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.

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.

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.

Uterine adenomyoma with exophytic subserosal growth: case report of rare manifestation with image diagnosis and laparoscopic-assisted excision.

Uterine adenomyoma is a nodular aggregated form of adenomyosis composed of heterotopic endometrial or endometrium-like structures in the myometrium, with adjacent myometrial hyperplasia. Although adenomyoma is not extremely rare, reports of adenomyoma showing exophytic subserosal growth are limited. A 32-year-old nulligravida woman had sudden onset of lower abdominal pain. In addition to a left endometriotic cyst, a heterogeneous mass lesion showing mural and exophytic subserosal growth was noted in the posterior wall of the uterus. In a two-port laparoscopic-assisted procedure, the subserosal nodule was excised using ultrasonic coagulating shears, followed by excision of the mural lesion using a round loop electrode and a high-frequency electrosurgical unit. The histopathologic diagnosis was adenomyoma.

Parasitic myomas after laparoscopic-assisted myomectomy in multiple endocrine neoplasia type 1.

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.

Early abdominal pregnancy complicated by parasitic dermoid cyst: diagnosis by diffusion-weighted magnetic resonance imaging and management by laparoendoscopic single-site surgery.

A 26-year-old primigravida patient was referred with suspicion of ectopic pregnancy 39 days after her last menstrual period. Her serum ß-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.

Uterus-like mass of ovarian ligament: Image diagnosis and management by laparoendoscopic single-site surgery.

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.

Isobaric laparoendoscopic single-site assisted extracorporeal cystectomy in treatment of selected adnexal tumors: initial experience and technique.

Laparoscopic-assisted ovarian cystectomy with exteriorization is a minimally invasive procedure. However, applicability of this procedure for transumbilical laparoendoscopic single-site (LESS) surgery is not well established. Herein, we describe our initial experience with isobaric (gasless) LESS-assisted extracorporeal cystectomy in management of selected adnexal tumors. Of 17 consecutive adnexal tumors, 15 (88.2%) (dermoid cyst, 10; serous cystadenoma, 2; mucinous cystadenoma, 1; and paraovarian cyst, 2) were successfully managed with isobaric LESS-assisted extracorporeal cystectomy. Two dermoid cysts required intracorporeal LESS cystectomy because of poor mobility of the adnexal tissue. No conversion to either conventional laparoscopic surgery or laparotomy was necessary in this series.

Paraneoplastic consumptive coagulopathy related to intramyometrial low-grade endometrial stromal sarcoma coexistent with adenomyosis diagnosed 7 years after laparoscopic-assisted myomectomy.

INTRODUCTION: Paraneoplastic coagulation disorders associated with benign and malignant gynecological tumors have been reported. However, reports on cutaneous purpural manifestation of paraneoplastic coagulopathy in cases of gynecological tumors are extremely limited. CASE REPORT: A 40-year-old woman was referred due to generalized ecchymosis 7 years after laparoscopic-assisted myomectomy. Coagulogram was markedly deranged with severe thrombocytopenia. After hematological disorders were excluded, image diagnostic modalities showed multiple intramyometrial heterogeneous mass lesions with extensive intratumoral hemorrhage. Laparoscopic-assisted vaginal hysterectomy was performed with supplementation of coagulation factors and platelets. Histological examination showed intramyometrial low-grade endometrial stromal sarcoma (ESS) coexistent with adenomyosis. Coagulation disorder immediately disappeared after hysterectomy and the postoperative course was uneventful. Recurrence of either ESS or coagulopathy has not been noted 15 months postoperatively, to date. CONCLUSIONS: This case illustrates a rare but potentially life-threatening consumptive coagulopathy caused by intramyometrial low-grade ESS that was assumed to secondarily arise from stromal cells of adenomyosis developed in postmyomectomy scar.

Conservative management of placenta increta after first trimester abortion by transcatheter arterial chemoembolization: a case report and review of the literature.

