To prevent serious complications during operative hysteroscopy, organized and systematic training is necessary. Various vegetable models have been reported in the literature as safe and inexpensive training models for hysteroscopic surgery. However, the vegetable models have not been used for hysteroscopic training in Japan. We describe a hysteroscopic training model using small Japanese pumpkin that is widely available in Japan. Preparation of the pumpkin model includes creating a canal into the inner cavity, removing the seeds, and applying a return plate electrode on the pumpkin skin.
Microwave treatment softens the firm flesh of the Japanese pumpkin so that resection can be done easily. Under video monitoring, loop resection and rollerball ablation are performed in the inner cavity. Various techniques required for hysteroscopic surgery can be learned using this model.

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Aim: To develop an effective self-training tool for operative hysteroscopy.
Methods: A resectoscope model of convenient size (20cm in length) was developed for self-training of operative hysteroscopy. The model consists of a wooden body, a plastic sheath, an elastic spring system, and a metal cutting loop. The spring system moves the cutting loop forward and back in the sheath, similar to a real resectoscope.
Results: The model is easily assembled from readily available materials. The cost for a training model is approximately 1 US$. The model facilitates hand-foot-eye coordination, clockwise rotation of a resectoscope while cutting, long cutting procedures, and palpation of intrauterine lesions using a cutting loop. Ninety-three percent of trainees considered the model effective for self training.
Conclusion: The resectoscope model is an effective and inexpensive self-training tool for operative hysteroscopy. Various techniques required for hysteroscopic surgery can be trained using this model.

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A 16-year-old female patient presented with chief complaints of secondary amenorrhea for 7 months and low abdominal mild pain. Magnetic resonance imaging, computed tomography, and ultrasonography showed a polycystic tumor of the right ovary about 5 cm in diameter with slight septal thickening and a thickening of the endometrium. The thickening of the endometrium persisted until the first surgical procedure. A benign ovarian cyst was diagnosed, with a mucinous cyst adenoma the most likely diagnosis. She underwent a laparoscopic cystectomy. The histopathologic examination revealed a granulosa cell tumor (adult type) . Post-operative magnetic resonance imaging after showed no evidence of recurrence. A laparoscopic oophorectomy was performed 4 months after the first operation, at which time no recurrent lesions were identified. The residual right ovary had no granulosa cell tumor on histopathologic findings. No adjuvant treatment was administered. After the first operation, the patient's menstrual cycles became regular. She is alive and well 2 years after the second surgery with no evidence of recurrence.
A polycystic ovarian tumor and abnormal menstruation, especially with persistent thickening of the endometrium, is possibly a granulosa cell tumor. In such a case, a laparotomy, not a laparoscopy, is the operative method of choice.

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Latex can cause life-threatening allergic reactions in patients with a history of a rubber allergy. We describe a case of severe anaphylactic shock due to latex in a woman who was undergoing laparoscopic surgery.
A 33-year-old woman with a uterine leiomyoma was admitted for a total laparoscopic myomectomy. The operation was converted to a laparoscopic-assisted myomectomy (open-laparotomy) because there were severe adhesions around the uterus. During the surgical procedure, the patient experienced the sudden onset of oxygen desaturation, severe hypotension, and bradycardia. We interrupted the surgery and the patient was given 100% oxygen. The diagnosis of anaphylaxis was not evident during the early period of resuscitation. First, we suspected the cause of shock was a pulmonary gas embolism; we then ruled out other causes, such as cardiogenic shock and hemorrhagic shock. Therefore, we performed a transesophageal echocardiography and chest X-ray. We noticed that her face and chest were flushed. We made a diagnosis of anaphylactic shock and suspected that latex was the cause of anaphylaxis. We changed the urinary catheter, which was made from latex, for a silicone catheter. The patient was resuscitated successfully with manual ventilation, intravenous fluids, and medications. The patient had undergone two laparotomies uneventfully, and later we determined she had atopy.
To prevent anaphylactic shock during surgery, it is important to identify potential risk factors, such as atopy, adverse reactions to foods, and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latexfree environment.

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Mature cystic teratomas are common, mostly benign ovarian tumors, which account for about 20% of all ovarian neoplasms; however, it is also known that malignant transformation occurs in approximately 1% to 2% of those cases. It has been reported that elevated squamous cell carcinoma antigen (SCC) is an indicator of the malignant potential of an ovarian mature cystic teratoma, therefore, special attention must be taken during surgery of those cases with an elevated SCC preoperatively.
We reported two cases of mature cystic teratomas with elevated SCC who underwent laparoscopic surgery. Although the SCC levels were >5.0ng/ml in our cases, the preoperative pelvic CT and MRI did not show any malignant characteristics.
Preventative measures were taken to avoid the potential rupture of tumors, and those tumors were resected laparoscopically without leakage of tumor content into the pelvic cavity. Histopathologic studies confirmed a benign teratoma. The SCC levels were normalized 1-2 months after surgery.
In these cases, it is controversial whether laparoscopic surgery is appropriate because of the potential interruption of capsule integrity during surgery of a possible malignant tumor when an endoscopic approach is chosen.
Laparoscopic surgery can be safely performed in cases in which if a malignant possibility is incontrovertible, intensive preoperative efforts to select less probable malignant case have been taken, and securing measures against the possible rupture of tumor is available.

