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We presented a case of uncontrolled genital bleeding caused by subserosal fibroid and treated by robotic-assisted hysterectomy during the coronavirus disease 2019 (COVID-19) pandemic. A 49-year-old woman had severe anemia with hypermenorrhea due to submucosal fibroid. Hysterectomy was deemed necessary to control genital bleeding. However, at that time, the number of confirmed COVID-19 cases has been increasing in Japan. Serious concerns have been raised about the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) dissemination during minimally invasive surgery due to pneumoperitoneum-associated aerosolization of particles. We tried to prevent the spread of surgical plume by performing surgery under low pneumoperitoneal pressure at 6 mmHg and by using an evacuation/filtration system. As a result, we successfully performed robotic-assisted hysterectomy with minimized risk of spreading surgical plume-containing aerosol particles into the operating room. It is essential to follow the guidelines issued by the relevant societies and act accordingly to reduce the risk of SARS-CoV-2 infection in medical settings while performing surgery. We hope that our experience will help prevent secondary cases of future SARS-CoV-2 infections.

Adenomyosis is commonly treated by total hysterectomy. Adenomyomectomy is considered for women of reproductive age who wish to preserve their fertility. However, a high recurrence rate following adenomyomectomy has been reported because complete removal of the lesion is difficult, and uterine rupture during pregnancy remains a complication. We previously reported that laparoscopic adenomyomectomy using a cold knife prevented thermal damage to the myometrium and elastography to avoid residual lesions. Here, we report the case of a patient who underwent complete resection of a subtype II adenomyosis and resection of deep endometriosis (DE) with the closure of the pouch of Douglas. The patient was 31 years old, had severe dysmenorrhea, and had left ureteral stenosis and subtype II adenomyosis associated with the closure of the pouch of Douglas by the DE. After resection of the DE posterior wall adenomyosis, residual lesions were confirmed by laparoscopic real-time elastography. Eight weeks after surgery, postoperative transvaginal ultrasound showed that the myometrium had shrunk from 28 to 22.7 mm, and the hydronephrosis had disappeared, although a stent remained necessary. In this study, we report the complete resection of subtype II adenomyosis and DE, combined with elastography to visualize the lesions during resection.

Ovarian abscess is thought to be caused by ascending infection. We experienced a case with ovarian abscess caused by Salmonella. The patient had been monitored for endometrial cysts at an outpatient clinic. She visited our hospital emergently with chief complaints of persistent fever and diarrhea. Although sexually transmitted disease was not suspected, she was diagnosed with pelvic inflammatory disease due to her high C-reactive protein (CRP) level and started antibacterial treatment. Two days later, diagnostic laparoscopy was performed for persisting CRP elevation, and she was diagnosed with ovarian abscesses due to Salmonella infection. As the patient had regularly eaten soft-boiled eggs and chicken, an association with her eating habits was strongly suspected as a cause. When a patient has symptoms of enteritis, preceding tubo-ovarian abscess should be considered the possibility of Salmonella infection. Early diagnosis and treatment are necessary for fertility preservation, and minimally invasive diagnostic laparoscopy is useful.

Objectives: We examined whether a new suturing method that used a single-thread unidirectional barbed suture without exposing the barbs on the wound surface was acceptable compared with the conventional suture method during laparoscopic myomectomy (LM). Materials and Methods: This was a retrospective study. The subjects were 26 women who underwent LM for symptomatic uterine fibroids. The operative time, amount of blood loss, and number of threads used were compared between a group in which suturing was performed with a conventional synthetic absorbable suture (conventional suture group, n = 13) and a group in which suturing was performed using a barbed suture (barbed suture group, n = 13). Results: Operative time in the barbed suture group was significantly shorter than that in the conventional suture group, while blood loss during LM in the barbed suture group was significantly lower than that in the conventional suture group. The number of threads used in the conventional suture group was significantly larger than that in the barbed suture group. No complications were observed in both the groups during LM. Conclusion: This new technique using a barbed suture is safe and feasible for LM.

