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Takeda A.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Mori M.,Gifu Prefectural Tajimi Hospital | Nakano T.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2011

Objective: To report our initial experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery using a wound retractor for the management of ectopic pregnancy. Study design: Twelve consecutive cases of ectopic pregnancy were managed by isobaric LESS surgery with the subcutaneous abdominal wall-lift method. In each case, a wound retractor was used as a transumbilical working port with insertion into the peritoneal cavity through a 2.5-cm vertical umbilical incision. Subsequent surgical procedures were performed with multiple conventional laparoscopic instruments through single umbilical port. Results: All cases of ectopic pregnancy were successfully managed by isobaric LESS surgery. Procedures included salpingectomy in eight cases of ampullary pregnancy and two cases of isthmic pregnancy, salpingectomy and local methotrexate injection in one case of isthmic pregnancy, and salpingo-oophorectomy for one case of ovarian pregnancy. Neither extraumbilical incisions nor conversion to laparotomy was required. In a case of ruptured ampullary pregnancy with massive hemoperitoneum, intraoperative autologous blood salvage and donation avoided the need for the transfusion of bank blood. Although postsurgical umbilical seroma was noted in one case and systemic methotrexate administration was required for persistent ectopic pregnancy in one case of isthmic pregnancy respectively, there were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within umbilicus. Retrospective comparison of surgical parameters including surgical duration, estimated blood loss, frequency of postoperative analgesic use, time of bowel recanalization, postoperative inflammatory response and postoperative hospital stay did not show any significant differences between isobaric LESS surgery group and conventional isobaric multiport laparoscopic surgery group. Conclusions: Based on the satisfactory outcome achieved in these initial 12 cases of ectopic pregnancy treated by isobaric LESS surgery, the wound retraction system combined with the subcutaneous abdominal wall-lift method appears to contribute favorably to LESS surgery for the management of ectopic pregnancy because the device permits free circumferential access and retraction during procedures without the closed condition required during pneumoperitoneum. © 2010 Elsevier Ireland Ltd.


Takeda A.,Gifu Prefectural Tajimi Hospital | Koike W.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2014

Objective Uterine artery pseudoaneurysm is a rare potentially life-threatening complication after myomectomy. Its clinical characteristics and management, and the outcomes of subsequent pregnancy, are not well understood. The purpose of this study was to clarify these important issues. Study design Retrospective analysis of a case series of uterine artery pseudoaneurysm detected after laparoscopic-assisted myomectomy (LAM) in a single center over a 13-year period. During the early postoperative course, gray scale ultrasonographic evaluation was carried out routinely by searching for an anechoic or hypoechoic well-defined cystic structure in the post-myomectomy scar. In suspicious cases, further evaluation was performed by color Doppler flow analysis and three-dimensional computerized tomographic angiography. After finally confirming the diagnosis by digital subtraction angiography, uterine artery pseudoaneurysm was conservatively managed by angiographic intervention. In cases achieving successful conception, cesarean delivery was chosen and the uterine scar was evaluated. Results Uterine artery pseudoaneurysm was diagnosed in 9 out of 854 cases of LAM. One case was undiagnosed until massive uterine hemorrhage occurred in the late postoperative period, while the other eight cases were diagnosed in the early postoperative course without hemorrhagic complication. Eight cases were managed by uterine artery embolization, but spontaneous resolution of pseudoaneurysm was observed in one case during a difficult prolonged attempt to superselect the offending branch of the uterine artery. Postembolization course was uneventful, except in a 41-year-old woman who developed oligomenorrhea. Among five women desiring preserved fertility, three women including one after spontaneous miscarriage achieved live birth by cesarean section. One woman experienced spontaneous miscarriage and one did not become pregnant by fertility treatment. In a case with elective cesarean delivery, severe early postpartum hemorrhage occurred from the placental bed and was conservatively managed by emergency uterine artery embolization. Conclusion The development of uterine artery pseudoaneurysm after myomectomy may be more common than previously considered, and should be carefully monitored to avoid potentially life-threatening hemorrhage and loss of fertility. Although spontaneous resolution may occur, conservative management by angiographic intervention could be a feasible management option for future fertility preservation, once a diagnosis has been made. © 2014 Elsevier Ltd. All rights reserved.


