Technique for transvaginal removal of large specimen using an Alexis Contained Extraction System during laparoscopic hysterectomy.

OBJECTIVE: Transvaginal removal of large specimens during laparoscopic hysterectomy can be a complex surgical procedure that poses a risk of organ injury and tissue spillage into the abdominal cavity and is associated with extraction of the specimen and manual morcellation. Our objective was to demonstrate a technique for transvaginal removal of large specimens using the Alexis Contained Extraction System (CES) in laparoscopic hysterectomy. METHODS: The technique used for transvaginal removal of large specimens using the Alexis CES was presented in this video. Surgery was performed at a tertiary hospital. RESULTS: Following resection of the specimen during laparoscopic hysterectomy, the Alexis CES was inserted into the abdominal cavity through the umbilical trocar wound. The specimen was placed in a bag to prevent tissue spillage. The ring retractor was guided to the vagina and pulled out transvaginally. By repeatedly turning the ring retractor, tension was applied to the specimen bag, and the vaginal wall was unfolded all around to enable a secure surgical field. During manual morcellation of the specimen in the bag, the retractor was pulled and additionally turned to roll and re-tension the specimen bag when the bag was loosened. The specimen was pushed out of the vagina and safely and effectively extracted without concerns about tissue spillage in the abdominal cavity or related organ injuries. CONCLUSION: The technique for transvaginal removal of large specimens using the Alexis CES enables simple, effective, and safe tissue extraction with contained manual morcellation during laparoscopic hysterectomy.

Laparoscopic Vaginoplasty Procedure Using a Modified Peritoneal Pull-Down Technique with Uterine Strand Incision in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome: Kisu Modification.

Various vaginoplasty procedures have been developed for patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Here, we describe a novel laparoscopic vaginoplasty procedure, known as the Kisu modification, using a pull-down technique of the peritoneal flaps with additional structural support to the neovaginal apex using the incised uterine strand in patients with MRKH syndrome. Ten patients with MRKH syndrome (mean age at surgery: 23.9 ± 6.5 years, mean postoperative follow-up period: 17.3 ± 3.7 months) underwent construction of a neovagina via laparoscopic vaginoplasty. All surgeries were performed successfully without complications. The mean neovaginal length at discharge was 10.3 ± 0.5 cm. Anatomical success was achieved in all patients, as two fingers were easily introduced, the neovagina was epithelialized, and the mean neovaginal length was 10.1 ± 1.0 cm 1 year postoperatively. No obliteration, granulation tissue formation at the neovaginal apex, or neovaginal prolapse was recorded. Five of the 10 patients attempted sexual intercourse and all five patients were satisfied with the sexual activity, indicating functional success. Although the number of cases in this case series is few, our favorable experience suggests that the Kisu modification of laparoscopic vaginoplasty procedure is an effective, feasible, and safe approach for neovaginal creation in patients with MRKH syndrome.

Real-time intraoperative ureter visualization with a novel Near-Infrared Ray Catheter during laparoscopic hysterectomy for gynecological cancer.

Ureteral injuries are well-known complications of gynecologic surgery, with a higher prevalence in laparoscopic surgery than in laparotomy [1]. The use of near-infrared fluorescent imaging navigation is currently being considered a novel method to identify the ureters intraoperatively and prevent ureteral injuries [2]. The Near-Infrared Ray Catheter (NIRC) fluorescent ureteral catheter is a newly developed device, containing a fluorescent resin that can be recognized by near-infrared irradiation. We found few reports on the use of this catheter in laparoscopic surgery for colon and rectal cancer [3, 4], but no reports in gynecologic surgery. We demonstrate the feasibility, safety, and potential usefulness of the real-time intraoperative visualization of the ureters using a novel NIRC fluorescent ureteral catheter in laparoscopic hysterectomy for endometrial cancer. A 30-year-old woman with early grade 1 endometrioid carcinoma was treated with medroxyprogesterone acetate for fertility preservation. After achieving complete response, she got pregnant and underwent cesarean section. The recurrence of atypical endometrial hyperplasia one year post-delivery prompted a total laparoscopic hysterectomy. Before the laparoscopic surgery began, the NIRC fluorescent ureteral catheters were placed in the ureters under the obtainment of informed consent from the patient. During the surgery, the catheters were successfully visualized by near-infrared fluorescence observation, which helped identify the ureters clearly and prevent ureteral injuries. This novel ureteral imaging navigation is expected to be an effective tool in cases of obesity, severe pelvic adhesion, deep infiltrating endometriosis, and malignancy in gynecologic laparoscopic surgery to clearly identify the ureter and to reduce the risk of ureteral injury.

