BACKGROUND: The number of females who undergo liver transplantation is growing and sometimes gynecologic operations are needed to control gynecologic diseases after liver transplantation. METHOD: Total laparoscopic hy...BACKGROUND: The number of females who undergo liver transplantation is growing and sometimes gynecologic operations are needed to control gynecologic diseases after liver transplantation. METHOD: Total laparoscopic hysterectomy was performed in 2 patients who had undergone liver transplantation, one for adenomyosis and the other for hysteromyoma. RESULTS: It was safe to create a pneumoperitoneum through the umbilical skinfold even though mild adhesion in the pelvic cavity occurred in one patient. The operative times were 95 and 90 minutes, with blood loss of about 100 and 60 ml, respectively. Oral intake, flatus passage, and ambulation recovered within a day, after the operation. No significant changes in liver function were observed except complication of diarrhea caused by Candida albicans in one patient. CONCLUSIONS: The result of the two patients suggest that total laparoscopic hysterectomy is a safe and effective surgical approach for patients who have undergone liver transplantation.展开更多
Objective:When performing cervical conization in post-menopausal cervical intraepithelial neoplasia 3(CIN3)patients,the positive rate of endocervical cone margin and the incidence of postoperative cervical stenosis in...Objective:When performing cervical conization in post-menopausal cervical intraepithelial neoplasia 3(CIN3)patients,the positive rate of endocervical cone margin and the incidence of postoperative cervical stenosis increase.This study summarized a 4-year experience of total laparoscopic hysterectomy as a treatment option for peri-menopausal and post-menopausal CIN3 patients at a single institution.Furthermore,it shared the refinement strategies used during the surgery.Methods:This study retrospectively analyzed the medical records of CIN3 patient aged45 years and who underwent open or laparoscopic hysterectomy at our institution from January 1,2017 to December 31,2020.Totally,30 CIN3 patients were enrolled and divided into abdominal hysterectomy group and laparoscopic hysterectomy based on surgery method,with 5 patients and 25 patients respectively.Results:Compared to the abdominal hysterectomy group,the perioperative blood loss(20 mL vs.220 mL,p=0.004)was less and the duration of in-hospital stay(7 d vs.11 d,p<0.001)were significantly shorter in the laparoscopic hysterectomy group.However,no significant differences in age at hysterectomy(53 y vs.77 y,p=0.054)and operative time(154.4±27.8 min vs.161.0±62.4 min,p=0.826)were observed between them.Diagnostic conization was performed in advance for 12 patients,and among them,10(83.3%)patients had positive endocervical cone margin.Postoperative intestinal obstructionwas noted in one abdominal hysterectomy patient,no other complications were observed in the remaining patients.Conclusion:Compared to conization,hysterectomy is more invasive;however,it is an acceptable treatment option for peri-menopausal and post-menopausal CIN3 patients.In such cases,opting for total laparoscopic hysterectomy adopted the marionette technique might be preferable because the procedure is less invasive.展开更多
BACKGROUND In the presence of a large uterus,total laparoscopic hysterectomy(TLH),always requires morcellation to allow removal of the tissues from the abdominal cavity.However,uncontained morcellation has been scruti...BACKGROUND In the presence of a large uterus,total laparoscopic hysterectomy(TLH),always requires morcellation to allow removal of the tissues from the abdominal cavity.However,uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma.Therefore,in-bag extracorporeal morcellation has been developed.However,tissue containment and extraction are extremely challenging,especially when considering the increasing uterine size to be removed through minimally invasive surgery.CASE SUMMARY Herein,we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH.The study enrolled patients who were planned for TLH for large uteri(weight>500 g).TLH was performed following the procedure reported in our previous studies.The novel technique has been described step-by-step in a video,which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g,1700 g,and 3700 g,respectively.The procedures were performed without any complications.The patients had an uneventful postoperative course,and in all cases,the pathology was benign leiomyoma.CONCLUSION Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies.The technique herein presented may be adopted in surgical practice,by adding it to the other available techniques of contained morcellation.It may represent a valid and feasible alternative,especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.展开更多
