position of the IUD in the pelvic cavity. After confirming the position of the IUD using a surgical C-arm-type X-ray fluoroscope in the operating room, we observed the abdominal cavity by 3D flexible laparoscope and found the IUD adhered to right ovary. We smoothly removed the migrated IUD by SILS. The patient was discharged from the hospital on the third postoperative day without any notable complications. In conclusion, SILS could be an effective option for IUD removal in appropriately selected cases with devised preoperative evaluation.

　Cervical pregnancy is rare and represents approximately 1% of all ectopic pregnancies. We retrospectively examined the medical records of five cervical pregnancy cases between 2014 and 2022. One patient underwent Uterine Artery Embolization (UAE) due to heavy bleeding during follow-up without diagnosis of cervical pregnancy, one patient underwent local MTX injection therapy, one patient underwent hysteroscopic surgery due to insufficient decrease in hCG level after local MTX injection therapy, and two patients underwent UAE with cervical curettage. MTX therapy and cervical curettage following UAE preserved the uterus in all cases. Surgical intervention, including hysteroscopic surgery, should be considered early in cases of prolonged MTX therapy. Cervical curettage following UAE is an effective treatment that reduces the risk of massive bleeding and shortens the hospital stay. However, the risk of subsequent pregnancy complications must be considered for determining the indication

　Most ectopic pregnancies occur in a ampulla of a fallopian tube, and it is estimated that ipsilateral interstitial pregnancy after salpingectomy accounts for 0.3-4.2% of all ectopic pregnancies. Although interstitial pregnancies are rare, they are prone to heavy bleeding if ruptured, due to abundant blood flow in the myometrium, and prompt treatment is desirable. We report a case of spontaneous pregnancy after salpingectomy, in which an ipsilateral interstitial pregnancy was suspected, but the patient had no symptoms. The pregnancy ruptured before deciding on laparoscopic surgery.

　The patient was 34 years old, 2 pregnancies and 0 deliveries, with a history of right salpingectomy for ectopic pregnancy. Her serum hCG level was 4,960 mIU/mL at 7 weeks and 2 days after her last menstrual period, but no fetal sac was found in the uterus. Ultrasound sonography revealed an 11 mm-sized cyst on the right side of the uterine fundus. There were no symptoms. The hCG level did not decrease after three days. The patient underwent dilation and curettage first, and if the hCG level did not decrease, laparoscopic surgery was planned. The day after surgery, hCG level was elevated, and ultrasound sonography showed ascites effusion. Suspecting a ruptured ectopic pregnancy, laparoscopic surgery was performed. A thinning and bulging of the myometrium in the right fallopian tube interstitium, as well as persistent bleeding were observed. Laparoscopic fallopian tube interstitial resection was performed. Postoperatively, hCG level decreased, and pathological examination revealed trophoblastic tissue in the resected area.

　Fallopian tube interstitial pregnancy is a relatively rare condition that occurs in about 1% of all ectopic pregnancies. We report a case of an ipsilateral tubal interstitial pregnancy after a left fallopian tube pregnancy treated by laparoscopic salpingectomy. The patient was 28 years old, had experienced 5 pregnancies and 2 deliveries, and underwent a laparoscopic left salpingectomy for a left fallopian tube pregnancy in February. Her blood hCG level became negative postoperatively, and her menstruation resumed in March. In April, she visited her primary care physician because of a positive pregnancy test. Her blood hCG level had risen to 5,072 mIU/ml, but since no fetal sac was found in the uterus, she was referred to our hospital on suspicion of an ectopic pregnancy. Transvaginal ultrasonography at our hospital revealed a fetal sac in the left adnexal region, and an emergency surgery was planned due to a suspected peritoneal pregnancy in the left fallopian tube mesentery. Intraoperative findings showed that the pregnancy tissue was enlarged from the left fallopian tube stroma and partially adhered to the fallopian tube mesentery. The surgery was completed by resecting the pregnancy tissue such that a portion of the stroma was cut away. The pathological results of the specimen showed chorionic villi and some endometrial tissue, leading to an estimation that the embryo was fertilized in the right fallopian tube, passed through the uterine lumen, and implanted in the left fallopian tube stroma after tubectomy. Considering that tissue-repairing mediators can play a supportive role in embryo implantation, the healing process after the previous ectopic pregnancy possibly induced embryo implantation at the site of tubal resection. Postoperatively, blood hCG levels quickly decreased, and after one month, the blood hCG level became negative.

