Asian Journal of Endoscopic Surgery

Splenic Metastasis of Endometrial Carcinoma Manifesting as a Hemorrhagic Splenic Cyst 17 Years After Surgery

ABSTRACT Splenic metastases from solid tumors are rare, particularly when they occur after a long postsurgical interval. We report the case of a 69‐year‐old woman who developed a splenic metastasis from endometrial carcinoma, presenting as a hemorrhagic splenic cyst, 17 years after her initial surgery. Laparoscopic splenectomy achieving R0 resection was successfully performed; however, the patient subsequently developed multiple liver metastases. This case highlights the importance of periodic evaluation for recurrence, including monitoring for symptoms and elevated tumor markers, in patients with a history of endometrial carcinoma or other solid tumors.

Sentinel Lymph Node Detection Using SPECT and Gamma Probe in Low‐Risk Endometrial Cancer: Efficacy and Factors Associated With Detection Failure

ABSTRACT Introduction This study examined factors that affected sentinel lymph node (SLN) identification of patients with endometrial cancer having a preoperative estimation of low recurrent risk. Methods This study included 97 patients with endometrial cancer who attempted to identify SLN using a uterine cervical injection of technetium‐99 m phytate under laparoscopic or robotic‐assisted surgery at our institute. A preoperative single photon emission computed tomography (SPECT) and intraoperative gamma probe were used to detect hot nodes. Multiple clinical factors, including age, body mass index (BMI), and so on, were investigated for their association with SLN mapping failure. Results Among 97 cases, SPECT failed to detect SLN unilaterally in 38 cases (39%) and on both sides in 9 cases (9%). Meanwhile, the gamma probe failed to detect SLN unilaterally in 23 cases (24%) and on both sides in 3 cases (3%). While only age was significantly associated with SLN detection failure using the SPECT detection system, both age and BMI were significantly associated with SLN detection failure using the gamma probe detection system. When limiting to the preoperative SLN detection failure cohort of 47 cases, there was a strong association between intraoperative SLN detection failure and BMI, but not age. Conclusion The SLN biopsy system was effectively applied to patients with endometrial cancer who underwent minimally invasive surgery (MIS). Attempts to improve SLN identification in older patients and those with obesity are warranted to obtain maximum benefits of MIS for low‐ or medium‐risk cases.

Extragonadal recurrence of benign mature teratoma in the pouch of Douglas

AbstractLaparoscopic cystectomy for mature teratomas is associated with a high incidence of intraperitoneal spillage and tumor spread; however, extragonadal recurrence of this benign tumor is rare. We hereby present an additional case of extragonadal mature teratoma that recurred in the pouch of Douglas after ovarian cystectomy. A 43‐year‐old Japanese woman presented with atypical genital bleeding. A 7 cm mature teratoma was detected using transvaginal ultrasonography and magnetic resonance imaging. At 26 years old, she underwent bilateral cystectomy for bilateral mature teratoma of the ovary. During laparoscopic surgery, a cystic tumor appeared in the pouch of Douglas and was firmly adhered to the surrounding tissues. Both ovaries were normal. The resected tumor was diagnosed as extragonadal, benign, mature teratoma. To avoid the extragonadal recurrence of mature teratoma, removal of tumor contents from intraperitoneal spillage by lavage should be performed at the end of surgery.

A simple technique of vaginal cuff closure to prevent tumor cell spillage in laparoscopic radical hysterectomy for uterine cervical cancer

AbstractIntroductionThe Laparoscopic Approach to Cervical Cancer (LACC) trial, a prospective randomized phase III clinical trial reported in 2018, unexpectedly showed inferior oncologic outcomes in laparoscopic radical hysterectomy (LRH) for cervical cancer compared with those in open surgery. It was proposed that the spillage of tumor cells into the peritoneal cavity might cause the inferiority of LRH. It has been suggested, based on retrospective studies, that transvaginal closure of the vaginal cuff before the colpotomy part of the surgery may prevent this.Materials and Surgical TechniqueBefore starting colpotomy, we closed the vaginal cuff transvaginally. After the assessment of the cutline of the vagina, the vaginal mucosa is pulled at the eight sites using the sutures. The four pairs of sutures on the diagonal line are ligated. A purse string suture is additionally placed on the vaginal mucosa to close the vaginal cuff completely. After that, we start the intracorporeal colpotomy using a vaginal pipe.DiscussionOur technique is simple and quick. The blood loss during the transvaginal procedures is minimal. The use of the vaginal pipe helps keep the vaginal cuff closed during the colpotomy. Our technique may be an alternative to the conventional approach closing the vaginal cuff.

