Objective: We present a retrospective analysis of 127 consecutive vNOTES (transvaginal natural orifice transluminal endoscopic surgery) cases, including hysterectomy and adnexal surgery, performed by a single surgeon between April 2021 to December 2022.

Results: One-hundred and five vaginally assisted NOTES hysterectomy (VANH) cases were performed using GelPOINT V-Path (9.5 cm). Four early cases were hybrid-VANH, which were performed via adding a 5 mm umbilical port to determine pelvic condition before vaginal approach. Among the other 101 VANH cases, one case was converted to hybrid-VANH. A 5 mm camera from the umbilical port was used to determine pelvic adhesion during the vaginal procedure and VANH was performed with supporting umbilical view. The remaining 100 cases were performed without any conversion to abdominal, laparoscopic, and vaginal surgery. Mean surgical time and uterine weight were 86 min and 160 g, respectively. There were no intraoperative complications but two cases had vaginal bleeding after discharge, requiring vaginal suturing.

　Twenty-two vNOTES adnexal surgery cases were performed using GelPOINT V-Path (7 cm). One case was converted to hybrid-vNOTES to determine pelvic condition from umbilical camera access, during the vaginal procedure. The other 21 cases were performed without any conversion to abdominal, laparoscopic, and vaginal surgery. Mean surgical time and extracted tumor weight were 63 min and 29 g, respectively. There were no intraoperative or postoperative complications.

Conclusion: vNOTES hysterectomy and adnexal surgery can be safely introduced using GelPOINT V-Path with appropriate patient selection.

　Laparoscopic para-aortic lymphadenectomy (LAPPAN) for endometrial cancer is a highly difficult new technique that has been performed at facilities that meet the implementation requirements.

　In September 2019, we began performing LAPPAN as advanced medical treatment A. After insurance began covering it in 2020, we performed primary laparoscopic endometrial carcinoma surgery for stage IA cases with high-risk histologies, in addition to secondary LAPPAN.

　We had performed 12 LAPPAN procedures by March 2022. In these cases (six with endometrial carcinoma grades 1/2, and six with high-risk endometrial carcinoma histologies), the average blood loss was 71 ml, and no intraoperative complications were observed. Recurrence was observed in three patients with high-risk histologies (vaginal cuffs in two cases and omentum in one case). We then compared laparoscopic surgery (six cases) and open surgery (seven cases) in high-risk histology performed during the same period. Recurrence was observed in one of seven cases (pelvic lymph nodes) in the laparotomy group. Total blood loss was significantly less in the laparoscopic group. No significant difference in dissected para-aortic lymph node number was observed. Also, no recurrence in para-aortic lymph nodes was observed in LAPPAN cases. Therefore, we confirmed the safety and efficacy of LAPPAN at our hospital.

Objective: In our department, we actively perform laparoscopic conservative surgery for adnexal torsion. We have also performed second look laparoscopy (SLL) to observe the preserved adnexa after conservative surgery. In this study, we investigated cases in which SLL was performed after conservative surgery and cases in which two-stage conservative surgery was performed, and examined the usefulness and complications of laparoscopic conservative surgery.

Methods: We retrospectively reviewed the medical and surgical records of patients who underwent laparoscopic surgery for adnexal torsion between June 2009 and April 2020.

Results: Conservative laparoscopic surgery was performed in 48 (46.6%) of 103 patients who underwent laparoscopic surgery for adnexal torsion. Among the 48 cases undergoing conservative laparoscopic surgery, SLL was performed in 13 (27.0%) cases. In 12 (25%) cases, the morphological color tone of the preserved ovaries was restored. We were able to confirm fallopian tube patency in eight cases with peri-adnexal adhesions in 11 cases. Salpingectomy was performed in three cases, including cases of oviductal edema and strong adhesions of the oviductal arches.

Conclusions: Laparoscopic conservative surgery for adnexal torsion is useful to preserve ovarian function in many cases. However, in numerous cases, we observed peritubal adhesions which result in hydrosalpinx. In laparoscopic conservative surgery, measures to prevent adhesions are essential, and postoperative follow-ups are required not only for ovarian function but also for postoperative adhesions and the condition of the fallopian tubes.

Objective: The purpose of this study was to identify future issues brought about by pelvic infection after fertility treatment and laparoscopic surgery.

Methods: We retrospectively reviewed the background, surgical details, complications, and course of cases of pelvic infection that underwent laparoscopic surgery after fertility treatment at our hospital from January 2009 to April 2022.