Abstract Background Endometriosis can potentially lead to the development of a malignant tumor. Most malignant tumors arising from the endometriosis originate from the ovarian endometrioma, whereas those arising from extragonadal lesions are rare. We report a rare case of endometrioid carcinoma that developed from deep infiltrating endometriosis in the uterosacral ligament 6 years after treatment for atypical proliferative endometrioid tumor of the ovary in a 48-year-old woman. Case presentation Six years ago, the patient underwent laparoscopic bilateral salpingo-oophorectomy for her right ovarian tumor with atypical proliferative (borderline) endometrioid tumor accompanied by ovarian endometrioma. The solid tumor in the cul-de-sac was detected during follow-up using magnetic resonance imaging. Positron emission tomography/computed tomography revealed an abnormal accumulation of 18F-fluorodeoxyglucose at the tumor site. Thus, tumor recurrence with borderline malignancy was suspected. The patient underwent diagnostic laparoscopy followed by hysterectomy and partial omentectomy. Retroperitoneal pelvic lymphadenectomy and para-aortic lymphadenectomy were also performed. The cul-de-sac tumor at the left uterosacral ligament was microscopically diagnosed as invasive endometrioid carcinoma arising from deep infiltrating endometriosis. The final diagnosis was primary stage IIB peritoneal carcinoma. The patient received six courses of monthly paclitaxel and carboplatin as adjuvant chemotherapy. The patient showed no evidence of recurrence for 2 years after the treatments. Conclusion This study reports a rare case of metachronous endometriosis-related malignancy that developed 6 years after treatment for borderline ovarian tumor. If endometriosis lesions remain after bilateral salpingo-oophorectomy, the physician should keep the malignant nature of endometriosis in mind.

Seprafilm® is an adhesion barrier sheet. However, it is difficult to handle it through a 5-mm trocar. We have devised a method of applying Seprafilm® safely and reliably through a 5-mm trocar by using a holder that comes with the film. We practiced this method in three cases of total laparoscopic hysterectomy for uterine leiomyoma. The quarter-pack is cut into three pieces. The film placed on the holder sheet was rolled up with forceps (or wrapped around forceps) and inserted into a 5 mm trocar. After application, the center of the short axis of the holder was pinched with a grasping forceps, and the holder was drawn out of the body through the trocar. Of the 36 pieces placed, Seprafilm® broke only in once. Insertion was successful in 100%, and the holder was successfully retrieved through the trocar in 92% (33/36) of the cases. The holder may be easily retrieved after application. This technique represents an extremely simple versatile application method in operations in which only 5-mm trocars can be used.

Detecting adenomyosis in the myometrium is a challenge since it is infiltrative with ill-defined margins and can be often confused with uterine fibroids. However, recent advances, such as ultrasound elastography, have enabled its detection in the myometrium, thereby facilitating its accurate diagnosis. We report our experience of performing complete laparoscopic resection of adenomyosis under real-time ultrasound elastography guidance in a 32-year-old woman who underwent laparoscopic adenomyomectomy following severe dysmenorrhea and heavy menstrual bleeding. Real-time ultrasound elastography was also utilized intraoperatively to detect residual adenomyosis. Complete adenomyosis resection and uterine reconstruction were achieved. Follow-up magnetic resonance imaging was conducted to confirm successful uterine reconstruction. The patient recovered rapidly with no complications. Intraoperative elastography-guided laparoscopic adenomyomectomy was feasible and effective in completely removing adenomyotic lesions.

Abstract Laparoscopic myomectomy (LM) is a minimally invasive surgery. However, several complications may occur in cases of extremely large myomas. For example, it can be difficult to acquire a full visual field, and the operation is limited by both technical and physiological restrictions. In addition, the volume of intraoperative bleeding is often increased in comparison to typically sized myomas; therefore, surgical indications are limited for technical reasons and for ensuring safety of the patient. Suturing and ligation techniques, which are indispensable in LM, are difficult procedures to perform. If clinicians are not confident in performing these procedures or experience difficulty in controlling bleeding, then they can alternatively choose to make a small incision in the abdominal wall and perform a procedure called laparoscopically assisted myomectomy. In this article, we describe the process of effectively using LM in cases with giant myomas.

Abstract Purpose Recently, endoscopic surgeries are widely performed in the gynecological field. Several studies on the use of local anesthesia for pain control after laparoscopic surgery have been conducted; however, its effects remain controversial. Herein, a randomized control study on gynecological laparoscopic surgeries was conducted to analyze the effectiveness of local anesthesia on postoperative pain. Methods Patients who underwent laparoscopic surgeries due to gynecologic benign diseases or endometrial cancer in the early stage were enrolled, and randomly divided into intervention (injected with levobupivacaine), and control (injected with saline) groups. The primary outcome was the dosage of analgesic consumption within 12 hours postoperatively. Results A total of 147 patients were enrolled in the intervention group and 147 in the control group. The outcome of local anesthesia was not significantly different between the two groups during the whole analysis. We analyzed the effects of local anesthesia in the laparoscopic surgery subgroup. The dosage of analgesic consumption within 12 h after a laparoscopic hysterectomy (TLH) or TLH with pelvic lymph node dissection (TLH+PLD) in the intervention group was significantly smaller than that in the control group. Conclusion Local infiltration anesthesia can effectively reduce postoperative pain in patients who underwent TLH or TLH +PLD.