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Introduction: Endometrial polyps are a common cause of abnormal uterine bleeding. In some cases, premalignant or malignant lesions are identified within polyps in a biopsy or polypectomy specimen. Hysteroscopic polypectomy, a minimal invasive surgical procedure, has the added benefit of accurate pathologic diagnosis based on complete removal of the lesion. Herein we report two cases of successful treatment of stage Ia endometrial carcinoma pathologically-diagnosed by hysteroscopic polypectomy.
Case: Case 1: A 49-year-old patient was referred to our hospital for a cervical polypoid lesion protruding from the external cervical os with abnormal vaginal bleeding. Ultrasound and MRI revealed a pedunculated endometrial polyp-like mass in the uterine cavity occupying the cervical canal. The histologic diagnosis after hysteroscopic resection showed an endometrial carcinoma (G2) confined to a small portion of the base of the polypoid lesion, with the prominent portion being a benign polyp. She underwent a semi-radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy. Case 2: A 37-year-old patient with a history of secondary infertility was referred to our hospital for selective chromotubation by hysterofiberscopy, in order to clarify the hysterosonographically-diagnosed left tubal obstruction. Hysterofiberscopic examination revealed a tiny polyp without abnormal vessels in the uterine cavity, which showed well-differentiated endometrial adenocarcinoma (G1) by hysteroscopic surgery. The patient was started on continuous oral medroxyprogesterone acetate (600 mg day for 6 months), and subsequently underwent laparoscopically-assisted myomectomy, followed by ovarian stimulation with clomiphene citrate. She gave delivered a male infant by cesarean section at 37 weeks gestation, weighing 2.3 kg.

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BACKGROUND: The use of conservative surgical techniques to treat ectopic pregnancies has been reported to increase the rate of incomplete trophoblastic tissue removal and subsequent regrowth.
CASE: Postcoital acute abdominal pain occurred in a woman treated with a laparoscopic linear salpingotomy without suturing for an ampullary ectopic pregnancy 20 days previously. The patient developed clinical symptoms despite satisfactory declining hCG levels. An emergency laparotomy was performed and a 600 ml hemoperitoneum was present The bleeding site of the prior salpingotomy was identified and closed. A few trophoblastic cells were noted in the intratubal clot during pathologic evaluation.
CONCLUSION: This case demonstrates that postoperative rupture and bleeding from the fallopian tube with an ectopic gestation can occur in spite of declining and low hCG values. It is conceivable that the hemorrhage at the site of the prior salpingotomy was caused by not only minimal residual trophoblastic tissue, but also mechanical stimulation during sexual intercourse. It is necessary to evaluate the additional benefit of suturing during linear salpingotomy for ectopic gestations.

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Background: Laparoscopic conservative surgery has become popular for the treatment of benign ovarian cystic tumors. The risk of recurrence is higher after conservative surgery; however, malignant recurrence is rare. We report a case of recurrence in the form of an invasive ovarian carcinoma after laparoscopically-assisted ovarian cystectomy for a mucinous cystic tumor of borderline malignancy.
Case presentation: A 34-year-old nulliparous patient underwent a laparoscopically-assisted ovarian cystectomy. The histological examination revealed a mucinous cystic tumor of borderline malignancy. No additional treatments were performed. Twenty-one months later, she relapsed with a mucinous cystadenocarcinoma. She underwent radical surgery (supracervical hysterectomy, bilateral adnexectomy, partial omentectomy, appendectomy, and pelvic and para-aortic lymphadenectomy) and platinum-based chemotherapy.
Conclusion: Malignant recurrence may occur in the same ovary after cystectomy in cases of mucinous cystic tumor of borderline malignancy. If a mucinous cystic tumor of borderline malignancy is revealed after laparoscopic conservative surgery, the patient should be treated by unilateral salpino-oophorectomy at least and receive strict follow-up.

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It is important that the course of the ureter is noted during gynecologic surgery. Operations via laparoscopy are considered to be minimally invasive. However, such is not the case when other internal organs are injured during laparoscopic surgery, resulting in a deterioration in the patient's quality of life. We report here three cases of intraligamental uterine myomas which were removed laparoscopically without ureteral injury. The risk of ureteral injury is increased while enucleating broad ligament myomas. It is essential that gynecologic surgeons understand the local dissection of female pelvic organs. A water dissection technique is useful to avoid injury to the ureter.