Takeda A.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2014

Objective: To evaluate the safety and feasibility of gasless transumbilical laparoendoscopic single-site (LESS) surgery for the management of adnexal masses in pediatric and adolescent girls aged 19 years or younger.Study design: Retrospective study of 28 pediatric and adolescent girls each undergoing gasless LESS surgery and gasless multiport laparoscopic surgery for adnexal masses. In each case, laparoscopic surgery was performed by the abdominal-wall lift method under endotracheal general anesthesia. The two groups were compared for their patient demographics and surgical outcome measures.Results: In the LESS surgery group, median age of the patients including three pre-menarcheal girls was 17.5 years. The most common symptom was abdominal pain. Median tumor diameter in the LESS surgery group was 7.4 cm. There were no statistical differences in clinical features between LESS surgery and multiport laparoscopic surgery groups. In the LESS surgery group, adnexal masses were managed by unilateral cystectomy (n = 20), unilateral salpingo-oophorectomy (n = 5), bilateral cystectomy (n = 2), and unilateral salpingectomy (n = 1). Emergency LESS surgery was performed for seven cases due to adnexal torsion and one case due to cyst rupture. Preservation of affected ovary was not achieved in three emergency cases with adnexal torsion due to severe necrosis, and in one case each of recurrent mucinous cystadenoma and huge mucinous cystadenoma. In 24 adnexal masses from 22 girls who received adnexal cystectomy by LESS surgery, LESS-assisted extracorporeal cystectomy, was possible in 14 masses while intracorporeal cystectomy was required in other 10. In a case of dermoid cyst managed by LESS-assisted extracorporeal cystectomy, additional hemostasis was required by intracorporeal suturing due to laceration of utero-ovarian ligament. Median-excised tissue weight in the LESS surgery group was 111 g. Significant differences between LESS surgery and multiport laparoscopic surgery groups were not noted in surgical outcomes and pathological diagnosis, except for significantly lower C-reactive protein value on postoperative day 3 in the LESS surgery group.Conclusion: Gasless LESS surgery for pediatric and adolescent adnexal masses is a safe and feasible alternative to multiport laparoscopic surgery. © 2014 Elsevier Ireland Ltd. All rights reserved.


Takeda A.,Gifu Prefectural Tajimi Hospital | Koike W.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2014

Objective To report our experience on the value of dynamic three-dimensional computerized tomographic (CT) angiography for immediate diagnosis and management of intractable postpartum hemorrhage (PPH). Study design Retrospective study of all cases of PPH examined by three-dimensional CT angiography between January 2007 and August 2013 in a single center. In each case, emergency dynamic CT was taken at the early arterial, late arterial and venous phases to identify the extravasated contrast agent that represents active hemorrhage. Images for three-dimensional CT angiography were reconstituted from multiplanar CT images. Based on these findings, management procedures were individually determined and those outcomes were compared with angiographic, surgical and clinical findings. Results Twenty-nine cases with primary PPH and 19 cases with secondary PPH were examined. In primary PPH, extravasation in the early arterial phase was noted in 12 cases. Those included vulvovaginal hematoma (n = 4), invasive placenta (n = 2), retained placenta (n = 2), uterine atony (n = 1), retroperitoneal hematoma (n = 1), retrovesical hematoma (n = 1) and rectus sheath hematoma after cesarean section (n = 1). Of these, ten cases were treated by transcatheter arterial embolization (TAE) of the offending vessels with or without additional therapies. In secondary PPH, extravasation was identified in 14 cases. Those included invasive placenta (n = 8), uterine artery pseudoaneurysm (n = 3), uterine arteriovenous fistula (n = 2), and subinvolution of placenta bed (n = 1), which were treated by TAE of the offending vessels with or without additional therapies. Successful hemostasis with fertility preservation was achieved in all cases. Complications were not identified except for a case of placenta increta that developed secondary amenorrhea after TAE of both uterine arteries. In subsequent gestation after TAE of both uterine arteries, normal vaginal delivery (n = 4), uncomplicated cesarean delivery (n = 3), cesarean delivery followed by recurrent arteriovenous fistula (n = 1) and spontaneous miscarriage followed by recurrent invasive placenta (n = 1) were identified. Conclusions This case series emphasizes that three-dimensional CT angiography has significant diagnostic value when the appropriate procedure for management of PPH was immediately determined to avoid potential maternal morbidity and mortality. © 2014 Elsevier Ireland Ltd.