INTRODUCTION: Placenta increta is a potentially life-threatening condition that may complicate a first trimester abortion in rare occasion. However, the therapeutic value of transcatheter arterial chemoembolization for the conservative management of this disorder is not described. CASE REPORT: A 27-year-old woman (gravida 3, para 1) with significant obstetric history for one previous lower segment cesarean section and one dilatation and curettage for missed abortion had uncomplicated dilatation and curettage for missed abortion. Eight weeks after curettage, the patient presented with increased amounts of vaginal bleeding. Image diagnostic modalities localized the heterogeneous mass within the myometrium in the fundal portion of the uterine corpus. Initially, arteriovenous fistula formation after abortion was suspected. However, an elevated serum hCG value indicated the presence of retained placental tissue and gave the diagnosis of persistent placenta increta after a first trimester abortion. Transcatheter arterial chemoembolization with dactinomycin was initiated to achieve immediate hemostasis and cytocidal effects on the placental tissue. The post-interventional course was uneventful. Twenty days after chemoembolization, the serum hCG value decreased to a normal level and the mass lesion disappeared on ultrasonography without secondary hemorrhagic complications. CONCLUSIONS: After precise diagnostic imaging, transcatheter arterial chemoembolization is a useful minimally invasive procedure to achieve uterine preservation in women with placenta increta masquerading as arteriovenous fistula after a first trimester abortion.

Computed tomographic angiography in diagnosis and management of placental polyp with neovascularization.

OBJECTIVE: To evaluate the neovascularization in placental polyp tissue by computed tomographic angiography and to determine the need for uterine artery embolization before hysteroscopic resection. STUDY DESIGN: Seventeen consecutive women with suspected placental polyp were enrolled in this retrospective study. Neovascularization in placental polyp tissue was assessed by computed tomographic angiography. Cases with neovascularization were treated by hysteroscopic resection with preoperative uterine artery embolization, while cases without neovascularization were treated by hysteroscopic resection alone. RESULTS: Of 17 patients with suspected placental polyp after abortion or parturition, nine patients were diagnosed to have placental polyp with prominent neovascularization by computed tomographic angiography, and were treated by uterine artery embolization followed by hysteroscopic resection. Two patients subsequently conceived after conservative management. CONCLUSIONS: After precise evaluation of neovascularization by computed tomographic angiography, hysteroscopic resection with preoperative uterine artery embolization is an effective minimally invasive procedure to conservatively treat placental polyp with prominent neovascularization.

Laparoscopic management of mature cystic teratoma of the ovary with multiple intracystic floating spherules.

INTRODUCTION: A feature of multiple spherical structures floating free in a cystic mass is one of the very rare patterns of mature cystic teratoma. CASE REPORT: A 32-year-old unmarried nulligravida was referred. Image diagnosis showed a large cystic tumor with unusual intracystic multiple floating spherules. Serum tumor marker test showed elevated squamous cell carcinoma antigen. Laparoscopic-assisted left salpingo-oophorectomy was performed. The histopathological diagnosis was mature cystic teratoma of the ovary with marked desquamative keratin formations. CONCLUSIONS: After obtaining pathognomonic findings on diagnostic imaging, laparoscopic management of a rare form of mature cystic teratoma of the ovary with numerous intracystic floating spherules was successfully performed.

Progressive formation of uterine arteriovenous fistula after laparoscopic-assisted myomectomy.

INTRODUCTION: Laparoscopic-assisted myomectomy (LAM) is a minimally invasive procedure with many advantages. However, progressive formation of uterine arteriovenous fistula (AVF) after LAM is not described as a significant complication. CASE REPORT: A 39-year-old nulligravida underwent LAM for multiple myomas. On ultrasonography obtained 13 days after LAM, a prominent vascular mass was identified in the post-myomectomy scar. Computed tomographic angiography showed AVF originating from the left uterine artery. Uterine AVF was endovascularly embolized by metallic coils to avoid future hemorrhage. CONCLUSIONS: Development of uterine AVF after LAM is a potentially life-threatening complication. Early diagnosis and endovascular management can provide a significant benefit for a woman wishing uterine preservation.