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Since the dawn of Japanese laparoscopic surgery at our hospital, we have made an effort to pioneer the latest equipment. We have performed 4, 069 laparoscopic cases in 16 years and reported a variety of complications at a single center. All cases were performed using an open-method. The ratio of gasless-to-gas methods in the cases was 6-to-4. We used a uterine manipulator in all cases, except the pregnant cases. We evaluated patients who had complications associated with laparoscopy within 5 days of surgery.
The rate of all complications was 2.58% (105/4, 069) . Three patients (0.074%) had urinary tract injuries, 3 patients (0.074%) had intestinal injuries, and 2 patients (0.049%) had vascular injuries in the pelvis. However, the only severe consequences of the complications involved a nephrectomy after a ureteral injury. Twenty-four of the patients (0.59%) were febrile postoperatively and 17 patients (0.42%) had wound hematomas. None of these cases had any severe consequences. We had one case that required a blood transfusion intraoperatively.
The rate of laparoscopic complications is reported to range between 0.5% and 3%. In our hospital, there was a similar incidence of complications, but there were fewer severe complications. The rate of unintended laparotomy was 1.74% (71 cases) because of severe adhesions, obesity, and unexpended hemorrhage.
We believe that this report will be of use to gynecologists with an interest in reducing the number of gynecologic laparoscopic surgeries.

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Lymphocele formation, a common complication of pelvic lymphadenectomy, can produce considerable morbidity. Treatment is sometimes problematic. We treated a 54-year-old woman with a symptomatic lymphocele by laparoscopic marspialization.
She developed hydronephrosis due to a retroperitoneal lymphocele following total abdominal hysterectomy and pelvic lymphadenectomy for endometrial cancer. Because conservative therapy, including percutaneous or transvaginal drainage, had a risk of bowel perforation, we chose laparoscopic marsupialisation under transvaginal ultrasonographic guidance. The 6-cm collection was opened, and the edges were cauterized and sutured with the surrounding peritoneum. The postoperative course was satisfactory and the hydronephosis resolved. This highly effective, minimally invasive procedure offers a significant advantage to the patient.

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A unicornate uterus with a rudimentary horn is a rare Müllerian duct abnormality. This uterine anomaly may cause variable gynecologic complications, including hematometra, endometriosis leading to acute pelvic pain, infertility, and obstetric complications, including miscarriage, preterm delivery, and rupture of the uterus, especially when the pregnancy implants in the rudimentary horn. To date, the standard treatment for the latter condition has been laparotomy, as patients usually experience massive abdominal hemorrhage or pregnancies too large to attempt laparoscopic removal. We report a case of a non-communicating rudimentary uterine horn pregnancy which was preoperatively diagnosed by ultrasonography, hysterofiberscopy, and magnetic resonance imaging, and then subsequently resected laparoscopically.

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The shortage of obstetricians and gynecologists is becoming serious in the Tohoku region. An important task as a local organizer of medical practitioners is for each medical school to make an effort to help the students with an interest in obstetrics and gynecology. Gynecologic endoscopic procedures have advanced and spread rapidly in recent years. The introduction of the endoscope makes the field of obstetrics and gynecology more attractive. We introduced a program of endoscopic surgery using a training box to medical education. The training box was set up in the Department of Medicine Skills lab of Tohoku University Hospital for use by 5^th year medical students. After an introductory video display, the students attempted to operate with devices in the training box. Practice was done based on the syllabus in four stages, culminating in suturing in the box. After practicing for 1 hour, the practice symposium was limited limit to 5 minutes. Every student worked with seriousness which had not been previously demonstrated. Further, practice guidance by the tutor, who was certified as a recognition medicine by this society, was extremely popular with the student. We conclude that introduction of practicing endoscopic surgery using a training box to the medical education deepens the students' interest in obstetrics and gynecology.
Such a training device might be useful also for student recruitment to obstetrics and gynecology in the future.

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Objectives: The true incidence of pulmonary embolism (PE) in patients undergoing laparoscopic surgery for gynecologic malignancies is unknown. The aims of this study were to determine the incidence of PE in laparoscopically-treated cancer patients, to compare the results with those treated with open surgery, and to investigate the efficacy of low-dose unfractionated heparin (LDUH) to prevent the occurrence of PE.
Methods: Thirty-three patients with gynecologic malignancies were laparoscopically-treated (laparoscopy group [LS] ) . The procedures included paraaortic-pelvic lymphadenectomy in all surgeries, along with hysterectomy, salpingo-oophorectomy, omentectomy, and/or appendectomy, depending on the cases. In all patients, elastic stockings (ES) and intermittent pneumatic compression (IPC) were used for postoperative thrombosis prophylaxis. In the latter half of the study period, LDUH was added to ES + IPC. Within 10 days postoperatively, lung perfusion scintigraphy was performed for the detection of PE, irrespective of clinical symptoms. The results were compared with those obtained from 20 control patients treated with traditional open surgery (laparotomy group [LT] ) .
Results: Pulmonary embolism developed in 5 cases (15.1%) in the LS group and in 3 cases (15.0%) in the LT group. Of 8 cases with PE, only 1 case presented a clinical symptom, but the other 7 cases showed abnormal findings only in lung perfusion scintigraphy. The addition of LDUH resulted in a smaller number of PE detected in both the LS (from 4/14 [28.6%] to 1/19 [5.7%] ) and LT groups (from 2/10 [20%] to 1/10 [10%] ), but the differences were not statistically significant.
Conclusion: The incidence of PE after laparoscopic and open surgery for gynecologic cancer was not different. Appropriate preventive measures against PE should be taken, even in laparoscopic surgery of gynecologic malignancies, as the incidence of PE is high and can be lethal.

