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A 45-year-old multiparous woman with a STK11 mutation and a history of Peutz-Jeghers syndrome underwent radical hysterectomy and bilateral salpingo-oophorectomy for a gastric-type cervical mucinous carcinoma. Four and a half years later, blood tests revealed elevations in CEA and CA125 tumor marker levels, and computed tomography showed multiple calcifications in the peritoneum. Peritoneal dissemination was suspected, and a laparoscopic biopsy was performed. Histopathology showed a high-grade serous carcinoma, and the patient was diagnosed with a metachronous stage IIIC primary peritoneal carcinoma. She had no BRCA1/2 mutation. After chemotherapy with docetaxel, carboplatin, and bevacizumab, she achieved complete remission.

Objective To describe the anatomic and technical highlights of a novel nerve-sparing surgery in deep endometriosis (DE) using near-infrared (NIR) fluorescence technology and indocyanine green (ICG). Design Stepwise demonstration of this method with narrated video footage. Setting An urban general hospital. Patient(s) A 48-year-old woman was referred for severe chronic pelvic pain, dysmenorrhea, and pain on defecation, all of which were resistant to medication therapy. Magnetic resonance imaging revealed uterine adenomyosis and left ovarian endometrioma with DE involving the uterosacral ligament, posterior cervix, and surface of the rectum, with complete cul-de-sac obliteration. Intervention(s) An intravenous injection of 0.25 mg/kg body weight of ICG for intraoperative NIR fluorescence imaging. Ethics approval was obtained from the institutional review board at our hospital (IRB No.: 985). Main Outcome Measure(s) Evaluation of blood perfusion of DE nodule and achieving better visualization of anatomic relationship to the pelvic autonomic nerves. Result(s) The procedure was performed using the following eight steps with the da Vinci Xi surgical platform: Step 0, observing peritoneal endometriotic lesions; Step 1, adhesiolysis and adnexal surgery; Step 2, separation of the nerve plane; Step 3, dissection of the ureter; Step 4, reopening of the pouch of Douglas; Step 5, complete removal of DE lesions while avoiding injury to the nerve plane; Step 6, hysterectomy (if the patient desires nonfertility-sparing surgery); Step 7, checking for rectal injury using air leakage test and tissue perfusion; and Step 8, barrier agents for adhesion prevention. During surgery, we could easily identify ischemic nodules, which included DE and fibrosis under NIR fluorescence imaging, beyond the limits of macroscopic disease. Endometriosis or fibrosis was confirmed pathologically from all resected tissues, and resection margins of these tissues were negative for the disease. These results suggest that this technique might be feasible for objectively identifying the border between DE lesions and healthy tissue. Furthermore, the hypogastric nerve and inferior hypogastric plexus were strongly highlighted by ICG and objectively preserved with the assessment of perfusion. The patient developed no perioperative complications, including postoperative bladder or rectal dysfunction after surgery. Conclusion(s) To our knowledge, this is the first reported use of ICG during nerve-sparing surgery for gynecologic disease. Application of ICG with NIR fluorescence appears potentially useful, not only to remove DE, but also to improve nerve-sparing.

Study Objective: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE).Design: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis.Setting: A private hospital that provide primary, secondary and tertiary care.Patients: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. Interventions: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed.Measurements and Main Results: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1 to 3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P

Aim The objective of this study was to investigate the long-term oncological outcomes of minimally invasive radical hysterectomy (MIRH) for the treatment of early-stage cervical cancer retrospectively in the wake of the laparoscopic approach to cervical cancer (LACC) trial. Methods A total of 109 patients with stage IA1 with lymphovascular space involvement, IA2, and IB1 cervical cancers were included in this study. The surgical and oncological outcomes were retrospectively evaluated. All patients underwent type C MIRH with a no-touch isolation technique for cervical tumor. Results The median number of resected pelvic lymph nodes was 36 (range, 14-94), and 10 patients (9.2%) had positive nodes. One patient (0.9%) had positive surgical margins. Forty-six patients (42%) underwent adjuvant therapy. The median follow-up time was 73 months (range, 30-146 months). Five patients (4.6%) developed recurrent disease, and 3 patients (2.8%) died of cervical cancer. The 5-year disease-free survival and overall survival rates were 96.3% and 97.2%, respectively. A comparison between patients with tumor diameter ≤ 2 cm (n = 59) and those with tumor diameter > 2 cm (n = 50) did not identify any significant differences, with 5-year disease-free survival 96.6% versus 94.0% and 5-year overall survival 98.3% versus 96.0%, respectively. Conclusion In this retrospective study, MIRH with a no-touch isolation technique for stage IA to IB1 cervical cancer was a safe approach in terms of oncological outcomes. However, every surgeon who treats early-stage cervical cancer should inform each patient of the results of the LACC trial because it has an exceedingly high impact.

