ロボット手術の弱点を挙げるとすると、１番はInstrumentが高コストであることであると考えられる。我々はコスト節約の対策として、「Dual Force Bipolar法」を用いたロボット手術を行なっている。この手技の特徴や工夫、成績について報告する。

　Force Bipolarとは２つのモードを使い分けることで、BipolarとしてもNeedle DriverとしてもRetraction armとしても用いることが可能となるInstrumentである。当科のロボット手術はda Vinci XiもしくはXで（１）Force Bipolar、（２）Endoscope、（３）Monopolar Scissors、（４）ProGrasp Forcepsおよび助手の補助ポートの５ portで行い、縫合時に（３）をNeedle Driverに入れ換えて行っていたが、コスト節約のために（４）もForce Bipolarとして、縫合時にInstrumentを入れ換えずに（１）（４）で縫合する方法へ変更した。左右ともにBipolarで行うことで、右上部靭帯・右基靭帯の処理なども従来法よりも容易に処理可能となったが、注意点として、踏み間違いによる誤焼灼には注意が必要である。この方法開始以降の同一術者の良性RASH/RSCではほとんどの症例（RASH94％，RSC89％）で完遂可能であり、手術成績も従来法と同等で、合併症も認めず、また一般的なTLH/LSCよりも消耗品のコストを低く抑えることが可能であった。またInstrumentを入れ換えずに手術完遂可能であることから助手負担の軽減や入れ換え時特有の他臓器損傷などの合併症がないことも利点の１つである。「Dual Force Bipolar法」により、低コスト・高完成度・高安全性のda Vinci手術が可能となりうる。

　腹腔鏡下仙骨腟固定術（LSC）では、腟内に挿入した腸ベラの押し込みの強さ・角度の調整や膀胱剥離の終点の目安であるAa点の内診などが十分な剥離操作の完遂に重要である。術者がこれを適宜行うことで適切な操作・評価が可能となるが、ロボット支援下腹腔鏡下仙骨腟固定術（RSC）では術者は術野から離れたコンソールで操作しているため、この重要な操作を第２助手に依存することとなることが現実的だと思われる。術者の的確な口頭指示が必要となるが、教育施設などでは第２助手は初期研修医などが担当していることも多く、例えばAa点の内診などは信頼度が低くなってしまい、結果的に不十分な剥離で終了となってしまう症例もあると思われる。

　我々は上記のRSCの弱点を克服するために、膀胱剥離の終点の目印としてぺアン鉗子でAa点を挟鉗・把持し、これを第２助手に適宜動かしてもらいメルクマールとして膀胱剥離を行うことで、第２助手が誰であっても術者はコンソールから動くことなく、十分な膀胱剥離を行うことが可能となると考えた。また、LSCと同様に腸ベラの挿入や気膀胱なども併用している。

　剥離の終点を第２助手の触覚ではなく、全員でモニターで共有可能な視覚的な目標とすることで、十分な膀胱剥離を完遂することができると思われる。

Objective: Our department introduced robot-assisted sacrocolpopexy (RSC) for pelvic organ prolapse in December 2022. Initially, RSC was performed with four arms and one assistant port (4a-RSC), but we modified this to three-arm RSC (3a3i-RSC) without the third arm to reduce interference between the arms. Later, we introduced the double bipolar method and remodified the system to a three-arm, two instrument RSC (3a2i-RSC). We reviewed the surgical outcomes of each modification of the RSC.

Methods: We retrospectively evaluated the records of 30 women who underwent RSC by the same surgeon at our hospital between December 2022 and October 2024, divided into three groups: 4a-RSC (3 cases), 3a3i-RSC (11 cases), and 3a2i-RSC (16 cases). The records were statistically analyzed for patient age, number of trimesters, BMI, operative time, console time, specimen weight, and blood loss. Costs were also compared between groups.