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Objectives: The purpose of this study was to compare early oral intake and the traditional timing of feeding after laparoscopic gynecologic surgery.
Method: One hundred seventy-eight patients underwent laparoscopic gynecologic surgery at Osaka Rosai Hospital between October 2004 and August 2007, and were allocated to two groups. One group was the traditional feeding group (89 patients), who began clear fluids on the first postoperative day and were advanced slowly to a solid diet. The other group was the early feeding group (89 patients), who also began clear fluids on the first postoperative day and received a regular solid diet. These groups were compared with respect to the incidence of adverse effects, the length of time until passage of gas and defecation, and the dietary intake.
Result: The demographic characteristics of the two groups were similar. The incidence of postoperative complications was 4.5% (4 patients) of women in the traditional feeding group and 2.2% (2 patients) of women in the early feeding group. There were no cases of ileus in either group. There were also no differences in the length of time elapsed for passage of gas and defecation, and the dietary intake between the two groups.
Conclusion: In our setting, early advancing of diet postoperatively after laparoscopic gynecologic surgery did not increase adverse effects. Early oral intake seems to be safe, and traditional feeding is not necessary.

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Although the prevention of pulmonary embolism is critical during the perioperative period, achieving a zero-rate of postoperative venous thrombosis is difficult, even with preventive measures. According to European and American reports, thrombosis occurs in 1% to 2% of patients, despite preventive measures. In this study, we prospectively implemented various preventive measures for postoperative venous thrombosis and compared the effects of these measures to determine the most effective measures.
The subjects (a total of 2, 222) were all of the patients who underwent surgery between January 2002 and June 2007, except for those who were pregnant. Of these, 411 patients who underwent surgery during 2002 did not receive any preventive measures, and these patients were considered the control group (Group A) . One hundred and ninety-one patients who underwent surgery between January and July 2003 received preventive measures that were determined based on their risk grades using the Risk grade-preventive measures table (Group B) . Elastic stockings and intermittent pneumatic compression (IPC) were used in all patients in this group. In 1, 620 patients who underwent surgery between July 2003 and June 2007, D-dimer was measured before surgery, and the Risk grade-preventive measures table was used (Group C) . If the D-dimer level exceeded 0.5 μg/mL, ultrasonography of the lower extremities was performed to check for the presence of deep vein thrombosis (DVT) . For patients in whom DVT was identified prior to surgery, IPC was not used. The three groups were compared with respect to the incidence of postoperative pulmonary embolism and the incidence of shock.
Postoperative pulmonary embolism was observed in 0.7% of patients in Group A, but it was observed in 3.1% of patients in Group B, which was significantly higher. The incidence in Group C was 0.06%, which was significantly lower than Groups A and B. Shock was observed in 0.5% of patients in Group A, but there was no case of shock in Group B or C.
Some patients in Group B had asymptomatic DVT, and IPC was used in those patients. As a result, in each case the thrombus was dislodged and carried through the bloodstream, causing pulmonary embolism. As such, in Group C D-dimer was measured in all patients prior to surgery, and ultrasonography of the lower extremities was performed in those who had a D-dimer level higher than the standard. For patients who had DVT prior to surgery, IPC was not used, and anticoagulant therapy was conducted prior to and following surgery. These preoperative and postoperative measures significantly reduced the incidence of thrombosis during the observation period, which indicates that our preventive measures are very effective.

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Objective: The laparoscopic management of borderline ovarian tumors is controversial. We examined the outcomes of six cases with borderline ovarian tumors diagnosed after laparoscopic cystectomy for benign ovarian tumors.
Methods: Among 127 patients who were treated by laparoscopic cystectomy for benign ovarian tumors between 1998 and 2006 at the University of the Ryukyus Hospital, 6 women were pathologically-diagnosed with borderline ovarian tumors. We retrospectively investigated the clinical outcomes of these patients.
Results: The mean age was 42.5±23.3 years (range, 23-74 years), and the tumor size was 15.7±6.5 cm (range, 8.1-25.0 cm) . Laparoscopic cystectomy was performed in four cases who wished to preserve fertility. The remaining two postmenopausal women were treated by laparoscopic bilateral salpingo-oophorectomy. All six cases had stage Ic (b) tumor due to intraoperative tumor rupture (three mucinous, two serous, and one carcinoid) . All of the patients were surveyed without re-laparotomy for surgical staging or postoperative chemotherapy. Two of 4 women who desired pregnancy became pregnant within 1 year, and 3 recurrences as borderline tumors occurred in patients treated by laparoscopic cystectomy, 3, 14, and 21 months after the initial laparoscopic surgery. Two recurrent patients underwent laparoscopic oophorectomy, and the other recurrence was treated by salpingo-oophorectomy and lymph node sampling. The patients remained disease-free for 44, 27, and 56 months.
Conclusions: Although long-term follow-up is indispensable, patients with borderline ovarian tumors can safely undergo conservative surgery.