R0 resection of vaginal stump recurrence of gynecologic malignancy by bi‐directional endoscopic approach: A case series of four patients

Abstract Vaginal stump recurrence post‐hysterectomy for gynecologic malignancies occurs in 2%–3% of cases. Local excision has been recognized as the primary treatment of localized recurrence, in which precise surgical margin is critical. However, R0 resection is not always easy, given the deep and narrow operation field, as well as severe postoperative fibrosis or adhesion of the vaginal stump at times. Here, we report four cases of vaginal stump recurrence of gynecologic malignancies resected by bi‐directional (laparoscopic and pneumovaginoscopic) endoscopy to overcome these difficulties. The primary tumors were uterine cancer in two cases and uterine cervical and ovarian cancer in one case each. The mean operating time was 199 (162–235) minutes, blood loss was minimal, and no perioperative complications were observed. Postoperative follow‐up (7.0–19.4 months) revealed no recurrence. This combined procedure could be a therapeutic option for localized vaginal stump recurrence.

Pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach for cervical esophageal cancer with right aortic arch: Case report

AbstractWe performed pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach and reconstruction of the elongated gastric conduit with microvascular anastomosis for an 83‐year‐old male patient with esophageal cancer and right aortic arch. For such cases, a surgical approach via the left thoracic cavity is rational, and cases of pharyngolaryngectomy with thoracoscopic esophagectomy require a long reconstruction organ. Also, in cases of right aortic arch, a longer reconstruction route is made to avoid Kommerell's diverticulum. The patient had laryngeal cancer and was diagnosed with cervical esophageal cancer and preoperative computed tomography revealed right aortic arch. There were no complications after surgery, and food intake was good. Pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach and reconstruction of the elongated gastric conduit with microvascular anastomosis is suggested to be a safe and feasible technique for cases of cervical esophageal cancer with right aortic arch.

Two Cases of vNOTES Assisted Vaginal Adnexectomy in Management of Paraneoplastic Anti‐ N ‐Methyl‐ D ‐Aspartate Receptor Encephalitis Secondary to Ovarian Teratoma

ABSTRACT Anti‐ N ‐Methyl‐ D ‐Aspartate receptor encephalitis typically presents with neuropsychiatric symptoms, followed by autonomic dysregulation sometimes necessitating Intensive Care admission. It has a 15% mortality rate and when associated with ovarian teratoma, early surgical excision improves recovery rate by 25%. We describe the first two cases of vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) assisted vaginal adnexectomy for surgical treatment of ovarian teratoma associated anti‐NMDA encephalitis and highlight the advantages of this novel approach. These include low insufflation pressures, shorter duration of surgery, avoidance of abdominal scarring, lower pain scores and more rapid recovery. While the outcomes in these two cases suggest that ovarian teratoma associated anti‐NMDA encephalitis could be surgically managed through the vNOTES route rather than conventional laparoscopy, more randomized data still need to be available before this becomes standard approach.

vNOTES Assisted Vaginal Bilateral Salpingo‐Oophorectomy in Postmenopausal Women With Large Ovarian Fibroma

ABSTRACT The authors describe two cases where women with large ovarian fibromas (6 and 9 cm, respectively) underwent a transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) assisted bilateral salpingo‐oophorectomy. Retrieval was facilitated by transvaginal cold knife morcellation in the Pouch of Douglas under direct vision following vNOTES assistance without abdominal incisions. This is the first time vNOTES has been described for excision of solid ovarian tumors of these dimensions; the authors discuss its advantages compared to conventional laparoscopy, together with challenges of retrieving a solid lesion through a posterior colpotomy incision.

A case of Herlyn–Werner–Wunderlich syndrome with exacerbation of hematometra after adnexectomy

Abstract A 27‐year‐old nulliparous woman presented with a feeling of fullness in the lower abdomen and abdominal pain. A left ovarian tumor, uterus didelphys, left renal agenesis, and left vaginal atresia were observed on imaging. The ovarian tumor was presumed to have caused the abdominal pain, and an abdominal left adnexectomy was performed. After 3 months, she reported severe lower abdominal pain during menstruation. Transvaginal ultrasonography revealed uterine enlargement. After 17 days, the patient presented with abdominal pain and fever. She was diagnosed with peritonitis due to infection and left uterine hematometra. Because she did not improve with antibiotic treatment, left laparoscopic hysterectomy was performed. Subsequently, she did not experience the lower abdominal pain. Appropriate diagnosis and treatment based on the morphology of the reproductive tract and symptoms must be considered in patients with Herlyn–Werner–Wunderlich syndrome. Treatment must permit the outflow of menstrual blood.