Results: Operative and console times were significantly shorter in the 3a2i RSC group than in the other two groups (operative time: 4a-RSC 348 min vs 3a3i-RSC 300 min vs 3a2i-RSC 215 min; console time: 234 min vs 192 min vs 149 min). In addition, the cost of 3a2i-RSC was reduced by approximately 82,000 yen compared to 4a-RSC.

Conclusion: The three-arm, two-instrument RSC had the advantages of improved cosmetics and reduced costs by reducing the number of arms and instruments used, as well as preventing potential errors associated with instrument replacement. In addition, it did not prolong operative time or increase blood loss, and the quality of the operation seemed to have been maintained.

Total laparoscopic hysterectomy (TLH) is associated with a higher frequency of ureteral injury and vaginal cuff dehiscence than abdominal total hysterectomy. The follow-up period after TLH varies by institution and attending physician. We conducted a retrospective study based on medical records to determine whether complications occurred during or after the follow-up period of TLH performed for benign diseases at our hospital. The subjects were 304 patients who underwent TLH for benign indications at our hospital from 2017 to 2021. The median follow-up period was 180 (range 80-298) days. There were no cases of ureteral injury. Vaginal cuff dehiscence occurred in three patients (1.0%), and all three required revision transvaginal surgery. The onset of vaginal cuff dehiscence was less than one month in two cases and six months postoperatively in one case. Four patients visited the department between the end of the consultation and one year and six months postoperatively, and only one (0.3%) required treatment for a hypertrophic scar in the umbilical region. The median follow-up period for TLH with good progress at our hospital was six months. We followed the medical record of each case from the end of the consultation to one year and six months postoperatively, and found that no complications requiring early intervention had occurred.

Objective: Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) have become increasingly common treatments for pelvic organ prolapse (POP). However, performing sacrocolpopexy can be challenging in patients with intra-abdominal adhesions or obesity. At our institution, we have been performing pectopexy, in which a mesh is fixed to the iliopectineal ligament, as an alternative procedure in such cases. We retrospectively evaluated cases of robot-assisted pectopexy performed at our hospital to determine the usefulness of the procedure as an alternative to sacrocolpopexy.

Methods: Cases that occurred between March 2022 and July 2024 were evaluated, analyzing factors such as age, BMI, operative time, blood loss, intraoperative and postoperative complications, and recurrence of POP. Quality of life was assessed using the Japanese version of the Pelvic Floor Distress Inventory Short Form (J-PFDI-SF20).

Results: In total, 16 cases were evaluated. The median age of the patients was 74 (range: 63～79) years, and the median BMI was 24.1 (range: 18.3～35.9) kg/m². Preoperative POP-Q stages were stage II in five cases, stage III in seven cases, and stage IV in four cases. The median operative time was 145 minutes (range: 118～219), and the median blood loss was 0 ml (range: 0～120). One case of bladder injury occurred as an intraoperative complication. Postoperative POP-Q stage improved in all cases. According to the J-PFDI-SF20 assessment, scores improved from a median of 22 points (range: 9～61) preoperatively to 4.5 points (range: 3～14) at 12 months, with no recurrence observed.

Conclusion: The results of robot-assisted pectopexy at our institution were favorable, suggesting that robot-assisted pectopexy could be a useful alternative in cases where sacrocolpopexy is difficult. Further accumulation of cases and long-term evaluation of treatment outcomes are necessary.

Objective: We retrospectively investigated the evolution of surgical procedures and surgical outcomes following total hysterectomy (TH), and discussed the background of an increase in the number of THs performed, especially in laparoscopic surgery.

Materials and Methods: The surgical procedures for TH performed at Fukushima Red Cross Hospital from 2002 to 2023 and the surgical outcomes and occurrence of complications of total laparoscopic hysterectomies (TLH) performed since 2013 were reviewed.

Results: Laparoscopic surgeries have accounted for more than half of all surgeries since 2012, and the number of laparoscopic surgeries performed has been increasing year on year since 2013. A detailed examination of the surgical outcomes of 609 TLHs performed since 2013 showed significant decreases in blood loss during surgery and the occurrence of complications. In addition, there was a significant increase in the proportion of smaller uteri (200g or less).

