Purpose: In 2004, the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy established a certification system for gynecologists of endoscopy (hysteroscopy). This year marks the 20th anniversary of the certification system. By analyzing the results of the hysteroscopy video evaluations for 2023, this study aimed to clarify important considerations for applicants and identify the types of surgical cases selected for submission in the evaluation videos.

Methods: The scoring rates for each item were examined based on the evaluation of 33 cases for which video assessment was performed using the 2021 technical certification scores for video screening. Additionally, factors such as the maximum diameter, weight, and protrusion rate of myomas, which are surgical indications, as well as operation time and irrigation fluid balance, were analyzed.

Results: The 2023 final passing rate of qualified gynecologists of endoscopy (hysteroscopy) was 63.6％. In the successful candidate group, the scoring rate for each sub-item was above 60％ for all items. In contrast, in the unsuccessful candidate group, the scoring rate was below 60％ for 10 out of 17 items and was as low as 20％ for two items. Regarding the relationship among the protrusion rate, maximum myoma diameter, and success rate, the success rate was 60％ (6/10) in the easiest group (protrusion rate of ≥70％ and maximum diameter of <2.47 cm) and 85.7％ (6/7) in the most difficult group (protrusion rate of <70％ and maximum diameter of ≥2.47 cm). The intergroup difference was not significant (p=0.252). The difference in the irrigation fluid balance tended to increase with longer operation times. In all cases in which hypotonic solutions were used, the difference was ≤500 ml, while in cases in which normal saline was used, six cases showed a difference of >500 ml.

Conclusion: To become a qualified gynecologist of endoscopy (hysteroscopy), it is crucial to ensure a clear and safe surgical field and perform incision and dissection in the correct anatomical layer without causing unnecessary damage to the normal mucosa.

　GelPOINT V-Path (Applied Medical Japan, Tokyo) was released in Japan in April 2021. It is used for Vaginally Assisted NOTES Hysterectomy (VANH) employing vaginal NOTES (vNOTES), and has become popular in the past few years. VANH is expected to be applied not only to uterine fibroids but also to various other gynecological diseases. Because in some surgical procedures, it is difficult to accomplish VANH only using a complete transvaginal technique, situation. VANH was performed for (1) uterine fibroids or adenomyosis, (2) sex reassignment surgery for transgender men (TM), and (3) pelvic organ prolapse (POP) complicated by uterine fibroids or ovarian cysts. This treatment for POP is based on a combination with total colpocleisis and is aimed at elderly patients who do not wish to preserve their sexual function. This hybrid VANH method has the advantage that the light of endoscope from an umbilical port can serve as a guide even in cases in which it is difficult to open the bladder uterine fossa because of a narrow vagina. Especially in cases of TM or nulliparous uterine fibroids, we adopted this hybrid method from the beginning of operation. However, in some POP cases in which the uterus was descending, we employed an umbilical port during surgery. This is because these patients had larger uterine fibroids, which made it difficult to open the bladder uterine fossa. It was noted that using an umbilical port can extend the range of application of VANH according to the situation.

　Rupture of mature ovarian cystic teratoma is often secondary to surgical procedures such as laparoscopic ovarian cystectomy, resulting in chemical peritonitis. We use a method of placing a bag under the tumor during laparoscopic ovarian cystectomy (In-Bag method) to prevent chemical peritonitis in our hospital. We retrospectively reviewed laparoscopic ovarian cystectomy performed in our hospital from 2020 to 2023, divided into an In-Bag method group and a Without In-Bag method group. No chemical peritonitis due to spillage of the cyst contents was observed．Compared to the Without In-Bag group, the In-Bag group had significantly shorter operative time (83 minutes vs. 88 minutes) and significantly lower C-reactive protein levels (0.5 mg/dL vs. 0.8 mg/dL). These results suggest that incorporation of the In-Bag method was associated with improved surgical outcomes.

Background: Since 2015, our hospital has been performing robot-assisted laparoscopic para-aortic lymphadenectomy for stage IA endometrial adenocarcinoma G3 and highly malignant histological types, as well as stages IB and II. In this study, we compared safety of robot-assisted surgery with laparoscopic and open surgery.

Methods: We retrospectively reviewed 49 cases of patients who underwent para-aortic lymphadenectomy for endometrial cancer between April 2016 and March 2024.

Results: For robot-assisted surgery, laparoscopic surgery, and open surgery, respectively, the median age and BMI were 56 years (range 43-69 years) and 21.8 (range 17.8-32.7), 54 years (range 28-68 years) and 22.9 (range 14.5-32.1), and 58 years (range 34-72 years) and 21.7 (range 15.3-24.6); the median operative time, blood loss, and number of lymph nodes removed were 264 minutes (range 213-326 minutes), 10 mL (range 10-50 mL), and 40 nodes (range 18-76 nodes), 297 minutes (range 288-366 minutes), 96 mL (range 10-400 mL), and 46 nodes (range 23-76 nodes), and 229 minutes (range 123-454 minutes), 833.5 mL (range 256-2,367 mL), and 34 nodes (range 11-54 nodes); the postoperative hospital stay was 4 days (range 3-7 days), 4 days, and 7 days (range 5-18 days). Intraoperative complications occurred in 1 case of laparoscopic surgery, while postoperative complications were seen in 5 cases of robot assisted surgery and 5 cases of open surgery.

Conclusion: Robot-assisted para-aortic lymphadenectomy for stage IA endometrial adenocarcinoma G3 and highly malignant histological types, as well as stages IB and II, appears to be a superior surgical technique in terms of surgical outcomes and safety compared to conventional methods.

　In recent years, Cesarean Scar Disorder (CSDi) has been gaining attention due to its association with niche formation in the uterine incision post-cesarean section, leading to symptoms such as prolonged menstruation, abnormal bleeding, and infertility. Although various treatment approaches have been reported, a standardized procedure remains elusive, with limited reports on fertility improvement post-treatment and pregnancy outcomes. This study aimed to report the treatment outcomes of hysteroscopy-assisted cesarean scar repair surgery, including postoperative pregnancy results. Specifically, we focused on identifying the extent of scar tissue removal during abdominal scar repair surgery and evaluate the technique's effectiveness at our institution. All 12 cases studied were infertile cases, and patients who had failed to conceive after undergoing fertility treatment were considered for surgery.

