Ovarian fibromatosis associated with large pedunculated fibroma in a 30-year-old woman: A rare coincidence or variant?

A 30-year-old nulligravida was referred under suspicion of large subserosal myoma. T2-weighted magnetic resonance imaging revealed multilobulated solid mass in the left lower abdomen measuring 16 cm in longitudinal diameter. The ovarian surface was covered with a marked T2-hypointense thick rim called "black garland sign," forming multiple nodular masses ranging from 1 to 5 cm in diameter in some portions of the bilateral ovaries. By laparoscopic-assisted minilaparotomy, the stalk of pedunculated mass originating from the left ovarian hilum was excised, followed by carrying out of the body after in-bag morcellation using a surgical scalpel. Right ovarian exophytic nodular masses larger than 1 cm were excised using monopolar electrode needle. Pathological examination of excised right and left masses showed fibroblast-like spindle cell proliferation with collagenous stroma; however, differences between right and left masses cannot be distinguished on a histological level. Postoperative diagnosis was ovarian fibromatosis coexisting with large pedunculated fibroma.

Short-term administration of oral relugolix before single-port laparoscopic-assisted vaginal hysterectomy for symptomatic uterine myomas: A retrospective comparative study with leuprorelin injection.

AIM: To investigate the efficacy of short-term administration of relugolix, a novel orally active gonadotropin-releasing hormone (GnRH) antagonist, before single-port laparoscopic-assisted vaginal hysterectomy (LAVH) for symptomatic uterine myomas, retrospectively compared with injection of leuprorelin, a GnRH agonist. METHODS: A retrospective comparative study of each 35 women with symptomatic myomas in the relugolix and leuprorelin groups. RESULTS: Before administration of relugolix and leuprorelin, the median uterine volume did not differ significantly between the two groups (p = 0.53). Median uterine volume change from baseline after short-term administration of relugolix and leuprorelin did not differ significantly (p = 0.17). Surgical duration (p = 0.84) and estimated blood loss (p = 0.48) were not different between the two groups. According to a patient questionnaire, the side effects of the drugs were not different between the two groups (p = 0.27). When patients were was asked if they wanted to have either of these drugs again, some relugolix users preferred leuprorelin due to concern about forgetting daily medication, while some leuprorelin users preferred relugolix to avoid pain at injection. CONCLUSION: Oral relugolix medication or leuprorelin injection administered before single-port LAVH for uterine myomas yielded an equivalent reduction of uterine volume and perioperative outcomes with no significant adverse events. Patient preference for either oral daily relugolix or a monthly injection of leuprorelin could be considered when preoperative management is determined.

Magnetic resonance imaging and gasless laparoendoscopic single-site surgery for the diagnosis and management of isolated tubal torsion with a paratubal cyst at 31 weeks of gestation: A case report and literature review.

A 30-year-old nulliparous woman was transferred under suspicion of acute appendicitis, due to the sudden onset of severe right lower quadrant pain at 31 weeks and 4 days of gestation. Magnetic resonance imaging showed a cystic mass measuring 40 mm in diameter in the right lower abdomen. Because the right ovary without edematous swelling was noted adjacent to the cystic mass, isolated tubal torsion was strongly suspected. Emergency gasless laparoendoscopic single-site surgery showed isolated torsion of the right fallopian tube with a paratubal cyst. The right ovary was not involved in this torsion. Because the color tone of the distal portion of the fallopian tube did not recover sufficiently after detorsion, right salpingectomy was performed. Postoperatively, the infusion of magnesium sulfate was initiated due to increased uterine contraction and continued until 36 weeks of gestation. At 38 weeks and 1 day of gestation, uneventful vaginal delivery yielded a healthy female infant.

Pregnancy outcome after emergency uterine artery embolisation for management of intractable haemorrhage associated with laparoscopic-assisted myomectomy.