Conclusion: It is thought that the main reason for the increase in TH is due to a shift from laparoscopically assisted vaginal hysterectomy (LAVH) to TLH. With the spread of GnRH antagonists and dienogest, it was previously thought that medical treatment would become the mainstay of treatment for benign uterine tumors, but with the rapid spread of TLH and the growing awareness of its minimally invasive nature and safety, it appears that the number of patients who prefer or choose surgical therapy is also increasing.

Objective: Vaginally assisted NOTES hysterectomy (VANH) is challenging in cases with pouch of Douglas adhesions. This study aimed to evaluate the accuracy of preoperative MRI in predicting these adhesions to aid surgical decision-making.

Method: We retrospectively analyzed 10 VANH and 10 retrograde total laparoscopic hysterectomy (TLH) cases performed between January and April 2024. MRI findings were assessed by two evaluators (a gynecologist and a radiologist) based on seven criteria including uterine retroflexion, vaginal vault elevation, and bowel tethering. Findings were compared with surgical observations.

Results: All retrograde TLH cases had adhesions, whereas no adhesions were found in VANH cases. Retrograde TLH showed more positive MRI findings (mean: 3.4 vs. 0.6). Bowel tethering and plaque-like low-intensity signals on the uterine serosa were the most reliable indicators of pouch of Douglas adhesions. The agreement rate between evaluators was 88.6%.

Conclusion: Our findings suggest that MRI effectively predicts pouch of Douglas adhesions. Key findings, such as bowel tethering and serosal plaque-like signals, may be useful in selecting the safest surgical approach, thereby reducing complications and improving outcomes.

　Pelvic organ prolapse often leads to urinary retention, but rarely to serious urinary tract infection. In this report, we describe a case of laparoscopic sacrocolpopexy for urinary tract infection due to urinary retention caused by pelvic organ prolapse, which developed into an iliopsoas muscle abscess and was difficult to manage preoperatively.

　The patient was 68 years old, (gravida, 2; para, 2), and visited our department for surgery for pelvic organ prolapse. Since she was able to urinate, she was managed as an outpatient. She visited our department again 31 days after her first visit, with complaint of fever, back pain, and left hip pain. Computed tomography (CT) led to diagnosis of iliopsoas abscess and she was admitted to the hospital for management. After admission, the patient underwent CT-guided drainage and antimicrobial therapy. The infection was controlled relatively quickly, but long-term rehabilitation was required, and the patient was transferred to a rehabilitation hospital on day 59 of admission. One month after discharge from the hospital, the iliopsoas abscess had completely disappeared on CT, and laparoscopic sacrocolpopexy was performed 6 months after discharge. The operation was performed in the supine position due to leg opening restrictions, with an operative time of 285 minutes and a blood loss of 60 ml. We removed the bladder catheter on postoperative day 1 without urinary retention, and the patient was discharged from the hospital on postoperative day 5 without any signs of infection.

　In this case, we experienced an iliopsoas abscess due to urinary retention associated with pelvic organ prolapse and a laparoscopic sacrocolpopexy after healing. Pelvic organ prolapse is often associated with urinary retention, and patients who require a prolonged surgical wait should be managed with the risk of developing serious complications in mind, as in this case.

　We present a case of small bowel injury that occurred during laparoscopic surgery in a 45-year-old multiparous woman with a history of prior laparotomy and severe adhesions. She had undergone cesarean section and hysterectomy and developed left ovarian cysts that required the laparoscopic surgery. During the initial laparoscopic access, the serosa of the small bowel, which was adhered to the umbilicus, was inadvertently injured. This serosal injury was not repaired immediately, leading to further damage during manipulation and necessitating small bowel resection with functional end-to-end anastomosis. In cases of laparoscopic surgery with severe adhesions, such as those with prior midline incisions, the risk of bowel injury during the initial approach is notably higher. Preoperative evaluation using ultrasound to detect the sliding viscera sign can help assess adhesions between the abdominal wall and bowel, while alternative entry points such as from above the umbilicus can mitigate injury risks. These approaches are essential for safer surgical outcomes in high-risk patients. This case emphasizes the importance of recognizing and promptly repairing serosal injuries intraoperatively to prevent further complications, particularly in patients with extensive adhesions.

