Objective: This study aimed to describe the appropriate diagnosis and management of adnexal torsion.

Methods: All patients who were surgically proven to have adnexal torsion between July 2015 and December 2021 were retrospectively investigated. We used their clinical backgrounds, blood test results, imaging test results, and surgical findings.

Results: During the study period, 65 patients suffered from adnexal torsion. The white blood cell count and CRP (C-reactive protein) at hospitalization did not necessarily rise, but the NLR (neutrophil-to-lymphocyte ratio) increased significantly. In an emergency, a CT (Computed Tomography) study was helpful for diagnosis, showing typical signs of adnexal torsion. Forty-one patients had laparoscopic surgeries, and 24 had laparotomies. They had significantly different sizes of adnexal swelling (89.37±28.96 mm and 122.25±55.76 mm, p=0.0268). Ovaries were preserved in 27 patients, while 38 underwent salpingo-oophorectomy. Among patients under 50 years of age, 27 had their ovaries preserved, while 26 had salpingo- oophorectomy. These patients had significant differences in age and parity (29.0±8.5 years vs. 37.9±7.1 years; p<0.01/ 0.30±0.11 vs. 1.1±0.23, p<0.01). The frequency of laparoscopic surgery and ovary preservation has been increasing year by year.

Conclusion: Imaging and blood tests, in addition to clinical features and a physical examination, were helpful in correctly diagnosing adnexal torsion, especially given the typical findings of a CT study and an increase in NLR. Furthermore, we should be cautious about ovary preservation and try to avoid a hasty decision on whether the adnexa are necrotic or not based solely on gross surgical findings.

Objectives: Robot-assisted gynecologic surgery is widely used throughout Japan. However, detailed reports examining the perioperative outcomes of robotic surgery and conventional laparoscopy in gynecology in Japan are limited. Hence, we aimed to compare the outcomes of robotic and laparoscopic surgeries.

Methods: Patients with benign disease and endometrial cancer who underwent robotic (robotic group) or conventional laparoscopic (lap group) surgery by the same surgeon at our hospital between 2020 and 2022 were included. Clinical background, surgical information, and postoperative histological examination findings were evaluated.

Results: There were 35 (24 benign, 11 endometrial cancer) and 47 (33 benign, 14 endometrial cancer) cases in the robotic and laparo groups, respectively. There were no significant differences in operative time, blood loss, or postoperative complications. The median (range) organ weight in the lap group was 260 g (60-1127), which was significantly larger than that in the robot group 162 g (46-551). The robot group had a significantly greater head-down angle [19° (15-21°) vs. 18° (10-20°)] and pneumoperitoneum pressure [10 mmHg vs. 10 mmHg (8-10)] than the lap group had.

Conclusion: Although there was no difference in the safety between robotic and conventional laparoscopic surgery, removal of larger uterus' tended to be performed via conventional laparoscopy.

Purpose: In 2002, the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy established a system for qualified gynecologists of endoscopy (laparoscopy). This year, this qualification system is celebrating its 20th anniversary. From the year 2021's application, the evaluation method was divided for each surgical procedure for the first time. By analyzing the results of last year's total laparoscopic hysterectomy video review, this study aimed to clarify the precautions for applicants.

Methods: The score rate was examined for each item based on the screening results of 255 cases that underwent video screening using The Technical Certification Video Screening Score in 2021. In addition, we evaluated the screening criteria based on the correlation between the surgical time, the resected object's weight, and the results of a questionnaire in the Technical Certification Consensus Meeting.

Results: The final acceptance rate for qualified gynecologists of endoscopy (laparoscopy) in 2021 was 52.7%. In the minor items, the passing group obtained a high score rate of ≥ 65% in all items. In contrast, in the failing group, 40% of the minor items had a low score rate of ≤ 50%. The median weight of the uterus in the submitted videos was 220.5 g (range: 35-900 g), and the median surgical time was 136 min (range: 70-242 min). In the passing rate, a significant difference was not observed at the cut-off of 280 g.

Conclusion: To become a qualified gynecologist of endoscopy (laparoscopy), it is important to perform surgery with care for basic techniques and safety.

　Some women suffer from pain and infertility because of deep endometriosis. We have performed laparoscopic excision of deep endometriosis for infertile women in order to relieve pain and improve fertility. However, according to some reports, excision of deep endometriosis does not always improve the pregnancy rate in fertility treatment after the surgery and has risks of postoperative adverse effect. Therefore, we examined patient background, surgical course, and postoperative pregnancy for laparoscopic deep endometriosis resection at our hospital. Twenty-three patients underwent deep endometriosis resection at our hospital between January 2020 and December 2022. In all cases, not only preoperative explanations of the surgical procedure and complications, but also the need for aggressive postoperative infertility treatment based on intra-abdominal findings and postoperative management, including the possibility of postoperative recurrence and progression, were fully explained to the patients. At the time of surgery, we carefully dissected adhesions from areas where normal anatomy was relatively preserved, keeping in mind that there was deviation from the normal anatomy. There were no serious complications in any of the patients in this study. Postoperatively, 16 pregnancies (69.6％) were achieved at fertility treatment based on the intraperitoneal findings. The mean time to pregnancy after surgery was 8 months (1-18 months). Deep endometriosis resection can be performed safely by pursuing resection of the necessary and sufficient extent of the lesion with adequate preoperative preparation. In addition, we believe that collaboration among the responsible physicians will lead to safe pregnancy and delivery.

Objective: Retained products of conception (RPOC) is defined as a condition of persistent fetal or placental tissue within the uterine cavity after abortion or delivery. Its chief clinical complications include irregular bleeding and excessive postpartum bleeding. In cases involving infertility treatment, the treatment must be interrupted until the lesions disappear. No standard treatment protocol has been established; transcervical resection (TCR) is the basic treatment strategy at our hospital. In this study, we retrospectively reviewed the outcomes of RPOC patients who underwent TCR at our hospital, aiming to evaluate its efficacy.

Methods: The medical records of patients who underwent TCR with a confirmed diagnosis of RPOC from July 2013 to June 2023 were retrospectively reviewed.

Results: This study included 18 patients, with a median age of 37 years; notably, 12 (66.7%) were concurrently undergoing fertility treatment. Pregnancies preceding RPOC included four (22.2%) complete abortions, 13 (72.2%) missed abortions, and one (5.6%) vaginal delivery case. Massive bleeding was observed in two patients (11.1%), and uterine artery embolization was performed in one patient (5.6%). Of the 17 patients evaluated by ultrasound doppler prior to TCR, eight (47.1%) exhibited blood flow to the mass, concomitant with pronounced symptoms of genital bleeding. The intraoperative blood loss was minimal, obviating the need for transfusions. Four patients achieved pregnancies postoperatively.

