廣田 穰

We report three cases in which umbilical endometriosis developed after a laparoscopic subtotal hysterectomy (LSH) for uterine myoma without endometriotic lesions.<BR>Case 1: A 36-year-old, gravida 2, para 2 underwent an LSH for uterine myoma. Removal of the uterus was performed using the peeling technique with an umbilical trocar. Twelve months postoperatively, induration appeared at the umbilical region (approximately 20 mm) and the right trocar region (approximately 5 mm). Therefore, a lumpectomy was performed 18 months after the initial surgery. The pathologic diagnosis was heterotopic endometriosis. Because the umbilical tumor relapsed 27 months following surgery, Dienogest was administered; eight months later, the tumor had resolved. The umbilical tumor reappeared two months after terminating the orally administered treatment; therefore, resection of the umbilical tumor was performed 55 months after the initial surgery.<BR>Case 2: A 44-year-old gravida 3, para 2 underwent an LSH for uterine myoma. The tumor was morcellated using a morcellator, then extracted using an umbilical trocar. Approximately 19 months postoperatively, an approximately 18 mm area of induration appeared near the umbilical region; therefore, a resection was performed. The pathological diagnosis was heterotopic endometriosis.<BR>Case 3: A 45-year-old gravida 2, para 2 underwent an LSH and left salpingectomy for a uterine myoma and left paraovarian cyst. The hysterectomy involved morcellation and extraction through the umbilical region. An approximately 46 mm area of induration with hemorrhage appeared in the umbilical region 70 months postoperatively. Due to the suspicion of an umbilical tumor, a needle biopsy was performed at the site; the pathologic diagnosis was heterotopic endometriosis. She is currently receiving Dienogest treatment as an outpatient, and is being followed-up with the possibility of surgical extraction in mind.<BR>Conclusion: Although endometriosis is a common gynecological disease, umbilical endometriosis is rare. Therefore, the disease that developed in these three cases was likely due to growth of endometrial tissue in the umbilical region at the time of tissue removal.

症例1(31歳、0経妊0経産婦)。症例2(35歳、1経妊1経産婦)。症例3(28歳、1経妊1経産婦)。3症例とも子宮筋腫に対する腹腔鏡下手術目的に受診となった。いずれの症例も術前検査にて子宮は正常形態を保ち、漿膜下および筋層内に筋腫は認められなかった。だが、腫瘤は子宮に近接しており、周囲臓器と強固な癒着を形成していたため臓器圧迫症状があった。以後、腹腔鏡下手術を行なったところ、腫瘤の癒着剥離操作により腫瘤は速やかに虚血性変化を示した。尚、病理検査では中心性壊死が認められ、臨床経過と総合し、PM(骨盤内腫瘤)の自然発生が考えられた。

We present three extremely rare cases of spontaneous spinal epidural hematoma occurring in pregnancy. The patients developed progressive paralysis of the upper and lower limbs and the diagnoses were confirmed by magnetic resonance imaging. Urgent decompression is required to prevent neurological sequelae. The pregnancy may either be continued or delivered depending on the gestational age and severity of the disorder. Pregnancy-induced structural changes of the vascular walls and hemodynamic changes may play a role in the pathogenesis of spontaneous spinal epidural hematoma.

24歳。月経過多と倦怠感を主訴とした。経腟超音波で子宮体部後壁に子宮内膜変形を伴う84×76×84mmの低輝度の腫瘤を認め、子宮筋腫の診断で腹腔鏡下筋腫核出術を施行した。子宮後壁筋層に切開を加えた途端、動脈性の強出血を認め、止血に難渋した。筋腫核出時に子宮内膜の一部が穿破し、術中出血が多いため1層での全層縫合を行い、その後子宮筋層の2層縫合を行った。術後経過は良好であったが、25日目の経腟超音波で筋腫核出部に最大径23mmの嚢胞性病変があり、カラードップラーで拍動性の噴水状血流を認めた。検査直後に突発的な大量性器出血を来たし、嚢胞性病変の破綻と考え緊急開腹術を施行した。嚢胞性病変内背側より直径1mmほどの動脈が数ミリ突出しており、拍動性出血を認め、単離結紮で完全止血可能であった。その後、嚢胞壁の穿孔部を含め筋層の3層縫合を行った。術後経過は良好で、77日目の超音波では子宮後壁の筋層切開部付近に異常血流を認めた。現在まで再発は認めていない。

