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OBJECTIVE: To demonstrate an innovative idea for a four-petal method for performing laparoscopic adenomyomectomy on a patient with focal-type adenomyosis. DESIGN: A step-by-step explanation of the technique with narrated video footage. SETTING: University hospital. PATIENT(S): A 38-year-old female with a 7 × 4 cm adenomyoma at the anterior uterine wall. INTERVENTION(S): Laparoscopic adenomyomectomy began with a cruciate incision to turn the adenomyoma into the shape of a blooming four-petal flower to fully expose the tumor and maximize the removal of adenomyotic tissue. During excision of the lesion, around a 1 cm thickness of the myometrium was preserved at the subendometrial region and around a 0.5 cm thickness of the serosa flap was also left in each "petal." Suture repair in the method introduced is different from closing the wound by approximation of myometrium to myometrium as in traditional myomectomy; instead, herein we repaired the adenomyomectomy wound by anchoring the serosal flap to the subendometrial tissue, with care taken to avoid dead space. MAIN OUTCOME MEASURE(S): Subjective clinical symptoms as well as serial ultrasonographic measurement of the uterine size, shape, and wall thickness. RESULT(S): The specimen removed was 92 g in weight. The symptoms have dramatically decreased since the procedure and dysmenorrhea improved from visual analog scale 8 to 1 postoperatively. Besides achieving satisfactory symptomatic relief, the ultrasonographic measurement of the myometrium was of adequate thickness (2.3 cm) after the operation and did not increase in a serial follow-up of 33 months. CONCLUSION(S): The four-petal method of adenomyomectomy with cruciate incision offers full exposure to the localized adenomyosis. It greatly facilitates a balance between the maximized resection of the lesions and tailored reserves of myometrium. Subsequent repair by anchoring the serosal flap to the subendometrial tissue ensures adequate thickness of the uterine wall after the operation.

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OBJECTIVES: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique in the area of minimally invasive procedures. Preliminary reports have confirmed transvaginal NOTES to be a safe and feasible method for performing hysterectomy and adnexal procedures. However, there are limitations regarding the feasibility of performing transvaginal NOTES hysterectomy in various uterine sizes. MATERIALS AND METHODS: Two hundred and seventy-five women who had undergone transvaginal NOTES hysterectomy for benign pelvic lesions were recruited from May 2012 to May 2016. Their medical records were retrospectively reviewed. All patients were placed into one of three groups depending on weight of the surgical specimen in order to assess surgical outcomes. RESULTS: One hundred ninety-one patients (69.46%) had a uterine weight of <500 g (group 1), 67 (24.36%) had a uterine weight of 500-999 g. (group 2), and 17 (6.18%) had a uterine weight of ≥1000 g. (group 3). The mean age± SD of group 1, group 2, and group 3 were 48.68 ± 6.63, 47.22 ± 3.81, and 46.53 ± 2.96 years, respectively (p value = 0.110). There was no statistical differences in terms of parity, body mass index (BMI), or history of abdominal surgery among the three groups. With regard to surgical outcomes, the mean operative times (Standard error: SE) were 76.70 (0.68), 99.99 (1.14), and 152.88 (3.37) minutes in Group 1, Group 2, and Group 3, respectively. The mean amounts of blood loss (SE) was 180.85 (4.61), 342.57 (6.98), and 532.35 (11.85) ml in Group 1, 2, and 3, respectively. There were statistically significant differences in terms of operative time and blood loss among the three groups (p = 0.0001 and 0.0001, respectively). CONCLUSIONS: Although the size of uterus has a significant effect on operative time and blood loss, NOTES hysterectomy can be successfully performed without any increase in complication rates. Natural orifice transluminal endoscopic surgery hysterectomy is a safe and feasible procedure even in large uteri.

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The introduction of newer vessel sealing systems has revolutionized techniques of hemostasis during laparoscopic surgery. These devices allow for rapid sequential tissue and vessel sealing, coagulation, and transection. Despite of widespread use of newer advanced bipolar and ultrasonic devices, monopolar and conventional bipolar electro-surgery still carry weightage due to wider range of tissue effect, dissection capabilities, cost effectiveness, and ease of availability. Here in we discussed different types of commonly available energy sources in terms of mechanism, efficacy and safety as thorough knowledge is utmost important for surgeon to choose appropriate instrument for surgical procedure.