Takeda A.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Mori M.,Gifu Prefectural Tajimi Hospital | Nakano T.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2011

Objective: To report our experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery in 100 patients with adnexal tumors at a single center. Study design: In each case, a wound retractor was used as a working port through a 2.5-cm vertical umbilical incision. The surgical view was secured with the subcutaneous abdominal wall-lift method. Surgical procedures were performed using conventional laparoscopic instruments under vision with a rigid 30°, 5-mm EndoEYE laparoscope. Clinical data regarding patient demographics and surgical outcomes were retrospectively analyzed. Results: Between August 2009 and July 2010, one hundred and seventeen tumors from 100 cases were treated with isobaric LESS surgery (unilateral salpingo-oophorectomy, 46; unilateral cystectomy, 33; bilateral cystectomy, 8; bilateral salpingo-oophorectomy, 6; unilateral cystectomy and contralateral cyst wall ablation, 4; unilateral cystectomy and contralateral salpingo-oophorectomy, 2; and unilateral salpingectomy, 1). Three normal adnexa were prophylactically resected at the same time as contralateral salpingo-oophorectomy of a diseased ovary. Previous abdominal surgery was noted in 20 cases. Emergency surgery was performed in 7 cases. Six pregnant women were treated in the late first trimester. Median tumor diameter was 6.9 cm. Median surgical duration was 55 min and median blood loss was 10 mL. Conversion to conventional laparoscopic surgery was noted in one case of recurrent endometriotic cyst with severe adhesion. Laparotomic conversion was not experienced. Prolonged administration of antibiotics with extended hospitalization was required in 7 cases due to elevated inflammatory parameters. There were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within the umbilicus. With exclusion of 4 endometriotic cysts treated with cyst wall ablation, pathological diagnosis was obtained for 113 tumors (dermoid cyst, 54; endometriotic cyst, 21; serous cystadenoma, 19; mucinous cystadenoma, 9; paraovarian cyst, 8; serous borderline tumor, 1; and paraovarian serous papillary borderline tumor, 1). Conclusions: With efficient wound retraction to create a wide and flexible orifice during instrumentation, the transumbilical wound retraction system combined with the subcutaneous abdominal wall-lift method contributes favorably to LESS surgery as a safe, feasible and reproducible alternative for a variety of ablative and reconstructive applications in the management of adnexal tumors. © 2011 Elsevier Ireland Ltd.


Takeda A.,Gifu Prefectural Tajimi Hospital | Sakurai A.,Shinshu University | Imoto S.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
Journal of Obstetrics and Gynaecology Research | Year: 2013

Multiple endocrine neoplasia type 1 (MEN1) is a rare autosomal dominant hereditary disorder that develops multiple tumors arising from various endocrine organs, including the parathyroid gland, endocrine pancreas and pituitary gland. Although mesenchymal tumors can be an integral part of the syndrome, parasitic peritoneal myomas have never been described in an MEN1 patient. Seven years after laparoscopic-assisted myomectomy, parasitic peritoneal myomas were diagnosed in a 31-year-old woman with situs inversus totalis and previous history of parathyroid adenoma. Subsequently, MEN1 was clinically diagnosed by identification of endocrine pancreatic, adrenal and pituitary tumors. Genetic analysis revealed a heterozygous germline mutation in the splice donor sequence of intron 6 of the MEN1 gene. Although rare, parasitic peritoneal myomas could potentially be associated with MEN1 syndrome. © 2013 The Authors.


Takeda A.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Mori M.,Gifu Prefectural Tajimi Hospital | Yamada J.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2013