　Lobular endocervical glandular hyperplasia (LEGH) is a rare benign hyperplastic lesion of the cervix that frequently arises from an upper lesion. Differential diagnosis of LEGH and minimal deviation adenocarcinoma (MDA) using imaging, cervical cytology, and biopsy is challenging. Cervical conization may help in the differential diagnosis of LEGH and MDA; however, conization involving an upper cervical lesion thins the remaining cervix, leading to uterine perforation during subsequent laparoscopic hysterectomy. Here, we report a case of LEGH that required additional resection of the remaining cervix and parametrial connective tissue during laparoscopic hysterectomy because of cervical perforation perioperatively. A 42-year-old uniparous woman with a multi-cystic cervical lesion was referred to our facility for suspected LEGH. Diagnostic cervical conization revealed LEGH with positive surgical margin; therefore, we performed laparoscopic hysterectomy. As we cut parametrium using the vessel-sealing system, we cut the endocervical tissue and accidentally perforated the cervix. Thus, we performed additional resection of the bilateral parametrial connective tissue that included the remaining cervix, following the procedure of the vesico-uterine ligament as performed in radical hysterectomy. The pathological diagnosis of the uterus was LEGH and the surgical margins were negative. Resected tissues showed no evidence of LEGH. In laparoscopic hysterectomy performed after conization, surgical techniques should be adjusted considering thinning of the remaining cervical tissue. The surgical technique used in radial hysterectomy helped to remove the residual cervix and parametrial tissue.

　Injuries to the external iliac vessels during total laparoscopic hysterectomy (TLH) often occur during lateral expansion of the uterine pia mater and pelvic lymph node dissection. In this case, we experienced external iliac vein injury during vaginal wall incision.

The patient, a 38-year-old woman, gravida four para four, had been treated for adenomyosis with LEP, but her pelvic pain worsened and she decided to undergo TLH.

　During the right-to-left incision of the anterior vaginal wall before hysterectomy, the shaft of the monopolar slid against the anterior wall of the uterus, and the hook at the tip of the monopolar bounced to the left side and injured the left external iliac vein. Since there was severe bleeding from the injured area, we identified the bleeding site and grasped it with forceps. Then, two Z sutures were performed and hemostasis was achieved. Blood loss was 920 ml (without transfusion), and operating time was 219 minutes. The postoperative course was uneventful, and the patient was discharged on the fifth day.

　In this case, the external iliac vein was unexpectedly damaged during incision of the anterior vaginal wall. Large vessel injuries can occur not only during perivascular procedures, but also accidentally during procedures away from the vessels. We believe that patients'invasiveness can be reduced by always being vigilant for large vessel injuries and, if they do occur, by reacting calmly and quickly stopping the bleeding.

　This report describes a rare case of simultaneous intrauterine and Douglas fossa peritoneal pregnancy after artificial insemination, treated by laparoscopy. The patient was 35 years old with a history of two pregnancies and one delivery. The pregnancy was achieved by ovulation induction and artificial insemination. At seven weeks' gestation, she developed lower abdominal pain. Transvaginal ultrasound revealed a suspected heterotopic pregnancy in the uterus and left fallopian tube, along with massive intra-abdominal bleeding. Emergency laparoscopic surgery was performed. A uterine manipulator could not be used and the Douglas fossa was not visible. A 2-0 Prolene suture with a straight needle was punctured through the left abdominal wall. The needle was advanced intraperitoneally to the right epiploic appendices to suspend the sigmoid colon and secure the visual field. No abnormalities were found in the bilateral adnexa. A chorionic component was found implanted in the peritoneum of the Douglas fossa, diagnosed as a peritoneal pregnancy. Adequate exposure allowed blunt dissection of the tissue and hemostasis to be achieved without injury to surrounding organs. Postoperative recovery was uneventful and the patient delivered a healthy baby at 38 weeks' gestation. Peritoneal pregnancies are difficult to diagnose and have a higher mortality risk than other ectopic sites. In this case, the peritoneal pregnancy had ruptured, resulting in hemorrhagic shock, and laparoscopic surgery was performed. Sigmoid colon elevation provided adequate exposure, allowing safe removal of the villous tissue and hemostasis.