　Procedures included hysteroscopy-assisted laparotomy in seven cases and laparoscopic surgery in five cases. Scar tissue removal was guided by hysteroscopic observation, with needle punctures marking the scar edges. Excision ensured adequate thickness of proximal and distal scar ends. Bilateral ends were sutured with absorbable material. Postoperatively, pregnancy was achieved in 58.3％ of cases, with six resulting in successful births and one experiencing recurrent miscarriages.

　No uterine ruptures or cesarean section complications were observed. The present study indicated that CSDi repair contributed to improve fertility and the post-operative pregnancy outcome was excellent. This technique, in which a needle is inserted from the abdominal cavity under hysteroscopic observation to identify and resect the scar site, was considered a safe and effective procedure.

Objective: Heavy menstrual bleeding (HMB) is common in women of reproductive age, and can affect physical health and quality of life. Endometrial ablation (EA) has become one of the most commonly performed gynecologic procedures for HMB. However, leiomyoma with distorted uterine cavity affects efficacy, and especially in FIGO type 2 leiomyoma the surgery is not clearly defined. This study aimed to evaluate the long-term efficacy of EA combined with transcervical resection of uterine leiomyoma (TCRM) for HMB.

Design: A total of six women with HMB and distorted uterine cavities who failed medical treatment for FIGO type 2 leiomyoma underwent microwave endometrial ablation (MEA) combined with hysteroscopic myomectomy. Outcome measures were reintervention, hysterectomy, and complications followed for more than eight years.

Results: Backgrounds of cases were as follows: mean age 47.5±4 years (mean ± standard deviation), maximum diameter of fibroid 51±24 mm, protrusion degree of submucous fibroid 35±14％, uterine cavity length 87±17 mm. Finally, two of the six women undergoing MEA combined with TCRM required subsequent treatment. One had to undergo hysterectomy for dysuria after seven months without HMB, and the other had to take GnRHa for HMB continuously for seven months after initial treatment.

　Postoperative complications were one case of pelvic infection leading to cavity adhesion and amenorreha, and two cases of partial cavity adhesion. After microwave endometrial ablation with hysteroscopic resection, four patients went through menopause naturally 5.3±1 years after operation without additional treatment.

Conclusion: MEA combined with hysteroscopic myomectomy is effective for reducing heavy menstrual bleeding of FIGO type 2 leiomyoma. To reduce endometrial ablation failure and complications, further research is required to identify long-term prognostic factors and appropriate criteria for patient selection.

　To evaluate the safety and usefulness of robot-assisted surgery for obese patients, 172 patients who received robot-assisted total hysterectomy for benign and malignant uterine diseases at our hospital from September 2019 to March 2023 were enrolled in this study. The patients were divided into two groups: obesity and non-obesity. The obesity group was classified as those with body mass index (BMI) of 30 or more. We retrospectively examined the preparation time and that of the console setup, console time, total operation time from the start of surgery, blood loss, and frequency of perioperative complications.

　There were 27 patients in the obesity group and 145 in the non-obesity group. The median BMI was 34.4 (30.5-51.1) and 21.9 (15.5-29.7) for the obesity and non-obesity groups, respectively. There were no significant differences in patients' characteristics between the groups. The median preparation time was 20 (12-37) and 18 (7-60) min in the obesity and non-obesity groups, respectively. Total operative time and console time also did not differ significantly. The median blood loss was 10 (0-300) ml in the obese group and 10 (0-450) ml in the non-obese group, with no statistical difference. In comparisons to cases with malignant uterine diseases or benign uterine diseases, no significant difference was observed. There was also no difference in the weight of the excised uteruses. Complications of Clavien-Dindo classification 2 or higher were all with postoperative infection in the obesity group (3/145, 2.1％), and was significantly more common in the obesity group (3/27, 11.1％) than in the non-obesity group (p=0.01). Perioperative infection strategy is recommended for obese patients. Robot-assisted surgery for obese patients with a BMI of 30 or greater is probably a valuable procedure that can be performed as safely as in non-obese patients.

Objective: In 2014, laparoscopic surgery for early-stage endometrial cancer was covered by insurance, and the number of cases has increased at the affiliated institutions, with recurrent cases also being experienced. In this study, we examined cases of recurrence after laparoscopic endometrial cancer surgery.

Methods: Patient background, surgical outcomes, and prognosis were retrospectively reviewed for patients who underwent laparoscopic endometrial cancer surgery at affiliated institutions between May 2014 and December 2022. In addition, time to recurrence, site of recurrence, and tumor size of excised specimens were also examined.

Results: Four hundred patients were included in the study, with a median age of 54 years (29-85) and a median observation period of 47 months (12-119). The risk categories of postoperative recurrence were 312 (78.0%) in the low-risk group, 65 (16.3%) in the intermediate-risk group, and 23 (5.8%) in the high-risk group. There were 15 (3.3%) recurrences, with postoperative recurrence risk classified as 9 in the low-risk group, 5 in the intermediate-risk group, and 1 in the high-risk group. The median time to recurrence was 29 months (17-37) in the intermediate and high-risk groups and 40 months (18-71) in the low-risk group (p=0.08). In the low-risk group, there were cases of recurrence more than five years after surgery, and peritoneal dissemination recurrence. Sealing of the fallopian tubes and in-bag collection were performed in all recurrent cases, but uterine manipulators were used.

Conclusion: Although no characteristic recurrence patterns were observed in laparoscopic surgery for endometrial cancer, long-term follow-up was considered necessary in the low-risk.

　The revised 2023 guidelines for endometrial cancer treatment recommend avoiding lymphadenectomy in early-stage cases (evidence level C). However, some patients initially diagnosed with early-stage cancer are later classified as intermediate or high risk after surgery and pathological evaluation. While pelvic lymphadenectomy remains critical for pathological assessment, its necessity and extent should be tailored to each patient based on therapeutic relevance.