Study Objective Some articles have reported the surgical management of Alcock canal syndrome (ACS) using the transperineal [1] , transgluteal [2] , or conventional laparoscopic approach [ 3 , 4 ]. In 2015, Rey and Oderda [5] reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements. However, to our knowledge, there have been no reports on the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS. Design Stepwise demonstration of the technique with narrated video footage. Setting An urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe pain when sitting, cyclic pelvic pain, and gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. Magnetic resonance imaging revealed adenomyosis with neither deep endometriosis nor vascular entrapment. On the basis of neuropelveologic evaluation, the patient was suspected to be suffering from ACS owing to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament. Interventions The procedure was performed using the following 9 steps while referencing the laparoscopic neuronavigation technique [6] : step 1, opening the peritoneum along the external iliac artery; step 2, exposure of the external iliac artery; step 3, development of the lumbosacral space; step 4, identification of the lumbosacral trunk; step 5, identification of the superior gluteal nerve; step 6, identification of the sciatic nerve; step 7, identification of the inferior gluteal nerve; step 8, identification of the pudendal nerve; and step 9, transection of the sacrospinous ligament. The surgery was completed successfully without any complications, and the postoperative course was uneventful. We considered that there was no relationship between the ACS and endometriosis. The patient reported that her pain decreased gradually at postoperative month 1 and month 3, and finally the neuralgia was completely resolved at month 6. Neuropelveologic evaluation still continues every 6 months. Conclusion Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7] .

Study Objective To demonstrate how the bipolar method allows for pinpoint dissection with minimal thermal spread in a variety of challenging operative scenarios in gynecology. Design Case presentations. Setting Urban general hospital in Japan. Patients or Participants From December 2018 to April 2021, we performed 485 robotic surgeries using the double bipolar method in a variety of procedures such as hysterectomy for benign pathology, robotic sacro-colpopexy and para-aortic and pelvic lymphadenectomy for cervical and endometrial cancer. Interventions Pinpoint dissection in the case of severe Douglas Pouch adhesion or bladder adhesion, transperitoneal lymphadenectomy and extraperitoneal para-aortic and pelvic lymphadenectomy and nerve-sparing radical trachelectomy is a great advantage. These challenging procedures require the elucidation of fine structures and well as accurate separation of adhered organs. The double bipolar method is accurate, powerful and efficient with minimal thermal spread. Measurements and Main Results Only one patient who had extensive adhesion due to previous surgery required surgery from postoperative peritonitis. All other patients recovered quickly and without complications. Conclusion Monopolar scissors are a standard robotic equipment, used by the majority of surgeons. Although monopolar scissors allow for good quality dissection, thermal spread is always a concern. The thermal spread is known to be source of intraoperative complications and reducing this problem is an important concern. As a result, we implemented the double bipolar method. Not only because of its pinpoint accuracy, but also because the cutting mechanism has minimal thermal spread which is desirable especially when dissection ultra-fine structures.

Study Objective To describe the anatomical and technical highlights of a novel nerve-sparing surgery for deep endometriosis (DE) using near-infrared (NIR) fluorescence technology and indocyanine green (ICG). Design Stepwise demonstration of a technique. Setting An urban general hospital. ICG is a fluorescent dye that allows accurate, intraoperative, real-time assessment of tissue vascularization, once excited with light of a specific wavelength in the near-infrared spectrum. NIR fluorescence technology and ICG have been confirmed as feasible, safe, and useful tools to guide surgery in several settings, including colorectal and urologic surgeries. However, no reports have discussed pelvic autonomic nerve-sparing surgery using this tool in the gynecological field. Patients or Participants Stage IV endometriosis patients with parametrial involvement. Interventions An intravenous injection of 0.25mg/kg body weight of ICG for intraoperative NIR fluorescence imaging. Pelvic autonomic nerves were highlighted by ICG because these nerves are surrounded by many capillaries. Measurements and Main Results Evaluation of blood perfusion of DE nodules and achieving better visualization of anatomical relationship to the pelvic autonomic nerves. We could easily identify ischemic nodules which included DE and fibrosis under NIR fluorescence imaging, beyond the limits of macroscopic disease. Endometriosis or fibrosis was confirmed pathologically from all resected tissues, and resection margins of these tissues were negative for disease. These results suggest that this technique might be feasible for objectively identifying the border between DE lesions and healthy tissue. Furthermore, the hypogastric nerve and inferior hypogastric plexus were strongly highlighted by ICG and objectively preserved with assessment of perfusion. The patients developed no perioperative complications, including postoperative bladder or rectal dysfunction after surgery. Conclusion Application of ICG with NIR fluorescence appears potentially useful, not only to remove DE, but also to improve nerve-sparing. To our knowledge, this is the first reported use of ICG during pelvic autonomic nerve-sparing surgery for gynecologic disease.