Conclusion: TCR for RPOC emerges as an effective lesion removal technique, irrespective of the timing of intervention, provided that genital bleeding is effectively managed before the TCR procedure.

Objective: Preoperative gonadotropin-releasing hormone analogue (GnRHa) therapy facilitates total laparoscopic hysterectomy (TLH) for uterine fibroids and adenomyomas by decreasing blood loss and operative time. However, GnRHa use can cause vaginal atrophy, making transvaginal procedures difficult. The aim of this study is to evaluate the effect of preoperative vaginal estriol use for TLH in patients on GnRHa therapy.

Methods: We retrospectively assessed 2,571 patients who underwent TLH with transvaginal specimen extraction between April 2014 and March 2023, of whom 2,505 were postmenopausal or undergoing GnRHa treatment. Patients were divided into two groups by vaginal estriol administration status. Patient characteristics, surgical outcomes, and postoperative outcomes were compared between the groups.

Results: No significant group differences were seen in age, BMI, proportion of nulliparas, serum estradiol and FSH levels, type and dose of GnRHa, and size and weight of uterus. In the analysis of surgical outcomes, the rate of colpoperineal laceration was significantly lower in the estriol group than in the non-estriol group (p<0.01). Operative time, blood loss, and specimen extraction time were similar in both groups. There were no significant group differences in hemorrhage from the vaginal stump requiring hospitalization or outpatient treatment for suture or pressure hemostasis.

Conclusion: This is the first study evaluating postoperative and surgical outcomes for vaginal estriol use in patients undergoing TLH on GnRHa therapy. Add-back therapy with vaginal estriol is effective for reducing the risk of colpoperineal laceration caused by transvaginal procedures. It may allow benefitting from GnRHa therapy while reducing its disadvantages.

Objective: We aimed to clarify the effectiveness of preoperative vaginal preparation with povidone-iodine in preventing pelvic infection after total laparoscopic hysterectomy (TLH).

Methods: Our retrospective study included 365 patients who underwent TLH at our hospital between June 2017 and August 2021. The rate of postoperative pelvic infection was compared between 2 groups: patients who underwent preoperative vaginal preparation using povidone-iodine (n=314) or benzethonium chloride (n=51).

Results: Postoperative pelvic infection was observed in 3.0% of the study participants. Morbidity from pelvic infection was more severe in patients who underwent preoperative vaginal preparation with benzethonium chloride than in patients who underwent preparation with povidone-iodine (13.3% vs 1.8%). No significant differences were found in operative time, blood loss, or weight of the uterus between the two groups.

Conclusion: Preoperative vaginal preparation with povidone-iodine before TLH can be considered more effective than benzethonium chloride in reducing morbidity from pelvic infection after surgery.

Objective: This study aimed to compare the safety and efficacy of pelvic lymphadenectomy by laparoscopy or laparotomy during the same period.

Method: The clinical data of 46 patients with endometrial cancer who underwent pelvic lymphadenectomy by laparoscopy or laparotomy in our hospital between April 2019 and March 2022 were analyzed retrospectively. Twenty-eight patients underwent laparotomy, while 18 patients underwent laparoscopy. We compared perioperative complications, the number of pelvic lymph nodes harvested, and the rate of recurrence between the laparotomy group (LG) and the laparoscopic surgery group (LSG).

Result: Compared with the LG, the LSG had a significantly longer operation time (208 minutes vs. 289 minutes, p≤0.001) and significantly less intraoperative blood loss (220 g vs. 139 g, p=0.04). However, the LG and LSG groups were similar regarding the hospitalization period (9 days vs 10 days, p=0.33); the frequencies of postoperative lymphedema (17.9% vs. 22.2%, p=0.72), lymphoceles (7.7% vs. 5.6%, p=1.00), and bowel obstruction (3.6% vs. 0%, p=1.00); and the number of excised lymph nodes (23.5 vs. 21, p=0.09). In this study, the dissection area of the common iliac lymph nodes was smaller with laparoscopy than with laparotomy, but no patients who underwent laparotomy had metastatic lymph nodes in only the common iliac region. Even if the area of potential lymphadenectomy includes all of the common iliac lymph nodes, this may not increase the number of undetectable metastases of these nodes.

Conclusion: At our hospital, laparoscopic pelvic lymphadenectomy in early-stage endometrial cancer was not inferior to laparotomy.

　Total laparoscopic hysterectomy (TLH) was introduced in our hospital in December 2018. A total of 145 patients underwent the procedure by April 2022, and five of them developed surgical site infection (SSI). After excluding one patient with laparotomy conversion and one with suspected beta-lactam allergy, 143 patients were categorized into the following three groups according to the type of perioperative antimicrobial prophylaxis, with the goal of retrospectively comparing patient characteristics and the incidence of SSI: 1) a single administration of 1 g flomoxef sodium (FMOX) (FMOX-A group, n=37), 2) a single administration of 1 g cefazolin (CEZ group, n=37), and 3) repeated administration of FMOX every 2 hours with weight-based dosing (FMOX-B group, n=69). There were no significant differences between the three groups in terms of age, body mass index, operative time, intraoperative blood loss, specimen weight, presence of endometriosis, presence of vaginal stump hematoma, or presence of diabetes or dialysis. SSI occurred in 2.7% (n=1), 10.8% (n=4), and 0% (n=0) of patients in the FMOX-A, CEZ, and FMOX-B groups, respectively. The incidence of SSI was significantly lower in the FMOX-B group compared with the CEZ group (p=0.04), suggesting that both the type of antimicrobial prophylaxis and the method of administration may influence the prevention of SSI.

　We investigated how using reusable rather than disposable uterine manipulators impacted surgical outcomes in laparoscopic ovarian tumor surgery. This was a retrospective study of patients who underwent laparoscopic ovarian tumor surgery with a diagnosis of ovarian endometriotic cyst from January to July 2022 at Yokohama Rosai Hospital. We switched from using a disposable uterine manipulator to a reusable product in May 2022, and compared patient backgrounds and outcomes before and after this time. Twenty patients were included, 9 in the disposable product group and 11 in the reusable product group. The time from anesthesia induction to the end of surgery, the amount of blood loss, and the frequency of complications did not differ between the two groups. In laparoscopic ovarian tumor surgery, switching from disposable to reusable uterine manipulators had no significant effects on surgical outcomes.