　A 45-year-old woman with a 40 mm right ovarian cyst initially presented with fever and lower abdominal pain, leading to suspicion of pelvic peritonitis. However, examination of dynamic contrast-enhanced CT scan showed signs of pelvic inflammatory disease. Despite conservative treatment with antibiotics, the patient's condition worsened. Laparoscopic surgery and adnexectomy were performed, revealing yellowish-brown ascites and mild peritonitis, though no clear evidence of ovarian cyst rupture was found.

　The presence of mild edema and inflammation in the right adnexa, left fallopian tube, and appendix led to their removal. Yellowish-brown ascites persisted even after extensive intra-abdominal lavage, particularly from the dorsal surface of the left upper abdomen. A BTB test paper, which changed color to blue, indicated alkaline fluid in the ascites, suggesting an intestinal content leakage.

　Consultation with a gastrointestinal surgeon revealed a 3-mm perforation in the small intestine, with no signs of intraoperative injury, indicating an idiopathic small intestinal perforation. The perforation was successfully repaired, and the patient was discharged without complications. Notably, the use of the BTB test paper in the operating room facilitated an early diagnosis of small intestinal perforation in this case of unexplained generalized peritonitis.

　Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a widely performed, minimally invasive procedure. However, transvaginal access to the abdominal cavity can be difficult for physicians, carrying the risk of bladder or rectal injury. We encountered 16 cases of Vaginally Assisted NOTES Hysterectomy (VANH) between April 2023 and April 2024. We report three cases in which we could not complete VANH and changed the procedure.

　Case 1. A 41-year-old woman with para four who had undergone two previous cesarean sections. She had excessive menstruation because of a uterine myoma. We incised the cystouterine fossa peritoneum, and placed the GelPOINT V-Path. Upon initiating pneumoperitoneum, we realized we had reached into the bladder. We performed a laparotomy, a total hysterectomy, and a bladder repair. Cases 2 and 3 had no previous surgeries. Due to the presence of multiple uterine fibroids and hypermenorrhea, VANH was selected. They had a thick peritoneum of Douglas fossa, which was difficult to reach intraperitoneally. Therefore, we placed a trocar at the umbilicus and found rectal adhesions. We stopped VANH and performed a total laparoscopic hysterectomy.

　For VANH, our selection criteria included: a history of vaginal delivery, less than fist-sized uterus, and no history of endometriosis or rectal surgery. However, in case 1, there was an adhesion between the cystouterine peritoneum and bladder due to a previous cesarean section, and in cases 2-3, there was a firm adhesion due to endometriosis, which went unrecognized before surgery. We discuss the case selection and intraoperative approach to prevent complications.

Patient: A 36-year-old woman with a BMI of 34 who had no significant past medical or family history. Six months after undergoing laparoscopic simple total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for stage IA endometrial cancer, contrast-enhanced CT scan revealed a pelvic lymph node enlarged to 15 mm in short diameter. FDG-PET/CT scan was performed to differentiate recurrence, revealing FDG accumulation in the same area, which raised suspicion for metastasis. Laparoscopic exploration and biopsy were performed for diagnostic and therapeutic purposes. During the surgery, no significant abnormalities were noted in the abdominal or pelvic cavity aside from postoperative changes. An enlarged lymph node was identified and excised from the area caudal to the left deep iliac circumflex vein. Pathological examination of the excised specimen revealed no malignant findings; however, numerous small granulomas were observed in the enlarged lymph node. Ziehl Neelsen staining showed a few positive acid-fast bacilli, leading to a diagnosis of mycobacterial lymphadenitis. Since all other tests for mycobacteria were negative, no additional treatment was administered, and a policy of careful observation was adopted.