First Robotic Hysterectomy Using Hugo RAS System for a 2‐Kg Uterus: Technical Insights From a High‐Volume Center

ABSTRACT We present the first documented case of a 2‐kg uterus successfully managed with the Hugo RAS system. The patient was a 45‐year‐old nulliparous woman with multiple fibroids and bilateral ovarian cysts. After a six‐month course of relugolix to improve anemia, we performed a total hysterectomy using Hugo. A “Narrow setting” port configuration was employed. The procedure was completed in 155 min, with a console time of 77 min and a docking time of 7 min; estimated blood loss was 50 mL. No intraoperative or postoperative complications occurred. Strategic port placement, early uterine artery ligation, and dividing the surgical procedure into defined anatomical zones helped minimize blood loss and maintain clear visualization. While this single‐case experience is limited in generalizability, it provides valuable insights into surgical strategies for large benign uterine conditions.

A Novel Port and Arm Placement Strategy for the Hugo Robotic‐Assisted Surgery ( RAS ) System in Gynecologic Oncology: Initial Experience and Technical Considerations

ABSTRACT Introduction The Hugo robotic‐assisted surgery (RAS) system is a novel surgical platform that expands the potential for minimally invasive procedures in gynecologic oncology. Early studies have shown promise, but the optimal configuration of ports and robotic arms requires further clarification. This study aimed to introduce a refined strategy for optimizing port placement and robotic arm arrangement with the Hugo RAS system and compare its performance to previously employed configurations. Materials and Surgical Technique Initial experiences in two cases of early‐stage endometrial cancer are presented. A new configuration was developed through iterative discussions and a review of emerging Hugo RAS literature. Port placement and arm arrangement with three arms on the patient's right side and one on the left—were designed to expand the assistant's working space. Two patients with stage IA endometrial cancer underwent surgery with this approach. Operative times, blood loss, and procedural details were evaluated. Discussion Both procedures were completed successfully with improved instrument articulation, reduced arm collisions, and enhanced workflow. Compared with previous strategies, this new configuration provided better ergonomics, minimized interference between robotic and assistant instruments, and expanded the operative field for both the first and second assistants, enabling smoother transvaginal specimen retrieval. Initial findings suggest that optimizing both port placement and arm settings enhances the surgical environment for the Hugo RAS system and may improve procedural efficiency and patient outcomes. Further studies with larger cohorts are warranted to validate these findings and potentially establish standardized guidelines.

Implementation of the Hugo Robotic System: Early Outcomes and Learning Curves in Hysterectomy by Surgeons With and Without Prior Robotic Experience

ABSTRACT Purpose To characterize early learning curves for two gynecologic oncologists and their first assistants using the Hugo robotic‐assisted surgery system for hysterectomy in benign uterine disease or FIGO stage IA endometrial cancer. Methods We retrospectively examined the first 43 Hugo hysterectomies performed at our center by two surgeons: Surgeon A (experienced with da Vinci) and Surgeon B (robotics‐naïve), assisted by three primary assistants (A, B, and C). We analyzed baseline patient characteristics, perioperative outcomes (operative time, docking time, console time, blood loss, complications, length of stay), and plotted learning curves using operative time trends and CUSUM analysis. Surgeon and assistant group comparisons used t ‐test or Kruskal–Wallis and chi‐square as appropriate, with p  < 0.05 considered significant. Complications graded ≥ Clavien–Dindo II were considered notable. Results Patient demographics were similar between groups. Surgeon A achieved significantly shorter operative times (128.6 ± 23.7 vs. 149.8 ± 19.6 min, p  = 0.003) and console times (90.9 ± 20.4 vs. 115.6 ± 18.9 min, p  < 0.001) versus Surgeon B. Docking times did not differ significantly. No conversions occurred, and complication rates were low and comparable (4% vs. 11%, p  = 0.56). CUSUM analysis revealed that Surgeon A's operative times stabilized by case 5, while Surgeon B required approximately 15 cases to reach comparable proficiency. Assistants demonstrated decreasing docking times, with no significant differences among groups. Conclusions In early Hugo RAS adoption, prior robotic experience led to a shorter learning curve, but robotics‐naïve surgeons achieved proficiency within ~15 cases without compromising safety. Assistants also rapidly mastered docking. These findings support safe and efficient implementation of new robotic platforms with structured training.

Safe Trocar Placement by Transvaginal Endoscopic Insertion in Robot‐Assisted Surgery for Endometrial Cancer With Umbilical Incisional Hernia and Prior Mesh Repair: Two Case Reports

ABSTRACT We report two cases of endometrial cancer with umbilical incisional hernia or prior mesh repair, in which robot‐assisted surgery was safely performed using transvaginal laparoscope insertion. Both patients had prior abdominal surgeries, and preoperative imaging raised concerns about adhesions or mesh near the umbilicus, making conventional trocar insertion risky. A laparoscope was inserted via the posterior vaginal fornix, allowing real‐time intra‐abdominal visualization and safe port placement under direct vision. In one case, mesh and adhesions were confirmed at the umbilicus. In the other, no adhesions were found within the hernia sac despite being suspected preoperatively, whereas dense adhesions were identified at Palmer's point, which could not be fully characterized by imaging alone. These cases highlight the limitations of relying solely on imaging and underscore the utility of intraoperative visual assessment. Transvaginal scope insertion offers a simple, reproducible method to enhance trocar safety. To our knowledge, no previous reports have described this technique used solely for observation in robot‐assisted surgery for endometrial cancer.