Rectal mobilization for laparoscopic pelvic lymphadenectomy of the lower paracervical pathway in patients with uterine cancer.

OBJECTIVE: The pelvic lymphatic drainage system comprises the upper and lower paracervical pathways (LPPs). Lymph node dissection of the LPP, including the cardinal ligament, internal iliac, internal common iliac, and presacral lymph nodes, requires higher surgical skills because of the anatomical limitations of the pelvic cavity and the dissection of vessels while preserving the nerves in the pelvic floor. In this video, we demonstrate rectal mobilization for laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer. METHODS: Rectal mobilization was performed before complete pelvic lymph node dissection of the LPP. The pararectal space was opened widely and the connective tissue between the presacral fascia and prehypogastric nerve fascia was dissected bilaterally, allowing the rectum to be pulled. RESULTS: This procedure created a wide-open space in the pelvic floor, allowing clear visualization of the nerves and lymph nodes of the LPP. Laparoscopic complete lymph node dissection of the LPP was performed in the open space while preserving the hypogastric and pelvic splanchnic nerves and isolating the extensive network of blood vessels in the pelvic cavity. CONCLUSION: Rectal mobilization enabled the safe execution of laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer.

Bilateral adrenal metastases of endometrial cancer with adrenal insufficiency.

Adrenal metastasis from endometrial cancer is extremely rare and has a poor prognosis, especially for bilateral adrenal metastases. It is usually asymptomatic without any adrenal hormonal abnormalities. A 50-year-old postmenopausal woman presented with acute right-sided back pain and history of occasional abnormal uterine bleeding. She was diagnosed with endometrial cancer with ruptured bilateral adrenal metastases. She underwent total hysterectomy and bilateral salpingo-oophorectomy, and the pathological findings revealed dedifferentiated carcinoma. After three courses of adjuvant chemotherapy, the bilateral adrenal metastases had increased in size, with worsening back pain and adrenal hormone insufficiency. The patient died 6 months after the identification of adrenal tumors. Acute back pain may lead to the identification of a ruptured adrenal metastasis. The possibility of gradual adrenal insufficiency should be considered in bilateral adrenal metastases. Although the prognosis is poor, tumor debulking surgery followed by adjuvant chemotherapy could be suggested to improve the prognosis.

Inappropriate surgery in a patient with misdiagnosed Robert's uterus.

BACKGROUND: Robert's uterus is a rare Mullerian anomaly, which can be described as an asymmetric, septate uterus with a non-communicating hemicavity. Herein, we present the case of a misdiagnosed Robert's uterus, resulting in an invasive and disadvantageous surgery. CASE PRESENTATION: A 16-year-old woman was referred to our department because of dysmenorrhea and suspicion of uterine malformation. We misdiagnosed Robert's uterus as a unicornuate uterus with a non-communicating rudimentary horn and hematometra, and performed laparoscopic hemi-hysterectomy. Although the patient's symptoms were relieved, our surgical procedure left the lateral uterine wall weak, making the patient's uterus susceptible to uterine rupture in any future pregnancy. CONCLUSIONS: Although the early diagnosis of Robert's uterus is challenging, it is important in order to determine appropriate surgical interventions and management for maintaining the quality of life and ensuring safety in future pregnancies.

New Laparoscopic Vaginoplasty Procedure With a Modified Peritoneal Pull-Down Technique in Four Patients With Mayer-Rokitansky-Küster-Hauser Syndrome.