Conclusion: This case illustrates a solitary mycobacterial lymphadenitis, which had not been previously reported as a condition requiring differentiation from malignant diseases in FDG-PET/CT scans. Laparoscopic biopsy proved useful as a method for differentiation in lymph nodes where malignancy could not be ruled out by FDG-PET/CT, as it provides better visualization and magnification.

　Inguinal endometriosis is very rare, and a percutaneous approach is predominantly used for surgical resection. Here, we report a case of laparoscopic excision for inguinal endometriosis.

　A 50-year-old female patient was treated with dienogest for endometriosis by her previous physician, who referred her to our hospital because of pain and mass sensation in the right inguinal region. She had right inguinal region tenderness, and transabdominal ultrasonography revealed a 13×11 mm echogenic free space in the same region. A blood test revealed a CA125 level of 13.9 U/ml, while a magnetic resonance imaging scan showed a hematoma-like mass, approximately 10 mm in diameter, inside the femoral arteriovenous vein in the right inguinal region, leading to the diagnosis of right inguinal endometriosis. Additionally, she had uterine fibroids and a left ovarian endometriotic cyst and thus simultaneously underwent a total laparoscopic hysterectomy, right oophorectomy, left salpingo-oophorectomy, and right inguinal mass resection in the Department of Surgery. The round ligament in the right inguinal canal was expanded peripherally, and an approximately 1 cm mass lesion in the right inguinal region was excised. The specimen was pathologically diagnosed as endometriosis. Reportedly, 91% of patients with inguinal endometriosis had intraperitoneal endometriosis. Therefore, intraperitoneal endometriosis should be considered on diagnosis of inguinal endometriosis, and a laparoscopic approach may be effective for surgical resection.

Introduction: In recent years, total laparoscopic hysterectomy (TLH) has become increasingly popular. Compared to abdominal total hysterectomy (ATH), TLH has been reported to require shorter hospital stays and is associated with reduced blood loss and less postoperative pain. However, TLH carries a higher risk of complications such as ureteral injury and compartment syndrome, especially in obese patients. Here, we report a case of TLH complicated by postoperative subcutaneous scalp hematoma and alopecia.

Case: The patient was a 44-year-old woman with a history of diabetes mellitus and hyperlipidemia, and a BMI of 30, with gravida 3, para 2 obstetric history. She presented with frequent urination as the main complaint. She was referred to our department after being diagnosed with uterine fibroids. Following a course of pseudo-menopausal therapy, TLH was performed. After anesthesia recovery, the patient complained of occipital pain. On postoperative day 1, ultrasonography revealed a subcutaneous fluid collection in the occipital region, diagnosed as a subcutaneous hematoma. The hematoma gradually decreased in size and resolved by postoperative day 24, but alopecia developed in the affected area.

Discussion: Although rare, alopecia has been reported as a postoperative complication. In this case, the development of a subcutaneous scalp hematoma followed by alopecia suggests that pressure-induced circulatory impairment was the likely cause. Risk factors for postoperative alopecia include prolonged surgery, intraoperative hypotension, blood loss, anemia, and hypothermia. Additionally, the effects of the Trendelenburg position, obesity, and even psychiatric conditions have been implicated.

Conclusion: While postoperative alopecia is rare and typically self-limiting, it can occasionally become permanent, emphasizing the need for preventive measures.