Growing teratoma syndrome (GTS) is a condition characterized by tumor growth during or after chemotherapy for a germ cell tumor, albeit with normal tumor marker levels in the absence of histopathological evidence of immature teratoma components. We encountered a 10-cm large GTS lesion in the para-aorti nodes after fertility-preserving surgery for a grade 3 ovarian immature teratoma. The patient was a 20 year old woman who presented to the hospital with complaints of abdominal pain and swelling. Imaging examination revealed an ovarian tumor mass measuring 24 cm in the abdominal cavity, suspected to be composed of a mixture of fat and other components. The α-fetoprotein (AFP) levels were elevated at 853 ng/mL. We elected to perform fertility-preserving surgery. The surgical findings included a tumor in the right ovary, which was excised without rupture with adnexectomy. The histopathological diagnosis was grade 3 immature teratoma. Palpation of the pelvic and para-aortic lymph node areas did not reveal significant lymphadenopathy. Subsequently, a para-aortic node metastasis (major axis: 8 cm) was discovered before chemotherapy (19 days after surgery). We confirmed that there was no swelling before surgery and assumed that the immature teratoma had recurred. Chemotherapy was initiated, and the serum AFP levels normalized after 4 courses of bleomycin, etoposide, and cisplatin (BEP) therapy. However, the para-aortic node metastasis had grown further (major axis: 10 cm). Another open surgery was performed. The nodal mass was completely excised and pathology revealed only mature teratoma. Growing teratoma syndrome should be considered in the setting of a recurrent mass with negative tumor markers. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery has become a standard treatment for early-stage endometrial cancer. Its outcomes are not inferior to those of open surgery, and it has a good prognosis. Thus, there have been a few studies on recurrence patterns in low-risk endometrial cancer. We described the case of a 45-year-old multiparous woman with the International Federation of Gynecology and Obstetrics stage IA, grade 1 endometrioid endometrial cancer, who was treated with laparoscopic modified radical hysterectomy with bilateral adnexectomy and pelvic lymph node dissection. The patient developed isolated recurrence around the left ureter 27 months later, which was also laparoscopically resected. Pathologically, she had a low risk of recurrence; therefore, we had to review our surgical procedures. The findings of a recent study have led to the development of the theory that there is a laparoscopy-specific recurrence pattern. We discussed this recurrence pattern in relation to our patient's case and aimed that our findings will prompt to reconsider laparoscopic surgery in preventing tumor spread and recurrence in early-stage low risk endometrial cancer. [ABSTRACT FROM AUTHOR]

Vasohibin-1 (VASH1) is an identified negative feedback inhibitor of angiogenesis induced by vascular endothelial growth factor (VEGF) in vascular endothelial cells (ECs). Expression of VASH1 has been reported not only in ECs of normal tissue, but also in ECs surrounding malignant tumors. In malignant tumors, VASH1 is also gaining attention as a prognosis prediction marker. The aim of this study is to investigate the correlation between VASH1 expression and vascular-related factors and various clinicopathological outcomes in clinical cases of ovarian carcinoma. We retrospectively analyzed clinical records of 58 patients with ovarian carcinoma. The expression patterns of VASH1 and other vascularrelated factors (CD31 as markers of microvessel density (MVD), VEGF receptor type 2 (VEGFR2), D2-40 as markers of lymphovessel density), and Ki67 (as proliferation markers of cancer cells) were examined immunohistochemically. We studied the correlation between immunohistochemical expression and overall survival. VASH1 expression pattern significantly differed between Federation of Obstetrics and Gynecology (FIGO) Stages. Numbers of VASH1-positive vessels had a significant positive correlation with MVD (Speaman's correlation coefficient (ρ) was 0.51, p < 0.001), VEGFR2-positive vessels (ρ = 0.61, p < 0.001), and percentage of Ki67 (ρ = 0.28, p = 0.034). The Cox univariable analyses revealed that the group of high VASH1 expression (> 14.6 vessels per mm²) at Stages I-III is a prognostic factor (HR = 3.3, 95%CI = 0.4-8.4; p = 0.013). Our results indicate that VASH1 expression in ovarian carcinoma is significantly associated with vascular-related factors and Ki67 expression. We propose that VASH1 is a prognostic marker in ovarian carcinoma. [ABSTRACT FROM AUTHOR]