　This retrospective review analyzed 141 minimally invasive surgeries performed between July 2017 and March 2023 to evaluate the appropriateness of lymphadenectomy. Surgical approaches included laparoscopic or robot-assisted hysterectomy, with four lymphadenectomy options (omission, biopsy, limited, or complete pelvic dissection) selected based on patient-specific factors such as comorbidities and quality of life. Intraoperative findings, and preoperative assessments, including MRI and the Mayo Criteria, proved essential in determining the scope of lymphadenectomy.

　An age-adjusted multivariate analysis identified “more than half myometrial invasion” and “positive peritoneal cytology” as significant predictors of lymphovascular space invasion, highlighting their importance in planning lymphadenectomy. Recent studies have suggested that robot-assisted surgery may result in longer operative times and poorer long-term outcomes than laparoscopic surgery. Regular evaluation of surgical outcomes and clinical courses is essential to ensure optimal pathological assessment. Revisiting and refining the necessity and appropriateness of lymphadenectomy is crucial for achieving precise and effective treatment strategies.

Objective: Ovarian torsion is an acute gynecological disease that causes acute abdominal symptoms. We retrospectively reviewed 87 cases of patients diagnosed with ovarian torsion in which surgery was performed in our hospital between January 2017 and December 2023.

Methods: The following parameters were examined: age, left or right occurrence, abdominal or laparoscopic surgery, maximum tumor diameter, time from onset to surgery, preoperative WBC count, preoperative CRP value, presence or absence of macroscopic ischemic findings indicated by color changes on the ovarian surface during surgery, histopathological diagnosis, and presence or absence of pathological necrosis.

Results: There was a tendency for the preoperative WBC count to be higher with a higher incidence of necrosis. The group with a preoperative CRP value of 0.3 mg/dl or higher had higher incidence of necrosis than the group with a preoperative CRP value of less than 0.3 mg/dl (p value = 0.00038). Cases in which time from onset to surgery was more than 24 hours tended to have a higher rate of necrosis. When fresh bleeding was observed from the normal ovary during surgery, there was a high possibility that the functional ovary remained. Conclusion: The results suggested that the time from onset to surgery, preoperative WBC, and preoperative CRP value may be useful factors indicative of necrosis. We believe that for young patients and patients who wish to preserve their ovaries, there is a great benefit to attempting ovarian-conserving surgery.

　Recently, there have been case reports of ovarian torsion occurring after total laparoscopic hysterectomy (TLH). At our institution, TLH is performed using a lateral approach, which results in a wide opening of the retroperitoneum, increasing ovarian mobility. Increased ovarian mobility may elevate the risk of postoperative ovarian torsion, and although methods for preventing torsion are needed, there is limited evidence supporting preventive measures. In our practice, we perform ovarian fixation to the retroperitoneum using a sealing device during surgery, and here we report the results of this fixation method. Ovarian fixation is achieved by coagulating the ovarian ligament to the retroperitoneum using an Erbe BiClamp® (bipolar coagulation forceps), typically employed for hemostasis during surgery. Between April and July 2024, 12 cases of ovarian fixation were performed during TLH using a BiClamp, and 10 of the 12 cases (83%) demonstrated visible ovaries on follow-up ultrasound post-surgery. Two cases showed successful fixation, with consistent ovarian observation at both immediate postoperative and follow-up transvaginal ultrasound three months later. The fixation is thus considered to persist reliably over time. Successful fixation requires collaboration with the assistant to grasp the ovarian ligament and retroperitoneum, coagulating multiple sites. Care must be taken to avoid thermal damage to blood vessels or the ovaries by elevating the tissue and coagulating the membrane only. No patients in this study reported ovarian loss symptoms postoperatively. The fixation technique we employed is simple, cost-effective, and may contribute to preventing torsion.

Objective: To evaluate the surgical outcomes and safety of robot-assisted hysterectomy during the first five years of its practice, we investigated the details and perioperative complications.

Methods: We retrospectively analyzed the cases of robot-assisted hysterectomy performed from March 2018 to March 2023.

Results: We extracted 128 cases (102 benign diseases, 26 malignancies). Based on a cumulative sum analysis of the operation duration, one surgeon exhibited a bimodal pattern with peaks at the 8th and 47th cases, while another showed a peak at the 24th case. The resurgence in the bimodal pattern between the 24th and 25th cases coincided with a six-month period of surgical restrictions. Although the uterus weight tended to increase, blood loss decreased after the 25th case. There was one (0.8%) intraoperative complication, of bladder wall injury during transvaginal uterine morcellation. Eight cases (6.3%) with fibroids and/or adenomyosis had blood loss of 500 mL or more. Their median uterus weight was 494 g, approximately twice that of all benign cases. Postoperative complications occurred in five cases (3.9%): two pelvic infections, one wound infection, and two incidents of vaginal cuff dehiscence. Patients had risk factors such as sexual intercourse, 11th case, and history of chemotherapy in cases of dehiscence.

Conclusions: Robot-assisted hysterectomy has been performed safely for the first five years. The interval between surgeries influenced the operation duration. Although cases with higher uterus weight tended to have higher blood loss, this relative incidence is expected to decrease with an increasing number of cases. It is necessary to assess risks on individual cases to reduce perioperative complications.

　This report describes our experience using ENDOCAMELEON in Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). vNOTES, introduced in Japan in 2020 with the GelPOINT V-Path, has rapidly gained popularity due to its minimal invasiveness and aesthetic benefits. However, the procedure presents challenges, particularly in securing a clear operative field and avoiding interference with instruments. ENDOCAMELEON, which allows flexible viewing angles between 0° and 90°, was used in five cases performed between August and October 2024. The system proved effective in securing a clear view during surgery. We found it particularly useful in overcoming the difficulties of single-port surgery, improving the surgical field visibility without requiring additional working space. Further investigation into optimal usage and more cases are necessary to validate its benefits.

Objective: This study identifies the non-technical skills required for robotic surgery and presents improvement efforts.

Methods: We analyzed 45 robotic surgeries performed with the Da Vinci Xi between January 1 and August 30, 2024. Surgical videos with recorded conversations between surgeons and assistants were analyzed to identify situations requiring non-technical skills and to determine the associated skills.