The feasibility of emergency uterine artery embolisation (UAE) after diagnosis by three-dimensional computed tomographic angiography (CTA) for conservative management of intractable haemorrhage associated with laparoscopic-assisted myomectomy (LAM) was evaluated. In 764 women undergoing LAM, 12 cases were managed by emergency UAE to achieve haemostasis after evaluation by CTA. In two cases, bleeding was diagnosed in the postoperative period, while, in another 10 cases, bleeding was identified at the near-end stage of the surgical procedure. Uterine preservation was achieved in all cases. Among five women desiring child bearing, five spontaneous conceptions and one conception by assisted reproductive technology occurred. Five pregnancies resulted in live birth by caesarean section. Emergency UAE could be a useful minimally invasive option for the salvage of intractable haemorrhage associated with LAM to avoid exploratory laparotomy and/or hysterectomy. In women with fertility wish, pregnancy outcomes were favourable with high number of spontaneous pregnancy rate and without significant negative effects.Impact statementWhat is already known on this subject? Uterine myoma is the most common benign pelvic tumour in women. Myomectomy is indicated as the primary intervention for women with symptomatic myoma, who are of reproductive age and desire uterine preservation, since it can significantly improve symptoms and quality of life and, in some clinical situations, improve reproductive outcomes. Intractable haemorrhage associated with any forms of myomectomy is a potentially life-threatening condition with potential loss of future fertility. However, clear consensus on its management are not well known so far.What do the results of this study add? Emergency uterine artery embolisation after diagnosis by three-dimensional computed tomographic angiography has been effective in preserving the uterus with avoidance of laparotomy and/or life-saving hysterectomy as a salvage therapy for intractable haemorrhage associated with laparoscopic-assisted myomectomy. Significant adverse outcomes were not observed. Furthermore, in women desiring child bearing, a high rate of spontaneous conceptions with live birth by caesarean section was achieved after these combined interventions.What are the implications of these findings for clinical practice and/or further research? Endovascular embolisation could be considered as a minimally invasive alternative with favourable pregnancy outcome to treat intractable haemorrhage associated with myomectomy.

Chronic tubal pregnancy manifesting as a heterogeneous adnexal mass with prominent neovascularization in a woman with a negative serum ß-human chorionic gonadotropin level.

A 41-year-old woman (gravida 2, para 1) underwent elective termination of pregnancy at approximately 7 weeks of gestation. At 1 month after the elective abortion, she was referred due to abnormal results in a cervical cytological examination. Transvaginal ultrasonography showed a heterogeneous mass of 16 mm in diameter in the left adnexal region. At 3 months after her referral, the asymptomatic left adnexal mass had increased to 55 mm in diameter. Prominent vascular flow was detected in the solid portion by color Doppler ultrasonography. Magnetic resonance imaging showed suspected hemorrhage in the left adnexal cystic mass. Three-dimensional computerized tomographic angiography showed the prominent development of tortuous blood vessels in the left adnexal region, which originated from the left ovarian artery. The patient had a negative ß-human chorionic gonadotropin (hCG) level. Left salpingectomy was performed by a single-port laparoscopic approach. A pathological examination revealed degenerated villous tissue with ß-hCG-positive syncytiotrophoblasts.

Identification of Leiomyoma Cell Sheets in Peritoneal Washings Retrieved by an Intraoperative Red Blood Cell Salvage Device during Laparoscopic-Assisted Myomectomy with in-Bag Manual Tissue Extraction: A Pilot Study.

STUDY OBJECTIVE: To examine whether peritoneal washings during laparoscopic-assisted myomectomy with in-bag manual tissue extraction can contain spilled leiomyoma cell sheets. DESIGN: Retrospective observational study (Canadian Task Force classification II-2). SETTING: Departments of Obstetrics and Gynecology and Diagnostic Pathology at a general hospital. PATIENTS: Twenty-four women. INTERVENTIONS: Hysterotomy followed by complete enucleation by blunt and sharp dissection was performed. Enucleated myomas were placed into a retriever bag and extracted through a suprapubic or umbilical mini-laparotomic incision by manual morcellation with a surgical scalpel. A histological examination was performed to identify the dispersed leiomyoma cell sheets in trapped tissues on the surface of a defoaming sponge equipped in the reservoir of an intraoperative red blood cell salvage device, which was used to collect peritoneal washing fluid along with blood. MEASUREMENTS AND MAIN RESULTS: Bag rupture was not observed in any case; however, apparent leiomyoma cell sheets were identified in 20 of 24 cases (83.3%). No devices or procedures that were used for myomectomy could completely prevent leiomyoma cells from appearing in the peritoneal washing fluid. CONCLUSION: Even when careful in-bag tissue extraction of myomas was performed in laparoscopic-assisted myomectomy, dispersion of leiomyoma cell was identified in most cases. Further study is needed to show that the feasibility of rigorous washing to reduce the potential risk of leiomyoma cell dissemination.

