Objective: We have found laparoscopic surgery to be both feasible and safe for large ovarian tumors, which at one time would have been managed strictly by conventional laparotomy. The aim of this study was to evaluate the potential risks and the outcomes of laparoscopic surgery for ovarian tumors on the basis of tumor size.Materials and methods: From among 1248 cases of adnexal tumor treated at our institution between June 2005 and June 2014, we identified 1196 cases of preoperatively diagnosed benign ovarian tumor treated by laparoscopic surgery. We divided the cases into three groups according to the diameter of the tumor: <= 5cm (Group A, n = 355), 6-9 cm (Group B, n = 688), and >= 10 cm (Group C, n = 153) and investigated the incidences of perioperative complications and the rates at which laparotomy was converted to open surgery.Results: Median operation time was 59 minutes, 7 minutes, and 73 minutes (p < 0.001) for Group A, Group B, and Group C, respectively. Median estimated blood loss was 7 mL, 16 mL, and 32 mL (p < 0.001), respectively. The perioperative complication rate (n = 4, n = 7, and n = 4, respectively), did not differ significantly between groups nor did the rate of conversion to laparotomy (n = 1, n = 2, and n = 2, respectively). Tumor size was not a prognostic indicator of perioperative complications (Hazard Ratio (HR), 0.96; 95% confidence interval, 0.79-1.16; p = 0.652).Conclusion: Operation time and estimated blood loss were shown to increase with the size of an ovarian tumor. However, we found no relation between tumor size and the perioperative complication rate or the rate of conversion to open surgery. Thus, we conclude that tumor size is not a factor limiting application of laparoscopic surgery to ovarian tumors. Copyright (C) 2015, The Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive Therapy. Published by Elsevier Taiwan LLC.

Object: Abdominal laparotomy is often performed to treat large ovarian endometrial cysts. We determined the safety and feasibility of performing laparoscopic resection for large endometrial ovarian cysts.Design: A retrospective cohort study. Methods: Between June 2005 and August 2013, we performed laparoscopic surgery in 534 patients with endometrial ovarian cysts at the Yotsuya Medical Cube Women's Center. Patients with ovarian endometrial cysts were divided into the large-cysts ( ≥ 10 cm) and normal-size cysts ( < 10 cm) groups. In cases of large ovarian endometriosis with severe adhesion, we performed laparoscopic-assisted ovarian cystectomy (LAC) using double balloon catheters, which combined intra- and extra-abdominal procedures with small incisions instead of a large open laparotomy. We compared the rates of operative complication, operative time, amount of bleeding, and pathological findings between the two groups.Results: We performed laparoscopic surgery in 45 patients with large ovarian cysts. More patients had high serum CA-125 scores and r-ASRM scores in the large-cysts group than in the normal-size cysts group. Patients in the large-cysts group had severe endometriosis, and we performed the LAC procedure in 14 patients of this group. The average operative time and amount of bleeding were increased in the large-cysts group compared with the normal-size cysts group. However, there were no differences in the operative complications between the groups.Conclusion: We performed laparoscopic cystectomy in 45 cases of large severe endometrial cysts without complications. These results suggest that laparoscopic management of large endometrial ovarian cysts is safe and feasible.

Our hospital was established 6 years ago as an institution that specializes in the laparoscopic surgery. A recent increase has been observed in the number of women who develop multiple and giant uterine myomas, indicating the need to react according to each case. In this report we present a method of laparoscopically assisted hysterectomy that we introduced as a countermeasure against multiple and giant uterine myomas. We review and compare the 312 cases of laparoscopic hysterectomy that we have performed and discuss on the selection of operation method based on the review. Further experience and technical improvements in laparoscopic hysterectomy based on each case will lead to improved safety and proper indications.

A number of patients with multi-focal and/or giant fibroids visit our clinic, a microinvasive surgery specific facility, seeking laparoscopic treatment because of its potential advantage both in cosmesis and preserved fertility. Laparoscopically assisted myomectomy (LAM) with supra-pubic mini-incision is our procedure of choice in these cases. In this report, our experience of LAM is retrospectively reviewed in order to assess optimal indication for the laparoscopic approach. A total of 677 patients who underwent LAM between 2005 and 2010 were included in this analysis. The maximum diameter of the enucleated fibroids was 8.93 ±3.29 (mean ±SD) cm and the number of enucleated fibroids was 13.44 ±29.46 (mean±SD). There was statistically significant correlation between the number of fibroids and operative time, and between the number of fibroids and blood loss. Although some cases are technically demanding, the laparoscopic approach seems to be feasible, even in cases of multi-focal and/or giant fibroids that are generally treated by the open approach. Further experience and technical improvement will be required to more definitively establish the acceptably safe and reasonable indications for the laparoscopic approach.