Results: Seven patients aged 31-47 years were included in this study. One had peritonitis only, and the remaining six had tubo-ovarian abscess (TOA), of which five had ovarian endometriotic cysts and one had a mature teratoma. The infection was triggered by intrauterine insemination in two cases, oocyte retrieval in two cases, and embryo transfer in three cases. The median time from onset to surgery for the seven patients was 16 days, and the median time for the five patients who underwent emergency surgery was 7 days. Patients with peritonitis underwent drainage, those with teratoma underwent adnexectomy, and those with endometriotic cysts underwent cystectomy and cauterization. Four patients became pregnant at a later embryo transfer and had live births at term. Complications were not observed, but three cases had reinfection due to resumed fertility treatment.

Conclusions: Laparoscopic surgery can be safely performed for pelvic infections and TOA associated with fertility treatment, and in more than half of the cases, pregnancy was possible in the next cycle or later. However, prolonged hospitalization and recurrence in nearly half of the cases were observed. Earlier surgical intervention and infection prevention during fertility treatment need to be considered in the future.

Objective: Since 2021, we have introduced vNOTES (Transvaginal Natural Orifice Transluminal Endoscopic Surgery) for Reduced Port Surgery in laparoscopic total hysterectomy. The vNOTES uses a natural vaginal orifice, which is less painful and more aesthetic. However, performing surgery for severe adhesions and narrow vaginas is challenging; thus, case selection is essential. Therefore, we started Hybrid vNOTES with umbilical port and have performed it in seven cases to date. In this study, we retrospectively reviewed these cases and compared the surgical results with those of conventional multiport laparoscopic surgery.

Results: The median age of the seven patients was 48 years. There were no nulliparous women, and the median body mass index was 21.4. The median uterine weight was 213 g. The median operative time and blood loss were 129 minutes and 121 g, respectively. One case required additional ports due to intraoperative adhesions. The median postoperative hospital stay was four days, and no perioperative complications were observed. Surgical time was significantly shorter, and postoperative blood tests showed lower C-reactive protein levels in the Hybrid vNOTES group than in multiport laparoscopic surgery. In contrast, intraoperative blood loss was significantly higher in the Hybrid vNOTES group than in multiport laparoscopic surgery.

Conclusion: Hybrid vNOTES was introduced as an initial experience of vNOTES. Although there were advantages over multiport surgery, such as shorter surgery time, there were still issues to be addressed for Pure vNOTES. Further case accumulation is necessary to reduce the complications associated with trocar insertion and to expand vNOTES indications from the standpoint of its cosmetic properties.

　Tubo-ovarian abscess (TOA) is a severe pelvic inflammatory disease and a possible complication of oocyte retrieval in patients with endometrial cysts. A 37-year-old nulligravida with infertility complicated by endometrial cysts had oocyte retrieval performed at a fertility clinic. On Day 9 after retrieval, she developed abdominal distention and fever, and was admitted to an emergency hospital with a diagnosis of ovarian enlargement and peritonitis. Antibiotics (meropenem) were administered, and she was discharged on Day 36 after symptoms improved. Following this, she experienced two flare-ups and was re-admitted to the hospital and treated with the same antibiotic. Despite a total hospital stay of 80 days, no improvement was seen, and she was transferred to our hospital. She was diagnosed with refractory left TOA, and underwent laparoscopic surgery, revealing strong intra-abdominal adhesions. Thereafter, she was shifted to an open laparotomy and underwent a left adnexectomy. In suspected cases of TOA, appropriate treatment should be given at the right time.

　Adult umbilical hernia is relatively rare in Japan; however, a shift toward Western dietary habits has led to an increase in the prevalence of this condition. A 51-year-old nulliparous woman with a history of endometrial cancer stage IA concomitant with umbilical hernia underwent laparoscopic hysterectomy and bilateral salpingo-oophorectomy accompanied by suture repair of the umbilical hernia. Intraoperatively, we created a deep longitudinal umbilical depression and performed umbilicoplasty using the novel “Kajikawa method.” No complications or recurrence have occurred 2 years postoperatively.

　Umbilical hernias are treated using mesh placement or suture repair. Some studies have reported that recurrence rates associated with suture repair are significantly higher than those associated with mesh repair for umbilical hernia. Mesh repair is associated with lower recurrence rates than those associated with suture repair in patients with umbilical hernia defects > 4 cm in size.