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Hysteroscopic procedures are best performed when the endometrium is thin, but it is not always possible to schedule the procedure at the appropriate time. The aim of this study was to describe the endometrial effects of medical pre-treatment with oral contraceptives (OC) and increase the ease and safety of the procedure. Patients underwent pretreatment with lowdose OC beginning on menstrual days 1-3. The surgery was scheduled on days 7-25 of the second cycle of OC administration. Estradiol (E2) and progesterone (P4) on the first and the second cycle of OC administration were statistically similar (p<0.01) . There was unpredictable bleeding in 27% of the patients on the first cycle of OC administration. The endometrium surrounding the lesions of interest was almost always thin and flat, such that the operating conditions were excellent. Pretreatment of the endometrium before surgery with OC has been shown to reduce the thickness and vascularity of the endometrium, decrease the amount of tissue removed, improve visualization, reduce operating time and fluid deficits, and increase the ease and safety of procedure. The basis for the effect is due to OC with minimal doses of E2 and P4, thus causing endometrial atrophy.

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[Purpose] The purpose of this study was to examine the effect of a patient's body shape on laparoscopic surgery. We focused on body mass index (BMI) as an index of body shape and evaluated its relevance to the outcome of laparoscopicallyassisted vaginal hysterectomy (LAVH) .
[Methods] The subjects for this study were 546 patients who underwent LAVH between July 1996 and December 2007. They were categorized into 4 groups based on the BMI calculated from their height and body weight, as follows: <18.5 (group A: underweight) ; 18.5-25 (group B: normal) ; 25-30 (group C: overweight) ; and 30< (group D: obese) . The duration of surgery, blood loss during surgery, post-operative hospital stay, and intra-operative and post-operative complications were compared among the groups. Also, in order to evaluate the relationship between BMI and duration of surgery, blood loss, and the weight of the removed uterus, the correlation among each parameter was examined.
[Results] No significant difference was observed in the surgical outcomes and complications among the four groups. No strong correlation was found between BMI and various surgical outcome parameters.
[Discussion] Generally, obesity can make surgery difficult by leading to narrowing of operative field and delayed wound healing. However, the benefit of laparoscopic surgery in obese cases has rarely been reported. Also, being underweight has been reported to be a factor which increases complications during laparoscopic surgery. In this study, BMI did not remarkably affect the outcome of LAVH. LAVH is a safe surgical method unrelated to the body habitus of patients.

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Objective: Minor bleeding that occurs for several days around ovulation is called intermenstrual or ovulation bleeding, and is classified as a type of menometrorrhagia with no organic abnormalities. We investigated the possibility that this condition may be related to intrauterine abnormalities.
Methods: Sixty-one patients with regular menstrual cycles (24-48 years of age), who complained of intermenstrual bleeding (IMB) comprised the study group. Examinations included transvaginal ultrasonography (USG) and hysteroscopy during the early follicular phase.
Results: Diagnoses based on hysteroscopy revealed endometrial polyps (E. polyps) in 55 patients (90.2%) . Including 4 cases of submucosal myomas and 2 cases of cervical polyps in the uterine cavity, intrauterine lesions were found in a total of 59 patients (with overlap in 2 patients; 96.7%) . E. polyps were observed in 6 patients who had no abnormalities on USG. For the 53 patients who onlyhad E. polyps, the findings on USG primarily included irregular echo patterns in patients with ≤4 polyps and tumor images in patients with 1-3 polyps (p<0.001) . Tumor images were observed for polyps ≥5 mm. In patients who were examined closely, IMB usually occurred prior to follicle rupture.
Conclusion: E. polyps and other protrusive lesions in the uterine cavity were observed in 96.7% of patients with IMB. These lesions were thus considered a possible cause of IMB. Organic abnormalities must thus be considered as causes of IMB. In addition, as not all protrusive lesions in the uterine cavity could be confirmed based on USG alone, hysteroscopy appears necessary for complete detection.

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Objective: Whether a diagnostic uterine dilatation and curettage [D&C] is necessary in cases of suspected ectopic pregnancy [EP] remains controversial. Some reports insist that a D&C is mandatory because the inaccuracy of presumed diagnoses of EP is quite high. Other reports claim that a D&C is redundant because the patient must undergo anesthesia and surgery twice if the final diagnosis is EP. At our institute, direct laparoscopic inspection without a D&C is employed in patients with suspected EP. We evaluated the accuracy of this method and the characteristics of misdiagnosed cases.
Design: Retrospective cohort analysis.
Methods: We performed a retrospective review of our gynecologic database of patients with suspected EP between 1994 and 2006. The total number of patients was 350. One hundred thirty-four patients who underwent a diagnostic D&C or a laparotomy were excluded and the final number of patients examined was 216. The patients were classified into 4 subgroups: group A, definite EP (an ectopic fetal heart movement [FHM] was detected by ultrasound [US] ) ; group B, suspected EP with abdominal pain and abnormal findings other than an ectopic FHM by US; group C, suspected EP with pain, but no US findings; and group D, suspected EP without pain, but with abnormal US findings. The outcome was determined using the pathologic evidence of the surgical specimen.
Results: Twelve patients did not have an EP, and the overall inaccuracy rate of diagnosis was 5.6%. When examined according to subgroups, the inaccuracy rates were 3.3% (1/30), 4.1% (6/144), 16.7% (1/6), and 11.1% (4/36) in groups A-D, respectively. One case in group A diagnosed as an interstitial pregnancy was revealed to be an intrauterine pregnancy [IUP] . The final diagnosis of 1 case in group B was ovarian bleeding, but the US findings led to a misdiagnosis in the other cases. All of the misdiagnosed cases in groups C and D were revealed to be IUPs.
Conclusion: Conclusion: The direct laparoscopic diagnosis of EP is reasonable in definite or suspected cases with both abdominal pain and abnormal US findings because this necessitates anesthesia and surgery to be performed one time only. A D&C should be considered in cases with either pain or abnormal US findings.