The Efficacy of a Silicone Plate for the Prevention of Re‐Adhesions in Asherman Syndrome: A Case Study

ABSTRACT This study highlights the effectiveness of using silicone plates to manage intrauterine adhesions (IUAs) in an enlarged uterine cavity caused by multiple fibroids. A 42‐year‐old woman developed Asherman syndrome following fibroid resection surgery, and despite initial attempts to prevent recurrence with an intrauterine device (IUD), IUAs reappeared. After successful hysteroscopic adhesiolysis, a customized silicone plate was introduced, preventing further IUAs for 1 month. The patient was then deemed suitable for fertility treatment. This case underscores the importance of innovative approaches in complex Asherman syndrome, particularly when standard treatments fail. Silicone plates prove useful for addressing enlarged or deformed uterine cavities caused by fibroids, expanding existing strategies for managing post‐hysteroscopic complications.

Intracorporeal colpotomy using the Gutclamper as a novel clamping device to prevent tumor spillage during laparoscopic radical hysterectomy for cervical cancer

AbstractIntroductionTumor cell spillage during the colpotomy has been suspected as one reason for poor oncologic outcomes in laparoscopic radical hysterectomy (LRH) for cervical cancer. To prevent such tumor spillage in LRH, we focused on use of a Gutclamper which is a device originally designed to clamp the colon and rectum during colorectal resections.Materials and Surgical TechniqueA woman with stage IB1 cervical cancer underwent LRH using the Gutclamper. The Gutclamper was inserted into the abdominal cavity via 5‐mm trocar, the vagina was clamped, and an intracorporeal colpotomy was performed caudal to this device.DiscussionThe Gutclamper can be used to clamp the vaginal canal and avoid the exposure of cervical tumor, regardless of the surgeon's skills or patient conditions. An intracorporeal colpotomy using the Gutclamper can contribute to the standardization of LRH.

Combined thoraco‐laparoscopic hepatectomy concomitant with resection of the diaphragm for solitary peritoneal seeding from cervical cancer: A case report

AbstractCombined thoraco‐laparoscopic resection can aid in precise resection of an invasive tumor of the diaphragm. A 44‐year‐old woman was referred to our department for resection of solitary peritoneal seeding from cervical cancer following systemic chemotherapy. The tumor was located in the right diaphragm with an ill‐defined border of the liver. Combined thoraco‐laparoscopic resection was proposed. Laparoscopy portrayed that the right diaphragm was partially attached to the liver, and the depth of tumor invasion to the diaphragm was ambiguous. Observation from the thoracic cavity indicated a white‐colored distortion following the location of peritoneal seeding. Partial resection and repair of the diaphragm were made using the thoracoscopic‐assisted approach, followed by laparoscopic hepatectomy. The postoperative course was uneventful, and pathological findings revealed that peritoneal metastases of the diaphragm and surgical margin was negative for cancer. Combined thoraco‐laparoscopic resection can cover the drawbacks of each approach and is among the options for minimally invasive surgery for invasive tumor of the diaphragm.

Low Geriatric‐8 Score as a Potential Risk Factor for Minimally Invasive Surgery in Elderly Patients With Gynecologic Malignancies

ABSTRACT Background The Geriatric‐8 (G8) is a validated screening tool for identifying frailty in elderly cancer patients. Although minimally invasive surgery (MIS) is increasingly performed in older adults with gynecologic malignancies, few studies have evaluated the association between G8 scores and perioperative complications in this setting. Methods This single‐center retrospective study included patients aged ≥ 65 years who underwent MIS for gynecologic malignancies between January 2019 and March 2024. G8 scores were retrospectively calculated using medical records, with a threshold of ≤ 12.5 indicating geriatric risk. Perioperative complications were defined as either (1) Clavien‐Dindo classification or CTCAE version 5 grade II or higher within 30 days postoperatively or (2) the need for rehabilitation intervention due to a decline in activities of daily living (ADL). Univariate and multivariate logistic regression analyses were conducted to identify associated factors. Results A total of 68 patients were included (median age: 72.5 years). The median G8 score was significantly lower in the complication group than in the non‐complication group (12.5 vs. 14.5, p  = 0.008). In multivariate analysis, a G8 score ≤ 12.5 was independently associated with perioperative complications (OR: 4.02, 95% CI: 1.38–11.70, p  = 0.011). No significant associations were found for operative time, hysterectomy, or lymphadenectomy. Conclusion A low G8 score was independently associated with perioperative complications and may be useful for preoperative risk assessment in elderly patients undergoing MIS for gynecologic malignancies.