doi:10.1111/jog.13774

J. Obstet. Gynaecol. Res. 2018

A nationwide survey on gynecologic endoscopic surgery inJapan, 2014–2016
Fuminori Taniguchi1 , Osamu Wada-Hiraike2, Tetsuya Hirata2, Hiroto Tajima3,
Hirotaka Masuda4, Mari Kitade5, Jun Kumakiri6, Ichiro Uchiide7, Juichiro Saito8,
Keisuke Kurose9, Toshiyuki Takeshita9, and Tasuku Harada1 , on behalf of the Surgical
Outcome Research Committee in Japan Society of Gynecologic and Obstetric Endoscopy
and Minimally Invasive Therapy (JSGOE)
1

Tottori University Faculty of Medicine, Yonago, 2Graduate School of Medicine and Faculty of Medicine, The University ofTokyo, 4Keio University School of Medicine, 5Juntendo University, 6Tokyo Women’s Medical University, 8Juntendo Tokyo Koto
Geriatric Medical Center, 9Nihon Medical School, Tokyo, 3Shin-Yurigaoka General Hospital, Kawasaki, and 7Uchiide Clinic,
Yokosuka, Japan

Abstract
Aim: Since 2014, Japan Society of Gynecologic and Obstetric Endoscopy and minimally invasive therapy(JSGOE) conducted a nationwide survey on gynecologic endoscopic surgery. We aimed to evaluate the current status and complications associated with endoscopic surgery by Japan gynecologic and obstetricendoscopy-database registry system (JOE-D).
Methods: Electrical medical records concerning the endoscopic surgery were generated from the daily useof reporting system. The subjects were all patients who underwent gynecologic endoscopic surgery. In addition to assessment of actual numbers, diagnosis, and operative methods, adverse events were registered.
Results: Total 203 970 patients performed laparoscopic, hysteroscopic and falloposcopic surgery for 3 years,
2014–2016. The numbers of endoscopic surgeries conducted in 2016 were increased more than 67 000, 13 000
or 450 cases, respectively. Incidence rates of complications involving these three types of surgeries in eachyear were approximately 3.1%. Incidences of intraoperative complications were relatively high in malignant
diseases, laparoscopic-assisted vaginal hysterectomy (LAVH) and myomectomy (LAM). In total laparoscopic
hysterectomy/laparoscopic hysterectomy (TLH/LH) performed from 2014 to 2016, ureteral injury as intra
and postoperative complication occurred in 0.35%. In the past 3 years, the rates of vascular injury, urinary
tract, and bowel injury as intraoperative complications caused by laparoscopic surgery were approximately
0.1%. In the hysteroscopic surgery, the rates of total intra- and postoperative complications were 0.78%.
Conclusion: We exhibited the current status by the nationwide survey of gynecologic endoscopic surgery allover Japan. Severe intra or postoperative complications were identiﬁed over the 3 years at a rate of 0.04%.
Key words: complication, endoscopic surgery, nationwide data entry system.

Introduction
Nowadays, the number of demanding gynecologic
endoscopic surgery has been increased across theworld. Gynecologic endoscopic surgery is adopted

and widespread besides the traditional open access,however, it has been insufﬁcient for the clinicians toknow the present status and the accurate information.
During the last decade endoscopic surgical procedures have been constantly evolving. Gynecologic

Received: May 15 2018.
Accepted: July 8 2018.
Correspondence: Fuminori Taniguchi, MD PhD, Department of Obstetrics and Gynecology, Tottori University Faculty of Medicine,36-1 Nishi-cho, Yonago 683-8504, Japan. Email: tani4327@med.tottori-u.ac.jp© 2018 Japan Society of Obstetrics and Gynecology

1F. Taniguchi et al.