　We performed suture repair in our patient considering a history of uncontrollable diabetes and a small hernia defect. Suture repair is preferred in patients with malignant tumors and a small hernia defect because the next surgical approach becomes difficult.

　Notably, the “Kajikawa method” of umbilical reconstruction results in a natural-looking umbilicus postoperatively.

　Hyperreactio luteinalis (HL) characterized by multicystic bilateral ovarian enlargement, increased serum β-human-derived chorionic gonadotrophic hormone levels, and spontaneous regression after delivery is a rare benign condition that complicates pregnancy.

　We present a case of conservative laparoscopic surgery performed for management of HL after miscarriage of a partial hydatidiform mole coexistent with a fetus.

　A 30-year-old woman presented after miscarriage of a partial hydatidiform mole coexistent with a fetus and was diagnosed with HL. She received conservative treatment, per our hospital policy; however, owing to persistent pain, we performed laparoscopy, which revealed torsion of the right adnexa around the ovarian ligament. We released the torsion and punctured the multicystic bilaterally enlarged ovaries.

　Effective obstetric training is important for accurate and early diagnosis to enable prompt management of associated complications and may prevent unnecessary oophorectomies. Laparoscopic surgery is useful for prompt management of symptoms and preservation of ovarian function.

Introduction: Uterine myomas often occur concomitantly with endometriosis; however, few studies have reported endometriosis within a uterine myoma. We report two cases of cystic endometriosis originating in a subserosal myoma.

Case 1: A 35-year-old gravida 0, para 0, with a history of endometriosis visited our hospital for evaluation of increasing lower abdominal pain. Transvaginal ultrasonography revealed an irregularly shaped, partially hyperintense mass (81 mm), and we performed laparoscopic surgery on the same day. The mass was contiguous with the posterior wall of the uterus, and we observed rupture of a hematoma within the mass and resected the lesion. Histopathological evaluation of the resected specimen revealed leiomyoma with endometriosis.

Case 2: A 43-year-old gravida 0, para 0, with a history of multiple uterine myomas was admitted to our hospital's cardiology department on an emergency basis for management of cardiac tamponade and was subsequently referred to our department for evaluation of a malignant tumor. She underwent laparoscopic total hysterectomy and bilateral oophorectomy, 7 months later. Intraoperatively, we detected a subserosal myoma, which was dissected and stored in a pouch and retrieved separately from the uterus. Histopathological evaluation revealed leiomyoma with endometriosis.

 Cystic endometriosis originating within a subserosal myoma causes sudden abdominal pain and is often indistinguishable from ovarian tumors and sarcomas. We laparoscopically removed only the subserosal myoma separately to prevent spread of the myoma fragments. This condition can be differentiated from a subserosal myoma with dysmenorrhea and nonspecific images on magnetic resonance imaging.

　We report a case of an intrapelvic neoplasm detected after pancreatic body cancer surgery, which was diagnosed laparoscopically as ovarian metastasis of pancreatic cancer.

　A 70-year-old woman (gravida 4, para 2) was diagnosed with pancreatic body cancer at 68 years of age. She underwent laparoscopic distal pancreatectomy after preoperative chemotherapy. Histopathological evaluation confirmed diagnosis of pancreatic body adenocarcinoma (stage IA, ypT1cN0M0). Computed tomography revealed an intrapelvic neoplasm accompanied by right-sided hydronephrosis during follow-up after completing chemotherapy, 17 months postoperatively, and the patient was referred to the Department of Gynecology. Urography and urine cytology showed no signs of urological malignancy. Following right ureteral stent placement, we performed staging laparoscopy, which revealed a solid neoplasm of the right adnexa; however, we observed no signs of intraperitoneal dissemination, ascites, or cystic enlargement of the right adnexa. This presentation was atypical of primary ovarian cancer. Rapid intraoperative diagnosis of the right adnexal lesion revealed adenocarcinoma with histopathological findings similar to those of the previous pancreatic cancer specimen. We suspected ovarian metastasis of pancreatic cancer and performed bilateral adnexectomy. Based on histopathological evaluation of the resected specimen, we diagnosed the patient with ovarian metastasis of pancreatic cancer, and mFOLFIRINOX chemotherapy was initiated postoperatively.