Objective: Chlamydia trachomatis is the most frequently encountered infectious disease in daily practice in gynecology. The infection exhibits a wide range of presentations, from asymptomatic infection to severe pelvic peritonitis, which is often difficult to differentiate from other forms of peritonitis. There have been reports of patients developing chlamydial peritonitis in the early postoperative stage after laparoscopic surgery. Here, we report 4 cases of chlamydial peritonitis that developed soon after laparoscopic surgery in asymptomatic patients.Patients: Patient ages ranged from 26-50 years. The surgeries included 1 total laparoscopic ovarian cystectomy (TLC), 1 total laparoscopic hysterectomy (TLH), and 2 laparoscopic assisted myomectomies (LAM). There were no operative findings suggestive of adhesive chlamydial infection, but increased levels of chlamydial IgA were confirmed in all 4 patients. Repeat laparoscopic surgery was required in 1 patient who developed ulcerative colitis after LAM due to delayed resolution of inflammatory response. Operative findings included severe pelvic peritonitis with extensive abscess formation from the pelvic cavity to the muscular layer at the site of the myomectomy. The repeat surgical procedure included exfoliation of inflammatory adhesions, drainage of the abscess, removal of the suture in uterine muscle, and thorough irrigation of the abdominal cavity with normal saline solution.Conclusions: We test all patients for Chlamydia antibodies as part of the pre-operative workup. Patients who test positive are treated with oral azithromycin hydrate before surgery.

At Yotsuya Medical Cube, during LAM, we have experienced three damages of forceps during surgery. All broken parts were successfully corrected immediately and no obvious invasion was observed during and after the surgery. However, such an interruption as damage of surgical instruments in a confined abdominal area always accompany risks like an extension of surgery and a possible shift to laparotomy. Moreover, interruptions during laparoscopic surgery give doctors a tremendous stress during procedure. In order to prevent such damage of surgical instruments, close attention of operating forceps as well as appropriate check and maintenance of all instruments for laparoscopic surgery are indispensable. At our hospital, we worked on establishing the maintenance management system of surgical instruments for laparoscopic surgery through cooperation with our clinical engineers. As a result, safer laparoscopic surgery has become possible, as no interruptions by damage of instruments has occurred and stress during procedures has been reduced. I think any medical facility requires to maintain quality control and establish its own management system of medical instruments. In this paper three cases of damage of forceps during LAM that we experienced will be reported and the maintenance management system of surgical instruments for laparoscopic surgery through cooperation with our clinical engineers will be introduced.

BACKGROUND: Vasopressin is often used locally to reduce blood loss during surgery. The use of a local infiltration of a low concentration of vasopressin, less than 0.05-0.3 units/mL, has been considered to be safe. The use of low-dose vasopressin is not free of side effects, and it can also sometimes cause lethal complications.CASE: In a healthy woman with multiple uterine myomas, we experienced a case of sudden cardiac arrest immediately after the intramyometrial injection of vasopressin at a total dose of 11 units (0.2 units/mL). The patient was successfully resuscitated.CONCLUSION: Local intramyometrial infiltration of low-dose vasopressin may cause lethal cardiopulmonary complications.

An increasing number of adnexal masses are currently managed laparoscopically, which has hampered progress regarding the different techniques of laparoscopic surgery. In this chapter, a modified application of surgical instrument was described in laparoscopic ovarian cystectomy-we named this device, Lap-Disc Mini. This new instrument has three rings, an inner flexible ring fixed to a middle ring by a rubber corset, and an additional dynamic outer ring that has a rubbery-like iris opening, which allows the application of different-sized trocars and extracorporeal ovarian cystectomy. This technique has proved to be effective and safe, especially in removing large ovarian cyst.

Laparoscopic surgery demands flexibility in that it requires selection of the method most suited to the patient, technician, and circumstances. The instruments used are also an important factor in determining the safety and ease with which laparoscopic surgery is conducted. Here we introduce procedures for the enucleation of uterine myoma and the laparoscopic, techniques we use, and compare the electric scalpel, laser scalpel, and ultrasound scalpel (harmonic scalpel). While the laser scalpel is an important tool in laparoscopic surgery, we did not find it to have any clear advantages over the electric scalpel. As for the harmonic scalpel, although it transiently produces a smoke-like vapor, the field of vision remains clear. The harmonic scalpel was equal to the laser scalpel in terms of incision and coagulation ability, and is expected to become an important tool in the futere.Ultimately, the advisability of surgery and the type of operations that are possible will depend not only on the instruments used, but also on the views of the surgeon regarding a particular procedure and the surgen's level of technical skill.