surgeons have made many efforts to improve the skill
thereby shortening the learning-curve for surgery andimprove the clinical outcomes, reducing iatrogenic
injuries, excessive blood loss, hospitalization days andrecovery time.
This project aims to contribute to the improvementof quality in endoscopic surgery by analyzing thedata concerning clinical factors, such as operative
methods, adverse events and prognosis in Japan.
Reduction of complications due to the endoscopic surgeries would not only improve the quality of life
(QOL) for the patients but also have the inﬂuence on
the public health economy. Also, a nationwide andcomprehensive survey regarding the gynecologic
endoscopic surgery has not been conducted yet. In
2016, approximately 3500 laparoscopic surgeries forgynecologic malignant diseases have been carried out.
Adverse events associated with endoscopic procedures are generally low frequencies, however, withincreasing operative complexity, it is apparent thatthey are experienced more often. Therefore, the large
scale-registry system has been required to evaluate
the current status of endoscopic treatments and theincidence of operative complications.
Japan Society of Gynecologic and ObstetricEndoscopy and minimally invasive therapy (JSGOE)
has implemented Japan gynecologic and obstetricendoscopy-database (JOE-D) as an endoscopic surgerydatabase. This type of data-accumulation system concerning the gynecologic endoscopic surgery on anationwide scale is the ﬁrst attempt all over the world.

Methods
The institutional review board of Tottori university
faculty of medicine approved this project (No. 2291,
obtained on October 19, 2015). Written and informed
consents were taken for all patients who underwent
the surgery in Japan. Data of the endoscopic surgery,
i.e. laparoscope, hysteroscope or falloposcope, for
3 years (from January 2014 to December 2016) in thefacilities of all over Japan were registered annually by
the JOE-D system. The information concerning thesurgical complication in each case was included. This
registry system is critically involved in the JSGOEcertiﬁed systems, that is, (i) the system as theapproved training-facilities for gynecologic endoscopic surgery and (ii) the license system as theapproved gynecologic endoscopic surgeons. This
entry system was conducted by using the same2

application software, File Maker Pro (FileMaker Inc).
Data from each institute were collected by the ofﬂinesystem without using the internet. In consideration of
the risk of erroneous input on this system, the speciﬁc
passwords for registration were set in every years.
The input items include age, identiﬁcation number ofpatients, major surgical indications, operative method,
the major intra and postoperative complications,
treatments in case of complications, and postoperative
outcomes. If the cases had multiple complications inan operation, the data was collected and submitted.
In terms of laparoscopic surgery, as the intraoperative complications, massive bleeding was deﬁned as
more than 500 mL, and bladder, ureter, bowel injuries, vascular injuries (major vessels or abdominal
wall vessels) and other complications resulting in
additive procedures or treatment during surgery wereclassiﬁed. In addition, the postoperative complications such as peritonitis, wound infection, bleeding or
hematoma, vagina stump-dehiscence, intestinal complication (ileus and hernia), ureteral injury and bladder injury were categorized. Peritonitis or wound
infection was deﬁned as those requiring antibiotics
treatment or drainage for abscess formation. In thecomplications of hysteroscopic surgery, uterine perforation, water intoxication, massive bleeding (morethan 500 mL), infection and adhesion in uterine cavity
were classiﬁed.

Results
The number of facilities (346, 402 and 440 per year)
and cases (56 233, 67 059 and 80 678 per year) performed the gynecologic endoscopic surgeries in Japan
were gradually increased in the past 3 years. Among
total 203 970 cases registered from 2014 to 2016, a
total of 6399 complications occurred in intra and/or
postoperatively. As shown in Table 1, the rates ofcomplications in each year were similar, approximately 3.1%.
In Table 2a,b, the lists of laparoscopic surgery
performed from 2014 to 2016 with 17 indications
for surgery and 23 operative methods, werearranged in descending order. The frequent indications for laparoscopic surgery were uterine ﬁbroid(58 328 cases, 33.7% in total 172 986 cases), benign
ovarian tumor (48 550 cases, 28.1%) or endometriosis and ovarian endometrioma (27 125 cases,
15.6%) as presented in Table 2aa and Figure 1a.
In Table 2b, total laparoscopic hysterectomy/© 2018 Japan Society of Obstetrics and Gynecology

Survey of gynecologic endoscopic surgery

Table 1 Annual numbers of gynecologic endoscopic surgery and incidence of complications in Japan
Year

Number of facilities

Number of surgery

Case of complications

Rate of complications (%)