　Laparoscopic resection of metastatic ovarian cancer was useful for diagnosis of ovarian metastasis of pancreatic cancer and therapeutic decision-making for management of recurrence. Laparoscopic surgery is minimally invasive and enables histopathological evaluation and prompt initiation of chemotherapy.

　Chocolate cyst-like lesions found in the uterus are referred to as cystic adenomyosis. Recently, a specific type of this condition, thought to be a developmental disorder of Müllerian ducts, has been termed an accessory and cavitated uterine mass (ACUM). Herein, we report the case of a 28-year-old nulligravida woman who was diagnosed with ACUM during infertility treatment and underwent an ultrasound-guided laparoscopic lumpectomy for treatment. The patient initially experienced pelvic pain after discontinuing hormone therapy for dysmenorrhea, which gradually worsened and became difficult to manage, leading to the decision for surgical intervention. Preoperatively, the patient relied on non-narcotic opioid analgesics for pain relief, but analgesics were no longer needed promptly postoperatively. ACUM was found in the uterine attachment zone of the round ligament of the normal uterus, unrelated to uterine adenomyosis. It can cause severe dysmenorrhea and chronic pelvic pain even when the mass is as small as 1 cm in diameter. Due to its location and size, the mass was difficult to identify intraoperatively from the surface of the uterus, but we were able to complete the removal of the mass laparoscopically with the use of ultrasound.

Background: Cases of tubo-ovarian abscess (TOA) may often be difficult to diagnose solely based on imaging findings. This report describes a case of a ruptured TOA that was successfully diagnosed and treated laparoscopically.

Case: A 42-year-old woman, gravida 3, para 3, presented to our hospital with a chief complaint of acute lower abdominal pain and vomiting. Upon admission, her vital signs were stable. Physical examination revealed rebound tenderness, at its maximum in the right lower abdomen. Blood tests showed a slight increase in the inflammatory response. Contrast-enhanced CT and MRI revealed a 4-cm cyst with fluid level formation in the right ovary. However, the possibility of torsion in the cyst could not be ruled out. Therefore, emergency laparoscopic surgery was performed for diagnosis and treatment. Intraoperative findings indicated a ruptured right ovary, enlarged to the size of a chicken egg, along with purulent ascites accumulated in the Douglas fossa. The patient was diagnosed with a ruptured ovarian abscess complicated by an endometrial cyst. A laparoscopic right salpingo-oophorectomy with intraperitoneal lavage was performed. Bacteroides fragilis was detected in the ascitic fluid, and blood cultures were obtained intraoperatively. The patient received a 14-day course of antibiotics and was discharged on the 15th postoperative day.

Conclusion: Early laparoscopic surgery is considered beneficial for the treatment of ruptured TOA.

　Uterine artery embolization (UAE) is less invasive therapy for uterine fibroids; however, it can lead to infection in the uterus, ovary, and fallopian tube. We report the case of a patient who developed a pyomyoma two years after undergoing UAE, and subsequently underwent total laparoscopic hysterectomy (TLH). This report presents our findings.

　A 50-year-old woman underwent UAE at a clinic two years ago; however, she discontinued her follow-up sessions due to her relocation. The patient was referred to our department due to the presence of discharge and fever of unknown origin for the past month.

　During her initial visit to our department, we identified a 7.7 cm uterine fibroid with mild tenderness and an elevated inflammatory response. Based on our suspicion of a pyomyoma, we performed a TLH. Histopathological analysis revealed a leiomyoma with an infection. On postoperative day 7, the white blood cell count and C-reactive protein were elevated, and we identified a pelvic abscess at the vaginal cuff. Therefore, transvaginal abscess drainage was conducted. On day 10, the inflammatory reaction was confirmed to be negative, and the patient was discharged on day 12.

　UAE can lead to complications in pyomyoma. TLH for pyomyoma presents challenges and increases the risk of postoperative infection. This condition requires bacterial culture, a combination of antibiotics, and early transvaginal drainage.

　Laparoscopic surgery has become a widely accepted standard for treating benign gynecological conditions in recent years. Total laparoscopic hysterectomy (TLH) is one of these procedures, which is performed at numerous medical institutions. Compared to total abdominal hysterectomy (TAH), TLH offers a less invasive approach, leading to reduced postoperative pain, a shorter hospital stay and quicker reintegration into society. However, the extensive use of electric scalpels and energy devices in a confined spaces increases the risk of serious complications such as intestinal injury and bladder injury. In such cases, a shift to laparotomy may be necessary. Herein, we report a case involving a rectal injury that occurred from the incorrect insertion of a vagi pipe. This complication led to a rectal incision, which was successfully repaired using a hemostatic clip during a postoperative colonoscopy.