Result: Fifteen situations requiring non-technical skills were identified. These situations were categorized into five groups: surgeon-assistant collaboration, unexpected events, situations unknown to the surgeon, scenarios in which the surgeon is absent, and environmental factors. Related non-technical skills were identified as communication, leadership, situational awareness, decision-making, and stress.

Conclusion: Communication and situational awareness emerged as particularly critical non-technical skills in robotic surgery. Our three key innovations include recording surgical videos with conversations, employing the Tile Pro function, and conducting simulation training for emergency scenarios.

Objective: We retrospectively reviewed laparoscopic surgery cases at our institution to assess the efficacy of intraoperative cell salvage (ICS).

Methods: Patients who underwent laparoscopic surgery patients with preoperative Gn-RH analogs and intraoperative blood loss ≧ 600 ml from January 2018 to April 2022 were included. Patients were divided into three groups: ICS, preoperative autologous blood transfusion (PABT), and no transfusions (non-use). Postoperative hemoglobin (Hb) levels, allogeneic transfusion, and complications were also compared. Patients who received both ICS and PABT were excluded. Complications were defined as Clavien-Dindo Grade 2 or higher, with p<0.05 deemed as significant.

Results: There were 224 cases of laparoscopic surgery: 127, 42, and 45 in the ICS, PABT, and non-use groups, respectively. There were no significant demographic differences between groups. The median decrease in Hb on postoperative day 1 was 1.7, 3.2, and 3.0 g/dl in the ICS, PABT, and non-use groups, respectively, that of the ICS group was significantly lower. Postoperative transfusions occurred in 1 (0.8%), 3 (7.1%), and 0 cases (0%) in the ICS, PABT, and non-use groups, respectively, there were more transfusions in the PABT group, although the difference was not statistically significant. Postoperative complications did not differ significantly between groups.

Conclusion: Patients who underwent ICS had a slower Hb decline and no increase in complications. ICS may reduce preoperative effort and patient stress compared to PABT, and effectively manage unpredictable heavy bleeding.

Objective: In Japan, total laparoscopic cystectomy for ovarian mature cystic teratoma (TLC-MCT) is commonly performed by early-career laparoscopists. However, some experienced gynecological surgeons view TLC-MCT as a technically demanding surgery that requires surgical proficiency. Additionally, postoperative ovarian reserve directly affects fertility potential in assisted reproductive technology. This poses a contradiction: inexperienced laparoscopists perform proficiency-dependent procedures with substantial impacts on fertility. While developing expert skills from the outset is unrealistic, supervising and junior gynecologists should focus on optimizing the learning curve. Thus, we surveyed early-career gynecologists on their awareness of surgical techniques and fertility considerations in TLC-MCT.

Methods: A questionnaire about TLC-MCT was distributed to early-career gynecologists who are or have been affiliated with our program.

Results: Thirty-one doctors (84%) responded. Among them, 97% agreed that TLC-MCT quality may impact fertility and recurrence. By their second year, 98% had performed TLC-MCT, but 73% responded little confidence in their ability to perform the procedure. The most challenging aspects were “initial ovarian incision,” “layer recognition,” and “dissection” (60%), “surgical field control” (47%), and “communication with assistants” (40%).

Conclusions: Early-career gynecologists are generally aware of the impact of technique on fertility. Surgery must be precise to preserve fertility, but inexperienced laparoscopists struggle with aspects of the procedure. To enhance patient outcomes, they must acquire skills without extensive case experience. Besides forceps dexterity training (dry box training), improving layer recognition and strategy by observing expert-led surgeries and videos (visual and cognitive training) is essential.

　Intravenous leiomyomatosis (IVL) is a rare disorder among benign leiomyomas, which may arise from uterine myoma or smooth muscle of the vessel wall, extend into the veins. It sometimes extends into the inferior vena cava or the right atrium, causing a serious condition that can lead to sudden death. A 32-year-old nulliparous woman underwent laparoscopic myomectomy for a degenerative myoma. Four years after the surgery, an indistinct borderline mass appeared in the uterine body, for which the possibility of a degenerative myoma or sarcoma could not be ruled out. After preoperative blood tests, contrast-enhanced CT scan, and MRI, total hysterectomy was performed. Intraoperatively, an elastic hard mass was palpated in the left ovarian adnexal vessels, and when the vessels were cut open to examine the interior, a leiomyoma-like mass was confirmed grossly. Suspecting IVL or another disease extending into the left ovarian adnexa, a left adnexectomy was additionally performed for diagnosis and to prevent dispersal of the embolus. Postoperative contrast-enhanced CT scan and a reexamination of the preoperative imaging studies revealed shadow defects in the iliac vein, the left renal vein, the inferior vena cava, and the right pulmonary artery. The patient was transferred to another hospital for tumor embolization in the inferior vena cava and iliac vein, bilateral ovarian vein ligation, bilateral internal iliac vein ligation, and right ovariectomy, and the diagnosis of IVL was confirmed.

　Although intravenous leiomyomatosis is a rare disease, imaging and consultation with the possibility of its occurrence in mind may lead to early intervention.

　The causes of sciatica are diverse and difficult to diagnose in orthopedic practice. In gynecological diseases, uterine myoma and endometriosis are often cited as differentials, but many gynecologists are not aware of their relationship to sciatic neuralgia. We report a case in which laparoscopic surgery was effective in treating sciatic neuralgia, which was difficult to diagnose by orthopedic surgeons. A 46-year-old woman, gravida 2 para 2, complained of low back pain and sensory disturbance in the right lower extremity, but there was no orthopedic abnormality. Pelvic MRI revealed endometriotic cysts in the bilateral ovaries, and laparoscopic surgery was performed to remove the endometriotic lesions, which resulted in the disappearance of pain. Pelvic endometriosis can be involved in sciatic neuralgia. It is important to collaborate with an orthopedic surgeon to make a systematic diagnosis and pain assessment, and to determine a treatment plan.

　Here we report on the management and outcomes of ventriculoperitoneal shunt (VPS) in uterine cancer patients undergoing MRI and subsequent laparoscopic surgery. VPS is crucial for hydrocephalus treatment, a cerebrovascular disease complication, by facilitating drainage from ventricles to the abdominal cavity. MRI scans in VPS patients necessitate neurosurgical consultation due to potential shunt dysfunction from altered valve pressure settings. We present two cases of uterine cancer patients with pre-existing VPS who underwent laparoscopic surgery following MRI diagnostics.