Objective: To report our experience with isobaric transumbilical laparoendoscopic single-site surgery for the management of large adnexal tumors exceeding 500 g of excised tissue weight including cystic contents. Study design: In each case, a wound retractor was used to make a working port through a 2.5-cm vertical umbilical incision. The surgical view was secured by the abdominal wall-lift method with an intra-Abdominal fan retractor system. After the tumor was punctured by a SAND balloon catheter and the cystic contents were aspirated, surgical procedures were performed with conventional laparoscopic instruments under vision with a rigid 30°, 5-mm EndoEYE laparoscope. Clinical data regarding patient demographics and surgical outcomes was retrospectively analyzed. Results: Between October 2010 and April 2012, 35 patients with large adnexal tumors were treated. The median age of the patients was 31.5 years. Previous abdominal surgery was noted in nine cases. The median tumor diameter was 17.7 cm. Emergency surgery was performed in two cases of adnexal torsion and one case of tumor rupture. Three cases with intrauterine pregnancy were treated in the late first trimester. Unilateral salpingo-oophorectomy was performed in 24 cases. Unilateral cystectomy was performed in five cases. Unilateral salpingo-oophorectomy and contralateral cystectomy, and bilateral cystectomy were performed in two cases each. Unilateral salpingectomy, unilateral salpingo-oophorectomy and contralateral salpingectomy were performed in one case each. The median excised tissue weight was 1100 g. The median surgical duration was 72 min, with median blood loss of 10 mL Extended hospitalization was required in two cases due to elevated inflammatory parameters, one case with pregnancy due to hyperemesis gravidarum and one case with pregnancy due to subchorionic hematoma. Readmission due to postoperative pelvic abscess was noted in one case and was conservatively managed. Major surgical complications were not experienced. The present technique yielded a minimal postoperative scar concealed within the umbilicus. Conclusion: The transumbilical wound retraction system combined with an intra-Abdominal fan retractor appears to contribute favorably to laparoendoscopic single-site surgery for the management of large adnexal tumors, because the device permits flexible and wide circumferential access by efficient wound retraction during instrumentation without the need for closed condition associated with pneumoperitoneum. © 2012 Elsevier Ireland Ltd.


Takeda A.,Gifu Prefectural Tajimi Hospital
The journal of obstetrics and gynaecology research | Year: 2011

Uterus-like mass composed of a cavity lined by mucosa resembling endometrium and surrounding smooth muscle layer simulating myometrium is an extremely rare disease entity of which the histogenesis is presently unknown. A 39-year-old, gravida 2, para 2, woman presented with sudden onset of lower abdominal pain and was found to have left adnexal mass with unusual image diagnostic appearance. The adnexal mass arising from the left ovarian ligament was excised by laparoendoscopic single-site surgery. Histopathological diagnosis was uterus-like mass of ovarian ligament. © 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.


Sato T.,Gifu Prefectural Tajimi Hospital | Kobayashi M.,Nagoya University
International Journal of Angiology | Year: 2012

Infective abdominal aortic aneurysm (IAAA) is relatively rare, but a case which is caused by Haemophilus influenzae type B is very rare. We experienced one IAAA case due to H. influenzae type B. The patient was 69-year-old man presenting with severe abdominal and back pain and elevated C-reactive protein (CRP), as inflammatory marker. The patient was found to have saccular aneurysm infrarenal aorta on computed tomography scanning. First, we started to treat him with antibiotic agent and second, we operated him at day 8 after admission with expanded polytetrafluoroethylene graft. Revascularization was made in situ reconstruction. As the result of culture with aneurysm wall, we found that the cause of this aneurysm was the infection of H. influenzae type B. As far as we know, this bacterium is scarcely reported as the cause of infective aortic aneurysms. We reported this IAAA case with the review of the English literature. Copyright © 2012 by Thieme Medical Publishers, Inc.


Takeda A.,Gifu Prefectural Tajimi Hospital | Imoto S.,Gifu Prefectural Tajimi Hospital | Mori M.,Gifu Prefectural Tajimi Hospital | Yamada J.,Gifu Prefectural Tajimi Hospital | Nakamura H.,Gifu Prefectural Tajimi Hospital
Journal of Minimally Invasive Gynecology | Year: 2012

A 26-year-old primigravida patient was referred with suspicion of ectopic pregnancy 39 days after her last menstrual period. Her serum β-human chorionic gonadotropin value was 3812 mIU/mL. As we suspected the existence of ectopic pregnancy with bilateral dermoid cysts, laparoendoscopic single-site surgery was performed. After dissection of dense pelvic adhesion, cystectomy was performed for a left ovarian dermoid cyst. Although there was a right ovary at the correct position, a parasitic dermoid cyst firmly attached to the peritoneal surface of cul-de-sac was identified. After excision of the parasitic dermoid cyst, early abdominal pregnancy tissue implanted in the peritoneal hollow of right deep pararectal space was identified under the guidance of diffusion-weighted magnetic resonance imaging and was excised. With systemic administration of methotorexate, the postoperative course was uneventful. © 2012 AAGL.

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