2014
2015
2016

346
402
440

56 23367 05980 678

1751
2110
2538

3.11
3.15
3.15

laparoscopic hysterectomy (TLH/LH) (16 940
cases, 25.0%), and cystectomy for ovarian tumor(excluding chocolate cyst) (10 786 cases, 15.9%)

were mainly performed more than 10 000 cases in
2016, and the cases conducted these operations
increased gradually every year. In Figure 2a,b, theTable 2 Classiﬁcation of gynecologic endoscopic surgery performed in Japan – Laparoscopic surgery(a) Classiﬁcation by indication for surgery
Diagnosis

2014

2015

2016

Uterine ﬁbroid
Benign ovarian tumor (except for ovarian
endometrioma)
Endometriosis and/or ovarian
endometrioma
Ectopic pregnancy
Adenomyosis
Uterine endometrial cancer
Tubal obstruction or hydrosalpinx
Pelvic organs prolapse
Ovarian cancer
Uterine cervical cancer
Adhesive adnexa
Polycystic ovary
Inspection of pelvic cavity
Ovarian bleeding
Congenital malformation in reproductive
organsOthersTotal

16 31913 67519 381
16 35522 62818 5408016

8973

10 136

2645
1637
1134
787
590
413
351
277
282
149
150
38

2938
1940
1773
825
804
517
499
319
265
218
194
49

3096
2564
2290
999
1184
708
492
409
284
255
192
66

1461
47 9242254
57 3043915
67 758(b) Classiﬁcation by operative method
Operation

2014

2015

2016

Total laparoscopic hysterectomy or laparoscopic hysterectomy(TLH or LH)
Cystectomy for ovarian neoplasm (excluding chocolate cyst)
Laparoscopic myomectomy (LM)
Adnexectomy (excluding ovarian endometrioma)
Cystectomy for ovarian endometrioma
Surgery for ectopic pregnancy
Adnexectomy (ovarian endometrioma)
Laparoscopically assisted myomectomy (LAM)
Surgery for malignant tumor (containing lymph-adenectomy)
Laparoscopically assisted vaginal hysterectomy (LAVH)
Removal of endometriosis lesions
Laparoscopic sacrocolpopexy (LSC)
Inspection of pelvic cavity
Intrapelvic adhesiolysis
Ovarian drilling for PCOS
Laparoscopic supra vaginal hysterectomy
Tuboplasty
Removal of adenomyosis lesion
Tubal ligation
Colpoplasty
Others
Total

9783
8129
6864
6192
5315
2591
1642
1521
952
1219
724
364
390
413
268
179
190
85
34
10
1060
47 92512 823
9631
7896
7520
5774
2848
2085
1576
1454
1239
768
555
474
461
248
205
149
112
50
18
1350
57 236

16 94010 786
8776
9365
5922
3023
2342
1434
2037
1491
906
342
559
594
261
224
240
92
14
29
2382
67 758© 2018 Japan Society of Obstetrics and Gynecology

3F. Taniguchi et al.

(a)

0

5,000

10,00015,00025,00020,000

Uterine fibroid
Benign ovarian tumor(except for ovarian endometrioma)
Endometriosis
and ovarian endometrioma
Ectopic pregnancy
Adenomyosis
2016

Uterine Endometrial cancer
Tubal obstruction

2015

or Hydrosalpinx
2014

Pelvic organs prolapse
Ovarian cancer
Uterine Cervical cancer
Adhesive adnexa
Polycystic ovary
Inspection of pelvic cavity
Ovarian bleeding
Congenital malformationin reproductive organs
Others

0

2,000

4,000

6,000

8,000

(b)
Endometrial polyp
Submucosal uterine
fibroidHeavy menstrual
bleeding
2016

Asherman’s syndrome

2015
2014

(Intrauterine adhesion)
Congenital uterine
malformations
OthersFigure 1 Annual numbers classiﬁed by indications for (a) laparoscopic surgery, and (b) hysteroscopic surgery performed
in Japan from 2014 to 2016.