Case 1: An 81-year-old woman with normal pressure hydrocephalus treated with VPS. Post-MRI, she experienced a sudden headache attributed to a 90-degree counterclockwise valve rotation, resolved by valve adjustment. She was diagnosed with stage IB endometrial cancer and underwent successful laparoscopic surgery without VPS complications.

Case 2: A 73-year-old woman with hydrocephalus following intraventricular hemorrhage, treated with VPS. MRI was performed under neurosurgical guidance to ensure valve settings were correct; no abnormalities were detected. She was also diagnosed with stage IB endometrial cancer and underwent laparoscopic surgery without perioperative VPS complications.

Conclusion: These cases underscore the importance of neurosurgical consultation prior to MRI in VPS patients to prevent complications and ensure safe surgical outcomes.

　This case was complicated by an umbilical hernia, probably due to a large 2,705 g uterine fibroid, which proved difficult to manage with a uterine manipulator. We successfully performed a robot-assisted total hysterectomy and hernia repair using an economical, aesthetically pleasing, and manpower-saving robotic surgical technique (using only four da Vinci ports without an assistant port and utilizing an endoscope and forceps port hopping).

　The operative time was 339 minutes (console time 197 minutes), with 119 minutes dedicated to removing the uterus and a recorded blood loss of 500 ml. The patient was comfortably discharged on the fifth postoperative day. No recurrence and complication of the umbilical hernia has been reported one year after surgery.

　Extrauterine leiomyomas, often sustained by neovascularization from adjacent tissues and organs, are commonly termed “parasitic leiomyomas.” Presented herein is a rare case of a completely isolated uterine fibroid found within the pelvic cavity, devoid of any discernible nutrient connection with neighboring tissues.

Case: A 36-year-old gravida 3, para 3, woman presented at 32 weeks of gestation with a known uterine fibroid. Upon thorough ultrasound and clinical evaluation, a 5-cm mass on the right side of the uterus was discovered. Following a normal full-term vaginal delivery, the patient underwent ultrasonography and magnetic resonance imaging 28 months postpartum, revealing a well-defined pelvic mass on the left side of the uterus measuring 7-cm in diameter, consistent with leiomyoma. Laparoscopic intervention showed a shiny white mass around 7 cm in diameter, extending from the left adnexa to Douglas’ fossa. The mass was completely isolated and without any nutrient or vascular connection to surrounding organs. After morcellation, the mass was removed, and the histopathological examination confirmed the diagnosis of leiomyoma with hyalinization.

Conclusion: We reported a case of a completely isolated intraperitoneal uterine fibroid. Pedunculated uterine fibroids have been identified, and when their location or characteristics change after delivery, it is advisable to investigate for diseases such as isolated intraperitoneal uterine fibroids and parasitic leiomyomas.

　This case report describes the effectiveness of the Holoeyes MD System in a case of robot-assisted laparoscopic total hysterectomy for a patient with a giant uterine fibroid complicated by right renal ureteral absence.

　The patient, a 47-year-old woman with a history of right renal ureteral absence, was admitted after being diagnosed with a giant uterine fibroid. Preoperative analysis was conducted using the Holoeyes MD System to understand the three-dimensional anatomical structures and assist intraoperative diagnosis. During the surgery, Holo Lens 2 and TilePro function were used to project MR space and display real-time anatomical information. The surgery proceeded as planned, and the postoperative course was uneventful.

　The Holoeyes MD System proved to be a valuable tool for improving the safety and accuracy of gynecological surgeries, from preoperative analysis to intraoperative assistance. The system enables minimizing the risk of complications while reducing patient invasiveness. With advancements in XR technology, further analysis is warranted and expected in the future.

　Total laparoscopic hysterectomy (TLH) carries a higher risk of ovarian torsion compared to abdominal or vaginal hysterectomy. We present three cases of ovarian torsion following TLH necessitating surgical intervention.

Case 1: A 50-year-old woman experienced abdominal pain 17 months post-TLH with bilateral oophorectomy for uterine fibroids. A 4.8-cm left ovarian cyst was discovered on CT scan, prompting emergency laparoscopic surgery. The cyst was torsed and necrotic, leading to left adnexectomy.

Case 2: A 50-year-old woman presented with persistent abdominal pain 11 months post-TLH with bilateral oophorectomy for fibroids. Contrast-enhanced CT scan revealed a 4.5-cm non-enhancing pelvic mass and hemorrhagic ascites, prompting emergency laparoscopic surgery. Right ovarian torsion and hemorrhagic necrosis necessitated right adnexectomy.

Case 3: A 44-year-old woman complained of abdominal pain 7 months post-TLH with bilateral oophorectomy for fibroids. Contrast-enhanced CT scan revealed a 6-cm pelvic mass, suspected to be a hematoma, prompting emergency laparoscopic surgery. Hemorrhagic cyst and left ovarian torsion led to left adnexectomy. TLH-related ovarian torsion is attributed to fewer adhesions, less ovarian damage, preservation of ovarian function, and incision of the posterior ligament, enhancing ovarian mobility. The risk of ovarian torsion after TLH is higher compared to abdominal and vaginal total hysterectomies, necessitating consideration of ovarian torsion in cases of acute abdomen with a history of TLH. As a preventive measure, ovarian fixation may be useful, and further investigation into its effectiveness will be necessary as more cases are accumulated.

　Cesarean Scar Pregnancy (CSP) is an ectopic pregnancy where the embryo implants within a previous cesarean scar. We present a case of laparoscopic uterine scar repair for CSP.

　A 25-year-old woman, gravida 2, para 1, with a history of cesarean section for her first child, presented to her physician at 9 weeks of gestation and was referred to our hospital with a suspected miscarriage. Examination revealed an intrauterine gestational sac corresponding to 7 weeks of gestation, with suspected implantation within the cesarean scar.