AIM Our hospital adopted laparoscopic surgery for early-stage cervical cancer in August 1998, with robot-assisted surgery implemented in October 2013. This study aimed to compare short-term outcomes for conventional laparoscopic radical hysterectomy (LRH) and robot-assisted radical hysterectomy (RARH) and assess the technical feasibility of RARH for early-stage cervical cancer. METHODS We retrospectively compared operative time, blood loss, number of resected lymph nodes, length of postoperative hospital stay, rate of positive vaginal margin and perioperative complications between two groups of 121 patients (LRH group, n = 57; RARH group, n = 64) with stage IA2 to IIB, among 164 patients who underwent endoscopic radical hysterectomy for early-stage cervical cancer performed between January 2010 and December 2017 by an expert surgeon, excluding cases of para-aortic lymphadenectomy. RESULTS No differences in patient background, in terms of age and body mass index, were identified. For the LRH/RARH groups (mean ± standard deviation), results obtained were as follows: operative time, 211 ± 38/280 ± 59 min (P

Objective To demonstrate anatomic and technical highlights of a robot-assisted nerve plane–sparing eradication of deep endometriosis (DE). Design Stepwise demonstration of the technique with narrated video footage. Setting An urban general hospital. Interventions Laparoscopic nerve-sparing techniques as represented by the Negrar method reportedly result in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches [1] . In addition, robotic surgery has become available, and 2 meta-analyses have confirmed that robotic surgery is safe and feasible for the treatment of endometriosis, especially in advanced cases [ 2 , 3 ]. However, few papers have shown the surgical techniques for a nerve-sparing procedure using a robotic approach. The patient was a 45-year-old woman who presented with severe chronic pelvic pain and dysmenorrhea resistant to medication therapy. She had no nerve-specific complaints such as pain in the pudendal distribution or a voiding dysfunction. Magnetic resonance imaging revealed multiple uterine fibromas and adenomyosis with DE, involving the uterosacral ligament and surface of the rectum, with cul-de-sac obliteration. The parametrium was not involved in the DE. Robot-assisted nerve plane–sparing excision of DE with a double-bipolar method was performed using the following 8 steps: step 1, adhesiolysis and adnexal surgery; step 2, checking the ureteral course; step 3, separation of the nerve plane (step 3.1, dissection of the avascular layer below the hypogastric nerve, between the prehypogastric nerve fascia and presacral fascia; and step 3.2, dissection of the avascular layer above the hypogastric nerve, between the prehypogastric nerve fascia and fascia propria of the rectum) [ 4 , 5 ]; step 4, reopening of the pouch of Douglas; step 5, complete removal of DE lesions while avoiding injury to the nerve plane; step 6, hysterectomy (if the patient desires non–fertility-sparing surgery); step 7, checking for rectal injury using an air leakage test; and step 8, barrier agents for adhesion prevention. With regard to step 3, as a result of sharp dissection between avascular layers both above and below the hypogastric nerve, autonomic nerves in the pelvis were separated like a sheet with the surrounding fascia (the nerve plane). We then performed steps 4 to 6 in a step-by-step manner while avoiding injury to the nerve plane. The urinary catheter was removed within 24 hours after the surgery, and no residual urine was seen. The patient developed no perioperative complications; in particular, no postoperative bladder or rectal dysfunctions. The precise sharp dissection of the right embryo-anatomic planes on the basis of the detailed mesoanatomy seems important for improving functional outcomes in nerve-sparing surgery [5] . Conclusion Robot-assisted nerve plane–sparing eradication of DE is as technically feasible as the conventional laparoscopic approach. The step-by-step technique should help surgeons perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete. However, the latent benefits of robot-assisted nerve-sparing surgery in the treatment of DE remain uncertain.

Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.

Study Objective To examine procedures of bowel repair after accidental bowel injury during gynecologic surgery and consider the role of colostomy. Demonstrate the appropriate management of accidental bowel injuries. Design Retrospective cohort study. Setting Urban general hospital in Japan. Patients or Participants From January 2010 to December 2020, 7,154 underwent laparoscopic or robotic hysterectomy for benign pathology. From these cases, the videos of surgeries where bowel injury was experienced were viewed. Interventions 21 cases suffered an intraoperative bowel injury that may normally be recommended for colostomy. These cases were managed by same-session intraoperative repair. In one case where multiple bowel injuries occurred during vaginal retrieval, a colostomy was performed. In the other 20 cases, intraoperative repair was safely completed, and no patients experienced pan-peritonitis after the original surgery. It is important to suture the bowel in two layers. Needle driving needs to be precise with the driving and pull-through perpendicular to the bowel wall. Tissue involvement needs to be both precise and consistent across all sutures. The seromuscular suture is placed to push the mucosa into the lumen. In very severe cases we use LAR (one case). After trimming of the damaged cut end of the rectum, a double stapling technique is very effective for event free anastomosis. Measurements and Main Results One case experienced leakage from the repair site and this was resolved with drainage and no colostomy was required. All other patients had an event-free recovery. Conclusion Bowel injuries have been routinely managed by colostomy. In our series, we have examined the effectiveness of our methods of repair without using colostomy and have found that when repair is sound, colostomy is not required. Colostomy-free surgery is more patient friendly and should be practiced in scenarios where repair training is adequate and suture repair can be performed safely.