4© 2018 Japan Society of Obstetrics and Gynecology

Survey of gynecologic endoscopic surgery

(a)

2014

2015

Table 3 Classiﬁcation of gynecologic endoscopic surgery performed in Japan – Hysteroscopic surgery

2016

493

(a) Classiﬁcation by indication for surgery

386
338
292
233

263
153

184

107

TLH /LH

LM

67 74

LAM

109

MT

92 102 111

LAVH

(b)
14.00
12.80
12.00
10.00

9.71

8.00

8.23

6.00
4.00

3.39
2.98

2.00
0.00

2014

7.44

LAVH
MT

5.09

5.35
4.40

3.33
2.64

2.91

2015

2014

2015

2016

Endometrial polyp
Submucosal uterine ﬁbroid
Heavy menstrual bleeding
Asherman’s syndrome(intrauterine adhesion)
Congenital uterine
malformations
Others
Total

4397
3576
222
111

5302
3887
184
83

7091
4733
194
147

69

89

115

267
8642

409
9954

1127
13 407(b) Classiﬁcation by operative method
LAM

7.55
7.03
7.04

DiagnosisLM
TLH/LH2016

Figure 2 Annual (a) numbers and (b) incidence rates ofmajor intraoperative complications occurred in laparoscopic surgery from 2014 to 2016.MT: Surgery formalignant tumor (containing lymph-adenectomy),
TLH/LH: Total laparoscopic hysterectomy or laparoscopic hysterectomy, LAVH: Laparoscopic-assisted vaginal hysterectomy (LAVH), LAM: Laparoscopic-assisted
myomectomy, LM: Laparoscopic myomectomy.

annual numbers and the incidence rates of major
intraoperative complications in laparoscopic surgery from 2014 to 2016 were exhibited.
As the combination of indication for surgery andoperative methods, the major frequent laparoscopic
surgeries performed in 2016 were noted in the following order: (i) TLH/LH for uterine ﬁbroid (11 289
cases), (ii) Cystectomy for ovarian tumor excluding
chocolate cyst (9950 cases), (iii) Laparoscopic myomectomy (LM) for uterine ﬁbroid (8701 cases) (datanot shown). The number of cases with malignant diseases, that is, uterine endometrial or cervical cancer,
and ovarian cancer, exhibited approximately 1.8-foldincrease (from 1898 to 3490 cases) within the past
3 years, although the rates of surgery performed for
malignant diseases in 2016 was merely 5.2% in total
67 758 cases of laparoscopic surgery (Table 2a,b).
In terms of hysteroscopic surgery in Table 3 andFigure 1b, the majority of surgeries performed for
3 years were the resection of endometrial polyps(16 869 cases, 52.6% in total 32 052 cases) and submucosal uterine ﬁbroids (12 182 cases, 38.0%). As the falloposcopic surgery in Table 4, the tuboplasty for tubal© 2018 Japan Society of Obstetrics and Gynecology

Operation

2014

2015

2016

Resection of endometrial
polyp
Resection of uterine
ﬁbroidMicrowave endometrial
ablation (MEA)
Adhesiolysis in uterine
cavityHysteroplasty
Others
Total

4375

5284

7210

3550

3885

4747

286

242

224

111

91

142

58
259
8639

79
425
10 006291055
13 407

Table 4 Classiﬁcation of gynecologic endoscopic surgery performed in Japan – Falloposcopic surgery(a) Classiﬁcation by indication for surgery
Diagnosis

2014

2015

2016

Tubal obstruction
Functional infertility
Tubal stenosis
Hydrosalpinx or hemosalpinx
Others
Total

300
207
74
23
2
606

339
4
64
15
0
422

385
2
68
5
6
466

(b) Classiﬁcation by operative method
Operation

2014

2015

2016

Falloposcopic tuboplasty
Falloposcopic tuboplasty withlaparoscopy
Others
Total

242
154

298
112

330
135

211
607

1
411

1
466

obstruction or stenosis was mainly performed (85.6%
in total 1484 cases).
In Table 5, the intraoperative accidental occurrencesin laparoscopic surgery were presented. In thesetypes, the most frequent occurrence was technicalproblems with the apparatus. Almost all cases ofCO2-gas erroneous insufﬂation were resulted in subcutaneous emphysema. The majority of failure or5

F. Taniguchi et al.

Table 5 Accidental occurrences in laparoscopic surgery
Occurrences
Technical problems with apparatus
CO2-gas erroneous insufﬂation
Failure or corruption of apparatus
Remnant of apparatus or specimen
Drug-induced accident
Total