Objective: The umbilical site is widely used as the initial entry site in laparoscopic surgery. The initial entry procedure may cause organ injury, and thus we use the upper abdominal region as the entry site when umbilical site adhesions are suspected. However, the upper abdominal region is far from the pelvis, and therefore use of this region for the entry site makes pelvic surgery challenging. We investigated which abdominal region, other than the umbilical site, would be suitable for the initial entry.

Methods: From January 2020 to December 2022, 181 of the 659 patients who underwent laparoscopic or robot-assisted endoscopic surgery at our hospital had a history of abdominal surgery. The presence of organ adhesion to the abdominal wall (umbilical site [US], left upper abdomen [LU], right upper abdomen [RU], left lower abdomen [LL], right lower abdomen [RL], and the midline of the lower abdomen [ML]) was retrospectively examined.

Results: The frequency of organ adhesions at each site was US 23.8%, LU 0.5%, RU 3.9%, LL 4.4%, RL 24.8%, and ML 11.0%. The frequency of organ adhesions in the LL was significantly lower than in the US (p < 0.05). There was no significant difference in the frequency of organ adhesions between the LL and ML. Nevertheless, in the presence of US adhesions, the frequency of organ adhesions was significantly lower in the LL than in the ML (p < 0.05).

Conclusion: In patients with a history of abdominal surgery, the left lower abdomen is a safe and appropriate initial entry site.

Objective: To consider of the surgery of the endometriotic cyst multifacedly, and to investigate the significance of performing resection of the median pelvic endometriosis (RME).

Design: Retrospective observational study.

Setting: Regional medical support hospital

Patients: A total of 885 patients who underwent laparoscopic surgery for the endometriotic cysts from 2005 to 2016 at Japanese Red Cross Maebashi Hospital were included.

Intervention: Under the diagnosis of endometriotic cyst based on physical findings, ultrasonography, MRI, etc., the cyst was operated by laparoscopic surgery, along with uterine fibroid enucleation or hysterectomy/supracervical hysterectomy, depending on the case. Of those, 420 underwent RME.

Main Outcomes: Pain symptoms were assessed with a 10 cm visual analogue scale (VAS), and the status of pain relief and recurrence after surgery were investigated. Additionally, recurrence of cysts, occurrence of premature menopause, pregnancy, delivery, perinatal complications, ovarian cancer, complications of other organ diseases were investigated.

Results: Resection of endometriotic cysts was effective in improving postoperative menstrual pain and chronic pelvic pain. Pain symptoms were relieved more effectively by performing RME. Postoperative pain recurrence was not related to the RME, and hormone therapy significantly suppressed pain recurrence. Recurrence of ovarian cysts was found in 4.6％. Premature menopause before 40 years of age occurred in 1.53％. Thirty-one ％ of those who wished to have children had at least one pregnancy. Eight patients (0.94％) were found to have ovarian cancer, 7 patients survived on disease free, of those three patients became pregnant and delivered after surgery.

Conclusions: In surgery for endometriotic cysts, combined RME improved pain more effectively.

　Serous endometrial intraepithelial carcinoma, a potential precursor to endometrial serous adenocarcinoma, may be challenging to diagnose through endometrial histology when the lesion is confined to a specific area. However, even in the absence of invasive carcinoma, metastasis may occur through the fallopian tubes. Therefore, early and reliable diagnosis and appropriate treatment are important. Here, we describe a case of serous endometrial intraepithelial carcinoma, diagnosed via laparoscopic total hysterectomy, in which the diagnosis was difficult despite the initial suspicion of serous carcinoma. The 57-year-old patient was referred to our hospital because of genital bleeding and abnormal endometrial cytology results. Endometrial histology was insufficient to confirm a diagnosis of serous carcinoma, and computed tomography and magnetic resonance imaging scans revealed no abnormalities. The patient underwent bilateral adnexectomy, which did not reveal any lesions, followed by laparoscopic total hysterectomy and the subsequent diagnosis of serous endometrial intraepithelial carcinoma. The patient received postoperative chemotherapy and is alive without disease. Our case highlights that, in cases of cytological abnormality or irregular genital bleeding, a thorough search must be conducted, including via total hysterectomy, even when histological examination does not reveal any abnormalities.

Synopsis: Peritoneal pseudomyxoma is a condition where a mucin-producing tumor ruptures and the mucus accumulates in the abdominal cavity. Surgical tumor reduction is the most common treatment abroad, and some cases are treated using laparoscopy. No consensus on the optimal treatment has been established. An 81-year-old woman was accidentally detected with an intra-pelvic tumor using magnetic resonance imaging. The tumor included a solid part, along with a small amount of ascites. However, no enlarged lymph nodes or distant metastasis was noted. We performed staging laparoscopy because we couldn't completely deny the possibility of the ovarian borderline tumor before an operation. The intra-abdominal findings revealed peritoneal pseudomyxoma. No adnexal enlargement was observed, but the appendix was enlarged and had ruptured. Thus, we performed an additional appendectomy and mucus drainage. We continue to follow up the patient in collaboration with the department of gastrointestinal surgery, and no relapse has occurred so far. Various cases have been reported about the operation for peritoneal pseudomyxoma. This report suggest that laparoscopic operation enables us to perform less-invasive tumor reduction.

Purpose: NOTES (natural orifice transluminal endoscopic surgery) is a type of endoscopic surgery using a natural orifice. In the field of gynecology, vaginal NOTES (vNOTES) is performed using the vaginal orifice. vNOTES is less invasive than abdominal surgery and the endoscopic approach enables a magnified field of view, resulting in safe and reliable procedures. By contrast, in cases with a narrow vaginal canal such as nulliparity, vNOTES is not ideal as opening the vaginal fornix under direct vision is difficult. In this report, we describe cases where the vaginal fornix was opened with the pneumovaginal approach and vNOTES was completed.

Methods: Among 112 patients in our hospital who underwent vNOTES between February 2020 and July 2022, the opening of the fornix using the pneumovaginal endoscopic approach was attempted in nine cases. Six patients were nulliparous, one had undergone transvaginal mesh surgery, and two were diagnosed with a narrow vagina. The vaginal fornix was opened using the pneumovaginal endoscopic approach. The GelSeal cap (7 cm) was removed from the vaginal canal, and the Alexis retractor and GelSeal cap were reattached to the vaginal fornix opening window; the procedure was then performed as usual. The median operative time was 105 minutes (62-160 minutes), median pneumovaginal endoscopic approach time was 25 minutes (14-112 minutes), and median blood loss was 30 mL (10-240 mL). Five cases of ovarian cystectomy, two cases of salpingo-oophorectomy, one case of total hysterectomy plus salpingectomy, and one salpingectomy were performed. One patient was converted to a conventional laparoscopic procedure due to pelvic adhesions. In eight cases, intraperitoneal access was achieved without adverse events, and the operation was safely completed.