Successful management of interstitial pregnancy with fetal cardiac activity by laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization.

INTRODUCTION: Interstitial pregnancy is a rare but dangerous form of ectopic pregnancy. Although various forms of minimally invasive management for this disorder have been previously reported, optimal treatment regimen has not been yet unknown due to its rarity. CASE REPORT: A 29-year-old married woman with no previous disease history was referred under suspicion of ectopic pregnancy. Serum hCG value was 95,365 mIU/mL. On ultrasonographic examination, gestational sac with a viable embryo was identified in the left cornual region. Three-dimensional computed tomographic angiography showed prominent vascular mass in the left cornual region. Preoperative transcatheter uterine artery embolization followed by laparoscopic-assisted cornual resection with local methotrexate injection was successfully performed. CONCLUSIONS: Laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization for interstitial pregnancy with prominent vascular flow is a safe and reliable minimally invasive procedure for woman wishing fertility preservation.

Chronic adnexal torsion: An under-recognized disease entity.

OBJECTIVE: To clarify the incidence, clinical background and surgical characteristics of chronic adnexal torsion in comparison to acute adnexal torsion. STUDY DESIGN: The patients were divided into three categories based on the period from the onset of symptoms to surgical management: acute (≤24h), subacute (2days) and chronic adnexal torsions (≥3days). Cases, in which the onset of symptoms was unspecified, were included in the chronic adnexal torsion group. Then, a retrospective comparative study of acute (49 patients) and chronic adnexal torsion (45 patients) was performed. Laparoscopic surgery was performed as a primary surgical procedure. RESULTS: In chronic adnexal torsion, surgery was performed at a median of 9days (range: 3-270days) after the onset of symptoms. The apparent onset of symptoms was not noted in 2 cases. All cases with acute adnexal torsion received emergency surgery. In contrast, emergency surgery was performed only in 13 patients with chronic adnexal torsion. Patients with chronic adnexal torsion were significantly older than those with acute adnexal torsion. Isolated tubal torsion was more frequent in chronic adnexal torsion. With the exception of 2 cases with chronic adnexal torsion in which laparotomic conversion was required due to severe adhesion, and 2 cases with acute adnexal torsion with advanced gestational age, who were managed by initial laparotomy, laparoscopic surgery was successful. Unilateral salpingo-oophorectomy was the most frequent surgical procedure in both groups. When confined to the patients who expressed a wish for adnexal preservation, adnexal cystectomy or detorsion was possible in 60.9% of the acute torsion cases and 57.1% of the chronic adnexal torsion cases. Severe necrosis of the adnexal tissue and extensive pelvic adhesion were the more frequent associated conditions in chronic adnexal torsion. Among the patients who were successfully managed by laparoscopic surgery, the duration of surgery was significantly longer in the patients with chronic adnexal torsion. Severe necrosis that makes a pathological diagnosis difficult was the most frequent finding in cases of chronic adnexal torsion. CONCLUSION: Chronic adnexal torsion still represents a diagnostic and therapeutic challenge that should be recognized as a distinct and more frequently encountered disease entity.

Gynandroblastoma with a Juvenile Granulosa Cell Component in an Adolescent: Case Report and Literature Review.

BACKGROUND: Gynandroblastoma is an extremely rare ovarian sex cord tumor with malignant potential. CASE: An 18-year-old adolescent experienced intermittent vaginal bleeding. A year later, a right adnexal mass with a heterogeneous imaging appearance was identified. Laparoendoscopic single-site ovarian tumorectomy was performed. A histopathological examination showed gynandroblastoma composed of juvenile granulosa and Sertoli-Leydig cells. Because the tumor was upstaged to stage Ic because of cyst rupture during surgery, three cycles of adjuvant chemotherapy with carboplatin and paclitaxel were added. Three years after surgery, no signs of recurrence have been noted. SUMMARY AND CONCLUSION: The present findings can help clinicians make an accurate preoperative imaging diagnosis of gynandroblastoma with a juvenile granulosa cell component and plan an adequate treatment strategy for this rare, potentially malignant neoplasm.