2014

2015

2016

47 (39.5%)
39 (32.8%)
23 (19.3%)
10 (8.4%)
0119 (100%)

61 (42.1%)
48 (33.1%)
29 (20.0%)
6 (4.1%)1 (0.7%)145 (100%)

68 (44.7%)
38 (25.0%)
22 (14.5%)
21 (13.8%)
3 (2.0%)152 (100%)

corruption of apparatus was the accidents involving
in uterine manipulators and forceps. Four cases of the
drug-induced accidents encountered in these 3 years
were caused by the injection of vasopressin or epinephrine to uterus. All these occurrences were notsevere, and could recover during the operations.
We summarized the number of cases, and major
intra or postoperative complications caused by laparoscopic or hysteroscopic surgery (the top ﬁve frequent operative methods in this study), and minor
operative methods were excluded in Tables 6–7 and8. In Tables 6 and 7, the rates of total intra or postoperative complications caused by laparoscopic surgery
in these 3 years were 2.35% or 1.22%. As we predicted, the rates of complications were higher in thesurgery for malignant tumor (intra and postoperative: 5.76% and 3.92%) compared with otheroperation methods. With regard to intraoperativecomplications, high rates of complications were
noticed in the surgery for malignant diseases,
laparoscopic-assisted vaginal hysterectomy (LAVH)
and laparoscopic-assisted myomectomy (LAM)(Table 6, Fig. 2a,b). In these three operations, therates of incidences involving vascular injury (large-,
abdominal wall- or other- blood vessels), urinary
tract (ureter and bladder) and bowel injury were relatively high. Especially, in every year, the high incidence rates of massive bleeding in LAVH (6.36%) or
LAM (9.43%) were found.
The total rates of intraoperative vascular, ureteral,
bladder or bowel injury occurred in 3 years were0.07%, 0.07%, 0.13% or 0.15% respectively (Table 6).
The annual incidence rates of them were almost similar. In contrast, the rates of postoperative complications including ureter, bladder injury, intestinal
complications such as ileus, perforation or herniation
were 0.05%, 0.03% and 0.12%, respectively (Table 7).
The incidence rates of intra or postoperative ureteraland bladder injury caused by TLH/LH, the most frequent operative method, in 3 years were similar,
approximately 0.35%.

6

In Table 8 concerning the hysteroscopic surgery, therates of total intra and postoperative complications
were 0.78% (250 in 32 052 cases) for 3 years. In termsof uterine perforation, the incidence rate was 0.41%.
Most frequent cause of uterine perforation (3.78%)
was the surgery of adhesiolysis in uterine cavity forthe treatment of Asherman’s syndrome or uterine
septum.
Clinical outcomes of cases which had operativecomplications were shown in Table 9 (laparoscopy:
intraoperative), Table 10 (laparoscopy: postoperative)
and Table 11 (hysteroscopy). In Table 9, the cases
needed the blood transfusion, including the autologous blood transfusion which had preserved prior to
the surgery, were increased in 2016. In Tables 10 and
11, the different proportion of the outcomeclassiﬁcation was not apparent. The severe cases
needed the treatment in ICU (intensive care unit), or
led to the death due to the complications were totally
83 for 3 years (Tables 9–10 and 11).

Discussion
The nationwide survey of the gynecologic endoscopic
surgeries in Japan (JOE-D) has been conducted toassess and share the current status and information
for the clinicians and patients. The number of endoscopic surgeries has continued to grow, while that of
abdominal procedure was decreased. These data represent the real status of the complications of gynecologic endoscopic surgery, in the situation where also
these surgeries are widely implemented throughout
the whole nation. From the registration in 2018, thedetailed items (i.e. disease name and operative
method) regarding the robot-assisted surgery and thegynecologic malignant tumors will be added. From
2019, we will present the data for the gynecologic
malignancies. The annual rates of complications bylaparoscopic, hysteroscopic and falloposcopic surgeries were 3.1% (Table 1).