Superselective microcoil embolization of the vasa recta of sigmoid artery for hemorrhaging after laparoscopic adnexectomy for corpus luteum hematoma with severe adhesion.

A 44-year-old multipara woman was referred because of the sudden onset of left lower abdominal pain. Corpus luteum hematoma was suspected and conservatively managed. Two days later, due to worsening of abdominal symptoms, emergency laparoscopic surgery was performed. Severe pelvic adhesion around the left ovary forming corpus luteum hematoma was identified. After adhesiolysis, which was complicated by massive bleeding, left adnexectomy was performed. Hemostasis was achieved by the coagulation of bleeding vessels, followed by spraying fibrin glue with the placement of oxidized cellulose cotton for bleeding oozing from dissected surface. Two hours after surgery, emergency computed tomography performed due to the development of hemodynamic instability demonstrated extravasation from the versa recta of the sigmoid artery. After the confirmation of hemorrhaging, superselective catheterization to the bleeding vessel followed by embolization by platinum microcoils were performed. Hemodynamic stability was immediately achieved, and the postoperative course was uneventful without manifestation of bowel ischemia.

Multimodal imaging for diagnosis and management of parasitic peritoneal myoma with myxoid degeneration after laparoscopic-assisted myomectomy with electric power morcellation.

A 45-year-old multipara woman was referred due to the rapid enlargement of an asymptomatic pelvic mass that was detected during a regular check up. She had undergone laparoscopic-assisted myomectomy 15 years previously. At the time, the uncontained extraction of an intraligamental myoma with electric power morcellation had been performed. Multimodal imaging revealed a heterogeneous mass in the vesicouterine pouch that was found to be supplied by the left gastro-omental and superior vesical arteries. Although malignancy could not be completely denied, parasitic peritoneal myoma with myxoid degeneration was the most probable diagnosis. Single-port laparoscopic excision of the peritoneal mass was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The excised peritoneal mass was placed into a retrieval bag and extracted through the vagina. The pathological diagnosis was a parasitic peritoneal myoma with myxoid degeneration. The postoperative course was uneventful, and there was no recurrence of parasitic myoma in the 1-year follow up after surgery.

Uterine metastasis of lung adenocarcinoma under molecular target therapy with epidermal growth factor receptor tyrosine kinase inhibitors: A case report and review of the literature.

A 63-year-old woman presented with abnormal vaginal bleeding. Her disease history was significant, and included advanced lung adenocarcinoma with a deletion mutation in exon 19 of the epidermal growth factor receptor (EGFR) gene, which was managed by concurrent chemoradiotherapy, followed by molecular targeted therapy with tyrosine kinase inhibitors (TKIs) for a two-year period. Contrast-enhanced computed tomography showed the enlargement of a previously suspicious myoma node, with peripheral enhancement. Hemorrhagic necrosis was also observed on magnetic resonance imaging. Transabdominal hysterectomy and bilateral salpingo-oophorectomy showed solitary intramyometrial metastatic lung adenocarcinoma with a second-site T790M gatekeeper mutation in exon 20 of the EGFR gene. In conclusion, uterine metastasis from lung adenocarcinoma can present a diagnostic challenge. The possibility of lung cancer metastasis should be considered when a uterine mass increases in size during treatment. Molecular analysis of the EGFR gene to detect mutations could provide useful information for planning the treatment strategy.

Microsatellite instability-high endocervical serous carcinoma manifesting as pulmonary thromboembolism: A case report and review of the literature.

A 53-year-old obese woman was referred because of sudden onset of dyspnea and chronic vaginal bleeding. In addition to severe anemia, multiple pulmonary emboli were identified. Pelvic imaging showed an irregular-shaped mass in the region of the endocervix extending to the lower uterine segment. After successful anticoagulant therapy, followed by placement of an inferior vena cava filter, transabdominal hysterectomy and bilateral salpingo-oophorectomy were performed. An immunopathological study resulted in the diagnosis of endocervical serous carcinoma. After the identification of a high level of microsatellite instability (MSI), an immunohistochemical analysis of mismatch repair (MMR) proteins showed the isolated loss of PMS2. Germline testing of MMR genes showed no mutations, indicating that the high MSI had occurred as a result of sporadic isolated loss of the PMS2 gene expression.