Conclusion: By opening the vaginal fornix using a pneumovaginal approach, vNOTES could be completed safely in patients with narrow vaginas. Based on these results, the surgical indications and techniques for the use of vNOTES in gynecology should be explored further.

　Malignant peritoneal mesothelioma is a malignant tumor that develops in peritoneal mesothelial cells. More than 80% of malignant mesotheliomas are caused by asbestos exposure and develop over a period of approximately 30-40 years. Preoperative diagnosis is difficult. Most cases are confirmed with postoperative histopathological examination. We describe a case of malignant peritoneal mesothelioma diagnosed via diagnostic laparoscopy surgery.

　The patient was a 51-year-old woman who presented to our emergency department with a chief complaint of abdominal pain. She was found to have localized peritonitis and peritoneal nodules. The peritonitis resolved with antibiotics. The patient was discharged from the hospital; she continued to visit the hospital annually for follow-up of the peritoneal nodule.

　Three years later, computed tomography (CT) showed aggravation of the peritoneal nodules. The patient was referred to our department for a close examination. Transvaginal ultrasonography showed bilateral ovarian enlargement. CT and pelvic MRI showed a strong likelihood of ovarian cancer and peritoneal dissemination. Thus, experimental laparoscopic surgery was performed. Postoperative histopathological examination led to a diagnosis of malignant peritoneal mesothelioma.

　It is important to perform experimental laparoscopic surgery and confirm the postoperative histopathological diagnosis before starting chemotherapy, even in cases where preoperative chemotherapy is considered to be indicated for patients referred to the gynecology department for ovarian cancer or primary peritoneal cancer.

　An intrauterine device (IUD) is a commonly used, reversible contraception. Reports of IUD-related complications have increased, and one of these is uterine perforation at IUD insertion with subsequent migration into the intraperitoneal cavity. This is a rare complication, occurring in approximately 0.2-3.6 per 1000 cases. We report a case of laparoscopic surgery for removal of an IUD that had migrated into the uterine myometrium. A 39-year-old nulliparous woman underwent IUD insertion to prevent intrauterine adhesions after laparoscopic myomectomy (LM). Three months after LM, the IUD could not be removed by pulling the IUD strings. CT and MRI revealed that the IUD had migrated into the uterine myometrium. We removed the IUD by laparoscopic surgery. Insertion of an IUD after myomectomy, especially under anesthesia, carries a risk of uterine perforation. Multiple cross-sectional images on CT and MRI are useful for diagnosing IUD migration into the uterine myometrium.

　We report a case of vaginal cancer that developed 1 year after total laparoscopic hysterectomy (TLH) and reconstruction of the anterior vaginal wall (RAVW) for pelvic organ prolapse (POP) and cervical intraepithelial neoplasia 3 (CIN3). A 56-year-old woman had received pessary treatment for POP since the age of 46. Cervical dysplasia was suspected at the age of 51, and the woman was followed up every 4-6 months. The dysplasia progressed to CIN3, and TLH and RAVW were therefore performed after conization ruled out invasive cancer. A uterine manipulator was used for hysterectomy. Pathological examination confirmed the diagnosis of CIN3. The patient skipped her follow-up visit at 6 months, and returned to us due to persistent vaginal bleeding at 1 year. A 3-cm-diameter tumor was found in the anterior vaginal wall. Squamous cell carcinoma was detected by biopsy, and pelvic lymph node metastases were suspected on the basis of MRI. Concurrent chemoradiotherapy was planned as treatment. A multicenter clinical trial of cervical cancer compared radical hysterectomy (RH) via minimally invasive surgery (MIS) vs. an abdominal approach, and showed that MIS was associated with a higher rate of local recurrence. This may have been because MIS caused tumor spillage due to the use of a uterine manipulator, and increased tumor-cell growth or spread resulting from CO₂ insufflation. Although the patient in the present case had CIN3, we hypothesize that chronic inflammation due to pessary treatment and surgical intervention for RAVW may also have enhanced carcinogenesis.

Recurrence of uterine cancer peaks at 3 years after treatment, and most cases occur within 5 years. Late recurrence exceeding 10 years is rare, but there have been a few reports of such cases, most of which were isolated recurrences for which surgical resection was chosen. Here, we describe a case in which para-aortic lymphadenectomy was performed with retroperitoneal laparoscopy to confirm a diagnosis of recurrence or metastasis in a para-aortic lymph node 15 years after treatment for uterine cancer. The patient was a 71-year-old woman who had undergone simple abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection for Grade 1 endometrial carcinoma of the uterus, and had received total pelvic irradiation as adjuvant therapy for a diagnosis of Stage IC (FIGO 1988) (pT1cN0M0). A routine examination 15 years after treatment indicated an elevated CA125 level (36.9 mg/dl), and PET-CT showed accumulation in the para-aortic lymph nodes, which led to suspicion of uterine cancer recurrence and referral to our department. Retroperitoneal laparoscopic para-aortic lymphadenectomy was performed for histological diagnosis and complete resection, and histopathological examination revealed recurrence of previous uterine cancer. This case shows that retroperitoneal laparoscopic observation and biopsy are useful as a minimally invasive approach for enlarged para-aortic lymph nodes in patients with suspected late recurrence of uterine cancer.

　We report the case of a patient with port site hernia that developed after robot-assisted sacrocolpopexy and eventually led to a uterine cervical abscess, which was treated conservatively without removing the mesh. With the chief complaint of dysuria, the 73-year-old female patient with a history of two vaginal deliveries underwent robotassisted sacrocolpopexy. At day 4 postoperatively, the patient vomited, and emergency computed tomography revealed incarceration of the intestinal tract in the left lower abdomen, which was diagnosed as port site hernia. On the 13^th postoperative day, purulent drainage was found in the vagina, and a left uterine cervical interstitial abscess was diagnosed using magnetic resonance imaging. Transcervical drainage and daily local irrigation with intravenous antibiotics were performed. The patient was discharged without mesh removal. Various complications have been reported after robot-assisted sacrocolpopexy, but this is the first report of uterine cervical abscess.