© 2018 Japan Society of Obstetrics and Gynecology© 2018 Japan Society of Obstetrics and Gynecology
305 (7.72%)

256 (5.76%)

882 (3.75%)
1123 (2.84%)4064 (2.35%)

3.949

4443

23 51639 546172 9192955 (1.71%)

731 (1.85%)

781 (3.32%)

149 (3.35%)

251 (6.36%)427 (9.43%)

Massive
bleeding

119 (0.07%)

32 (0.08%)

6 (0.03%)41 (0.92%)

7 (0.18%)

1 (0.02%)

Vascularinjury115 (0.07%)

84 (0.21%)

3 (0.01%)

6 (0.14%)7 (0.18%)

0

Ureter injury

219 (0.13%)

113 (0.29%)

8 (0.03%)

11 (0.51%)

20 (0.51%)

4 (0.09%)

Bladder injury

n.a.: not applicable.

Surgery for malignant
tumor (containing
lymph-adenectomy)
Total laparoscopic
hysterectomy orlaparoscopic
hysterectomy(TLH or LH)
Laparoscopic-assisted
vaginal hysterectomy(LAVH)
Laparoscopic-assisted
myomectomy (LAM)
Laparoscopic
myomectomy (LM)Total

Operation
30 (0.68%)

Peritonitis
20 (0.45%)

Wound
Infection

70 (1.54%)
182 (0.77%)

4531
23 53636 (0.15%)

12 (0.26%)

17 (0.43%)

43 (0.18%)

11 (0.24%)

14 (0.35%)

16 (0.36%)

48 (0.2%)

22 (0.49%)

13 (0.33%)

15 (0.06%)

9 (0.20%)8 (0.2%)48 (0.12%)25 (0.56%)

191 (0.10%) 203 (0.12%)

n.a.

n.a.

5 (0.13)91 (0.23%) 161 (0.41%)

9 (0.20%)

Bleeding or Vaginal cuff Intestinal
hematoma dehiscence complication

172 919 2104 (1.22%) 415 (0.24%) 413 (0.24%) 304 (0.18%)

79 (2.0%)945 (2.39%) 214 (0.54%) 187 (0.47%)

174 (3.92%)

Number ofComplication

3949

39 546

4443

Cases

84 (0.05%)

2 (0.01%)1 (0.02%)5 (0.13%)7

19 (0.08%)

4 (0.09%)

11 (0.28%)

67 (0.17%)

37(0.83%)

Others398 (0.23%)

91 (0.23%)

57 (0.24%)

30 (0.41%)

12 (0.41%)

8 (0.18%)

Others45 (0.03%) 245 (0.14%)

3 (0.01%)00

29 (0.07%)(0.16%)

Bladder
injury260 (0.15%)

75 (0.19%)

23 (0.10%)

15 (0.13%)

5 (0.13%)3 (0.07%)

Bowel injury

53 (0.13%)

8(0.18%)

UreterinjuryTable 7 Classiﬁcation of postoperative complications in laparoscopic surgery. Major postoperative complications in 3 years

414 (9.14%)4528

Laparoscopic-assisted
myomectomy (LAM)
Laparoscopic-assisted
vaginal hysterectomy(LAVH)
Surgery for malignant
tumor (containing
lymph-adenectomy)
Laparoscopic
myomectomy (LM)Total laparoscopic
hysterectomy orlaparoscopic
hysterectomy(TLH or LH)
Total

Number ofComplication

Cases

Operation

Table 6 Classiﬁcation of intraoperative complications in laparoscopic surgery. Major intraoperative complications in 3 years

Survey of gynecologic endoscopic surgery

78

22 (0.07%)
3 (0.01%)
11 (0.03%)
9 (0.03%)12 (0.04%)
19 (0.06%)
24 (0.07%)
250 (0.78%)
32 052132 (0.41%)

7 (0.04%)01 (0.01%)0
3 (0.02%)2 (0.01%)1 (0.01%)57 (0.34%)
16 86934 (0.2%)

13 (0.11%)
2 (0.02%)2 (0.02%)
6 (0.05%)
8 (0.07%)7 (0.06%)
22 (0.18%)
121 (0.99%)
12 18258 (0.48%)

02 (0.27%)00
0
6 (0.8%)1 (0.6%)00
0
1 (0.6%)000
6 (3.6%)12 (1.6%)
166
752

5 (3.0%)4 (0.53%)01 (0.29%)00000
13 (3.78%)
15 (4.36%)
344

Adhesion lysis inuterine cavity
Uteroplasty
Microwave
endometrial
ablation (MEA)
Resection ofuterine ﬁbroid
Resection ofendometrial
polyp
Total

Adhesion
Infection

Postoperative complication

Bleeding
Others
Massive
bleeding
Water
intoxication

Intraoperative complication

Perforation
Number ofcomplication
Cases
Operation

Table 8 Classiﬁcation of complications in hysteroscopic surgery. Major intra and postoperative complications in 3 years

OthersF. Taniguchi et al.