Portomesenteric Vein Thrombosis After Excision of Parasitic Peritoneal Myomas.

An enlargement of multiple asymptomatic pelvic masses was detected during a regular checkup of a 39-year-old woman. Twelve years earlier, she had undergone laparoscopic-assisted myomectomy, at which time an uncontained manual extraction of a posterior intramural myoma was performed. This was followed by 2 uneventful cesarean deliveries after spontaneous conceptions. Diagnostic imaging revealed at least 3 abdominal masses, 1 of which received its major blood supply from the inferior mesenteric artery. Gasless single-port laparoscopic excision of the peritoneal masses, was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo- oophorectomy. The masses were histopathologically diagnosed as parasitic peritoneal myomas. The patient's immediate postoperative course was uneventful; however, on day 6 after surgery, she complained of severe periumbilical abdominal pain and vomiting. Anticoagulant therapy was initiated after hematologic examination revealed an elevated D-dimer level and dynamic computed tomography angiography showed portomesenteric vein thrombosis. Vaginal stump bleeding, which occurred 17 days after the initiation of anticoagulant therapy, was managed conservatively, and there was no recurrence of venous thrombosis in the year after surgery. To avoid significant morbidities and potential mortality when parasitic peritoneal myomas with aberrant neovascularization are excised, attention should be given to the perioperative development of venous thromboembolic events in rare locations.

Delayed hemorrhage as a result of ruptured uterine artery pseudoaneurysm after transmyometrial oocyte retrieval: Management by transcatheter arterial embolization using N-butyl-2-cyanoacrylate.

Uterine artery pseudoaneurysm is a rare but potentially life-threatening complication that can occur after various uterine manipulations. A 34-year-old nulliparous patient with a previous history of four consecutive miscarriages with unknown etiologies underwent transmyometrial oocyte retrieval as a result of malpositioning of the right ovary. Six days later, she experienced massive vaginal bleeding after a day of intermittent bleeding and was transferred to our hospital. At triage, continuous bleeding from the cervical canal was observed. Color Doppler ultrasonography and three-dimensional computerized tomographic angiography revealed a ruptured pseudoaneurysm originating from the peripheral branch of the right uterine artery in the lower uterine segment. It was successfully treated by transcatheter arterial embolization with N-butyl-2-cyanoacrylate. Transcatheter arterial embolization with N-butyl-2-cyanoacrylate is a feasible option for uterus-preserving management of late massive hemorrhage resulting from a ruptured uterine artery pseudoaneurysm after transmyometrial oocyte retrieval.

Conservative endovascular management of retained placenta accreta with marked vascularity after abortion or delivery.

OBJECTIVE: To report our experience on the value of transcatheter arterial embolization (TAE) or transcatheter arterial chemoembolization (TACE) for the uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery. STUDY DESIGN: Thirty-eight consecutive women with retained placenta accreta were retrospectively analyzed over a 5-year period. When elevated levels of serum ß-hCG (> 25 mIU/mL) were detected, TACE with dactinomycin was chosen for devascularization along with cytotoxic effects on active trophoblasts; in contrast, if the serum ß-hCG level was low (≤ 25 mIU/mL), TAE was chosen. After confirming devascularization, the additional need for hysteroscopic resection and systemic methotrexate administration was individually determined. RESULTS: The most frequent sign and symptom in the abortion group was significant hemorrhaging, while a hypervascular mass detected at a regular check-up was the most frequent in the delivery group. The median time elapsed between abortion and endovascular management was 36 days, and the median time elapsed after delivery was 31.5 days. TACE was performed more frequently than TAE in the abortion group, while TAE was the more frequent procedure in the delivery group. In 10 and 11 cases, after abortion and delivery, respectively, hysteroscopic resection was performed. Systemic methotrexate administration was additionally done in three and one cases after abortion and delivery, respectively. Uterine preservation was achieved in all cases. CONCLUSION: This case series emphasizes that endovascular embolization is an effective key intervention with or without additional therapies for uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery.