Objective To show technical highlights of a nerve-sparing laparoscopic eradication of deep endometriosis (DE) with posterior compartment peritonectomy. Design Demonstration of the technique with narrated video footage. Setting An urban general hospital. A systematic review and meta-analysis has suggested significant advantages of the nerve-sparing technique when considering the relative risk of persistent urinary retention in the treatment of DE [1] . In addition, a recent article has suggested that complete excision of DE with posterior compartment peritonectomy could be the surgical treatment of choice to decrease postoperative pain, improve fertility rate, and prevent future recurrence [2] . However, in DE, nerve-sparing procedures are even more challenging than oncologic radical procedures because the pathology resembles both ovarian/rectal cancer in terms of visceral involvement and advanced cervical cancer in terms of wide parametrial infiltration through the pelvic wall. Interventions The video highlights the anatomic and technical aspects of a fertility- and nerve-sparing surgery in DE with posterior compartment peritonectomy. After adhesiolysis and ovarian surgery, we developed retroperitoneal space at the level of promontory. The hypogastric nerve consists of the upper edge of the pelvic plexus, therefore the autonomic nerves were separated in a “nerve plane” by sharp interfascial dissection of the loose connective tissue layers both above (between the fascia propria of the rectum and the prehypogastric nerve fascia) and below (between the prehypogastric nerve fascia and the presacral fascia) the hypogastric nerve [ 3 , 4 ]. As a result of these dissections, the autonomic nerves in the pelvis were separated like a sheet with surrounding fascia. We then completely resected all DE lesions including peritoneal endometriosis while avoiding injury to the nerve plane. In a small number of our experiences, none of the patients (n = 51) required clean intermittent self-catheterization after this procedure. Conclusion Fertility- and nerve-sparing laparoscopic eradication of DE with total posterior compartment peritonectomy is a feasible technique and may provide both curability of DE and functional preservation. Our nerve-sparing technique can reproducibly simplify this complex procedure.

Objective To evaluate the effect of dienogest (DNG) in preventing the occurrence of pain and endometriomas after laparoscopic resection of uterosacral ligaments (USLs) with deep infiltrating endometriosis (DIE). Study design This retrospective analysis included 126 patients who underwent laparoscopic resection of USLs with DIE followed by postoperative administration of DNG or no medication. Every 6 months postoperatively, patients answered questions and underwent ultrasound examination to identify pain and/or endometrioma. Result There were three (5.0%) cases of endometrioma in 59 patients from the DNG group and 21 (31.3%) cases in 67 patients from the no medication group ( P = 0.0002). Pain returned to preoperative levels in eight (11.9%) cases in the no medication group. No recurrence of pain occurred in the DNG group ( P = 0.0061). Conclusion The administration of DNG after resection of USLs with DIE significantly reduces the occurrence rate of endometriosis-related pain and endometriomas.

Study Objective To report the application of the double bipolar technique in a patient with 1b1 cervical cancer who wished to preserve her fertility potential. Design After experiencing 105 cases of laparoscopic and robotic radical trachelectomy with a 5 year survival rate of 98% and the birth of 29 babies from 51 of these patients who attempted pregnancy, we introduced the double bipolar method to overcome technical difficulties of the procedure due to the necessity for precise dissection and reconstruction in the deep pelvis. We will show our operative techniques, such as nerve sparing radical trachelectomy and retroperitoneal lymphadenectomy for early invasive cervical cancer in a bloodless operative field. Setting Urban general hospital. Patients or Participants Robotic radical trachelectomy using the double bipolar method was performed in three patients with 1b1 cervical cancer. Interventions After Robotic radical trachelectomy using monopolar scissors in 30 cases of stage Ib1 cervical cancer, we considered techniques for a more bloodless operative field. The double bipolar method (DBM) was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. Using robotic Maryland forceps as a cutting device allows for pinpoint accuracy that cannot be found in other instruments. It is important for bladder and ureteral dissection and exposure of vessels. Cuts are made at a very limited point by a lightning strike mechanism, meaning there is minimal thermal spread to adjacent organs. Measurements and Main Results Blood loss was 250ml in the cases presented. In surgeries not using the DBM(n=34), the blood loss ranged from 350ml(100-1200ml). While there is no supporting data, the dissection of the ureter was very smooth. Conclusion A bloodless operative field allows for accurate dissection and can prevent intraoperative injuries. The double bipolar method is able to provide precision cutting and limit thermal spread to adjacent tissue, reducing injury and allowing for a clear operative field.