Laparoscopy is now widely recognized as an indispensable tool in gynecologic surgery. Out of 172 919
laparoscopic surgeries performed from 2014 to 2016,
the number of cases which had intra or postoperativecomplications was 6168 cases (3.57%), although thedeﬁnition of massive bleeding as more than 500 mL
would be strict. Among the gynecologic surgeries forpelvic organs, especially in TLH/LH, the urinary tract
damage remains the major concern related to the laparoscopic surgery. An earlier national prospective survey in Finland was conducted in 1996, with a higher(1.1%) incidence of ureteral injury in LH.1 Retrospective analyses have showed a decrease since then,reaching 0.3%.2,3 In FINHYST study in Finland, therates of ureteral or bladder injury in TLH/LH performed in 2006 was indicated as 0.3% or 1.0%.4 An
institute of Korea reported that the rates of ureteral or
bladder injury as the postoperative complications in
TLH from 2005 to 2014 were totally 0.4% or 0.8%,
however, after 2010, no complication occurred by the
improvement of surgical technique.5 A single institutein Japan reported that the rates of ureteral and bladder injury was 0.32%, and 0.48%, respectively, in total
1253 TLH by using early ureteral identiﬁcation technique.6 Similar incidences (0.3–0.4%) occurred in large
single-institute reports.7,8 In the present data, the incidence rate of urinary tract injury in TLH/LH (ureteral: 0.25%, bladder: 0.36%) was almost similar tothese previous studies. The JSGOE-license system
requiring the approval of the training-facilities andthe endoscopic surgeons may lead to this low incidence rate. This license system with proper training
and education would contribute the surgeons toacquire the proﬁcient surgical skill and allow for
the safe procedures and the minimization ofcomplications.
In Table 9 concerning the clinical outcomes ofpatients who had laparoscopic intraoperative complications, the proportion required the repair of laparoscopic or laparotomic surgery was gradually
declined. The high rate (27.7%) of blood transfusion
in 2016 was caused by the increase of cases that wereneeded for the autologous blood transfusion in LM
or LAM (Table 6 and Fig. 2). It is beneﬁcial for thepatients to have damage repaired instantly without
excessive re-operations. Nevertheless, it should be
noted that all severe and harmful complicationinduced mortality, such as a major vascular injury(119 cases: 0.07% in Table 6) and bowel injury(260 cases: 0.15% in Table 6), occurred with laparoscopic surgery.
© 2018 Japan Society of Obstetrics and Gynecology

Survey of gynecologic endoscopic surgery

Table 9 Clinical outcomes of patients who have had intraoperative complications in laparoscopic surgery
Outcome
Follow-up at outpatients
Blood transfusion
Repair by intraopearative laparoscopic
surgery
Extended hospital stay
Repair by intraoperative laparotomic
surgery
Prolonged treatment with antibiotics
Re-operation
Treatment In ICU
Re-admission
Death
Others
Total

2014

2015

2016

445 (34.2%)
124 (9.5%)
251 (19.3%)

567 (36.0%)
148 (9.4%)
274 (17.4%)

567 (28.5%)553 (27.7%)
334 (16.8%)

115 (8.8%)
154 (11.8%)

144 (9.1%)
152 (9.7%)

183 (9.2%)
153 (7.7%)

36 (2.8%)
26 (2.0%)
11 (0.8%)
2 (0.2%)1 (0.1%)136 (10.5%)1301

48 (3.0%)41 (2.6%)
13 (0.8%)
6 (0.4%)1 (0.1%)180 (11.5%)
1574

35 (1.8%)
33 (1.7%)
25 (1.3%)
9 (0.5%)3 (0.2%)96 (4.8%)
1991

Table 10 Clinical outcomes of patients had postoperative complications in laparoscopic surgery
Outcome
Follow-up at outpatients
Prolonged treatment with antibiotics
Extended hospital stayRe-operation
Re-hospitalization
Blood transfusion
Treatment In ICU
Death
Others
Total