<b>Background & Aims:</b> The multimodal analgesia provides superior pain relief and reduces opioid consumption and its side effects. Gabapentin has been used successfully in multi-modal analgesia in d...<b>Background & Aims:</b> The multimodal analgesia provides superior pain relief and reduces opioid consumption and its side effects. Gabapentin has been used successfully in multi-modal analgesia in different doses. We designed a double-blind randomized control trial to find the minimal effective dose of gabapentin in multimodal analgesia for postoperative pain following total abdominal hysterectomy. <b>Material & Methods:</b> After informed consent, total of 87 patients were randomly assigned to A, B & C groups to receive gabapentin orally 300 mg, 600 mg, and 900 mg respectively one to two hours before surgery. Postoperatively pain was managed by patient-controlled analgesia (PCA) using pethidine. Pain score, opioid consumption, and side effects of gabapentin were monitored. Rescue analgesia was given and monitored. <b>Results:</b> There was no statistically significant difference among the groups with respect to age, weight, height, pethidine consumption, and rescue analgesia. Mean pain scores were statistically insignificant at baseline, 8, 12, and 24 hours postoperatively. Only at 4 hours, the highest pain score (mean) was found in group A, which is statistically significant. The side effects of gabapentin like nausea, vomiting, somnolence, and dizziness were also statistically insignificant. <b>Conclusion:</b> A single preoperative oral gabapentin 300 mg was found to be minimal effective dose in multimodal analgesic regimen for reducing post-operative pain and analgesic requirement following total abdominal hysterectomy.展开更多
Objective: Cervical cystic lesions are often observed in gynecological clinical practice. Many are caused by benign diseases such as lobular endocervical glandular hyperplasia (LEGH), and it is important to differenti...Objective: Cervical cystic lesions are often observed in gynecological clinical practice. Many are caused by benign diseases such as lobular endocervical glandular hyperplasia (LEGH), and it is important to differentiate these lesions from those due to malignant diseases such as minimal deviation adenocarcinoma (MDA). In cases in which fertility preservation is not a concern, the final pathology is often confirmed by hysterectomy. To investigate the feasibility and safety of laparoscopic surgery for cervical cystic lesions, we retrospectively examined cases in which total laparoscopic hysterectomy (TLH) was performed for diagnosis and treatment. Methods: The subjects were 28 women who underwent TLH from April 2012 to March 2017 at Keio University Hospital. The pre- and post-operative courses of these patients were examined. Results: The average age was 49.4 (range 39 - 65) years and the mean body mass index was 21.7 (16.8 - 30.5) kg/m2. The average operation time was 159 (101 - 314) min and the average bleeding volume was 106.8 (0 - 600) g. There were no severe perioperative complications. The average hospital stay was 8.4 (7 - 14) days. In postoperative pathological diagnosis, 13 cases had benign diseases such as Nabot cysts, there were 14 cases of LEGH, and one patient was diagnosed with MDA. In the MDA case, additional bilateral salpingo-oophorectomy and pelvic lymph node dissection were performed at a later date. No metastasis was observed in these excised specimens. Conclusions: Our results suggest that TLH for cervical cystic lesions can be performed safely. However, it is important to consider the TLH indication before surgery based on the possibility of malignant disease.展开更多
Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysi...Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysis of women who underwent TLH for benign diseases between April, 2014 and March, 2016 was conducted by a single surgeon in a single hospital (Showa University of Fujigaoka Hospital). We divided the main procedures of the TLH operation into five sections, and measured the time required for each section. These cases were divided into three groups, group 1, 2, and 3. Results: There were 54 cases of TLH over two years for a single surgeon, and 21 cases that included essential operative procedures were divided into three groups of seven cases each. The average duration of the surgery (min.) was 178.3 ± 48.2 in the group 1, 128.3 ± 15.6 in the group 2, and 111.3 ± 15.9 in the group 3. A significant reduction in the required time was observed between group 1, 2, and 3 groups. As the number of cases increased, the operation time became statistically significantly shorter for every section except B and D. The skill growth rate was different at each section. Conclusion: For a single surgeon, as the number of surgical cases increased, we recognized the increased skill with the procedure in every section and the rate of skill growth differed for different sections. The difference of growth rate for each section implied that the number of operative cases required for a surgeon in each section was different.展开更多
BACKGROUND Uterine myomas are the most common benign gynecological soft tissue tumors in women but polycythemia associated with these tumors is rare.Polycythemia is significantly associated with risk of venous thrombo...BACKGROUND Uterine myomas are the most common benign gynecological soft tissue tumors in women but polycythemia associated with these tumors is rare.Polycythemia is significantly associated with risk of venous thromboembolism(VTE),which is further increased in case of a large pelvic mass and obesity.Here we report the surgical challenges in the case of an obese patient with a giant fibromatous uterus and associated polycythemia.CASE SUMMARY A 42-year-old obese woman was referred to our department for treatment for a huge fibromatous uterus.She suffered of pelvic pressure and abdominal distension and reported severe dyspnea from several months.Laboratory analyses including hemoglobin(Hb)19.2 g/dL and hematocrit(Hct)59.7%were indicative of polycythemia.Arterial blood gas analysis showed arterial oxygen pressure(pO2)of 81.5 mmHg.Abdominal computed tomography confirmed a giant fibromatous uterus measuring 28.2 cm×17 cm×25 cm.To reduce the thromboembolic risk,the patient underwent low molecular weight heparin,phlebotomy twice before surgery,and we opted for a laparoscopic hysterectomy.The uterus weighed 5400 g and the histology confirmed a diagnosis of leiomyoma.We did not find increased erythropoietin levels in the supernatant of the myomatous uterine tissue.There were no complications.On postoperative day 1,the Hb and the Hct levels normalized to 13.3 g/dL and 41.7%,respectively.Arterial blood gas analysis after surgery showed a pO2 of 144.7 mmHg.These results suggested the diagnosis of myomatous erythrocytosis syndrome.The patient was discharged on the second postoperative day in very good condition with no symptoms.CONCLUSION We believe this is the first reported laparoscopic hysterectomy in a patient with a giant uterus,polycythemia and obesity.Multiple VTE risk factors warranted a laparoscopic approach.展开更多
文摘BACKGROUND: The number of females who undergo liver transplantation is growing and sometimes gynecologic operations are needed to control gynecologic diseases after liver transplantation. METHOD: Total laparoscopic hysterectomy was performed in 2 patients who had undergone liver transplantation, one for adenomyosis and the other for hysteromyoma. RESULTS: It was safe to create a pneumoperitoneum through the umbilical skinfold even though mild adhesion in the pelvic cavity occurred in one patient. The operative times were 95 and 90 minutes, with blood loss of about 100 and 60 ml, respectively. Oral intake, flatus passage, and ambulation recovered within a day, after the operation. No significant changes in liver function were observed except complication of diarrhea caused by Candida albicans in one patient. CONCLUSIONS: The result of the two patients suggest that total laparoscopic hysterectomy is a safe and effective surgical approach for patients who have undergone liver transplantation.