AIM We compared the short-term outcomes between conventional laparoscopic surgery (CLS) and robot-assisted surgery (RAS) to assess the technical feasibility of the latter for early-stage endometrial cancer. METHODS We retrospectively compared the perioperative outcomes between two groups of 223 patients (CLS group, n = 102; RAS group, n = 121) with early-stage endometrial cancer. Surgical procedures included hysterectomy, bilateral salpingo-oophorectomy and retroperitoneal lymphadenectomy. We analyzed the data from intrapelvic surgery alone because para-aortic lymphadenectomy was performed via conventional endoscopic extraperitoneal approach without robot for both groups. RESULTS No differences were identified in patients' age and body mass index. The mean operative time was 133 ± 28 versus 178 ± 41 min (P

Robot-assisted extraperitoneal para-aortic lymphadenectomy has been reported to be feasible option for the surgical management of gynecologic malignancy previously ( Narducci et al., 2009 ) ( Hudry et al., 2019 ). We have reported the feasibility of laparoscopic extraperitoneal total para-aortic and pelvic lymphadenectomy ( Andou, 2016 ). This article aims to show the safety of robot-assisted extraperitoneal “total para-aortic and pelvic” lymphadenectomy. The video is the staging surgery for 67-year-old woman suspected clinical stage IA ovarian clear cell carcinoma after abdominal hysterectomy and salpingo-oophorectomy. As abdominal adhesion was predicted, she was treated using robot-assisted extraperitoneal total para-aortic and pelvic lymphadenectomy. The patient was placed in the supine position and tilted 7 degrees to the right. Three robot arms were docked at the patient’s left side. The center port was used for the scope. The bipolar cutting method was performed using the surgeon’s right hand. An AirSeal® port (ConMed, Utica, NY, USA) was placed on the side near the assistant. After the extraperitoneal space was expanded, lymphadenectomy was performed up to the renal veins and below to the obturator muscles using the bipolar cutting method. This was followed by omentectomy. The operative time were 189 minutes, and the estimated blood loss was 75 ml. A total of 56 lymph nodes were harvested (22 para-aortic lymph nodes and 34 pelvic lymph nodes). Total extraperitoneal lymphadenectomy by robot-assisted surgery was a feasible procedure for this patient. The procedure, which does not require the Trendelenburg position and is not obstructed by bowel, may be suitable for patients with hypertension, glaucoma, obesity or abdominal adhesion.

Study Objective To evaluate the efficacy of robotic extraperitoneal paraaortic dissection using the double bipolar method (DBM). Design We will show our double bipolar technique and give retrospective analysis of data. Setting Urban general hospital. Patients or Participants From December 26th 2018 to April 22nd 2019, 13 patients underwent extraperitoneal paraaortic dissection and 3 patients underwent both paraaortic and pelvic extraperitoneal dissection for stage I ovarian cancer (n=5) and endometrial cancer (n=8)- stage I-III. Interventions Informed consent was gained from all patients. Underlaparoscopic observation, we accessed the retroperitoneal space at the lower left flank extraperitoneally using an Endotip cannula. We expanded the peritoneal pocket to establish pneumo-retroperitoneum. Four extraperitoneal trocars along the left flank were placed. The DBM was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. This technique uses Robotic Maryland forceps for both cutting and coagulation. The cutting device is set with a special energy platform at macromode 60W. The lightning strike cutting mechanism is more precise than other instrumentation such as monopolar scissors and causes minimal thermal spread to adjacent organs. Measurements and Main Results The median number of retrieved lymph nodes in the paraaortic dissection was 32, in the pelvic dissection- 27. The estimated blood loss in the paraaortic dissection was almost 0ml, and 75ml in the pelvic. The median operating time was 147mins for the paraaortic dissection and 50mins for the pelvic dissection. No patients who underwent these interventions suffered organ injury or required a blood transfusion. Conclusion Extraperitoneal approach has the advantage of being a no-bowel operative field. The DBM makes it possible to perform accurate, bloodless dissection making it applicable to extended retroperitoneal dissection. The combination of this approach and technique can potentially be applied to total retroperitoneal dissection including para-aortic and pelvic lymphadenectomy cases.

Video Objective Uterine leiomyosarcoma (uLMS) is aggressive mesenchymal neoplasm and is associated with a high risk of recurrence and poor prognosis. The 5year overall survival rate is about 60% even in FIGO stage I disease. There is no firm evidence of chemotherapy, so surgical resection should be considered to control the disease in case of localized recurrence. We will report a case underwent total laparoscopic complete resection for recurrent mass involved sigmoid colon and right ureter. Setting Gynecology and Obstetrics department of a general hospital. Interventions The patient was a 56-year-old woman underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy for enlarged 9cm cervical leiomyoma. The pathological examination of the uterus resected showed cytologic atypia,nuclear mitoses and coagulative necrosis, she was diagnosed as primary uLMS, stageⅠB. She rejected to receive adjuvant chemotherapy. After 7months, the isolated metastasis in pelvic and lung was suspected. Magnetic resonance imaging revealed that the 4cm tumor possibly be involved sigmoid colon and right lower ureter. Resection of the recurrent mass with segmental bowel resection and partial resection of ureter with ureteroneocystotomy was performed laparoscopically without any complications. Complete tumor resection with histologic negative margins was achieved. She had postoperative adjuvant chemotherapy with doxorubicinfor 6 cycles and additional surgery for lung meta is scheduled. Also, we experienced another three salvage cases with successful resection in combination with laparoscope and thoracoscope. Conclusion The surgical indications for recurrent uLMS should be selected, but the complete resection of localized recurrence may lead to control the disease. Minimally invasive approach may be one of the feasibleoption.