　The adoption of laparoscopic surgery for managing uterine fibroids has significantly increased in recent years. However, iatrogenic ectopic uterine fibroids may occur in up to 1% of cases following laparoscopic tumor shredding with a morcellator. Here, we report the case of a patient who underwent a laparoscopic total hysterectomy with tumor shredding performed without in-bag containment. Ten months post-surgery, the patient began experiencing abdominal pain. Ultrasonography and MRI revealed multiple intraperitoneal tumors. GnRHa hormone therapy was administered to reduce estrogen levels, and a reoperation was performed to establish a definitive diagnosis. Pathological examination confirmed uterine sarcoma stage IIIb. The patient underwent chemotherapy and continued treatment for 35 months following surgery. This case highlights the risks associated with tumor shredding during laparoscopic total hysterectomy and myomectomy. Intraperitoneal scattering poses a significant risk, particularly in cases of parasitic myoma or undiagnosed malignant tumors. We recommend considering in-bag shredding techniques whenever feasible to minimize the potential for tumor dissemination and improve patient outcomes.

　We report a case of intra-abdominal abscess caused by gonococcal peritonitis that was treated by laparoscopic abscess drainage. The patient was 19 years old, nulligravida and unmarried. She presented at our hospital with a complaint of severe lower abdominal pain. We diagnosed pelvic inflammatory disease, and antibiotic treatment was started. On the second day of hospitalization, gonococcal PCR in the cervix was found to be positive. On the fifth day, CT imaging performed because of persistent fever revealed an intra-abdominal abscess, and laparoscopic drainage of the abscess was performed on the same day. Adhesions between the bowel and uterine adnexa were observed, and dissection of the adhesions led to spontaneous drainage of the abscess. On the third postoperative day, Pseudomonas aeruginosa was detected in a culture of the abscess. We changed the antibiotic to ceftazidime for susceptibility. The patient's symptoms improved, and she was discharged from the hospital on the seventh postoperative day. Laparoscopic drainage of the abscess was useful for this patient with intraabdominal abscess caused by gonococcal peritonitis.

　Endometriosis is a benign gynecological disorder characterized by the implantation of ectopic endometrial tissue outside the uterine cavity. Endometriotic lesions are commonly found in the pelvic cavity. Extra-pelvic endometriosis occurs much less frequently, and diaphragmatic endometriosis is estimated to affect 0.19-1.5% of all endometriosis cases.

　We present a case of diaphragmatic endometriosis diagnosed by laparoscopic surgery. A 45-year-old woman was referred to our hospital for the investigation of a right ovarian tumor. Enhanced computed tomography incidentally revealed nodular lesions in the right diaphragm and left pelvis, which suggested malignant dissemination. Positron emission tomography showed slightly abnormal fluorine-18-deoxyglucose accumulation. A surgical biopsy was required to confirm the diagnosis, and laparoscopic surgery was performed. Intraoperative findings suggested endometriosis, and a diaphragmatic mass was partially resected. Histopathological and immunohistochemical findings were consistent with endometriosis without malignant transformation.

　It is quite difficult to make a preoperative diagnosis of diaphragmatic endometriosis due to the lack of specific radiological characteristics. This case highlights the importance of considering endometriosis in the differential diagnoses when a diaphragmatic lesion is found, and the efficacy of laparoscopic biopsy to confirm the diagnosis.

　In recent years, there has been an increasing trend to continue antithrombotic therapy perioperatively, considering the risks associated with interruption, but definitive guidelines are lacking. We report a case of hysteroscopic myomectomy in a patient with a submucosal uterine fibroid who was on direct oral anticoagulants (DOACs). The patient, a 34-year-old nulligravid woman, presented with menorrhagia due to a submucosal fibroid, initially treated with a low-dose oral contraceptive. She subsequently developed deep vein thrombosis of the lower extremity and pulmonary embolism. Despite anticoagulation therapy, residual thrombus remained in the lower leg veins, necessitating continued DOAC administration. Due to ongoing menorrhagia, a decision was made to perform hysteroscopic myomectomy. DOAC therapy was discontinued only on the morning of the surgery, and a local vasopressin injection was administered intraoperatively to minimize blood loss. The procedure was completed safely with minimal bleeding, DOAC therapy was resumed three hours postoperatively, and the patient's postoperative course was uneventful. Management of uterine fibroid surgery in patients undergoing anticoagulation therapy requires individualized assessment of the surgical approach and perioperative interruption of anticoagulation. There are few case reports on this topic, and additional data are needed to evaluate the safety of hysteroscopic procedures during ongoing anticoagulation therapy.