　Meckel's diverticulum, a rare congenital intestinal abnormality occurring in 0.3-2.9％ of the population, is rarely associated with carcinoma and typically diagnosed at an advanced stage with poor prognosis. We present a case of early stage Meckel's diverticulum carcinoma incidentally discovered in a 73-year-old woman. Initially suspected of right fallopian tube carcinoma based on pelvic MRI findings of a tubular structure in the lower abdomen, further investigation through diagnostic laparoscopy was conducted. The patient, never pregnant and menopausal since age 55, had a medical history of cataracts, colonic diverticulitis, diverticular hemorrhage, and reflux esophagitis. Despite the absence of significant symptoms, MRI results suggested malignancy. A contrast-enhanced CT scan suggested a highly mobile lesion, leading to suspicion of a right fallopian tube lesion. PET-CT results were inconclusive, leading to the decision for laparoscopy. This revealed normal uterine, fallopian tube, and appendix conditions, but a small intestinal lesion was noted. Following a gastroenterological consult, a laparoscopically assisted small bowel resection and D1 dissection were performed. Histopathological examination led to diagnosis of Meckel's diverticulum carcinoma (pT2N0M0, Stage I). This case illustrates the necessity of considering gastrointestinal diseases when well-migrated tubular lesions are detected in the pelvis, highlighting the utility of review laparoscopy for early detection.

　Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome) is a congenital disorder characterized by uterine and vaginal hypoplasia or defects due to Müllerian duct dysplasia. We report a case of MRKH syndrome in which a patient underwent laparoscopic surgery for bilateral adnexal tumors 20 years after laparoscopic-assisted vaginoplasty, and it was a rare case in that we could observe the intraperitoneal after the vaginoplasty. The patient was diagnosed with MRKH syndrome type I at the age of 20 and underwent a modified laparoscopic Davydov procedure at our hospital. At the age of 40, she had right lower abdominal pain, and a CT scan revealed suspected ovarian tumor. Multiple 10 cm-sized cysts were found in the pelvis. Intra-abdominal findings showed that the left ovary was normal with a 7-cm large monocystic paraovarian cyst, and the right ovary had multiple 7-cm large cysts. A white scar was seen at the peritoneal suture site at the time of vaginoplasty, and there was a mild adhesion to the rectum. A right salpingo-oophorectomy and a left salpingectomy were performed. The operative time was 122 minutes, and blood loss was 20 mL. Histopathological diagnoses were left paraovarian cyst and right serous cystadenoma. The degree of structural abnormality in MRKH syndrome is variable. We approached surgery with the possibility that the anatomy of the adnexa might be different from the usual structure because of the effects of vaginoplasty, but in this case the anatomy of the adnexa was preserved, and the surgery could be performed as usual.

　Accessory cavitated uterine masses (ACUM) is rare, and patients present with severe dysmenorrhea at a young age. Surgical treatment is recommended due to the limited efficacy of drug therapy. Here, we report two cases of ACUM diagnosed by laparoscopic surgery performed at our hospital.

　Case 1 was of a 24-year-old woman with lower abdominal pain that had persisted for 2 years who was diagnosed with ACUM by her previous doctor. Her symptoms were relieved by oral medication, but only temporarily before worsening. She was referred to our department for surgery. Case 2 was of a 23-year-old woman who was diagnosed with cystic adenomyosis at the age of 14 years, and was referred to our department for surgery because the lesion was increasing after 8 years of medical treatment. Both patients underwent laparoscopic cystectomy. Based on the postoperative histopathology, we diagnosed both patients with ACUM.