　In laparoscopic total hysterectomy (TLH), several methods of specimen retrieval exist, including vaginal retrieval, retrieval through a small incision in the abdominal wall and the use of morcellator. While vaginal retrieval does not create new wounds, it demands skill and time, particularly when retrieving a large uterus. It also carries the risk of perineal and vaginal wall lacerations and entrapment of the intestinal tract. In this report, we present a case of inadvertent removal of an ovary during the transvaginal retrieval of the uterus in TLH. The patient, a 50-year-old woman, was referred to our hospital with a diagnosis of uterine fibroids resulting in excessive menstruation. TLH was performed for uterine fibroids. Preoperative imaging and intraoperative findings indicated normal bilateral ovaries, prompting the decision to preserve them. After hysterectomy, the transvaginal retrieval of the uterus was conducted through traction with forceps and using a scalpel and cooper for sectioning. After suturing of the vaginal segment, the patient experienced bleeding from the right pelvic funnel ligament area due to accidental removal of the right ovary, which had become interspersed with fragmented uterine tissue. Upon reviewing the operative video, it became evident that during transvaginal retrieval, the right ovary had been positioned underneath the uterus, leading to tearing of the pelvic funnel ligament as it was pulled into the vagina along with the uterus. During TLH, transvaginal retrieval of the uterus should be performed with extreme care due to the risk of adjacent organs becoming entrapped in the vaginal canal.

　Cervical ectopic pregnancy can now be detected relatively early using diagnostic ultrasound technology, but some cases are not detected early and require a hysterectomy due to major bleeding. We report a case in which the uterus was preserved using laparoscopic temporary clipping of the bilateral uterine and ovarian arteries.

　A 32-year-old gravida 1 para 0 woman was suspected of having an ectopic pregnancy in the cervix. She was hospitalized and had decreased levels of human chorionic gonadotropin (hCG) after two cycles of methotrexate (MTX). She was discharged from the hospital but readmitted due to persistent bleeding four weeks after MTX treatment had been initiated. Surgery was performed, during which the uterine and ovarian arteries were temporarily clipped laparoscopically. Bleeding was minimal while curettage of the endocervical canal was performed, and hemostasis was maintained even after the arterial clips were released. The patient recovered well postoperatively, and the hCG level normalized.

　Although conservative treatment with MTX is effective for asymptomatic cervical pregnancy, some patients require surgical intervention. However, any bleeding that occurs is often difficult to stop without performing a hysterectomy. Uterine preservation for this patient was accomplished with laparoscopic temporary clipping of the bilateral uterine and ovarian arteries. It is important to treat cervical pregnancy in a manner that preserves fertility. Laparoscopic temporary clipping of the bilateral uterine and ovarian arteries is minimally invasive and preserves fertility. The procedure can also be performed on obstetric patients who have conditions that may cause massive bleeding, such as placental retention. The technique for exposing the uterine artery is especially important to master and is part of the procedure for safely performing a laparoscopic hysterectomy.

　Although heterotopic pregnancy (HP) is a very rare condition in the natural ovulation cycle with an incidence of approximately 1/30,000 cases, the incidence has been increasing to up to 1/100 cases by worldwide adoption of assisted reproductive therapy. Risk factors include multiple embryo transfer and the use of oocyte induction. Laparoscopic surgery (LS) has been reported as an effective diagnostic and therapeutic option, and almost 60-80% of pregnant women could deliver their live babies after LS.

　In this report, we present the patient characteristics, operative results, and pregnancy outcomes of four HP cases treated by LS in our affiliated institutions from January 2015 to March 2020. Of the four cases, two suspected cases at preoperative examinations could be successfully diagnosed by LS.

　Three cases had an ectopic mass at the fallopian tube and underwent salpingectomy. The other case was found to be an ectopic ovarian pregnancy and underwent partial ovariectomy. No major perioperative complication occurred in all cases. Two patients delivered healthy babies at term, while one resulted in spontaneous abortion before LS, and the other one underwent abortion after 11 weeks of LS. In conclusion, laparoscopic surgery is a reasonable diagnostic and therapeutic option for HP. We need to adequately explain to patients the risks and benefits of LS, preoperative complications, and expected pregnancy outcomes before the surgery.