　Cervical pregnancy is rare (incidence of 1 in 10,000 pregnancies). Uterine artery embolization (UAE), local or systemic methotrexate (MTX) therapy, hysteroscopic surgery, and total hysterectomy are known therapeutic approaches for management of this condition; however, a standard treatment strategy remains unavailable. Cervical pregnancy is therapeutically challenging owing to the high risk of massive bleeding. We report a case of cervical pregnancy accompanied by a fetal heartbeat in a woman with a serum human chorionic gonadotropin (hCG) level as high as 41,033 mIU/mL. Considering the abundant blood flow around the gestational sac, the patient was at a high risk of bleeding and highly resistant to treatment; therefore, she underwent UAE followed by local administration of MTX into the gestational sac. Although the fetal heartbeat disappeared following this treatment, the patient’s blood hCG level on postoperative day 6 remained high at 28,776 mIU/mL; therefore, she was administered systemic MTX. Her blood hCG levels decreased after two doses of systemic MTX; however, pregnant tissue was not spontaneously cleared even after >50 days. Transvaginal ultrasonography showed a gestational sac in the cervix with arterial blood flow around it. Therefore, pregnant tissue was removed hysteroscopically. We report a case of in vitro fertilization and embryo transfer followed by full-term delivery 10 months after hysteroscopic surgery.

　Pedicle torsion of the ovaries is more commonly seen in children but is rare in menstruating women. We present a case of recurrent non-neoplastic adnexal torsion in a reproductive-age woman. An 18-year-old woman experienced sudden abdominal pain and was admitted to our emergency department. Magnetic resonance imaging revealed that her left ovary was swollen to 60 mm and had become twisted, and that several small cysts were present beneath the ovarian capsule; however, no malignancy was detected. The blood supply to the left ovary was still intact, and the patient was discharged after 1 day upon symptom improvement.

　After 4 years, the patient was referred to our department due to rapidly worsening left lower quadrant pain. Transvaginal ultrasonography showed an enlarged stroma of the left ovary with multiple small cysts under the ovarian capsule. Computed tomography revealed that the left ovary was swollen to 48 mm and twisted with a weak enhancement effect, while the right ovary was polycystic. The patient underwent emergency laparoscopic detorsion, and her postoperative course was uneventful. Oral low-dose combined estrogen-progestin was used to alleviate dysmenorrhea symptoms. A follow-up at 12 months postoperatively revealed bilateral polycystic ovaries, but no abdominal symptoms. However, after 18 days, she visited the emergency department again with persistent abdominal pain. The diagnosis of left adnexal torsion and massive ovarian edema was confirmed, as in the previous case. She underwent laparoscopic detorsion and left ovarian fixation. Non-neoplastic adnexal torsion is mostly recurrent; hence, careful follow-up is important even after detorsion.

Introduction: Blood transfusion may be required due to massive bleeding in patients with ectopic pregnancy, though allogeneic blood transfusion can be complicated by infection. Furthermore, Rh(D) antigen-negative blood is not always available. This report presents a patient who was Rh(D) antigen-negative with suspected ectopic pregnancy who underwent laparoscopic surgery with autologous blood transfusion. She was ultimately diagnosed with ovarian hemorrhage.

Case: A 29-year-old gravida 1 para 0 woman presented six weeks and zero days after her last menstrual period with lower abdominal pain. She was transferred to our hospital with suspected ectopic pregnancy and received four units of Rh(D) antigen-negative red blood cells. No additional allogeneic blood was available for transfusion; therefore collected autologous blood was used for intra-operative transfusion during an exploratory laparoscopic surgery. Surgery revealed bleeding from the right ovary. A right partial oophorectomy was performed, though no chorion could be confirmed. The operation lasted two hours and nine minutes. The estimated blood loss was 2,531 mL. The postoperative hemoglobin was 7.2 g/dL, and 1,100 ml of collected autologous blood was transfused. The final diagnosis was right ovarian hemorrhage.

Discussion: Autologous blood transfusion can be conducted when allogeneic blood is difficult to secure.

Introduction: Gynecological surgery of patients with severe motor and intellectual disabilities (SMID) carry specific risks associated with the difficulties in gynecological examination, the presenting symptoms, and the demands of adapting to the inpatient environment. We report on a SMID patient who underwent a total laparoscopic hysterectomy (TLH) after information pertaining to her condition was shared between the multidisciplinary team and the resident facility staff.

Case: Our patient was a 45-year-old nulliparous female with SMID. She was unable to walk and communicate; and had been institutionalized since childhood. She had undergone abdominal bilateral adnexectomy for primary ovarian cancer two years prior at our department. Postoperative restlessness persisted, and the perioperative management posed difficulty. Abnormal vaginal bleeding was observed during the postoperative follow-up of ovarian cancer, an endometrium biopsy under intravenous anesthesia confirmed the diagnosis of endometrial cancer. A TLH was planned as a curative surgery, because of the challenges associated with the requirements of gynecological procedures and institutional care. Surgery was performed after patient information was shared between the multidisciplinary team and the resident facility staff. Surgical time was 131 minutes, with minor hemorrhaging. During the surgery, development of the retroperitoneal space was minimized, and the vaginal pipe was inserted carefully with attention to the narrow vaginal wall. Although, lacerations of the hymen ring and perineum occurred during the vaginal retrieval of the uterus, requiring suture repair; she did not become restless and was discharged as scheduled.

Conclusion: During laparoscopic surgery for a SMID patient, use of a surgical method that reduces postoperative pain and multidisciplinary collaboration are necessary.

　A unicornuate uterus with a rudimentary horn is an uncommon anomaly that affects 0.1% of all women. Here, we present the case of a 29-year-old woman who underwent laparoscopic surgery for a rudimentary uterine horn.

　At 28 years of age, she became pregnant with her first child. The pregnancy resulted in intrauterine fetal death at 23 weeks of gestation.Initially, a uterine malformation was not diagnosed, but no apparent connection was observed between the uterus and vagina, leading to a suspicion of noncommunicating rudimentary horn pregnancy. She underwent a cesarean section because vaginal delivery was deemed impossible.