　Because the effectiveness of drug therapy is limited in ACUM, clinicians should consider surgery. However, it is difficult to determine the extent of resection at the time of cyst excision, and the possibility of residual tumor tissue after resection cannot be ruled out. In fact, there have been reports of patients with residual symptoms after surgery. At present, reports with long-term follow-up are limited; thus, it is necessary to report additional cases in the future, including longer-term follow-up and postoperative course.

　Approaches such as laparoscopy and robotic surgery are the current standards of care for malignancies in multiple medical specialties. Among them, there are rare instances of “port-site recurrence,” which have been reported most frequently in cases of bladder, colorectal, and gallbladder cancers. In gynecology, reports are limited to a few instances of ovarian cancer. Here we present a case of port-site recurrence that emerged 2 years after laparoscopic total hysterectomy with bilateral salpingo-oophorectomy for grade 1 endometrioid adenocarcinoma of the uterine corpus. A 41-year-old nulliparous woman with abnormal uterine bleeding was examined in detail and diagnosed with grade 1 endometrioid adenocarcinoma (stage IA) of the uterine corpus. A laparoscopic total hysterectomy with bilateral salpingo-oophorectomy was subsequently performed using the parallel technique (three ports, including the bilateral upper anterior iliac spine and left navel height). Preoperatively, the fallopian tubes were sealed and the uterus placed in a retrieval bag and removed vaginally. At 2 years postoperative, a mass was detected just below the port site. Fine-needle aspiration cytology (III) and various imaging examinations indicated port-site recurrence with liver and lung metastases. The mass was then surgically removed. However, the pathological diagnosis revealed recurrent endometrioid adenocarcinoma with high microsatellite instability. The patient underwent six courses of paclitaxel carboplatin therapy. As brain metastases were discovered immediately after the end of six courses of treatment, she underwent brain tumor resection, whole-brain irradiation, and simultaneous pembrolizumab treatment. However, her condition deteriorated, and she died 3 years after the initial surgery and 8 months after the recurrent tumor removal. Review of the surgical video did not aid the identification of the cause of the port-site recurrence. Although rare, port-site recurrence may occur even in gynecological malignancies and should be more widely recognized to ensure prompt treatment.

　Sarcoidosis is a systemic disease that forms non-desmoplastic epithelioid cell granulomas, with lesions in the lungs, heart, eyes, skin, lymph nodes, and other organs, presenting with a variety of symptoms, and it has been suggested to be associated with malignancy.

　We present a case of a 71-year-old woman (gravida 2, para 2), in whom a robot-assisted laparoscopic total hysterectomy was performed for CIN3. The postoperative diagnosis was stage IB1 cervical cancer, and postoperative PET/CT scan showed multiple FDG accumulations in lymph nodes. Since metastasis of cervical cancer or malignant lymphoma were considered as differential diagnoses, bronchoscopic lymph node biopsy was performed, and the final diagnosis of sarcoidosis was made.

　When lymph node enlargement is observed, it is important to consider not only cancer metastasis but also sarcoidosis and to perform a pathological search.

　A 63-year-old woman, G4P3, presented to our hospital after being diagnosed with pelvic organ prolapse (Pelvic Organ Prolapse Quantification System stage III) during a routine health examination. Abdominal CT revealed that the patient's cecum had shifted to the middle lower abdomen with the small intestine on its right and the ascending colon on its left. Although intestinal malrotation was noted, no adhesions or vascular abnormalities were observed on the sacral promontory. Accordingly, the patient was scheduled to undergo laparoscopic sacrocolpopexy. Intraoperatively, most of the small intestine was found to be positioned on the right. By elevating the pelvic organs, we achieved adequate visibility without additional manipulation of the intestines. No positional abnormalities were observed with regard to the sigmoid colon, rectum, or ovarian vessels. The planned surgery was completed successfully, and the postoperative course was uneventful. As of the most recent outpatient clinic follow-up 4 years postoperatively, the patient was asymptomatic and had no signs of recurrence.