文摘Objective:When performing cervical conization in post-menopausal cervical intraepithelial neoplasia 3(CIN3)patients,the positive rate of endocervical cone margin and the incidence of postoperative cervical stenosis increase.This study summarized a 4-year experience of total laparoscopic hysterectomy as a treatment option for peri-menopausal and post-menopausal CIN3 patients at a single institution.Furthermore,it shared the refinement strategies used during the surgery.Methods:This study retrospectively analyzed the medical records of CIN3 patient aged45 years and who underwent open or laparoscopic hysterectomy at our institution from January 1,2017 to December 31,2020.Totally,30 CIN3 patients were enrolled and divided into abdominal hysterectomy group and laparoscopic hysterectomy based on surgery method,with 5 patients and 25 patients respectively.Results:Compared to the abdominal hysterectomy group,the perioperative blood loss(20 mL vs.220 mL,p=0.004)was less and the duration of in-hospital stay(7 d vs.11 d,p<0.001)were significantly shorter in the laparoscopic hysterectomy group.However,no significant differences in age at hysterectomy(53 y vs.77 y,p=0.054)and operative time(154.4±27.8 min vs.161.0±62.4 min,p=0.826)were observed between them.Diagnostic conization was performed in advance for 12 patients,and among them,10(83.3%)patients had positive endocervical cone margin.Postoperative intestinal obstructionwas noted in one abdominal hysterectomy patient,no other complications were observed in the remaining patients.Conclusion:Compared to conization,hysterectomy is more invasive;however,it is an acceptable treatment option for peri-menopausal and post-menopausal CIN3 patients.In such cases,opting for total laparoscopic hysterectomy adopted the marionette technique might be preferable because the procedure is less invasive.
文摘BACKGROUND In the presence of a large uterus,total laparoscopic hysterectomy(TLH),always requires morcellation to allow removal of the tissues from the abdominal cavity.However,uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma.Therefore,in-bag extracorporeal morcellation has been developed.However,tissue containment and extraction are extremely challenging,especially when considering the increasing uterine size to be removed through minimally invasive surgery.CASE SUMMARY Herein,we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH.The study enrolled patients who were planned for TLH for large uteri(weight>500 g).TLH was performed following the procedure reported in our previous studies.The novel technique has been described step-by-step in a video,which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g,1700 g,and 3700 g,respectively.The procedures were performed without any complications.The patients had an uneventful postoperative course,and in all cases,the pathology was benign leiomyoma.CONCLUSION Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies.The technique herein presented may be adopted in surgical practice,by adding it to the other available techniques of contained morcellation.It may represent a valid and feasible alternative,especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.
文摘<b>Background & Aims:</b> The multimodal analgesia provides superior pain relief and reduces opioid consumption and its side effects. Gabapentin has been used successfully in multi-modal analgesia in different doses. We designed a double-blind randomized control trial to find the minimal effective dose of gabapentin in multimodal analgesia for postoperative pain following total abdominal hysterectomy. <b>Material & Methods:</b> After informed consent, total of 87 patients were randomly assigned to A, B & C groups to receive gabapentin orally 300 mg, 600 mg, and 900 mg respectively one to two hours before surgery. Postoperatively pain was managed by patient-controlled analgesia (PCA) using pethidine. Pain score, opioid consumption, and side effects of gabapentin were monitored. Rescue analgesia was given and monitored. <b>Results:</b> There was no statistically significant difference among the groups with respect to age, weight, height, pethidine consumption, and rescue analgesia. Mean pain scores were statistically insignificant at baseline, 8, 12, and 24 hours postoperatively. Only at 4 hours, the highest pain score (mean) was found in group A, which is statistically significant. The side effects of gabapentin like nausea, vomiting, somnolence, and dizziness were also statistically insignificant. <b>Conclusion:</b> A single preoperative oral gabapentin 300 mg was found to be minimal effective dose in multimodal analgesic regimen for reducing post-operative pain and analgesic requirement following total abdominal hysterectomy.