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Sexually transmitted diseases involving chlamydia are increasing, and sterility as a chronic sequela of chlamydial infection appears to be on the rise. Prevention of progression and sequelae is possible if appropriate antibacterial drugs are given during the early period of infection. However, many cases develop so-called silent pelvic inflammatory disease (silent PID), which progresses asymptomatically from cervicitis to abdominal cavity infection. While recently performing laparoscopic ovarian drilling to treat a patient with polycystic ovary syndrome (PCOS), we observed edematous swelling and softening of bilateral ovaries. Two months later, the patient developed a large quantity of ascites and a high CA125 level. Therefore, the patient underwent further investigation and antibacterial therapy was started. The ascites disappeared soon after antibacterial treatment was given. The clinical test results and the typical filmy adhesions around the adnexa observed on subsequent laparoscopy confirmed that this patient's clinical course was due to chlamydial PID.

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A 13-year-old patient was admitted for laparoscopic resection of a right ovarian dermoid cyst. She had a history of a congenital patent urachus that connected the dome of the urinary bladder with the umbilicus. Excision of the urachus and umbilicoplasty was performed 4 days after birth. During the laparoscopic ovarian cystectomy, the first trocar was inserted in a supraumbilical incision using an open technique. Direct laparoscopic observation could not clearly identify the upper margin of the bladder. To lessen the risk of bladder injury, we distended the bladder with 300 ml of saline and identified the bladder margin. The dome of the bladder was significantly elevated, located 8.5 cm above the symphysis pubis and 4.5 cm below the umbilicus. Ancillary trocars were carefully inserted while keeping away from the bladder and the entire ovarian cyst was removed. When performing laparoscopic surgery in a patient who had congenital urachal anomalies, the dome of the urinary bladder can be unusually elevated and saline infusion may help in the identification of the bladder margin.

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Objective: We report a retrospective study of myomectomies, especially using the gasless laparoscopic myomectomy with an abdominal wall lifting system.
Method: Ninety-four women with subserosal or intramural myomas underwent LM (laparoscopic myomectomy) between 2004 and 2007. The abdominal wall lifting device was used for gasless laparoscopic surgery while partly using conventional surgical instruments.
Results: LM was successful in 90 patients: 4 patients (4.3%) had a laparoconversion. The mean size of the myoma was 6.1 cm. The mean number of myomas per patient was 2.8. The mean operating time was 176 minutes. There was no relationship between the number of fibroids and the blood loss. The mean time before conception was 8.1 months, and the spontaneous pregnancy rate was 75.0%.
Conclusion: Gasless laparoscopic myomectomy for the removal of subserosal or intramural myomas using an abdominal wall lifting device is feasible and safe.

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Introduction: We investigated the correlation among antibodies against Chlamydia trachomatis (CT) and 60 kDa C. trachomatis heat shock protein (cHSP60), the avidity index (AI; an indicator of the period of infection), and tubal pathology (such as tubal occlusion and peritubal adhesions) .
Methods: Thirty-six infertile women were enrolled in this study. The serological CT antibody titers (IgG and IgA) and the AT, together with C. pneumoniae and cHSP60 antibody titers (IgG) were evaluated by ELISA. As for tubo-ovarian structure, peritubal adhesions were evaluated in accordance with the rASRM score and tubal passage using indigo carmine was confirmed by diagnostic laparoscopy. The correlation between tubo-ovarian structure, such as peritubal adhesions and tubal, and all of the serologic indicators was investigated in a double-blind study.
Results: Thirty-six cases were categorized by the cHSP60 antibody titer into three groups (n=12: group A, 0.5 ± 0.2; group B, 1.7 ± 0.3; and group C, 4.3 ± 1.2 [COI] ) . As for the serologic indicators, the CT IgA titer was significantly higher in group C (group A, 1.5 ± 1.1; group B, 2.0 ± 1.6; and group C, 5.5 ± 3.4 [COI] ) . As for tubo-ovarian structure, the number of cases in which the rASRM score was < 2 points with unilateral tubal passage was significantly lower in group C (group A, 10/12; group B, 8/12; and group C, 1/12 [case] ) .
Conclusion: The results that the cHSP60 antibody titer correlates significantly both with CT IgA and the degree of the tuboovarian structure's damage suggest that the cHSP60 induced by active infection may have some effects on tubal pathology.