　Benign metastasizing leiomyoma (BML), a leiomyoma that metastasizes various parts of the body other than the uterus, is an extremely rare disease. We report a case of BML that developed during hormone replacement therapy after laparoscopic total hysterectomy (TLH) for uterine myoma. A 50-year-old woman presented with multiple myomas. After 4 courses of GnRH agonist, TLH and risk-reducing salpingectomy were performed. The operative time was 91 minutes, blood loss was 200 g, and the specimen weight was 1,050 g. The histopathological diagnosis of the specimen was leiomyoma with no malignant findings. She was started on estrogen replacement therapy for menopausal symptoms by a local doctor 3 years and 9 months after surgery. At 4 years and 4 months after the surgery, a pulmonary nodule was detected on chest computed tomography during the medical examination, and a thoracoscopic partial left lung resection was performed at the respiratory surgery department of another hospital. Histologically, the tumor was diagnosed as BML. She was referred back to our hospital for follow-up of the residual tumor, and estrogen replacement therapy was discontinued. At 5 years and 7 months after the initial surgery, she was doing well without tumor growth. It is important to recognize that BML can occur after laparoscopic surgery, and there is a possibility that HRT is a risk factor for BML.

　Hysterectomies by vaginal natural orifice transluminal endoscopic surgery (vNOTES) have advantages, including reduced pain and shorter hospital stays than conventional endoscopic hysterectomies. However, we often experience difficulties with vaginal surgery in patients with obesity. Herein, we show how to open the peritoneum easily using indigo carmine staining in a patient with obesity.

　A 49-year-old female who had experienced three pregnancies and two deliveries (body mass index [BMI] 37) exhibited pallor suggestive of anemia during physical examination 4 years before surgery and was diagnosed with uterine adenomyosis. She was referred to our hospital for surgery due to recurrent menorrhagia after GnRH agonist treatment. Internal examination revealed uterine mobility, and magnetic resonance imaging (MRI) revealed anterior wall thickening up to 7 cm, suggesting adenomyosis. Due to obesity, her vNOTES hysterectomy was expected to be difficult. A fallopian tube spacing catheter was inserted into the uterine cavity, and 30 ml of indigo carmine solution diluted with saline was injected. A circular cervical incision was made, the bladder was detached from the cervix, and a transverse incision was made through the cysto-uterine and Douglas fossae's peritoneum, which were transparent blue. Total hysterectomy and bilateral salpingectomy were performed. Rare occurrences of bladder injury during vNOTES hysterectomies. Vaginal surgery is particularly difficult in patients with obesity. In this case, vNOTES hysterectomy was easily performed using indigo carmine staining in a patient with obesity. Consent was obtained from the patient to submit this report.

Introduction: Although supracervical hysterectomy is performed less frequently than total hysterectomy, preservation of the cervix is still focused on in consideration of pelvic floor function and sexual function. Robot-assisted sacrocolpopexy is becoming more popular for pelvic organ prolapse, and the use of supracervical hysterectomy may increase in future. Perioperative complications such as heavy bleeding and ileus occur at high rates in residual cervix excision after supracervical hysterectomy. In this report, we present a case of a patient with prolapse in the residual cervix after supracervical hysterectomy who underwent a cervix excision with laparoscopy.

Case presentation: The patient was a 78-year-old woman who underwent supracervical hysterectomy at the time of cesarean section at the age of 24. She presented to our department because of prolapse of the residual cervix. Concerned about intra-abdominal adhesions, we performed a vaginal procedure under laparoscopic observation to detach the adhesions and avoid damage to the surrounding organs. The patient had no significant perioperative complications.

Conclusions: In this case, the use of a laparoscope for residual cervix excision allowed us to observe the adhesion and avoid organ damage. The laparoscope may generally be useful in preventing intraoperative hemorrhage and ileus. It is important to inform the patient preoperatively of the possibility of residual cervical lesions and the complications associated with adhesions when cervical excision is necessary as a part of the informed consent for supracervical hysterectomy. The use of laparoscopy for retained cervix excision is suggested to be useful.