In-Bag Manual Extraction of Excised Myomas by Surgical Scalpel through Suprapubic Mini-Laparotomic Incision in Laparoscopic-Assisted Myomectomy.

STUDY OBJECTIVE: To evaluate the safety and feasibility of in-bag manual extraction for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy. DESIGN: Retrospective comparative study (Canadian Task Force classification II-2). SETTING: Departments of obstetrics and gynecology and diagnostic pathology at a general hospital. PATIENTS: Twenty-six patients undergoing open manual extraction and 26 patients undergoing in-bag manual extraction by surgical scalpel for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy. INTERVENTIONS: In patients with open manual extraction, myoma tissues were directly morcellated in an uncontained setting, whereas in patients managed by in-bag manual extraction, enucleated myomas were put into a retriever bag and then were morcellated by a surgical scalpel while monitoring bag damage by the leakage of indigo carmine dye filled in a bag. The patient demographics and surgical outcome measures were compared between the 2 groups. In the initial 15 patients with in-bag manual extraction, the macroscopic myoma fragments retained in the bag were collected and removed after completion of myoma extraction. Then, the bag contents were washed with normal saline and spilled microscopic tissues salvaged by centrifugation. A histologic examination was performed for collected tissue materials to identify the microscopic myoma fragments. MEASUREMENTS AND MAIN RESULTS: In patient demographics and surgical outcomes, which include excised tissue weight, surgical duration, and estimated intraoperative blood loss, no significant differences could be identified between the 2 groups. Bag rupture as monitored by the leakage of indigo carmine dye in vivo and ex vivo was not observed. In all patients managed by in-bag manual extraction, spilled macroscopic myoma fragments were identified in the bag. Furthermore, histologic examinations of collected bag contents detected microscopic myoma tissues in 53.3% of patients. These results suggest that without closed conditions, these microscopic myoma particles, which could be difficult to completely remove even by rigorous washing of the peritoneal cavity under laparoscopic vision, might be dispersed in the peritoneal cavity and potentially form iatrogenic peritoneal parasitic myomas if they survive and grow. CONCLUSION: In-bag manual extraction of myoma tissues through a suprapubic mini-laparotomic incision by a surgical scalpel is a feasible alternative to prevent the dispersion of microscopic myoma fragments and to avoid the potential risk of spreading occult malignancy in 2-port laparoscopic-assisted myomectomy.

Cervico-isthmic pregnancy: early diagnostic imaging and successful dual therapy for uterine-sparing treatment.

Cervico-isthmic pregnancy is a rare and potentially life-threatening form of ectopic gestation in which the blastocyst implants in the uterine cervico-isthmus between the histological and anatomical internal os, followed by subsequent extension to the lower uterine segment. Early diagnosis may allow a conservative therapeutic approach that avoids catastrophic hemorrhage requiring hysterectomy. Here we report the case of a 43-year-old primigravida woman whose cervico-isthmic pregnancy complicated by massive hematometra was diagnosed at 6 weeks gestation by multimodal imaging and successfully treated by hysteroscopic resection, securing adequate hemostasis, after transcatheter arterial chemoembolization.

Magnetic Resonance Imaging and 3-dimensional Computed Tomographic Angiography for Conservative Management of Proximal Interstitial Pregnancy by Hysteroscopic Resection After Transcatheter Arterial Chemoembolization.

Ectopic pregnancy implanted in the interstitial portion of the fallopian tube is a rare potentially life-threatening disorder. A case of unruptured interstitial pregnancy with prominent neovascularization in a 37-year-old woman was precisely localized in the proximal interstitial portion of the fallopian tube with a dilated proximal tubal ostium by magnetic resonance imaging and 3-dimensional computed tomographic angiography. After devascularization by transcatheter arterial chemoembolization, hysteroscopic resection of the interstitial gestational products was performed with single-port laparoscopic assistance. Postoperatively, 3 rescue doses of systemic methotrexate were administered to accelerate the resolution of gestational products followed by uneventful recovery. The uterine wall structure around the interstitial portion was well preserved at the cesarean delivery in the subsequent spontaneous gestation.