Video Objective Experts of laparoscopic surgery have tacit skills such as bodily skills and empirical knowledge. We have developed laparoscopic training to learn such skills using an expert's surgical movie simulator. We aimed to investigate usefulness of this training. Setting This was a single-institutional, quasi-experimental study. We included 3 gynecology residents in Kurashiki medical center, Japan as participants. We used 2 images, a video of expert's laparoscopic surgery and a real-time image of the training box. We overlaid these images and displayed them on a screen. Participants manipulated the forceps in the training box and imitated the motion of expert's forceps while watching the videos. This is the training system of reliving an expert's operation. Interventions 2 residents received the reliving training for a week and a resident did not received this training. Before and after the training, every resident joined an operation of total laparoscopic hysterectomy as an assistant. They practically performed isolation of the uterine artery and ureter. The number of errors and the time required the procedure were measured. Conclusion Both residents groups had comparable characteristics. After the training of reliving an operation, object residents showed improved laparoscopic skills compared with resident who did not receive the training. Although it was difficult to learn expert's tacit skills with conventional box training, the expert's surgical movie simulator had the potential to acquire such skills. Future research will need longer period of training and more participants to strengthen these conclusions.

BackgroundPain-relieving effects of dienogest against endometriosis are comparable to leuprolide acetate for 24 weeks. We assessed whether long-term dienogest administration reduces recurrence after endometrioma excision.MethodsIn this retrospective cohort study, 568 women with MRI-based diagnosis of ovarian endometrioma, who underwent laparoscopic stripping between 2008 and 2013, were studied. Recurrence rates and side effects over 5 years were investigated in 417 without postoperative medication and 151 who received dienogest postoperatively at 2 mg. Transvaginal sonography was performed every 3 months, and when cystic lesions ≥2 cm were observed, diagnostic MRI was conducted. Recurrence was defined as a lesion previously diagnosed as endometrioma by MRI, equal in size or larger 3 months later on ultrasonography. Cumulative recurrence rates were calculated with the Kaplan-Meier method, and group comparison involved log-rank tests. Blood examinations were completed every 3 months, and bone mineral densit...

Video Objective To demonstrate techniques to regulate and improve the safety and completeness of laparoscopic and robotic radical hysterectomy/radical trachelectomy (L-RH/RT+R-RH/RT=MI-RH/RT) for early invasive cervical cancer. We will present our techniques and skills as well as data on our long-term outcomes for MI-RH/RT patients. Setting Urban general hospital in Japan. Interventions 170 early invasive cervical carcinoma stage IA1(LSVI+)-IB1 who underwent MI-RH/RT between 2006-2015 were reviewed. Cases who underwent neo-adjuvant therapy were excluded from this study. In laparoscopy, knowledge laparoscopic anatomy and how to dissect are the most important points for reaching the goals of the surgery. Setting landmarks for dissection boundaries ensures completeness of dissection. For our type C radical hysterectomy/ trachelectomy, our goal is to remove the full length of the cardinal ligament. This is to prevent recurrence. To prevent the scattering of tumor cells, we create a vaginal cuff as an initial stage of our procedure and don't use a uterine manipulator as there is the concern that this could stimulate any tumors in the vicinity. When extracting the specimen, we use a large protection bag. This bag prevents spillage of tumor cells in the abdominal cavity and prevents possible port site/ extraction site contamination. Of the patients included in this study, disease-free survival is 97.1% and the 5 year overall survival in 98.2%. Conclusion In our retrospective study, minimally invasive approach for early-stage non-bulky cervical cancer is feasible and safe in terms of oncological outcomes.

Video Objective In laparoscopic intracorporal knot tying, we have to ligate securely in the limited space. The slip knot technique is useful in these situations. I will show the key and logic of slip knot using a two-color suture, and some techniques. Setting The procedures to perform slip knot are as following: Firstly, you make a square knot by two opposite half knots consisted of one clockwise and the other counter-clockwise. Then, you can push and slide the “unlocked” square knot toward the ligation point and secure the tissues. “Unlocked” means the state of which the square knot is slidable, and keeping this state is the secret of slip knot. A two-color suture is helpful to understand this state. Various slip knot techniques are below: 1) Standard slip knot. This is the basic way, an unlocked square knot is slid to the ligation point. 2) Loose one-hand slip knot. As a square knot is unlocked and loose, you can tie the knot by pulling the long tail one-handed. 3) In case of the locked knot. You should pull the long tail and release the knot before you slide it. 4) Pulling the short tail. You can also tie the knot by pulling short tail in theory. 5) Knot tying combined with surgeon's knot. You can alter the first opposite half knot to double half knot. To get your slip knot more smoothly and quickly, you should manage the suture near the knot, omit the time and effort for catching the suture of second opposite half knot. And training never cheats on you. Interventions N/A Conclusion These techniques can help your operation get better definitely.

