Hiroto Shimanuki

Recurrence rate of endometriomas following a laparoscopic cystectomy

Background. The objectives were to observe the clinical course of patients who underwent laparoscopic cystectomy (LC) using transvaginal ultrasonography. Method. The definition of “recurrence” was to detect a diffuse, hypoechoic area whose long axis was at least 2 centimeters (cm) on the transvaginal ultrasonogram during the postoperative follow‐up period. Using the Cox regression test, we analyzed each patients background variables, namely, patients age, the revised American Society of Reproductive Medicine score (r‐ASRM score), use of gonadotropin releasing hormone analogues (GnRHa), and pregnancy during the observation period. Next, cyst size and multi‐lobularity of each of the 417 cysts were also analyzed as recurrence risk factors per cyst. Results. The mean postoperative observation period was 21.4±16.8 months. During the observation period, 50 (15.9%) out of 315 patients experienced recurrence and 51 (16.2%) out of 315 patients became pregnant. The cumulative recurrence rate per patient was 31.7% over 60 months. Among prognostic factors per patient, age and showed negative and r‐ASRM scores positive correlations with cyst recurrence. On the other hand, we did not identify any cyst factors associated with recurrence. The patients who underwent hemilateral LC showed a 5.2% cyst recurrence rate in the ovary that appeared to be normal at the time of the initial surgery. Conclusion. Young age and severe endometriosis appeared to be the factors associated with high recurrence risk. Recurring ovarian endometrimas probably include cysts occurring spontaneously and those recurring from the cyst residues in the lesions where cystectomy has been performed.

Prospective Evaluation for the Feasibility and Safety of Vaginal Birth after Laparoscopic Myomectomy

STUDY OBJECTIVE To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM). DESIGN Prospective clinical study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005. INTERVENTIONS Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture. CONCLUSION Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.

Assessment of tubal disorder as a risk factor for repeat ectopic pregnancy after laparoscopic surgery for tubal pregnancy.

Heading Aims:  We evaluated tubal disorders, including peritubal adhesions, as risk factors for repeat ectopic pregnancy (REP) after laparoscopic linear salpingotomy (LS) or salpingectomy for tubal pregnancy.

A novel method of ninth-intercostal microlaparoscopic approach for patients with previous laparotomy

Background. To evaluate the availability of a primary laparoscopic approach for a patient with previous laparotomy and to assess postoperative adhesion to the abdominal wall. Methods. A total of 172 patients with a history of laparotomy who were undergoing laparoscopic surgery in our hospital were evaluated. The primary trocar insertion was performed via the ninth‐intercostal microlaparoscopic approach for these patients. Results. This procedure could be performed on all patients and there were no complications. Postoperative abdominal wall adhesion was found in 53 (30.8%) of 172 patients, and periumbilical adhesion was found in 16 patients (9.3%). Among the 172 patients, 150, 19, and three patients had undergone laparotomy once, twice, and thrice, respectively, prior to this study. Considering the number of previous laparotomies, the frequency of periumbilical adhesion was 5.3% (eight of 150 patients), 36.8% (seven of 19 patients), and 33.3% (one of three patients), respectively. Among 150 patients who had undergone laparotomy once, the type of laparotomy was an obstetric‐and‐gynecologic surgery in 126 patients and other surgeries in 24 patients. There was no significance in the frequency of adhesion between types of previous laparotomies. Surgical incisions were classified as median infra‐umbilical incision (94 patients), median supra‐umbilical incision (three patients), Pfannenstiels incision (33 patients), para‐rectal incision (15 patients), and peri‐rectal incision (five patients). A high frequency of periumbilical adhesion was recognized in the all three median supra‐umbilical incisions. Conclusion. Ninth‐intercostal microlaparoscopic approach is safe for laparoscopic surgery in patients who have undergone laparotomy previously, and this procedure could prevent the risk of bowel injury.

Accurate preoperative diagnosis and laparoscopic removal of the cavitated non-communicated uterine horn for obstructive Mullerian anomalies

Obstructive Mullerian anomalies cause severe dysmenorrhea following menarche as a result of disturbed menstrual outflow. Therefore, surgical management such as extirpation of the obstructive uterine horn is required for treatment of these patients. It is necessary to have a detailed understanding of the pathological conditions of the pelvic organs and urinary system prior to surgery. We report three cases of reproductive, nulligravid patients diagnosed as having obstructive Mullerian anomalies. Preoperative accurate diagnosis was obtained by magnetic resonance imaging (MRI) and 3‐D computed tomography (CT) angiography. Laparoscopic resection of the rudimentary uterine horn was performed safely and completely, and resolved all problems. MRI and 3‐D CT angiography are useful tools for diagnosing complex Mullerian anomalies, and operative laparoscopy may be an alternative treatment for these cases.