　The patient experienced lower abdominal pain and abdominal fluid retention, raising concerns of impending uterine rupture. Emergency laparoscopic resection was performed. During the procedure, the bilateral uterine arteries were clamped using vascular tapes, vasopressin was locally injected around the scar, an incision was made in the myometrial layer, and the gestational sac was excised and retrieved in a bag. The myometrial layer was then sutured in two layers. The surgery lasted 2 hours and 46 minutes, with a blood loss of 10 mL. A levonorgestrel-releasing intrauterine system was placed 2 weeks postoperatively.

　Six months postoperatively, magnetic resonance imaging revealed a myometrial thickness of 10 mm, and the patient was cleared for pregnancy one year post-surgery. Sixteen months post-operation, the patient conceived naturally and delivered via elective cesarean section at 37 weeks and 4 days of gestation.

For suspected incomplete uterine rupture, laparoscopic surgery should be considered the treatment of choice for CSP.

　Accessory and cavitated uterine masses (ACUM) are cystic masses within the normal myometrium that cause dysmenorrhea. When analgesics and low-dose estrogen/progestin therapy are ineffective, excision of the ACUM is a treatment option. However, there is no clear consensus on how to reliably remove ACUM. In this study, we report a case in which ACUM was completely removed using a laparoscopic ultrasound probe.

　The patient was 23 years old, nulligravida, and had been experiencing dysmenorrhea since the age of 19. Suspecting ACUM, we decided to perform a laparoscopic cystectomy, and the patient was removed without disrupting the contents of the mass, using a laparoscopic ultrasound probe to delineate the boundary region of the mass. The mass was removed without disrupting its contents. Pathologically, endometrial tissue was observed on the luminal surface, and uterine smooth muscle tissue covered the outer surface, leading to the diagnosis of ACUM. Postoperatively, dysmenorrhea disappeared and no analgesic medication was needed, and there was no recurrence 9 months after surgery.

　It is important to remove ACUM completely, because its boundary with the normal myometrium is indistinct and its rupture may cause a relapse of symptoms. Using intraoperative ultrasonography, ACUM was easily identified and the operation could be completed laparoscopically. Intraoperative transtrocar ultrasonography was found to be useful for laparoscopic excision of endometrial tissue of ACUM.

　There have been few reports on laparoscopic surgery in the field of gynecology for patients with a stoma, and the optimal surgical procedure remains unclear. We report a case of emergency laparoscopic surgery for ovarian tumor torsion in an elderly patient with multiple underlying medical conditions, including a colostomy. The patient was 86 years old, and had multiple underlying diseases: type 2 diabetes, Parkinson’s syndrome, hypertension, hyperlipidemia, and lumbar spine compression fracture. In addition, she had undergone eight surgical procedures, including Hartmann’s operation, coronary artery bypass graft, and subdural hematoma evacuation. She presented to our hospital with left lower abdominal pain, and was diagnosed with torsion of a left ovarian cyst by CT imaging and gynecologic examination.

　Due to her advanced age and multiple comorbidities, we opted for a relatively minimally invasive procedure, performing laparoscopic bilateral salpingo oophorectomy. Given her history of midline abdominal incision extending to the umbilicus and the presence of a colostomy in the left lower abdomen, we inserted the first port using an open technique at Palmer’s point to avoid organ injury, and then placed the other ports in safe positions under direct observation within the abdominal cavity. The surgeon stood on the patient’s right side and completed the surgery without complications using the right parallel technique. It is essential to consider port placement according to the case in laparoscopic surgery following stoma creation or open surgery, particularly the selection of the first puncture site, which is important for avoiding complications.

　Pyomyoma is considered to occur following necrosis or ischemia of the fibroid, often during pregnancy, postpartum, or postmenopause. This report describes a case of successful treatment of pyomyoma in the postpartum period with total laparoscopic hysterectomy.

　The patient was a 39-year-old, G1P0 woman who had no significant medical history or medication use. She had a 10-cm intramural fibroid on the posterior wall of the uterus before pregnancy, which did not cause issues during her pregnancy, leading to a vaginal delivery at 39 weeks gestation. She was discharged on postpartum day 5 but readmitted on day 11 with lower abdominal pain and fever. She was diagnosed with pyomyoma based on localized pain, elevated inflammatory markers, and imaging findings. Antibiotic therapy was initiated, but fever and mild abdominal pain persisted. Due to a lack of improvement with conservative treatment and no desire for future pregnancies, she underwent total laparoscopic hysterectomy on day 14 of hospitalization, resulting in successful removal of an 800-g fibroid with signs of degeneration and purulent discharge.

　In this case, it is believed that the uterine fibroid underwent degeneration due to changes in blood circulation during the postpartum period, leading to an associated infection. There are reports of fibroid abscess rupture causing peritonitis and sepsis with disease progression. Therefore, surgical intervention is beneficial when conservative treatment with antibiotics is not effective. Laparoscopic surgery allows detailed observation of the pelvic area, and its small incisions contribute to reduced risks of infection and early mobilization.

　We report a case of a 74-years-old female with sigmoidouterine fistula and abdominouterine abscess as a complication of progressive Crohn's disease and treated successfully by a laparoscopic total hysterectomy. The patient was treated for Crohn's disease for over 20 years with oral and rectal mesalamine. Her disease was difficult to control because of recurrent multiple rectal ulcerations and subilius even under the treatments with various biologicals. The patient was admitted into our hospital with abdominal pain and fever. CT scan showed an abdominal abscess and colonoscopy found worsening of the ulcerations. Initially, she was treated conservatively with antibiotics and her symptoms improved temporarily, until she was found to have fecal vaginal discharge. MRI identified a fistula formation between the sigmoid colon and the left side of the uterus, and fecal material in the uterus. Repeated MRI following antibiotic treatments showed the persistent sigmoidouterine fistula and intrauterine abscess with fecal material. Total laparoscopic hysterectomy, bilateral adnexectomy, and sigmoid colon resection were performed following bilateral tubal ligations with LigaSure and cervical cerclage to prevent from intraabdominal leakage of the abscess and intrauterine fecal material. The patient was discharged on Day 14 postoperatively as she had an excellent recovery with no signs of recurrent infection. Pathology revealed endometriosis on uterine side and Crohn's disease on the other side of the fistula. In advanced Crohn's disease, fistulae may form with surrounding organs, but the fistula with the uterus is uncommon as it is an organ with thick muscular wall. Inflammatory bowel disease such as Crohn's disease has been increasing in recent years and may not be unusual in long standing, treatment resistant and complicated cases affecting female pelvic organs that require total hysterectomy. In addition to the collaboration with other departments, neo-surgical techniques should be devised to prevent from spreding intraperitoneal infection.