　Placental site trophoblastic tumor (PSTT) is a rare trophoblastic disease in which intermediate trophoblastic cells form a mass in the lumen and myometrium of the uterus. PSTT is characterized by relatively low hCG levels and chemotherapy resistance. Symptoms include amenorrhea and irregular genital bleeding, but there are few other clinical symptoms. In this study, we report a case of PSTT diagnosed by laparoscopic surgery for a uterine tumor.

　The patient was 28 years old, G2P1. Her chief complaint was amenorrhea at adminstration. The blood level of β-hCG was 18.5 mIU/ml with no evidence of normal pregnancy. In MRI, a 32 mm mass at the uterine fundus was suspected to be a red degenerative myoma. hCG levels gradually increased and methotrexate was administered, but hCG levels did not decrease. A pelvic MRI was performed again, and the mass in the uterine fundus had shrunk and was protruding into the angle of the left uterine horn. Therefore a laparoscopic surgery was performed for diagnostic purposes. The tumor that was thought to be a myoma was removed by wedge resection of the angle of the left uterine horn because it was found to have invaded the surrounding muscle layer on gross examination. Postoperative histopathological examination revealed the diagnosis of PSTT, so a TLH was performed. No obvious residual lesions were found in the removed uterus. The postoperative hCG level was confirmed to be negative. We will continue to monitor the patient closely.

　We experienced two cases of low-grade appendiceal mucinous neoplasms (LAMNs) that were difficult to distinguish from right ovarian and fallopian tube tumors.

　Case one was diagnosed as an appendiceal tumor during the operation. Ultrasound and magnetic resonance imaging (MRI) revealed a rod-shaped tumor in the pelvis, leading us to consider the possibility of a right fallopian tube tumor or intestinal tumor rather than a right ovarian tumor. Subsequent computed tomography (CT) ruled out any continuity between the tumor and intestinal tract, eventually confirming a preoperative diagnosis of a right ovarian or fallopian tube tumor. Conversely, Case two was diagnosed as an appendiceal tumor preoperatively. In addition to the aforementioned tests, colonoscopy and barium enema examination were useful. The colonoscopy showed submucosal tumor-like swelling at the cecum, while the barium enema examination revealed a smooth oval filling defect at the cecum, both indicating the likelihood of an appendiceal tumor. Both cases were successfully treated laparoscopically.

　Among the various differential diagnoses for pelvic tumors, LAMN with appendiceal endometriosis, like Case two, is exceptionally rare, with only two cases reported in English literature to date. To the best of our knowledge, this is the first report on this condition in Japanese literature. A careful operation is crucial to avoid rupture and subsequent pseudomyxoma peritonei. Collaboration with other departments is essential for accurate evaluation and treatment. Furthermore, a minimally invasive approach for appendiceal tumors may become increasingly popular in the future, ensuring careful and effective operations.

　Epithelioid trophoblastic tumor (ETT) is classified as an intermediate trophoblastic tumor. Like placental site trophoblastic tumor, ETT is rare and is caused by tumorigenesis of intermediate trophoblastic cells. In this case report, we described a 32-year-old patient with ETT, diagnosed by hysteroscopic biopsy, and treated by total laparoscopic hysterectomy. The patient survived without recurrence after surgery. The patient had two pregnancies and two vaginal deliveries at the ages of 26 and 29 years. A transvaginal ultrasonography showed a hyperechoic area on the posterior wall of the uterus, and thus, endometrial biopsy was performed. Histopathologic examination suspected a placental remnant, but a definitive diagnosis was not reached, and the patient underwent hysteroscopy to obtain a definitive diagnosis. The hysteroscopic examination revealed white thickened tissues on the posterior wall of the uterus, which was biopsied. Histopathologic examination revealed a honeycomb-like proliferation of round, mononuclear atypical giant cells and hyaline degeneration of the interstitium. Immunohistochemical staining was positive for placental alkaline phosphatase (PLAP). Consequently, ETT was diagnosed. The CT showed no evidence of lymph node enlargement or distant metastasis. Management involved laparoscopic surgery, which confirmed the absence of disseminated lesions in the abdominal cavity, laparoscopic total hysterectomy, and bilateral salpingectomy. The patient has been followed up regularly, including monitoring of hCG and CT. Two years have passed without any postoperative recurrence. The hysteroscopic observation and precise excision of the lesion led to the diagnosis of ETT and provided important information for treatment planning.