　Postoperatively, the dysmenorrhea worsened. Magnetic resonance imaging (MRI) revealed a cesarean scar defect and a retained hematoma in the fallopian tube. She was referred to our hospital six months after her cesarean section. Laparoscopic resection of the rudimentary horn was performed to ease her symptoms and increase her chances of future pregnancy. No apparent connections were observed between the contralateral horns. Her dysmenorrhea subsided after the laparoscopic surgery. An MRI performed two months after surgery revealed no rudimentary horn resection scar defects. She conceived spontaneously 16 months after the laparoscopic surgery and delivered via cesarean section. When a cesarean section is performed for a rudimentary horn pregnancy, early removal of the rudimentary horn is desirable to prevent recurrence. During the waiting period or when the rudimentary horn is preserved, postoperative dysmenorrhea may occur. The evaluation of surgical scarring using MRI after rudimentary horn resection is useful for managing patients who wish to conceive.

　Cases of ectopic pregnancies in the ipsilateral fallopian tube after salpingectomy are rare. This report presents a unique case of an ectopic twin pregnancy that occurred in the residual isthmus of the ipsilateral fallopian tube after a prior salpingectomy for an ampullary tubal pregnancy. This case led to a live birth following a second ectopic pregnancy surgery.

　A 39-year-old woman underwent laparoscopic salpingectomy due to a right ampullary tubal pregnancy at 36 years of age. She had previously undergone a frozen embryo transfer at the age of 38. At 5 weeks and 6 days of gestation, the absence of a gestational sac within the uterus and the detection of one gestational sac and two yolk sacs near the right adnexal area raised suspicions of an ectopic twin pregnancy. Initial imaging studies were inconclusive regarding the precise site of pregnancy, necessitating additional diagnostic examinations and hospitalization. On the third day of hospitalization, the suspected site had expanded, and further examinations confirmed the presence of an ectopic twin pregnancy in the residual tubal isthmus of the right fallopian tube. The ectopic pregnancy was successfully excised during a second laparoscopic surgery. Subsequently, the patient underwent a frozen embryo transfer. The pregnancy progressed without complications, resulting in the delivery of a 2,790 g infant by cesarean section. Careful patient management is crucial, given the potential for ectopic pregnancies in the ipsilateral fallopian tube following salpingectomy. Moreover, adding tubal interstitial sutures during salpingectomy may prevent ipsilateral residual tubal pregnancy.

Introduction: Hemoperitoneum due to spontaneous bleeding of uterine leiomyoma, is rare and is difficult to diagnose preoperatively. Additionally, there are few reports of laparoscopic treatment. Here, we report two patients with hemoperitoneum due to spontaneous bleeding of uterine leiomyoma who underwent successful laparoscopic surgery.

Case 1: A 31-year-old nulliparous woman with dizziness and abdominal pain was brought to the emergency department. Abdominal imaging revealed intra-abdominal masses and ascites. Emergency laparoscopic surgery identified bleeding from a subserosal uterine leiomyoma. The patient was successfully treated with laparoscopic myomectomy.

Case 2: A 43-year-old nulliparous woman visited a local doctor for abdominal pain. A few hours later, the patient developed hemorrhagic shock and was transported to our emergency room. Abdominal imaging revealed uterine fibroids and intraperitoneal bleeding. Emergency laparoscopic surgery identified spontaneous bleeding from a subserosal uterine leiomyoma, and laparoscopic uterine myomectomy was performed.

Conclusion: Although rare, spontaneous bleeding due to uterine fibroids can cause hemorrhagic shock, which is a lifethreatening condition. Since it is difficult to preoperatively diagnose hemoperitoneum secondary to bleeding of uterine leiomyoma, laparoscopic surgery is useful for its diagnosis and treatment if the patient is in stable condition.

Objective: Diagnosing lower abdominal pain in early pregnancy is often difficult due to the dangers of radiation exposure associated with diagnostic imaging. Here we report a case in which lower abdominal pain of unknown etiology in the first trimester of pregnancy was relieved by laparoscopy after removal of adhesions around the uterus and uterine adnexa.

Case: A 28-year-old woman underwent laparoscopic enucleation of a left ovarian tumor at age 25. She presented to our department with labor-like lower abdominal pain at 6 weeks and 2 days after her last menstrual period. Since there were no abnormal findings, she was followed up by observation. However, the pain gradually increased and she was admitted to our department for pain management and to investigate the cause. Blood tests showed elevated β-human chorionic gonadotrophin levels, but there was no fetal sac in the uterus; thus, miscarriage and ectopic pregnancy were considered. At 7 weeks and 2 days after the last menstrual period, a fetal sac was found in the uterus. On the same day, we performed laparoscopy to determine the cause of the abdominal pain. Adhesions around the uterine adnexa were found and removed. The patient’s lower abdominal pain disappeared postoperatively.

Conclusion: Laparoscopy may be an option for diagnosing patients in early pregnancy who have lower abdominal pain of unknown etiology.

　There are a variety of uterine malformations, but those with a closed cavity that present with severe dysmenorrhea require emergency opening of the cavity or removal of the isolated chamber. If misdiagnosed as functional dysmenorrhea, the condition can worsen and cause future pelvic endometriosis and infertility; however, children who have never had sexual intercourse are difficult to diagnose and treat because of the difficulty of outpatient transvaginal observation. There are no established methods for the diagnosis or treatment of uterine malformations in children, but there are scattered case reports of diagnostic treatment using morphological evaluation with MRI, and of transvaginal examination using a hysteroscope. The usefulness of upper gastrointestinal endoscopy has been reported in gynecology, but there are no reports of its application in pediatric uterovaginal lesions. We performed upper gastrointestinal endoscopy in two cases of pediatric uterine malformations.

　This procedure is excellent for vaginal observation because the upper gastrointestinal endoscope has very high resolution, its external diameter matches that of the vaginal inlet of the child, and the water-sealing maneuver maintains adequate water pressure. By contrast, hysteroscopic resectoscopy is superior to transvaginal incision manipulation. For intravaginal evaluation, laparoscopy should be used in combination with transvaginal manipulation if the diagnosis and treatment are difficult. All endoscopic devices are expected to be appropriate for the treatment of pediatric uterine malformations.

　Because bicornuate uterus is relatively rare, most obstetricians and gynecologists have minimal experience with this condition. In some cases, the rectovesical (RV) ligament, which is attached anteriorly to the bladder, is detected passing over and between the hemi-uteri and continuing posteriorly to the serosa of the sigmoid or rectum. Here we report a case in which bicornuate uterus with the RV ligament was safely treated by total laparoscopic hysterectomy (TLH).