Magnetic resonance imaging for diagnosis and management of unruptured interstitial pregnancy.

AIM: The aim of this study was to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis and management of suspicious unruptured interstitial pregnancy. MATERIAL AND METHODS: Only patients with unruptured interstitial pregnancy evaluated by MRI and observed for at least a year after surgery were included. Initial evaluation was performed by measurement of serum ß-human chorionic gonadotrophin level and ultrasonography. In suspicious cases, emergency MRI was performed to diagnose interstitial pregnancies with the exclusion of rudimentary horn pregnancy and angular pregnancy. Three-dimensional computed tomographic (CT) angiography was additionally performed if the uteroplacental neovascularization needed to be evaluated. Then, management procedures were individually determined along with the need for preoperative transcatheter arterial chemoembolization for immediate devascularization, and for the local or systemic administration of methotrexate. Either laparoscopic cornuostomy or cornual resection was chosen to excise the gestational mass. RESULTS: Five consecutive women with unruptured interstitial pregnancy were enrolled. One case each of rudimentary horn pregnancy and angular pregnancy was excluded. Three-dimensional CT angiography was performed in three cases due to increased vascular flow on color Doppler ultrasonography. Preoperative devascularization by transcatheter arterial chemoembolization was performed in two cases, in which a prominent neovascularized gestational mass was identified. Uterine preservation was achieved by cornuostomy or cornual resection in all cases. Two patients with a desire to become pregnant conceived spontaneously thereafter, followed by successful cesarean birth. CONCLUSION: This small case series emphasizes that precise localization of gestational products in the interstitial portion of the fallopian tube by MRI can facilitate the minimally invasive management of unruptured interstitial pregnancy for uterine preservation.

Ionization-induced π → H site-switching in phenol-CH4 complexes studied using IR dip spectroscopy.

IR spectra of phenol-CH4 complexes generated in a supersonic expansion were measured before and after photoionization. The IR spectrum before ionization shows the free OH stretching vibration (ν(OH)) and the structure of neutral phenol-CH4 in the electronic ground state (S0) is assigned to a π-bound geometry, in which the CH4 ligand is located above the phenol ring. The IR spectrum after ionization to the cationic ground state (D0) exhibits a red shifted ν(OH) band assigned to a hydrogen-bonded cationic structure, in which the CH4 ligand binds to the phenolic OH group. In contrast to phenol-Ar/Kr, the observed ionization-induced π → H migration has unity yield for CH4. This difference is attributed to intracluster vibrational energy redistribution processes.

Pregnancy outcomes after emergent laparoscopic surgery for acute adnexal disorders at less than 10 weeks of gestation.

AIM: To report our experience with pregnancy outcomes after emergent laparoscopic surgery for acute adnexal disorders at less than 10 weeks of gestation when surgical intervention could be more invasive to intrauterine pregnancy. METHODS: Gasless multiport laparoscopic surgery or transumbilical laparoendoscopic single-site surgery was performed with securing of the surgical view by the abdominal wall-lift method. Intraoperative autologous blood salvage and donation was performed in cases associated with significant hemoperitoneum. RESULTS: Six cases of ovarian bleeding with ruptured corpus luteal cyst, three cases of adnexal torsion with corpus luteal cyst, and one case each of ruptured heterotopic ampullary pregnancy and heterotopic tubal stump isthmic pregnancy after salpingectomy were managed. For ruptured corpus luteal cyst, hemostasis was achieved by removal of hematoma followed by suturing. For adnexal torsion, detorsion with cyst aspiration was performed in two cases and detorsion alone was performed in one case. For ruptured heterotopic ampullary pregnancy, unilateral salpingectomy was performed. For ruptured heterotopic tubal stump isthmic pregnancy after salpingectomy, removal of the expelled villous tissue followed by hemostatic coagulation was performed. In five cases associated with massive hemoperitoneum, intraoperative autologous blood salvage and donation were performed to avoid homologous blood transfusion. After surgery, seven live births were achieved, while two cases of biochemical pregnancy loss and a case of complete miscarriage were noted. CONCLUSION: Although miscarriage could be a significant concern in the perioperative period, gasless laparoscopic surgery appeared to be feasible for management of acute adnexal disorders at less than 10 weeks of gestation.