Interstitial pregnancy with huge adenomyosis uteri managed laparoscopically by using pre-operative and intra-operative imaging: case report.

A 38 year old woman, who was gravida 2, para 0, was admitted to another hospital with complaints of dysmenorrhea and menorrhagia and was diagnosed with adenomyosis uteri. Her menstrual cycle was regular, and she had been receiving low dose danazol therapy (100 mg/day) for three years. She wanted a baby in the future and approached our outpatient department for surgical consultation. The uterus was enlarged to a size corresponding to 12 weeks of gestation, with reduced mobility. Transvaginal ultrasound revealed a poorly defined solid tumour measuring approximately 8 cm. A MRI showed a poorly defined tumour in the posterior wall of uterus with low signal intensity on the T1-weighted image and a slightly high signal intensity on the T2-weighted image. It was diagnosed as adenomyosis of the uterus. The danazol therapy was discontinued and she was next seen with five weeks and five days amenorrhea, and a positive urine pregnancy test. Transvaginal ultrasound could not define a definitive gestational sac in the uterus. At seven weeks and three days of gestation, the serum h-hCG level was 9460 mIU/mL, and the adenomyosis uteri had enlarged to a size corresponding to 15 weeks of gestation (Fig. 1A). Because the gestational sac and embryo could not be identified by transvaginal and transabdominal ultrasound, an ectopic pregnancy was suspected. A MRI scan showed a cystic mass, measuring 3 cm 2 cm and with a low signal intensity on the T1-weighted image and a high signal intensity on the T2-weighted image, in the interstitial portion of the left fallopian tube (Fig. 1B). At laparoscopy, the operative area was completely occupied by the enlarged uterus. A contact ultrasonography (CUS) probe type UST-52109 (ALOKA, Tokyo, Japan) was placed over the interstitial portion of the left tube where the ectopic pregnancy was predicted by MRI, and a gestational sac was detected (Fig. 1C). The area of excision was established by CUS, 5 U of vasopressin diluted 100-fold in saline was injected around this, and cornual resection was performed using a monopolar needle. During incision, an embryo covered in amnion sac was found and extracted (Fig. 1D). The excision area was sutured in three layers with continuous sutures by using 0-polysobe (Tyco Healthcare, Tokyo, Japan), and the wound was closed. The intraoperative blood loss was 50 mL, and the operating time was 84 minutes. The extracted specimen weighed 10 g. Complete excision of the ectopic pregnancy mass was confirmed by histopathological examination in which the villus, decidua and embryo were found to be surrounded by the myometrium. Her post-operative course was uneventful, and she was discharged on the second postoperative day. The post-operative serum h-hCG values fell from 5139 mIU/mL on the 2nd day to 262.2 mIU/mL on the 7th day, and 1.7 mIU/mL on the 30th day.

Initial closed trocar entry for laparoscopic surgery: Technique, umbilical cosmesis, and patient satisfaction

Background/Aims: Despite the benefits of laparoscopic surgery, which is being performed with increasing frequency, complications that do not occur during laparotomy are sometimes encountered. Such complications commonly occur during the initial trocar insertion, making this a procedural step of critical importance. Methods: In 2002, we experienced, upon initial trocar insertion, a serious major vascular injury (MVI) that led to hemorrhagic shock, and we thus modified the conventional closed entry method to an approach that we have found to be safe. We began developing the method by first measuring, in a patient undergoing laparoscopic cystectomy, the distance between the inner surface of the abdominal wall and the anterior spine when the abdominal wall was lifted manually for trocar insertion and when it was lifted by other methods, and we determined which method provided the greatest distance. We then devised a new approach, summarized as follows: The umbilical ring is elevated with Kocher forceps. The umbilicus is everted, and the base is incised longitudinally. This allows penetration of the abdominal wall at its thinnest point, and it shortens the distance to the abdominal cavity. A bladeless trocar (Step trocar) is used to allow insertion of the Veress needle. We began applying the new entry technique in July 2002, and by December 2014, we had applied it to 9676 patients undergoing laparoscopic gynecology surgery. Results: All entries were performed successfully, and no MVI occurred. The umbilical incision often resulted in an umbilical deformity, but in a questionnaire-based survey, patients generally reported satisfaction with the cosmetic outcome. Conclusion: A current new approach provides safe outcome with a minor cosmetic problem.