Case: A 49-year-old woman, gravida 1 para 1, with a complete bicornuate uterus, underwent TLH because of endometrial hyperplasia without atypia or adenomyosis. Enhanced abdominal computed tomography before the operation showed no congenital anomalies of the urinary system. Laparoscopy identified the RV ligament attached anteriorly to the bladder between the hemi-uteri and posteriorly to the serosa of the sigmoid. The peritoneum of the vesicouterine pouch of the hemi-uteri was cut, and saline was then injected into the bladder and the RV ligament was resected. TLH was concluded without injury to the bladder or rectum.

Conclusion: Previous studies reported frequent detection of the RV ligament in cases of bicornuate uterus without renal agenesis. Safe TLH is possible if the RV ligament is resected with care taken to protect the bladder and rectum.

　No effective treatment for cervical pregnancy has been established thus far. Here we report successfully treating a patient with cervical pregnancy using a hysteroscopic approach with laparoscopic uterine artery clipping (LUAC). A 38-year-old woman, gravida 2, parity 1, presented with painless vaginal bleeding and was diagnosed with cervical ectopic pregnancy. As she had a desire for fertility preservation, a hysteroscopic approach with LUAC was used. The surgical procedure was performed by laparoscopically clipping the bilateral uterine arteries with a vascular clip, removing the gestational sac in the uterine cervix using a hysteroscopic approach, and finally unclipping the bilateral uterine arteries, all without active bleeding. The patient progressed favorably after the surgery, without any complications such as massive rebleeding or retention of the gestational sac. Natural menstruation reoccurred on postoperative day 23, and the human chorionic gonadotropin level was negative on day 32. Five months after the operation, she conceived naturally and delivered at full term. This case indicates that LUAC and hysteroscopic resection are a highly effective combination for treating cervical pregnancy while preserving fertility.

Introduction: Ovarian tissue cryopreservation is a fertility-preserving technique for young women whose ovarian reserve is expected to be greatly reduced by cancer treatment. It may be achieved via oophorectomy, which for this purpose is generally performed by single- or multi-port laparoscopic surgery. In our hospital, ovarian cystectomy is performed by low-position single-incision laparoscopic surgery (L-SILS) with Higuchi’s transverse incision. We report two cases in which oophorectomy for ovarian tissue cryopreservation was performed with L-SILS.

Method: Higuchi’s transverse incision is made at a lower position than Pfannenstiel transverse incision, and is superior in terms of cosmetic outcomes. It involves a T-shaped incision made in the rectus abdominis sheath for the purpose of avoiding bladder injury and securing the surgical field. Single-port L-SILS with Higuchi’s transverse incision was performed with a 2–3 cm skin incision to achieve unilateral oophorectomy for ovarian tissue cryopreservation.

Cases: Case 1 was a 39-year-old breast cancer patient who requested embryo and ovarian tissue cryopreservation. Right oophorectomy was performed with L-SILS, and 22 ovarian tissue pieces were frozen. Case 2 was a 33-year-old breast cancer patient who requested ovarian tissue cryopreservation. Left oophorectomy was conducted with L-SILS, and 29 ovarian tissue pieces were frozen.

Discussion: L-SILS is minimally invasive, has excellent cosmesis, and can be performed straightforwardly for oophorectomy.

　Malignant peritoneal mesothelioma is a rare malignant tumor with poor prognosis that arises from mesothelial cells of the peritoneum. The diagnosis of this tumor is not always straightforward because of its resemblance to cancerous peritonitis, and histological examination is essential for a definitive diagnosis. A 75-year-old woman presented to her doctor with complaints of lower abdominal discomfort and weight loss. A contrast-enhanced thoracoabdominal CT scan showed pleural effusion, pleural dissemination, ascites, and peritoneal dissemination, and the patient was referred to our department. Since a contrast-enhanced pelvic MRI scan revealed no tumor in the uterus or bilateral adnexa, peritoneal cancer with cancerous pleuritis and peritonitis was suspected. Diagnostic laparoscopic surgery was performed and several peritoneal disseminated nodules were biopsied. Histopathological examination finally led to a diagnosis of biphasic malignant mesothelioma, and chemotherapy with pemetrexed and cisplatin was started on postoperative day 23. Regrettably, the tumor was refractory to chemotherapy and the patient died 6 months after the initial diagnosis.

Introduction: Although heterotopic pregnancies are extremely rare, their incidence has been rising in recent years with the increased use of assisted reproductive technologies. We experienced a case in which a live birth was achieved after single-site laparoscopic surgery for a heterotopic pregnancy.

Case: A 35-year-old woman, G1P0, became pregnant using clomiphene and timing therapy. At 7 weeks 2 days of pregnancy, she experienced genital bleeding and lower abdominal pain, and visited a hospital. A fetal heartbeat was detected, but a blood clot was found in the pelvis, and the woman was admitted to another hospital with a diagnosis of threatened miscarriage. At 8 weeks 2 days of pregnancy, she was referred to our hospital due to increasing lower abdominal pain and progressive anemia. Ovarian bleeding or heterotopic pregnancy was suspected on the basis of blood retention around the right adnexa and worsening anemia, and single-site laparoscopic surgery was performed. The presence of an enlarged right fallopian tube led to the diagnosis of heterotopic pregnancy. The woman’s postoperative course was good, and a baby boy weighing 2,926 g was born spontaneously at 40 weeks 0 days of pregnancy.

Conclusion: Heterotopic pregnancies are easily missed, and are difficult to diagnose and treat. Even if an intrauterine pregnancy is identified, the possibility of heterotopic pregnancy must be kept in mind, with single-site laparoscopic surgery as a potential treatment option.

　In general, acute abdominal pain due to ovarian endometrioma is strongly associated with ovarian cyst rupture, as a result of adhesions to tissues around the cyst, especially the broad ligament. Therefore, the choice between surgery or palliative treatment may be difficult. However, torsion of endometrioma can occur, especially among adolescent females with weak adhesions, and palliative treatment in such situations can impair ovarian function.

　Here, we describe a case in which torsion of ovarian endometrioma developed in an adolescent female, and we discuss the relevant literature. A 17-year-old female presented with severe abdominal pain. We previously demonstrated that she had a left ovarian endometrioma with a diameter of 7 cm, and planned laparoscopic surgery after magnetic resonance imaging evaluation. At that time, the area of her pain was consistent with left ovarian endometrioma, and its diameter subsequently increased to 10 cm. We diagnosed ruptured endometrioma, and performed emergency laparoscopic surgery. The left ovarian endometrioma with mild adhesions to the broad ligament was found to be twisted 180° counterclockwise around the axis of the point of adhesion and the tubal ligament. Postoperatively, the patient’s pain was relieved, and she is now receiving a prophylactic course of low-dose oral contraceptive medication.