BACKGROUND: Various vaginal reconstructive procedures have been described for patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. We describe the success of a novel laparoscopic vaginoplasty procedure using an anteroposterior peritoneal pull-down technique. CASE: Four patients with MRKH syndrome underwent a modified laparoscopic Davydov procedure using an anteroposterior peritoneal pull-down technique with a transverse laparoscopic incision below the strand. Anatomical success was achieved in all patients, allowing easy introduction of 2 fingers, an epithelialized neovagina, and a mean length of 8.0 cm (range 7.0-9.0cm). All 3 patients who attempted sexual intercourse were successful, and neovagina size was adequately maintained at the long-term follow-up in the remaining patient. SUMMARY AND CONCLUSION: This novel procedure presents as a feasible and an effective approach for vaginal reconstruction in patients with MRKH syndrome.

Application of Saline Infusion Sonocolpography in Diagnosis and Treatment of Perforated Transverse Vaginal Septum.

Transverse vaginal septum (TVS) is a particularly rare vaginal anomaly, and diagnosis is often difficult in a genital examination. We herein present a case of perforated TVS for which successful diagnosis and treatment were achieved using a new technique referred to as saline infusion sonocolpography. A 32-year-old female presented with primary infertility. Speculum examination revealed a blind vaginal canal with two pinpoint perforating holes. Foley catheters with inflated balloon were inserted into the two apertures, and then normal saline was injected through the catheters to distend the vaginal pouch. This procedure of saline infusion sonocolpography revealed the uterine cervix and vaginal pouch and permitted diagnosis of perforated TVS of the upper vagina. The septum was excised and a normal cervix was ascertained. The patient had no complication such as agglutination of the vagina postoperatively. This case suggests that saline infusion sonocolpography may be useful for diagnosis and treatment of TVS.

Feeding-suppressive mechanism of sulfated cholecystokinin (26-33) in chicks.

The anorexigenic effect of cholecystokinin (CCK) is well documented in mammals, but documentation in neonatal chicks is limited. Thus, the present study investigated the mechanism underlying the anorexigenic effect of CCK in neonatal chicks. Intraperitoneal (IP) injection of sulfated CCK(26-33) (CCK8S) significantly decreased food intake in chicks at 60 and 300 nmol/kg. Non-sulfated CCK(26-33) (CCK8) also significantly decreased food intake, but its anorexigenic effect was observed only at the highest dose (300 nmol/kg) and short-lived. However, CCK(30-33) (CCK4) had no effect on food intake. Also, the intracerebroventricular (ICV) injection of CCK8S (0.2 and 1 nmol) significantly decreased food intake in chicks. Similar to IP administration, the anorexigenic effect of CCK8 was weak and CCK4 did not affect food intake. IP and ICV injections of CCK8S caused conditioned aversion and increased plasma corticosterone concentrations, suggesting that their anorexigenic effects might be related to stress and/or malaise. This might be true in ICV-injected CCK8S because co-injection of astressin, a corticotropin-releasing hormone receptor antagonist, tended to attenuate the effect of CCK8S. The present study revealed that N-terminal amino acids and the sulfation of Tyr are important for the anorexigenic effect of CCK8S after IP and ICV administered in chicks. Additionally, the effect of central CCK8S might be related to stress and/or malaise.

Differential thresholds of neuromedins B-, C-, and bombesin-induced anorexia and crop-emptying rate in chicks.