文摘Objective: Cervical cystic lesions are often observed in gynecological clinical practice. Many are caused by benign diseases such as lobular endocervical glandular hyperplasia (LEGH), and it is important to differentiate these lesions from those due to malignant diseases such as minimal deviation adenocarcinoma (MDA). In cases in which fertility preservation is not a concern, the final pathology is often confirmed by hysterectomy. To investigate the feasibility and safety of laparoscopic surgery for cervical cystic lesions, we retrospectively examined cases in which total laparoscopic hysterectomy (TLH) was performed for diagnosis and treatment. Methods: The subjects were 28 women who underwent TLH from April 2012 to March 2017 at Keio University Hospital. The pre- and post-operative courses of these patients were examined. Results: The average age was 49.4 (range 39 - 65) years and the mean body mass index was 21.7 (16.8 - 30.5) kg/m2. The average operation time was 159 (101 - 314) min and the average bleeding volume was 106.8 (0 - 600) g. There were no severe perioperative complications. The average hospital stay was 8.4 (7 - 14) days. In postoperative pathological diagnosis, 13 cases had benign diseases such as Nabot cysts, there were 14 cases of LEGH, and one patient was diagnosed with MDA. In the MDA case, additional bilateral salpingo-oophorectomy and pelvic lymph node dissection were performed at a later date. No metastasis was observed in these excised specimens. Conclusions: Our results suggest that TLH for cervical cystic lesions can be performed safely. However, it is important to consider the TLH indication before surgery based on the possibility of malignant disease.
文摘Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysis of women who underwent TLH for benign diseases between April, 2014 and March, 2016 was conducted by a single surgeon in a single hospital (Showa University of Fujigaoka Hospital). We divided the main procedures of the TLH operation into five sections, and measured the time required for each section. These cases were divided into three groups, group 1, 2, and 3. Results: There were 54 cases of TLH over two years for a single surgeon, and 21 cases that included essential operative procedures were divided into three groups of seven cases each. The average duration of the surgery (min.) was 178.3 ± 48.2 in the group 1, 128.3 ± 15.6 in the group 2, and 111.3 ± 15.9 in the group 3. A significant reduction in the required time was observed between group 1, 2, and 3 groups. As the number of cases increased, the operation time became statistically significantly shorter for every section except B and D. The skill growth rate was different at each section. Conclusion: For a single surgeon, as the number of surgical cases increased, we recognized the increased skill with the procedure in every section and the rate of skill growth differed for different sections. The difference of growth rate for each section implied that the number of operative cases required for a surgeon in each section was different.
文摘BACKGROUND Uterine myomas are the most common benign gynecological soft tissue tumors in women but polycythemia associated with these tumors is rare.Polycythemia is significantly associated with risk of venous thromboembolism(VTE),which is further increased in case of a large pelvic mass and obesity.Here we report the surgical challenges in the case of an obese patient with a giant fibromatous uterus and associated polycythemia.CASE SUMMARY A 42-year-old obese woman was referred to our department for treatment for a huge fibromatous uterus.She suffered of pelvic pressure and abdominal distension and reported severe dyspnea from several months.Laboratory analyses including hemoglobin(Hb)19.2 g/dL and hematocrit(Hct)59.7%were indicative of polycythemia.Arterial blood gas analysis showed arterial oxygen pressure(pO2)of 81.5 mmHg.Abdominal computed tomography confirmed a giant fibromatous uterus measuring 28.2 cm×17 cm×25 cm.To reduce the thromboembolic risk,the patient underwent low molecular weight heparin,phlebotomy twice before surgery,and we opted for a laparoscopic hysterectomy.The uterus weighed 5400 g and the histology confirmed a diagnosis of leiomyoma.We did not find increased erythropoietin levels in the supernatant of the myomatous uterine tissue.There were no complications.On postoperative day 1,the Hb and the Hct levels normalized to 13.3 g/dL and 41.7%,respectively.Arterial blood gas analysis after surgery showed a pO2 of 144.7 mmHg.These results suggested the diagnosis of myomatous erythrocytosis syndrome.The patient was discharged on the second postoperative day in very good condition with no symptoms.CONCLUSION We believe this is the first reported laparoscopic hysterectomy in a patient with a giant uterus,polycythemia and obesity.Multiple VTE risk factors warranted a laparoscopic approach.