We present a case of a 52-year-old patient with persistent cervical intraepithelial neoplasm I (CIN I) positive for HPV type 16. Since the patient was taking immunosuppressants after liver transplantation, exacerbation of CIN was suspected. A total hysterectomy was planned; however, first puncture using umbilicus was considered difficult because of severe adhesion of upper abdominal wall due to liver transplantation. Therefore, a total hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES), which is an approach from the vagina, was planned. Although the vaginal wall was narrow due to nulliparous, it was confirmed that there were no adhesions within the pelvis. A hysterectomy with vNOTES was performed. In laparoscopic surgery, if intraperitoneal adhesions are suspected, organ damage upon the first puncture is a problem, but vNOTES reached the abdominal cavity safely. vNOTES was considered useful and safe for hysterectomy in a patient with suspected severe intra-abdominal adhesion.

We recently encountered a case of postoperative chylous ascites after total laparoscopic hysterectomy for uterine leiomyoma. The case involved a 47-year-old woman who had undergone total laparoscopic hysterectomy and bilateral salpingectomy for leiomyoma of the uterus. Histopathological examination revealed leiomyoma without any malignant tumors. The patient was referred to our hospital, where she presented with a considerable amount of milky white ascites. After excluding carcinomatous peritonitis, ureter rauma, bowel injury, and bacterial peritonitis, we made the diagnosis of chylous ascites due to a high level of triglycerides in the ascites. Oral feeding of the patient was stopped, and she received intravenous hyperalimentation and subcutaneous injection of octreotide. The presence of ascites decreased gradually and eventually disappeared after restart of food intake. Recurrence of the ascites was not observed. Most cases of chylous ascites after gynecologic surgery involve patients who have undergone retroperitoneal lymph node dissection. However, there has been no case of chylous ascites after benign gynecologic surgery. When ascites are found after benign gynecologic surgery, not only carcinomatous peritonitis, ureter trauma, bowel injury and bacterial peritonitis, but also chylous ascites, should be considered.

　We report a case of laparoscopic removal of a cystic uterine fibroid in a 42-year-old woman (G3P3). Transvaginal ultrasonography revealed a giant cystic tumor in the pelvis. The ovaries were unremarkable bilaterally; therefore, we suspected a tubal or peritoneal tumor and performed laparoscopic surgery. Intraoperatively, we observed a large cystic tumor continuous with the anterior uterine wall, with normal bilateral adnexa. We performed cystectomy, and the patient was diagnosed with cystic leiomyoma and has shown no recurrence postoperatively. Cystic uterine fibroids are rare and may mimic uterine adnexal tumors. Laparoscopic surgery as a diagnostic treatment was considered to be useful from the viewpoint of curability and minimal invasiveness.

　We report the case of a 70-year-old woman who presented with chronic severe abdominal pain, possibly caused by a torsion that developed into a fistula between a tumor and her bladder after an ovarian tumor torsion. The patient noted the development of pyuria, unresolved by antibiotics. Cystoscopy revealed a torose lesion in the bladder, and magnetic resonance imaging revealed bilateral ovarian teratoma and bladder penetration. Gynecologists and urologists performed a laparoscopic surgery. Intraoperatively, the greater omentum adhered to the bilateral ovarian tumors and torsion of the ovarian tumor pedicle. We performed a bilateral adnexectomy, with partial cystectomy under cystoscopy control. Pathological examination revealed mature ovarian teratomas, with inflammation on the bladder wall.

　Although various types of surgeries have recently been performed using robotic surgery, experienced doctors who can provide guidance are few. The introduction of a tele-mentoring system under the guidance of experienced physicians can provide good medical care regardless of the location and is expected to improve patient outcome. However, many medical institutions are reluctant to introduce such systems owing to weak network systems and complicated procedures. Therefore, we devised a new online video guidance system using Zoom video communications that can be easily implemented by anybody. Additionally, we examined the feasibility of our new system in this study.

　In our hospital, five surgeries were performed using an internet connection with an experienced physician at a remote site sharing images identical to those of the surgeon through Zoom video communication.

　No line delays were observed and communication between the physicians was satisfactory. This system allows physicians to draw lines or letters on the shared screen through a Zoom video communications tool during the operation, which helps in verbal guidance. The robotic surgery was completed in all patients with safe outcomes.

　In conclusion, our new system is feasible and is expected to be a method of improving physicians' skills and providing high-quality medical care regardless of location.