Recently, an increasing number of women with multiple uterine myomas have opted for laparoscopic myomectomy, and with this increase, the need to define the indications and limitations of this approach has become apparent. The purpose of this study was to investigate these factors. A total of 130 patients undergoing laparoscopic myomectomy per standard indications between January, 2005 and December, 2010 were studied. Those with complications such as endometriosis and adnexal disease were excluded. The sum of the maximum myoma diameters (SMD), reflecting both size and count, served as a new unit of measurement. Operative blood loss correlated at a statistically significant level with maximum diameter and number of enucleated myomas (r= 0.286, p= 0.001 and r= 0.194 p= 0.028, respectively), as did with operating time (r= 0.277, p= 0.001 and r= 0.405, p< 0.001). With respect to SMD and operative blood loss or operating time, the positive correlations were even more significant (r= 0.380, p< 0.001 and r= 0.562, p<0.001, respectively). In cases exceeding the 90^th percentile of operative blood loss and operating time, the average of SMD was 183.3mm. When the average of SMD was more than 183.3mm, odds ratios (OR) for the relationship between SMD and excessive bleeding (>90^th percentile) and excessive operating time (>90^th percentile) were 6.06 (95%CI;1.58-23.18, P=0.013) and 7.14 (95%CI;2.31-22.08, P=0.001), respectively. Thus, SMD was considered an appropriate determinant for laparoscopic myomectomy in borderline cases. Evaluation of eligibility criteria is equally important as equipment and technique advancements in improving the patient safety and outcomes in this setting.

Ectopic ovary is a rare gynecologic entity. A variety of synonymous terms such as ectopic ovary, supernumerary ovary, accessory ovary, and autoamputation of the ovary have been used to describe this condition. The etiology for ectopic ovary has not been elucidated, but several mechanisms have been proposed. They are categorized as either congenital (embryologically derived) or acquired. This report presents two cases of ectopic ovary resulting from different causes and one case of potential ectopic ovary. © 2010 Japan Society for Reproductive Medicine.

The purpose of this study was to assess the clinical features and characteristics of the blood flow in uterine vascular abnormalities using ultrasound and magnetic resonance imaging (MRI). A total of 17 women were diagnosed with uterine vascular abnormalities by ultrasound. The clinical characteristics of the patients and the distribution and waveform of the intrauterine vessels were examined using transvaginal gray-scale and Doppler ultrasonography, spin-echo MRI, and MR angiography. The average age of the 17 subjects was 44.3 years, and 5 were postmenopausal women. The number of pregnancies and deliveries was 2.0 and 1.7, respectively. Of the 17 subjects, 7 had a moderate or severe grade of dysmenorrhea and 7 had a history of vascular disease. In all subjects, vaginal ultrasound demonstrated tubular or numerous tortuous anechoic areas in the uterine wall, and Doppler ultrasound showed that the tubular or numerous dilated tortuous vessels had an atypical wave flow, unlike that of an artery or a vein. The distribution of displayed flow varied, and the waveforms of the Doppler ultrasound displayed three patterns. The averages of the pulse Doppler flow indices showed low impedance in the abnormal uterine vessel and the uterine artery, especially in cases of true arteriovenous malformations. MR angiography demonstrated distinct, tortuous, and coiled vascular channels in the pelvis during and just after the arterial phase. Characterization of the clinical features of uterine vascular abnormalities is considered to be valuable for obstetricians and gynecologists.