2014

2015

2016

235 (24.4%)
196 (20.3%)
183 (19.0%)
122 (12.6%)
109 (11.3%)
28 (2.9%)
6 (0.6%)0
86 (8.9%)965

243 (25.1%)
172 (17.8%)
190 (19.7%)
134 (13.9%)
115 (11.9%)27 (2.8%)
5 (0.5%)080 (8.3%)966

241 (21.3%)
239 (21.2%)
205 (18.1%)
161 (14.2%)
163 (14.4%)
52 (4.6%)
13 (1.2%)
055 (4.9%)1130

Table 11 Clinical outcome of patients had complications in hysteroscopic surgery
OutcomeRepair by intraoperative laparoscopic
surgery
Extension of hospital stay
Follow-up at outpatients
Prolonged treatment with antibiotics
Repair by intraoperative laparotomic
surgery
Re-operation
Blood transfusion
Re-admission
Repair by intraoperative hysteroscopic
surgery
Treatment In ICU
Death
Others
Total

With the extended indications for gynecologic
endoscopic surgeries, the surgical procedures havebeen constantly developed. The complications inendoscopic operations can be minimized with© 2018 Japan Society of Obstetrics and Gynecology

2014

2015

2016

21 (28.1%)

30 (28.3%)

241 (20.5%)

15 (20.0%)
9 (12.0%)
7 (9.3%)10 (13.3%)

19 (17.9%)
18 (17.0%)
9 (8.5%)5 (4.7%)24 (20.5%)
19 (16.2%)
10 (8.5%)
10 (8.5%)5 (6.7%)
1 (1.3%)
1 (1.3%)0

2 (1.9%)5 (4.7%)5 (4.7%)4 (3.8%)6 (5.1%)6 (5.1%)6 (5.1%)2 (1.7%)

1 (1.3%)0
5 (6.7%)75

2 (1.9%)0
7 (6.6%)106

2 (1.7%)0
8 (6.8%)117

advanced training, experience and surgical technique.
In addition, the improved surgical technique and the
new endoscopic apparatus, such as the tissue-sealing
device and the ultrasonic scalpel in laparoscopic

9F. Taniguchi et al.

operation might decrease the incidence rates ofcomplication.
On the other hand, in hysteroscopic surgeries, there
are the complications that relate to intraluminal endoscopic surgery that largely comprise perforation andinjuries to surrounding structures and blood vessels,
although hysteroscopic surgery is regarded as a safe
and well-tolerated procedure with low complication
rate. Uterine perforation is one of the most common
complications of hysteroscopic surgery, with an incidence of 0.12–3.0%,9,10 in this study, the rate of uterine perforation was 0.41% (Table 8). Importantly,
uterine perforation is a potential cause of uterine rupture in pregnancy. There is also an increasing awareness of uncommon but problematic sequelae related
to the use of uterine resectoscopes. Damage by electrosurgical electrodes may also lead to more serious
bowel injuries. Better understanding of the mechanisms involved in these adverse events has provided
the opportunity to perform hysteroscopic surgery in amanner that minimizes risk to the patient.
In conclusion, the gynecologic endoscopic surgeries
have multiple advantages and appropriate technique.
Prevention of the complications is feasible with precautionary measures and awareness of risk factors. A reduction of complications and need for re-operations would
not only improve the prognosis for the patients, however, also have a great inﬂuence on the national publichealth economy. We hope these data will contribute toimprove the daily clinical decision-making process andbeneﬁt the patients undergoing these procedures.

Acknowledgments
We appriciate Ms. Megumi Saito (JSGOE: Convention
Linkage, Inc.) and Ms. Yin Mon Khine (Tottori University Faculty of Medicine) for the technical supportand editing in this project. This report had the cooperation of all the registered-facilities that provided theinformation of the patients. We would like to express

10

our sincere gratitude to these facilities, and ask that
this registry system will be promoted and continued.
This study was supported by JSGOE.

Disclosure
None declared.

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