　We present a case of gonadectomy in androgen insensitivity syndrome (AIS), in which the gonad was difficult to remove because it was entrapped in the inguinal canal. A 22-year-old phenotypical female was referred to a previous hospital for primary amenorrhea. Her two sisters had AIS and her chromosome test showed a 46XY karyotype. Therefore, she was referred to our hospital for treatment. Pelvic MRI showed the left gonad in the abdominal cavity and the right one completely in the inguinal canal. We decided to perform laparoscopic bilateral gonadectomy and inguinal hernia repair. Laparoscopic observation revealed the left gonad in the abdominal cavity. The right gonad could not be observed from the abdominal side and completely fell into the inguinal canal. Therefore, we incised the preperitoneal cavity, expanded it to the inguinal canal, inverted it into the abdominal cavity, and removed the gonad. Since both internal rings were enlarged after gonadectomy, meshes (3D Max Light Mesh) were fixed accordingly with the transabdominal preperitoneal repair. As no complications occurred, the patient was discharged on the third postoperative day. Pathohistological observations showed no malignancy.

　In the case of gonadal enlargement associated with bilateral inguinal hernias in AIS, gonadectomy can be performed by expanding the preperitoneal space and pulling and guiding the gonads into the preperitoneal cavity from the inguinal canal. Furthermore, hernia repair can be performed if necessary.

Introduction: There are insufficient reports of experience regarding laparoscopic surgery in cases with metastatic ovarian tumor. We report four cases of metastatic ovarian tumor in patients who underwent laparoscopic bilateral salpingo-oophorectomy.

Case 1: A 62-year-old woman with a history of sigmoid colon cancer was suspected of recurrence in the right ovary, with 54-mm pelvic mass. For diagnostic and therapeutic purposes, we performed bilateral salpingo-oophorectomy. There was no ascites or peritoneal dissemination.

Case 2: A 40-year-old woman with a history of gastric cancer was suspected of recurrence in the right ovary, with 47-mm mass. For diagnostic purposes, we performed bilateral salpingo-oophorectomy. Ascites was small in volume and dissemination was not observed.

Case 3: A 74-year-old woman with a history of gastric cancer was suspected of recurrence in the right ovary, with 50-mm mass. To enable discontinuation of chemotherapy by achieving disease-free status, we performed bilateral salpingooophorectomy. Ascites volume was small and dissemination was not observed. Due to its solid component, the specimen was extracted from the extended umbilical port-site.

Case 4: A 54-year-old woman with a history of gastric cancer was suspected of recurrence in the right ovary, with 76-mm mass. For therapeutic purposes, we performed bilateral salpingo-oophorectomy. Ascites was 1,575 ml and dissemination was not observed. Due to its solid component, the specimen was dissected and extracted from the extended umbilical port-site.

Conclusion: There was no conversion to open surgery and no complication. Laparoscopic bilateral salpingo-oophorectomy was safe in cases with metastatic ovarian tumor.

　Wunderlich syndrome is a disorder of a duplicated uterus with unilateral cervical obstruction and ipsilateral kidney agenesis, and its frequency is reported to be 0.1-3.8％ in the general population. We report a case of Wunderlich syndrome that was difficult to diagnose and treat at our hospital. The patient, an 11-year-old girl, was diagnosed with OHVIRA syndrome on imaging findings and underwent four vaginal septectomies, but the recurrence was repeated. Careful evaluation of pathology specimens led to the diagnosis of Wunderlich syndrome. The OHVIRA syndrome and Herlyn-Werner syndrome are often confused with Wunderlich syndrome because of their similar clinical manifestations and imaging findings, and it is important to submit the closed cyst wall and vaginal wall to pathology for histopathologic differentiation to obtain a final diagnosis. The basic treatment is septal resection. However, signs such as dysmenorrhea of Wunderlich syndrome and OHVIRA syndrome often occur at an early age without a history of sexual intercourse, and in conventional surgery performed under direct vision with a narrow vaginal canal it is difficult to expand the operative field and may result in hymen or perineal lacerations. We devised surgical techniques using not only conventional methods, but also a combined use of the resectoscope, laparoscope, and Harmonic HD1000i shears. The recurrence rate has not been fully investigated, and further research is needed.

　We report on the treatment progress and pregnancy outcomes of two cases of infertility due to cesarean scar disorder, treated with laparoscopic uterine scar repair.