Video Objective Endometriosis is known to have a remarkably negative effect on the Quality of Life (QOL) of the women. Surgery is considered when medical therapy is unsuccessful or in the setting of infertility. A high recurrence rate is reported in advanced stages of endometriosis. Thus, Complete excision and prevention of recurrence is particularly important. Following hysterectomy, pelvic pain and vaginal bleeding are a rare but real occurrence. We evaluated the recurrence of pain and bleeding in patients following hysterectomy and infertility sparing procedures. Design Retrospective cohort. Setting Kurashiki medical center, private hospital, in Japan. Interventions We evaluated postoperative recurrence of endometriosis from January, 2004 to December, 2018 in patients who underwent laparoscopic excision of endometriosis, with or without postoperative hormone therapy. Main Results In our facility, endometriosis recurred in 20 cases (3.85%) out of 519 total laparoscopic hysterectomy (TLH) with ovarian sparing procedures. 17 of the 20 cases were not treated with hormone therapy postoperatively. No recurrence was found in 288 patients who underwent TLH plus bilateral salpingo-oophorectomy. In fertility sparing cases, 7.5%(152/2012 cases) had recurrence after surgery. Recurrence rate decreased to 4.9%(85/1750 cases) after January, 2008 compared with 24.7%(67/271) before December, 2007.For fertility sparing endometriosis excision surgery, postoperative recurrence without hormone therapy was found in six (1case in rectum, 5 cases in ovaries) out of fifteen cases. With postoperative hormone treatment using dienogest, a “fourth-generation” progestin, recurrence was found in only one case out of fifteen hormone therapy groups. Median recurrent period was 6 months. Surprisingly, 11 out of 22 fertility sparing cases were diagnosed as endometrioma with 1 month postoperative MRI. Conclusion Approval of dienogest in 2008 may have contributed to the dramatic improvement in preventing recurrence of endometriosis. Hysterectomy significantly decreases patient symptoms and recurrence rate. Ovarian conservation conferred a higher rate of recurrence of symptoms of endometriosis.

Video Objective To expand laparoscopic surgical skills, we need to strategies to cope with the very large uterus.Traditionally, there are three techniques to detect and mobilize the ureter and uterine artery: the anterior, lateral and posterior approach. Generally, the lateral approach is most common as one can easily detect the ureters transperitoneally at the rim of psoas muscle. But, in the case of a large and bulky uterus, advanced techniques are required. Design Laparoscopic demonstration of fascial planes and surgical techniques used to cope with the huge uterus. Setting Kurashiki medical center, private hospital, in Japan. Patients Total laparoscopic hysterectomy for uterus greater than 800 grams. Interventions In anterior approach, by making a bladder flap one can firstly detect and ligate uterine arteries to reduce bleeding. Measurements and Main Results In the case of adenomyosis and endometriosis, bleeding from severe fibrosis may be encountered in the parametrium. Ligation of the uterine arteries first will help to avoid bleeding. Open the bladder flap wide and lifting it sufficiently and cutting the loose connective tissue caudally will expose the palpable ascending and inward vessel. That is the uterine artery. The separation between the uterine artery and the ureter opens Latzko's pararectal space. In the case of fibroid, we find the ureter first as the broad ligament is more elastic allowing for stretching. By making the broad ligament tense, you can elevate the posterior leaf of broad ligament to separate the mesoureter. This procedure allows entry into Okabayashi's pararectal space. The entry point is at about 1cm medially to the root of the lateral umbilical ligament. This space is avascular and stretches to easily find the mesoureter containing the ureter above it. Conclusion Mastering an anterior approach and recognizing fascial layers contributes to our surgical toolbox in coping with more complicated hysterectomies.

Objective To assess the obstetric outcomes of our total laparoscopic radical trachelectomy (TLRT) cases for early stage cervical cancer. Materials and methods A total of 56 patients who underwent TLRT between December 2001 and August 2012 were reviewed retrospectively using clinicopathological, surgical, and follow-up data from patients' medical records. Results We performed this operation on 56 patients during the study period. The mean age of these 56 patients was 31.9years (range 22–42years). Fifty-three patients' fertility was preserved without requiring post-operative adjuvant treatment. Twenty-five women attempted to conceive, of whom 13 succeeded for a total of 21 pregnancies (52% pregnancy rate). Ten of these 21 pregnancies were the result of assisted reproductive technologies. Of those, 5 resulted in first trimester miscarriages, 2 in second trimester miscarriages, and 13 in live births. Ten pregnancies reached the third trimester. Preterm premature rupture of membranes (8/13, 61.5%) was the most common complication during pregnancy. The rate of preterm delivery was 47.6%. Three patients delivered at 22–28weeks of gestational age. Two of these babies showed permanent damage: one has cerebral palsy; the other has developmental retardation. One pregnancy is ongoing. Conclusion TLRT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer.