　The squamocolumnar junction in postmenopausal women, the SCJ often regresses into the cervix; hence, conization may require deeper excision because the lesions may remain on the uterus. However, deep resection increases the risks of bleeding, infection, and cervical canal stenosis. Herein, we report the case of a postmenopausal woman who underwent laparoscopic total hysterectomy for uterine perforation during conization.

　The patient was a 57-year-old woman (G2P2) who had reached menopause at 48 years of age and had a history of depression and nervous exhaustion. She had CIN2 and tested positive for HPV16, 31, 33, and 39, prompting conization. Perioperatively, active bleeding was noted immediately after the cervical excision, which was difficult to control using sutures. Transvaginal ultrasonography revealed a hematoma in the right Douglas pauch, which raised the suspicion of uterine perforation. Emergency laparoscopy confirmed a perforation extending from the lower uterine body to the right side of the cervix with bleeding from the ascending branch of the right uterine artery. Suture repair was challenging because of the significant tissue loss; thus, TLH was performed. In this case, conization may have caused the uterine perforation. Therefore, if bleeding is difficult to stop during cervical resection or if transvaginal ultrasonography shows echogenic free space in the Douglas pauch laparoscopy should be performed to suspect intraperitoneal bleeding due to uterine perforation. Laparoscopy is useful for the reliable diagnosis of intra-abdominal bleeding due to uterine perforations.

Objective: The umbilicus is commonly used for the insertion of the first trocar in laparoscopic surgery, but detailed anatomical information is limited. This study aimed to elucidate umbilical anatomy to improve the open technique for trocar insertion.

Method: The subumbilical region was observed from within the abdominal cavity using a 4K camera during both open and laparoscopic procedures. The open trocar insertion approach was further assessed through close-up observation, and the umbilical region was examined using magnetic resonance imaging (MRI). Refinements to the open technique were made, and its utility was evaluated by comparing insertion times under three conditions using the Mann-Whitney U test: (1) a resident before modification, (2) the same resident after modification, and (3) two qualified gynecologists in endoscopic surgery.

Results: Intraabdominal observations revealed a depression directly below the umbilicus, with increased preperitoneal fat compared to the surrounding area. The tissue in this depression appeared thin, as ambient light passed through it when the camera light was turned off. Close-up observation during open insertion revealed findings suggestive of peritoneal fusion, which were corroborated by MRI evidence. The refined “preperitoneal fat compression” method, developed based on these anatomical insights, significantly reduced the resident’s insertion time (median) from 446.5 s to 139.5 s (p = 0.048), which was no significant difference with the time taken by the qualified gynecologists (125.5 s, p = 0.65).

Conclusion: Preperitoneal fat compression, a refined open trocar insertion method based on new anatomical insights about the umbilicus, improves the safety of first trocar insertion.

　Over the past few years, laparoscopic colposuspension has become an option as native tissue repair (NTR) surgery for pelvic organ prolapse, but there is no established surgical procedure. Reported here is a colposuspension technique involving reefing of the uterosacral ligaments via vaginal nature orifice transluminal endoscopic surgery (vNOTES) that we performed at this facility. After hysterectomy using vNOTES, guide sutures are laparoscopically placed in both uterosacral ligaments (USL), and the sutures are pulled tight against the abdominal wall to lift the ligaments, completing the vNOTES procedure. Using the USL traction suture as a guide, the ligaments are then sutured with non-absorbable sutures and secured to the vaginal stump via a transvaginal procedure. This technique enables visualization of the procedure and it has a low risk of serious surgical complications. The vaginal stump is elevated in an anatomically appropriate direction, and the non-absorbable sutures should remain effective for a prolonged period. This procedure is useful in treating pelvic organ prolapse in the form of uterine prolapse.