　Recent reports demonstrate that approximately 1％ of women experience ovarian torsion following total laparoscopic hysterectomy (TLH). We have performed 1325 cases of TLH over the past 17 years and experienced 2 cases of ovarian torsion following total laparoscopic hysterectomy.

Case 1: A 50-year-old woman who had two previous pregnancies and two successful deliveries. She presented with an enlarged uterine myoma and anemia, which were surgically managed by performing a TLH+bilateral salpingectomy (BS). A 6-cm uterine myoma was removed, and her bilateral adnexa were normal. Six months post-operation, an emergency surgery was performed due to right ovarian torsion. The findings included an edematous and enlarged right ovary, which had twisted 540°; thus, a laparoscopic right ovarian resection was performed.

Case 2: A 44-year-old woman who had three previous pregnancies and three successful deliveries. She presented with back pain that was likely caused by a uterine myoma, which was surgically managed by performing a TLH+BS. An 8-cm cervical myoma was removed, and her bilateral adnexa were normal. Fifteen months post-operation, an emergency surgery was performed due to the torsion of a 6-cm right ovarian cyst. The right ovary was twisted 540°. A laparoscopic right ovarian resection was performed.

　Although it is unclear whether hysterectomy is a risk factor for ovarian torsion, studies have reported that the incidence of ovarian torsion is higher in patients who have undergone a laparoscopic hysterectomy procedure in comparison to those who have undergone an abdominal hysterectomy. Therefore, it is important to consider that TLH may be a risk factor for ovarian torsion and that precautions may be necessary to prevent such in some cases.

　A 40-year-old woman, G4P2, presented after an abnormal gynecological screening indicated ASC-US. Subsequent cervical biopsy led to diagnosis of HSIL/CIN3, followed by a cervical conization. Histopathology revealed HPV-related adenocarcinoma (usual type endocervical adenocarcinoma), stage IB1, without vascular invasion and with negative surgical margins. The patient underwent a laparoscopic radical hysterectomy and bilateral adnexectomy. No residual tumor was detected, confirming the final diagnosis of HPV-related adenocarcinoma, pT1b1N0M0. Two months post-surgery, the patient presented with acute abdominal pain. A contrast abdominal CT scan suggested a strangulated small bowel obstruction, prompting emergency laparotomy. The small intestine was found incarcerated at the right umbilical ligament, serving as a hernial orifice and causing strangulated obstruction. Strangulation release and partial small bowel resection were performed. Due to the difficulty of closing the right retroperitoneal space, the gap in the right umbilical ligament was filled with omentum. Currently, the patient is under outpatient observation with no signs of recurrence or bowel obstruction symptoms. Strangulated bowel obstruction is a critical condition that can lead to bowel necrosis, peritonitis, sepsis, and multi-organ failure. Postoperative cases suggest that exposed vascular structures after lymphadenectomy can serve as hernial orifices, indicating the need for vigilance for strangulated bowel obstruction after pelvic lymph node dissection in gynecological malignancy surgeries.

Background: Fallopian tube carcinoma is a rare malignancy, representing approximately 1％ of all female genital cancers. The typical clinical manifestations include watery discharge, pelvic pain, and a palpable pelvic mass. However, many cases are asymptomatic or present with nonspecific symptoms, leading to a low rate of preoperative diagnosis. In this case, pathological evaluation of specimens obtained via diagnostic laparoscopy proved instrumental in establishing the diagnosis.

Case: A 66-year-old female with a history of an abdominal left linear salpingostomy for ectopic pregnancy was referred to our hospital for the management of a right adnexal mass. MRI and CT imaging suggested a pelvic abscess. Diagnostic laparoscopy revealed purulent ascites and an abscess adhered to the pouch of Douglas. Both ovaries and fallopian tubes appeared grossly normal. The mass and bilateral adnexa were resected, and histopathological examination revealed high-grade serous carcinoma of the right fallopian tube accompanied by serous tubal intraepithelial carcinoma. The patient was subsequently started on neo-adjuvant chemotherapy.

Conclusion: Fallopian tube carcinoma is a rare and aggressive malignancy difficult to diagnose preoperatively. Pelvic abscesses are atypical in postmenopausal women and can occasionally be associated with underlying malignancies. In such cases, even if the adnexa appear grossly normal, bilateral adnexectomy should be considered.

　Uterine artery pseudoaneurysm is a rare and potentially life-threatening disease as it causes massive bleeding. We herein describe a patient who underwent vaginally assisted natural orifice transluminal endoscopic hysterectomy (VANH) for a uterine artery pseudoaneurysm that occurred following spontaneous abortion and who yielded a good outcome.

　The patient was a 37-year-old woman with six spontaneous vaginal deliveries and no history of previous miscarriages. A Spontaneous abortion occurred on X-17 month, followed by persistent abnormal uterine bleeding. On X-six month, she was treated with norgestrel and ethinyl estradiol. However, the bleeding did not stop. Thus, four cycles of leuprolide acetate were performed. Transvaginal ultrasonography revealed a hypoechoic area measuring 30 mm on the left lateral wall of the uterus with abundant blood flow spiraling around the mass. Furthermore, contrast-enhanced magnetic resonance imaging revealed a uterine artery pseudoaneurysm. The patient did not wish to have a child; thus, VANH and bilateral tubectomy were performed. No bleeding from the pseudoaneurysm occurred during the operation, and the patient achieved a good postoperative course.

　Uterine artery pseudoaneurysm causes heavy bleeding and requires early diagnosis and treatment. The treatment plan should be determined considering the patient's background and risk of rupture. In this case, due to the risk of bleeding from the pseudoaneurysm, VANH was performed, this is a safe and minimally invasive procedure that does not involve the use of manipulators and requires minimal manipulation of the uterine body.