Aim: The aim of this study was to determine the incidence of perioperative complications and evaluate risk factors for the major complications of total laparoscopic hysterectomy (TLH) using an early ureteral identification technique. We describe the technique we standardized and used for TLH, without exclusion criteria. Material and Methods: A retrospective study was carried out at Kurashiki Medical Center, Japan, based on 1253 TLH procedures performed from January 2005 to March 2009. We reviewed records to identify the major perioperative complications, including bladder, ureteral, and intestinal injuries, and incidences of reoperation. Risk factors for major complications were analyzed using multivariate logistic regression models. Results: A total of 24 patients encountered major complications (1.91%). Complications included 10 intraoperative urologic injuries, five cases of postoperative hydronephrosis, five cases of vaginal dehiscence, one bowel injury, one postoperative hemorrhage, one bowel obstruction, and one ureterovaginal fistula. All 11 cases of intraoperative visceral injury were recognized during the surgery and repaired during the same laparoscopic surgical procedure. Of the risk factors analyzed, a history of abdominal surgery was the only one associated with the occurrence of major complications, with an odds ratio of 2.48 (95% confidence interval 1.23–6.49). Conclusion: While complications are inevitable, even in the hands of the most skilled surgeon, they can be minimized without conversion to laparotomy by a sufficiently developed suturing technique and a precise knowledge of pelvic anatomy. The presented data indicate that our method allows for safe TLH and minimization of ureteral injury, without the use of stringent exclusion criteria.

Introduction: Total laparoscopic hysterectomy has been reported as having a higher incidence of vaginal cuff dehiscence compared with the abdominal and/or vaginal hysterectomy. The cause of vaginal cuff dehiscence after total laparoscopic hysterectomy is not specified, but possible causes may be the use of thermal energy for vaginal incision, reduced suturing width due to magnification, low quality of laparoscopic suturing skills and early resumption of regular activities after surgery. Methods: We performed 677 cases of total laparoscopic hysterectomy for benign diseases, such as fibroids or adenomyosis, from January 2007 to December 2008 in our institute. We experienced four cases (0.6%) of vaginal cuff dehiscence. We checked the operative parameters for these cases, such as whether the retroperitoneum was sutured or not and intrapelvic adhesion, as well as examined operative duration, blood loss, weight of removed organs, and body mass index. Results: Sexual intercourse was the triggering event for three cases (96 days, 103 days and 47 days after total laparoscopic hysterectomy) and the other case occurred during defecation (18 days and no sexual intercourse after total laparoscopic hysterectomy). There were no significant differences in vaginal cuff dehiscence with or without retroperitoneum suture and intrapelvic adhesion. Conclusion: After these four cases of vaginal cuff dehiscence, we recognized the need to review these cases carefully in order to discover the cause and how to prevent this from occurring in other patients. We do not have the answers to prevent this complication at present, but reducing the power-source and attempting different suturing techniques may be important steps.

Study Objective We describe our ultra-minimally invasive retroperitoneal lymphadenectomy using the extraperitoneal approach. This technique was developed to make traditionally invasive oncologic surgery more patient friendly and safer by eliminating the bowel from the operative field. Design Description of a surgical technique. Canadian Task Force II-3. Setting Urban general hospital in Japan. Patients 320 Women undergoing endoscopic extraperitoneal paraaortic and pelvic lymphadenectomy for endometrial cancer from Jan 2001 to Dec 2013. Interventions Patients underwent endoscopic extraperitoneal para-aortic and pelvic lymphadenectomy for endometrial cancer. We accessed the retroperitoneal space with a visual access cannula (Endotip). This device easily facilitates peritoneal tenting. After expanding the extraperitoneal space by blunt dissection with forceps, carbon dioxide was infused. The upper limit of our dissection was the renal vein and the lower limit was the iliac circumflex vein. The extraperitoneal approach naturally creates a bowel-free operative field, even when dissecting in the pelvis. This approach only requires a 5-mm access hole, making it the least invasive approach to this kind of surgery. Measurements and Main Results The 5-year survival rates for this intervention combined with hysterectomy and bilateral adnexectomy are extremely favorable at 90% for patients with stage I to III disease, making this technique a viable minimally invasive approach for selected patients. Conclusion We can achieve a total para-aortic and pelvic retroperitoneal dissection with this extraperitoneal approach without the bowel invading the operative field. This procedure is focused on the barrier-free nature of working in the retroperitoneal space, meaning a space that is not hindered by the invasion of the bowel or other intraperitoneal structures.