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月経時に増強する血尿、排尿時痛を伴う膀胱子宮内膜症に対して、腹腔鏡下膀胱部分切除により症状の改善を認めた症例を経験したので報告する。42歳、未経妊未経産。肉眼的血尿を主訴に近医泌尿器科を受診し、膀胱鏡により腫瘍性病変を認めた。腫瘍生検で膀胱内子宮内膜症と診断され、精査加療目的に当院へ紹介となった。骨盤MRI像で膀胱と子宮前壁の境界部に約4cmの腫瘤性病変を認め、子宮内膜症膀胱内浸潤の診断で腹腔鏡下手術を行った。膀胱と子宮前壁の境界部に癒着を認め、これを剥離後、膀胱を切開、腫瘍を肉眼的に確認し、膀胱部分切除を行った。膀胱鏡で創部に異常がないことを確認、術後14日目に尿道カテーテルを抜去し、経過良好で術後16日目に退院となった。術後8ヶ月経過、再発症状、血尿、排尿困難等泌尿器系症状は認められていない。

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2000年から2007年までの過去8年間での、子宮内膜症性嚢胞の術後再発率、再発に寄与する因子を明らかにすることを本研究の目的とした。対象は当院で子宮内膜症性嚢胞に対して、嚢腫核出及び片側付属器切除術を施行した患者で、術後6ヶ月以上経過観察可能であった患者98例を対象とした。嚢胞の取り扱いは嚢胞摘出が63例、片側付属器切除が35例であった。術後超音波断層法で径3cm以上の嚢胞ができたものを再発症例とした。術式別の累積再発率の算出はカプランマイヤー法を有意差検定はログランクテストを用い検討し、さらに再発の危険因子として年齢、嚢胞径、BMI、嚢胞の両側性、r-ASRMスコアを挙げコックス回帰分析を用いてどの因子が再発に寄与するかを解析した。対象症例において平均観察期間は31ヶ月。嚢胞摘出例 (63例) に限ると観察期間中の再発は17.4% (11/63) 、術後5年間での累積再発率は22.6%であった。嚢胞摘出例において、さきに挙げた再発の危険因子の中ではr-ASRMスコアが高い症例が有意に再発と相関していた。

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Massive ovarian edema (MOE) was first described by Kalstone et al. in 1969 as a“massive, solid enlargement of the ovary associated with interstitial edema, without neoplastic change.”A literature review revealed>100 reported cases, and although most of the patients were young, they usually underwent removal of the affected ovaries. We report a case involving a 23-year-old woman admitted to our department with sudden right lower abdominal pain. The ultrasonographic study showed an enlarged right ovary, approximately 6 cm in diameter, with multiple small low echoic lesions. A CT scan showed no malignant features of this mass. With a preoperative diagnosis as MOE with right adnexal torsion, we performed a laparoscopy. As we had expected, the right adnexa was twisted and the right ovary was gray and swollen. Within 10 minutes of detorsion, we noted that the color of the ovary had improved. Postoperatively, she was pain-free and began taking oral contraceptives to diminish the size of the ovary. Eight months after the surgery, the ovary was near-normal in appearance by an ultrasonographic study and there has been no recurrence of pain. Since there are very few cases of young women with neoplasms, to avoid the unnecessary removal of the ovary, we should suspect MOE when we care for young women with abdominal pain and a solid, enlarged ovary. Although there is no established treatment for MOE, laparoscopy is a powerful diagnostic tool. Moreover, oral contraceptives postoperatively may be effective in preventing the recurrence of MOE.

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Between 2007 and 2008, 11 patients>65 years of age underwent laparoscopy for ovarian tumors without malignancy or a prolapsed uterus at our center. The patients were treated according to our clinical pathology-based patient management strategy.
The average length of postoperative hospitalization was 7.2 days. Two patients developed postoperative complications, but there were no long-term sequelae. Even though the risk of preoperative complications is higher in elderly patients, laparoscopy is a less invasive procedure and is a safe and useful approach in these patients. Moreover, in this series, there were no barriers to clinical pathology-based treatment, which is also useful for elderly patients.

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Objective: Tubal disease is the main cause of infertility and 10-25% of the cases are due to proximal tubal obstruction. Hysterosalpingography (HSG) is part of the standard diagnostic work-up for infertility; however, the diagnostic accuracy of HSG has been criticized. Selective hydrotubation is a useful tool by which to evaluate tubal obstruction. The aim of this study was to estimate the diagnostic findings and fertility outcomes after selective hydrotubation and to determine the prognostic significance of Chlamydia trachomatis infection for recanalization.
Patients: Fifty-seven women undergoing selective hydrotubation for proximal tubal obstruction detected on HSG between January 2000 and December 2007 in the Department of Obstetrics and Gynecology of the University of Tokyo were studied.
Results: Of the proximally occluded tubes detected by HSG, 41.9% were shown to be patent after selective hydrotubation. The success rate of recanalization by selective hydrotubation in unilateral obstruction (62.5%) was significantly higher than in bilateral obstruction (17.6%; P<0.01) . After recanalization by selective hydrotubation, 33.3% of the patients conceived without IVF or ICSI. With respect to C. trachomatis infection, the success rate of recanalization in patients with negative chlamydial antibodies was significantly higher (65.6%) than in patients with positive chlamydial antibodies (30.4%; P<0.01) .
Conclusions: Selective hydrotubation is a useful tool in the diagnosis and treatment of proximal tubal obstruction detected by HSG. Especially in cases of proximal tubal obstruction with negative chlamydial antibodies, the success rate of recanalization can be high.