Background: Treatment options for cervical ectopic pregnancy have been reported to include methotrexate therapy or a combination of uterine artery embolization and hysteroscopic surgery. There are concerns about the prolonged duration of treatment and the risk of decreased fertility with these methods. We report four cases of cervical ectopic pregnancy in which vasopressin was locally injected around the gestational sac under transvaginal ultrasound guidance, and hysteroscopic observation was performed after the gestational sac was removed.

Methods: The gestation period was 5-6 weeks, blood human chorionic gonadotropin (HCG) level was 3,000-40,000 IU/L, and fetal heartbeat was confirmed in two cases. Diluted vasopressin with saline was locally injected around the gestational sac under ultrasound guidance. The endpoints of vasopressin administration were loss of blood flow to the gestational sac and fetal cardiac arrest. After the gestational sac was removed, hysteroscopy was performed to remove residual tissue and stop bleeding.

Results: In all cases, the gestational sac was detached only by cervical dilation before hysteroscopy. Hysteroscopic observation revealed residual tissue in three cases and removed it with blunt manipulation. Bleeding was observed and stopped in one case. Intraoperative blood loss was 1-20 g, and all the patients were discharged from the hospital on the first postoperative day. HCG-negative status was confirmed between 29 and 50 days postoperatively, and there was no persistent ectopic pregnancy.

Discussion: Local vasopressin injection around the gestational sac is highly feasible because of short-term treatment period and it may not affect fertility. Moreover, adding hysteroscopy may improve safety by ensuring removal of residual tissue and hemostasis.

Conclusion: Local vasopressin injection around the gestational sac and hysteroscopic observation may become standard treatments for cervical ectopic pregnancy.

　Genital bleeding after total hysterectomy is minor and often relieved with follow-up and gauze compression. In this study, we report a case of shock from profuse genital bleeding on the 49th day after total laparoscopic hysterectomy (TLH).

　―A 42-year-old woman with uterine fibroids underwent total laparoscopic hysterectomy at our hospital. The postoperative course was uneventful. On day 49 after surgery, she noticed heavy genital bleeding without any cause and was referred to the emergency clinic. On arrival, she developed hemorrhagic shock, and she underwent blood transfusion and contrast-enhanced CT. There was no apparent contrast leakage. After her general condition had stabilized, she was transferred to our hospital. There was no vaginal dissection, and a diagnostic laparoscopy was performed. The absence of intra-abdominal bleeding suggested retroperitoneal hemorrhage, but there were no active bleeding sites. She was subsequently discharged without re-bleeding. We speculated that the bleeding was due to a ruptured of uterine artery pseudoaneurysm, because the acute phase had passed and there was no obvious vaginal dissection.

　It has been suggested that acute phase CT may not confirm contrast leakage or aneurysm due to circulatory failure. Similar events, although rare, can be very serious when they occur. For early detection, color Doppler testing for abnormal blood flow behind the vaginal stump is suggested.

Objective: This study aimed to investigate a newly developed ALLY Uterine Positioning SystemTM. ALLY is a device that supports uterine and vaginal holding performed by a second assistant in gynecologic laparoscopic or robot-assisted surgery and is expected to reduce the workload of the second assistant and enable the surgery to proceed even in the absence of a second assistant.

Materials and Methods: We interviewed physicians (primary surgeons and second assistants) about their experiences and opinions of using ALLY. Using videos, we reviewed the time required by the second assistant to operate the uterine manipulator and compared cases that did and did not use ALLY.

　A questionnaire regarding the second assistant was sent to young physicians, both internal and external to the hospital.

Results: One physician mentioned that using ALLY stabilized the surgical field and allowed surgeries to be performed without a second assistant. Another reported that ALLY gave second assistants an opportunity to learn by participating in discussions. With ALLY, the second assistant was required for approximately 1/12th of the typical time in a total hysterectomy. About half of the young physicians who responded to the questionnaire reported that they had previously experienced pain and physical fatigue from performing manual procedures and operations.

Conclusion: The ALLY system may contribute to safety by providing stabilization of the surgical field and can reduce the workload of second assistants in surgeries. Further, it can help physicians focus on learning and allow surgeries without a second assistant to be conducted.

　In laparoscopic radical hysterectomy for cervical cancer, it is important to ensure appropriate traction and fixation of the uterus. The use of uterine manipulators during this procedure is reportedly associated with a worse prognosis. Therefore, we do not use uterine manipulators. Instead, we employ a novel method of applying appropriate traction to the uterus during laparoscopic radical hysterectomy. Specifically, we place traction threads on the bilateral upper ligaments of the uterus, and use of these threads to apply traction provides a good surgical field that facilitates completion of the surgery. This method is useful in ensuring an optimal surgical field for a smooth operation.

　Ovarian endometrioma is an ovarian cyst formed when endometrial tissue grows on the surface of the ovaries, often leading to chronic abdominal pain and fertility problems. This study evaluated the technique and efficacy of transvaginal ethanol sclerotherapy under laparoscopic supervision for the treatment of endometrioma. The procedure involves transvaginal ultrasound-guided aspiration and washing of cyst contents, followed by injection of ethanol, which is allowed to sclerose the cyst wall over a period of seven minutes. Laparoscopic surgery is then performed for partial resection and biopsy of the cyst wall and removal of the endometriotic lesion and adhesiolysis of the peritoneal cavity. Normal saline is used to fill the peritoneal cavity, preventing ethanol leakage and minimizing the risk of adhesion formation. This approach aims to reduce cyst size, alleviate pain, and preserve ovarian function, which is crucial for maintaining fertility. Our findings suggest that this technique may be particularly appropriate for unmarried, nulliparous women and in cases where ovarian function decline is anticipated, as it offers a favorable balance between symptom relief and fertility preservation. In addition, the combination of this procedure with postoperative hormonal therapy has been suggested to reduce the recurrence rate of endometriotic cysts, potentially leading to favorable long-term outcomes. Despite these promising results, the potential risks, such as ethanol leakage and its effect on ovarian tissue, require further investigation. Further research is needed to refine this technique, evaluate long-term recurrence rates, and develop optimized postoperative management strategies to improve patient outcomes.