Case 1: A 40-year-old woman, after delivering her first child via emergency cesarean section due to arrested labor, repeatedly underwent embryo transfers in her desire for a second child, but failed to conceive. Following imaging examinations, she was diagnosed with infertility caused by cesarean scar disorder. Following laparoscopic uterine scar repair, she was permitted to conceive six months after the surgery. Subsequent embryo transfer led to pregnancy, which unfortunately resulted in premature delivery at 24 weeks.

Case 2: A 35-year-old woman, whose first child was born by emergency cesarean section due to early placental abruption, conceived and delivered her second child via cesarean section. Despite her desire for a third child, she did not conceive for about 30 months. We diagnosed and treated her for infertility caused by cesarean scar disorder, similarly to Case 1. Post-treatment, she spontaneously conceived and gave birth by planned cesarean section at 38 weeks. When compared with Case 2, the uterine scar in Case 1 was located on the caudal side, and the postoperative cervix in Case 1 was shortened.

Conclusion: We hypothesize that in Case 1 the extensive resection of the uterine scar might have induced a condition akin to cervical incompetence. Therefore, we emphasize the crucial importance of ensuring that the resection area during the repair procedure is as minimal as possible.

　Laparoscopic sacrocolpopexy (LSC) is a useful method to treat pelvic organ prolapse (POP).

　LSC has a lower incidence of POP recurrence, compared to native tissue repair (NTR), which was performed frequently in the past¹⁾. LSC is often in Japan performed on a nationwide scale because LSC has been covered by national insurance since 2016. Notably, reports on the long-term prognosis are limited. We managed a patient with bowel obstruction who required bowel resection due to mesh insertion during LSC. The patient was a 56-year-old woman. She underwent a LSC at 53 years of age, and developed a bowel obstruction that required bowel resection. Surgeons in another hospital performed emergency surgery for her ambulatory abdominal symptoms, which revealed that there was peritoneal pocket opening due to erosion of the mesh or incomplete reperitonealization at the time of LSC 3 years earlier. The surgeons resected the inserted mesh or an adhesional band-like fragment, which was composed of a hernial orifice and a part of the small intestine, because necrotic changes were observed. The surgeons decided that the pocket was not sutured. She made a good progress postoperatively and had no bowel obstruction recurrences for the present. Even though there are not many reports of bowel obstruction after LSC, bowel obstruction is a possible complication. We suggest evaluation for this potential complication for a long time after performing LSC.

　The incidence of uterine cancer is increasing due to obesity and an aging population. Minimally invasive surgery is now covered by insurance and the number of surgeries is increasing. Pelvic organ prolapse (POP) is also increasing owing to an aging population. Laparoscopic sacrocolpopexy (LSC) is now covered by insurance and widely performed, with supracervical hysterectomy being the mainstay of the procedure. Some uterus-sparing techniques are reported, however, we did not search the literature for cases of uterine malignancies that occur after uterus-sparing LSC. Here, we describe a case of uterine carcinoma in a patient with a preserved uterus. The 67-year-old woman underwent uterus-sparing LSC for POP in the urology department. Five months after surgery, the patient developed irregular bleeding, and a preoperative diagnosis of stage IA uterine cancer (endometrial carcinoma, grade 2) was made upon further examination. We performed a modified laparoscopic radical hysterectomy. We completed the planned procedure by amputating the uterine side as appropriate to preserve the mesh. The final pathological diagnosis was stage IB uterine cancer (endometrial carcinoma grade 3) and the patient was treated postoperatively. Eighteen months after surgery, there was no evidence of uterine cancer recurrence or POP. It is important to reduce the possibility of postoperative uterine malignancy by including preoperative imaging and endometrial biopsies. It is also necessary to determine the appropriate line of resection, because mesh preservation may prevent POP recurrence.