　In this case, we performed surgery due to the patient’s severe abdominal pain, and if we had not, her left ovarian function would have been impaired. Torsion of endometrioma should be considered in the differential diagnosis of acute abdominal pain in adolescent females.

　We report a case of pyogenic spondylitis due to postoperative mesh infection. The patient was a 59-year-old woman, gravida 3, para 2, who experienced menopause at age 50. Robotic-assisted sacrocolpopexy (RSC) was performed to diagnose pelvic organ prolapse classified as Stage 3 on the Pelvic Organ Quantification System. The removed uterus and fallopian tubes were collected in a bag and retrieved from the posterior vaginal canal. A 3-cm-wide mesh was then fixed to the anterior vaginal wall and the remaining cervix was secured to the sacral anterior longitudinal ligament with Ethibond®. The patient’s posterior vaginal fornix was continuously sutured with No. 1 Vicryl®. On postoperative days 19 and 24, bleeding occurred from the posterior vaginal fornix, and hemostasis was achieved by suturing. On postoperative day 40, the patient visited our hospital due to difficulty standing. She was diagnosed with pyogenic spondylitis by plain lumbar CT and MRI. After admission, she was treated with antibiotics. She developed severe numbness and pain in both lower limbs, and therefore laparoscopic mesh removal and abscess drainage were performed. Mesh removal was conducted from the cape angle to the sacral uterine ligament. The patient was discharged on postoperative day 53. If low back pain or neurological symptoms are observed after RSC, it is important to consider the possibility of pyogenic spondylitis and to evaluate radiological images accordingly. If pyogenic spondylitis is diagnosed, antibiotic treatment is required and mesh removal should be considered. Particular attention should be paid to infection when transvaginal procedures are performed during and after RSC.

　Laparoscopic surgery allows for visualization of the entire abdominal cavity, in addition to the pelvic area. Therefore, we rarely identify abnormalities of the upper abdomen. We report a case in which a swollen gallbladder discovered during laparoscopy led to the diagnosis of cholangiocarcinoma.

　A 58-year-old patient (gravida 5, para 2) presented to our outpatient department with lower abdominal pain. She was diagnosed with degenerating uterine myoma on MRI. Although she was already menopausal, both ovaries were conserved. She wished for a complete cure; thus, we decided to perform total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. During the operation, we incidentally detected gallbladder swelling. There were no signs of tumor dissemination. Postoperatively, blood tests revealed abnormal hepatic function, and therefore CT was performed to examine the area around the liver. The findings raised the suspicion of cholangiocarcinoma or pancreatic head cancer. Liver biopsy led to the histological diagnosis of adenocarcinoma, but did not confirm the identity of the primary tumor. On the basis of the results of CT, endoscopic retrograde cholangiopancreatography, and liver biopsy, the patient was diagnosed with cholangiocarcinoma. Anticancer treatment was administered.

　Ventriculoperitoneal shunt (VPS) implantation is a surgical treatment for hydrocephalus. Laparoscopic surgery for VPS implantation is associated with the risk of shunt dysfunction due to increased intra-abdominal pressure, intracranial pressure, and infection. Therefore, patients with VPS implantation should be managed carefully during the perioperative period.

　A 43-year-old woman presented with hypermenorrhea. She had undergone VPS implantation for hydrocephalus due to meningitis when she was 1 month old. Further investigation with computed tomography (CT) and ultrasonography led to a diagnosis of adenomyosis. The patient preferred hysterectomy over medical treatment. Thus, in collaboration with neurosurgeons, we performed total laparoscopic hysterectomy.

　To avoid damaging the VPS, we examined the VPS route by CT. Because the shunt did not have a backflow prevention valve, we clamped the bilateral shunts before CO₂ insufflation and placed the patient in the Trendelenburg position. Finally, we cut off the tips of the shunt to release the clamp and confirmed the presence of cerebral fluid from the shunt tips. The operation was performed without complications.

　There is no consensus regarding the conditions of laparoscopic surgery for patients with VPS, for example, CO₂ insufflation pressure, clamping, and patient body position. Because most recent VPSs contain shunt valves, it is important to consider the operative procedures for each case in cooperation with neurosurgeons.

　Pelvic organ prolapse (POP) is a common gynecological disease in adult women. It is characterized by vaginal bulging and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, all of which may impair quality of life. There are various treatments for POP, including conservative approaches and surgical procedures. Transvaginal mesh (TVM) surgery for POP repair has been associated with various complications, such as mesh exposure, chronic pelvic pain, and dyspareunia. After a U.S. Food and Drug Administration (FDA) alert in 2011, we began paying more attention to native tissue repair, laparoscopic sacrocolpopexy, and other related issues.

　We report a case of recurrent vaginal prolapse after TVM surgery, with successful treatment by laparoscopic uterosacral ligament suspension (LUSLS). The patient was a 72-year-old woman who had undergone TVM surgery at 64 years of age. She noticed POP recurrence with vaginal mesh exposure and dyspareunia 3 years after TVM surgery. She visited our hospital at 72 years old. She underwent LUSLS and has had no subsequent recurrence of POP. LUSLS is a safe and effective surgical procedure for POP repair, even in cases of recurrent POP following TVM surgery.

Background: Ovarian torsion may rarely occur after ovary-sparing total laparoscopic hysterectomy. In recent years, the number of cases of robot-assisted total hysterectomy has gradually increased, but there have been no reported cases of ovarian torsion after this procedure. Here, we report a case of right ovarian torsion after robot-assisted total hysterectomy.

Case: A 46-year-old woman with multiple myoma uteri underwent robot-assisted total hysterectomy. One year later, she developed right lower abdominal pain, then visited our hospital, where we suspected right ovarian torsion. Since her pain did not diminish, she underwent laparoscopic surgery. Her right ovary was enlarged to 6 cm in diameter, with ovarian torsion, and laparoscopic right oophorectomy was performed.

Conclusion: Postoperative ovarian torsion is more frequent with total laparoscopic hysterectomy than with open or vaginal hysterectomy. Reasons for this include increased ovarian mobility due to excessive incision of the broad membrane with the lateral approach and fewer postoperative adhesions. To prevent ovarian torsion, it is important to use a posterior approach and to perform ovarian fixation if needed. In addition, it is recommended to consider the possibility of ovarian torsion when patients have abdominal pain after hysterectomy.