Neuromedin B (NMB) and neuromedin C (NMC) are homologs of bombesin and are distributed throughout both the brain and gastrointestinal tract. The physiological roles of these bombesin-like peptides in chicks (Gallus gallus) have not been documented. Therefore, the purpose of the present study was to measure the effects of these bombesin-like peptides on food intake, crop-emptying rate and body temperature in chicks, and then to compare these effects with those of bombesin. Intracerebroventricular (ICV, 5 nmol) and intraperitoneal (IP, 300 nmol/kg) injections of NMB, NMC, and bombesin significantly decreased food deprivation-induced food intake. When ICV injected (5 nmol), all three peptides significantly reduced crop-emptying rate. IP injection of NMC and bombesin (300 nmol/kg) also reduced crop-emptying rate while NMB did not. The magnitude of food intake suppression and crop-emptying rate reduction were greater for bombesin than NMB and NMC. ICV and IP injections of NMB, NMC and bombesin did not affect cloacal temperature. In sum, the present study suggests that central and peripheral NMB and NMC are associated with reduced food intake and crop-emptying of chicks, but these effects are weaker than those of bombesin.

Feeding and drinking response following central administration of neuromedin S in chicks.

Neuromedin S (NMS) is recognized as an anorexigenic peptide in the brain of mammals. In chicks (Gallus gallus), however, the effect of NMS has not been investigated. Therefore, the purpose of the present study was to investigate whether intracerebroventricular (ICV) injection of NMS affected feeding and drinking behavior in chicks. The injection of NMS (0.01-1 nmol) significantly decreased food intake under both ad libitum and food deprivation-induced feeding conditions. However, NMS did not affect water deprivation-induced drinking behavior. ICV injection of NMS stimulated voluntary locomotion and wing-flapping behavior. In addition, we found that those effects of NMS might be related to the hypothalamus-pituitary-adrenal axis because ICV injection of NMS stimulated corticosterone release. The present study suggests that central NMS functions an anorexigenic factor in chicks.

Feeding and drinking response following central administrations of bombesin-like peptides in chicks.

Gastrin-releasing peptide (GRP) and neuromedin B (NMB) have been isolated as homologues of bombesin. Central administration of bombesin inhibits feeding behavior in chicks (Gallus gallus) while the effects of GRP and NMB have not been reported. The purpose of the present study was to investigate whether intracerebroventricular (ICV) injection of GRP, NMB and neuromedin C (NMC, the C-terminus decapeptide of GRP) affected feeding and drinking behavior in chicks. Injection of GRP, NMC and NMB (0.2-5 nmol) decreased feeding behavior in chicks while drinking behavior was not affected. ICV injection of 5 nmol GRP and NMC decreased voluntary locomotion while NMB did not. It is therefore possible that GRP- and NMC-associated hypoactivity is related to the peptides' anorexigenic effects. GRP, NMC and NMB did not affect plasma corticosterone concentration, suggesting that hypothalamus-pituitary-adrenal axis might not be related to the anorexigenic action of these peptides. All these findings support the hypothesis that GRP, NMC and NMB function as anorexigenic factors in the brain of chicks.

Central administration of substance P inhibits feeding behavior in chicks.

The purpose of the present study was to determine whether central administration of substance P (SP), a tachykinin neuropeptide, influenced feeding behavior in layer chicks (Gallus gallus). Intracerebroventricular (ICV) injections of 5 nmol SP decreased food intake in 5- and 6-day-old chicks under both ad libitum and 3-h fasting conditions. There are 3 major subtypes of tachykinin receptors, namely, neurokinin 1, 2 and 3 receptors. Injection of neurokinin A and neurokinin B, which are respectively endogenous agonists for neurokinin 2 and 3 receptors, did not suppress feeding behavior in chicks, suggesting that the anorexigenic effect of SP might be mediated by the neurokinin 1 receptor rather than neurokinin 2 and 3 receptors. Chicks that received 5 nmol SP did not change their locomotion, standing, sitting or drinking time, suggesting that its anorexigenic action might not be due to SP-induced hyperactivity or sedation. ICV injection of SP increased water intake, also indicating that SP likely did not affect feeding behavior through malaise. In addition, the anorexigenic effect of SP might not be related to corticotrophin-releasing hormone (CRH) because plasma corticosterone concentration was not affected by ICV injection of SP and co-administration of the CRH receptor antagonist astressin did not affect the anorexigenic effect of SP. The present study suggests that central SP acts as an anorexigenic neuropeptide in chicks.