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Maintenance of an adequate laparoscopic view by an assistant is a fundamental aspect for performing effective laparoscopic surgery. We describe a self training model for obtaining optimal laparoscopic view using a web camera and a bench trainer. Trainees held a needle-holder with the right hand and introduced a needle into the trainer, sutured a sponge pad, and withdrew the needle; while the left hand held the web camera for monitoring the operating field. They were videotaped during the procedure and were scored before and after training by independent observers using an objective assessment of a technical skill scoring system. Results showed the scores after training were significantly higher than before training (P=0.0021) . Thus, we conclude the self-training method could improve the skill in manipulating the laparoscope by an assistant.

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Cesarean scar pregnancy (CSP) is a comparatively rare clinical condition, but it is complicated by hemorrhage that is often difficult to achieve hemostasis following detachment or removal of the products of conception. Our aim was to preserve the uterus in a CSP, and after the systemic administration of methotrexate (MTX), removal of the conceptus with a hysteroscope was attempted.
A 35-year-old woman was referred to our hospital from another institute with a diagnosis of a cervical pregnancy CSP was diagnosed by transvaginal ultrasonography, and the serum hCG value was 37, 376 mIU/ml with a positive fetal heart beat. The serum hCG value declined gradually thereafter, although it temporarily rose to 79, 914 mIU/ml after the systemic administration of MTX. There were no symptoms, such as hemorrhage, and at the point when the serum hCG value had dropped to 2303 mIU/ml, we performed a hysteroscopic resection.
Treatment of CSP by hysteroscopy has the advantage of direct visualization of the implantation site. Hysteroscopic resection is a useful technique in selective cases.

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Blind insertion of the Veress needle and of the first trocar is a significant cause of complications in laparoscopic surgery. Despite this risk, the closed technique is more popular than the open technique. The aim of this study was to determine the thickness of abdominal wall at the umbilicus for more safety entry into the abdominal cavity. We retrospectively studied 253 patients who underwent laparoscopic gynecologic surgery between September 2006 and December 2007.
The thickness of the abdominal wall was measured intra-operatively. We then determined the relationship between the thickness of the abdominal wall and the BMI. The mean thickness of abdominal wall was 15.2 ± 5.6 mm. There was no significant correlation between the thickness of the abdominal wall and the BMI.
It has generally been thought that the entry of the first trocar from the umbilical area is comparatively safe. However, blind entry may cause serious vascular injuries. Our data suggest that there was no significant correlation between the thickness of the abdominal wall and the BMI, so caution should be exercised with trocar insertions when the abdominal wall exceeds 30 mm.

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Uterine myoma is one of the most common gynecologic benign tumors, and surgical treatment is often needed. Myomectomy is ideal for the reproductive-aged woman who desires to preserve fertility, and the laparoscopic approach is becoming increasingly popular as a minimally invasive and safe procedure. Because laparoscopic myomectomy is technically demanding, various researchers have reported criteria for the proper selection of patients for this procedure. Almost every study proposes a size of myoma as the most important exclusion criteria. In this study, we report three cases of laparoscopic myomectomies for large myomas. Precise pre-operative evaluation, GnRH analogue pretreatment, new port placement to establish a superior operative field, and pre-operative preparation of autologous blood for transfusion may enable laparoscopic myomectomy for large myomas to be a safe and feasible procedure.

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Objective: To evaluated the utility and safety of the Cavitron ultrasonic surgical aspirator (CUSA) for laparoscopic paraaortic lymphadenectomy in gynecologic malignancies.
Methods: Between January 2007 and January 2008, we performed laparoscopic treatment of gynecologic cancer in 22 patients. In all patients, laparoscopic lymphadenectomy was included in the surgical procedures. In 10 of 22 patients, CUSA was used for the dissection of the left-sided para-aortic lymph nodes. The range of lymphadenectomy was up to the renal vein for patients with endometrial and ovarian cancers, and up to the inframesentric artery for patients with cervical cancer. We analyzed the number of removed lymph nodes and the time needed for the procedure. The results in the group with CUSA and those without CUSA were compared.
Result: The number of lymph nodes removed was equivalent between the groups, irrespective of the range of lymphadenectomy. However, the operative time was shortened in the group with CUSA. We had no particular complications in either group.
Conclusion: We safely performed laparoscopic lymphadenectomy using CUSA. There is a possibility that by using CUSA, the time required for laparoscopic lymphadenectomy may be shortened.

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