　A 41-year-old woman with a history of two cesarean sections visited our department complaining of dysmenorrhea, prolonged menstruation, and dyspareunia. Pelvic transvaginal ultrasound and Magnetic Resonance Imaging (MRI) confirmed a chocolate cyst-like mass approximately 6 cm in diameter in the vesicouterine pouch. Since a fistula-like finding was observed at the cesarean section scar, we suspected that a uteroperitoneal fistula formed by accumulation of menstrual blood in the vesicouterine pouch through this fistula. There are reports of fistula closure by pseudomenopause therapy as a treatment for vesicouterine and uteroperitoneal fistula. Four months after starting administration of leuprorelin acetate, the patient presented with a chief complaint of fever. A large amount of pus was found in the cyst and uterine cavity, and culture confirmed the presence of Escherichia coli. The symptoms and findings were alleviated with combined administration of antibiotics and transcervical drainage. Laparoscopic hysterectomy was performed because the fistula could not be closed with this treatment. Based on intraoperative observations and examination of resected samples, uteroperitoneal fistula was ruled out, and cesarean scar disorder (CSDi) was diagnosed in which the cesarean scar expanded like a chocolate cyst.

　CSDi can sometimes involve formation of a chocolate cyst-like mass in the vesicouterine pouch, and must be differentiated from uteroperitoneal fistula. For similar cases, cesarean scar repair is performed if maintenance of fertility is desired, and hysterectomy is performed if maintenance of fertility is not desired.

　Adnexal torsion of normal sized ovary during pregnancy is rare, and the cause of its onset is not clear. Here, we report a case of a patient who developed torsion of a normal ovary at 34 weeks of gestation and underwent laparoscopic salpingo-oophorectomy.

　A 25-year-old pregnant woman (gravida 2, para 1) attended hospital at 34 weeks of gestation with acute left lower abdominal pain. Transabdominal ultrasonography revealed normal size left ovary (40×20 mm), which was with strong tenderness. Adnexal torsion of the left normal ovary was suspected and laparoscopic surgery was performed. Surgery was performed under general anesthesia with the patient in the supine position. Intraoperatively, a 12-mm umbilical port was initially inserted with open access technique, and two 5-mm trocars were inserted through the left abdomen near the left ovary. A 10-mm, 30-degree scope was used, and the pneumoperitoneum pressure was 10 mmHg. The scope was inserted along the abdominal wall, avoiding the pregnant uterus. The left ovary was twisted 360 degrees. The torsion was released and salpingo-oophorectomy was performed. Histopathological examination of the left ovary revealed mild congestion and hemorrhage in the ovarian stroma, and dilated veins, but no tumorous lesions were found. There were no problems during the operation, and the operation time was 28 min; the blood loss was minimal. The course of her pregnancy was uneventful, and she had a normal vaginal delivery at 40 weeks of gestation.

　It is necessary to recognize that one of the causes of acute abdomen in late pregnancy is adnexa torsion of the normal ovary. Laparoscopic surgery is an option for the treatment of torsion; however, it is necessary to consider the surgical position, port position, and scope according to the physical and physiological changes in late pregnancy.

　Ovarian hemorrhage occurs in women across a broad age range; however, conservative therapy effectively controls bleeding in most cases. Notably, in some patients, it can lead to massive life-threatening bleeding, which necessitates surgical intervention and exploration of the underlying contributors. We report a case of ovarian bleeding associated with intra-abdominal hemorrhage (2,900 ml) in a patient with chronic myeloid leukemia. A 32-year-old nulligravida was urgently referred to our facility in a state of shock secondary to significant intra-abdominal bleeding. Initial evaluation revealed a serum hemoglobin level of 4.7 g/dl, white blood cell count of 217,000/μl, and platelet count of 53.5 × 10⁴/μl, with abnormal blood cell parameters. Exploratory laparoscopy led to diagnosis of left ovarian bleeding. Subsequent postoperative investigations confirmed concomitant chronic myeloid leukemia. Myeloproliferative disorders, including chronic myeloid leukemia, can lead to the development of acquired von Willebrand syndrome (aVWS). An increase in the platelet count in myeloproliferative disorders is associated with aVWS, which paradoxically causes a bleeding tendency. In addition to significant ovarian bleeding, aVWS may cause postoperative port-site bleeding. Although aVWS is considered rare, evidence suggests that it occurs at a high frequency in patients with specific underlying conditions.