Guidelines for Endoscopic Surgery in Obstetrics and Gynecology 2024 by Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy: A Secondary Publication Based on the Japanese Edition.

These guidelines primarily aimed to promote the appropriate and judicious use of endoscopic surgery in gynecology within Japan. They do not aim to determine the suitability of surgery for a particular disease or stage; rather, they provide guidance on the safe and effective performance of endoscopic procedures when deemed clinically indicated. These guidelines are intended for surgeons certified in laparoscopic surgery by the JSGOE or those possessing equivalent skills and expertise. These guidelines, which represent the standard of care at the time of their publication, are not intended to dictate specific clinical practices. Physicians are encouraged to exercise their clinical judgment in conjunction with these guidelines to determine the optimal course of treatment for each patient. While the JSGOE assumes responsibility for the content of this manuscript, ultimately, the attending physician is the only one responsible for clinical outcomes as neither the JSGOE nor the guideline development committee assumes liability for any such outcome. The Minds Handbook is a key resource in Japan offering evidence-based clinical practice guidelines to aid patient and healthcare professional decision-making for significant medical practices. Minds, aiming to disseminate high-quality guidelines, defines them as documents presenting optimal recommendations based on systematic evidence reviews and consideration of benefits and harms. The handbook explains guideline definitions and essential concepts and provides resources for guideline development. Minds also operates the free “Minds Guideline Library,” offering access to guidelines and lay summaries, supporting their evaluation, creation, and use. These guidelines were developed in accordance with the Minds Handbook for Guideline Development, 2020, version 3.0.[ 8 ] Key CQs were formulated based on identified critical clinical issues, each structured using the PICO framework (P: Patients, problem, population; I: Interventions; C: Comparisons, controls, comparators; O: Outcome). A comprehensive literature search conducted by the Japan Medical Library Association encompassed PubMed, Cochrane Library, and Igaku Chuo Zasshi, covering publications from January 1, 1990, to November 30, 2022. Seminal articles published outside this timeframe were also identified via manual searching and included. Established knowledge and techniques with broad clinical consensus were addressed as BQs. Future challenges and areas requiring further research were presented as columns or FRQs. The “Column” sections offer supplementary information, distinct from the main text, intended to deepen reader understanding and maintain engagement. The content presented in these Columns does not represent the guideline’s core recommendations, and consequently, they are not assigned evidence levels or consensus rates. Grade of recommendation indicates the extent to which one can be confident that the desirable effects of an intervention outweigh the undesirable effects. It reflects the confidence that adhering to the recommendation will do more good than harm. Recommendations or nonimplementations are categorized as strong or weak. Stronger recommendations imply a higher confidence in the balance of benefits and harms. Recommendation levels are categorized as follows: level 1 indicates a strong recommendation, denoted by (↑↑) when recommending implementation and (↓↓) when recommending nonimplementation. Level 2 indicates a weak recommendation, denoted by (↑) when proposing implementation and (↓) when proposing nonimplementation. The level of evidence reflects confidence in the accuracy of an estimated effect. GRADE categorizes it into High (further research unlikely to change confidence), Moderate (further research likely to impact confidence and possibly change the estimate), Low (further research very likely to impact confidence and likely to change the estimate), and Very Low (very little confidence, true effect likely substantially different). The initial level often depends on study design (RCTs start high, observational low) and can be downgraded (e.g., due to study limitations) or upgraded (e.g., due to large effect). The certainty of evidence is stratified into four levels (A through D), reflecting the strength of the evidence underpinning the recommendation. Level A denotes high certainty, Level B moderate certainty, Level C limited certainty, and Level D minimal certainty that the estimated effect supports the recommendation’s appropriateness. The chair of the JSGOE scientific committee also chaired the guideline development committee and appointed two subcommittee chairs: one for benign diseases and hysteroscopy and the other for malignant diseases. Each subcommittee chair then selected a vice chair and managing secretary. The guideline committee chair and each subcommittee chair appointed guideline formulation committee members from experts in their respective fields within the JSGOE membership, and those who accepted were designated as guideline development committee members. Drafts developed by the committee members were presented at the JSGOE general assembly for a consensus meeting, incorporating feedback from members. Subsequently, the drafts underwent further review and refinement by the evaluation committee, culminating in a recommendation decision meeting held in March 2024. The consensus rates indicate the level of agreement among the guideline development committee members for each recommendation and were determined by the votes cast by 29 members of the guideline development committee who participated in the recommendation decision meeting. Before voting at this meeting, any conflicts of interest (COI) related to the CQ under discussion were disclosed, and members with COIs recused themselves from voting. Statements were finalized on the basis of agreement from at least 75% of the participating members. Failure to achieve 75% agreement culminated in further discussion and re-voting. Voting results are presented as consensus rates. Revisions of these guidelines are scheduled every 4–5 years to ensure they reflect the latest advancements in gynecological endoscopic surgery. Interim revisions will be made as necessary and published on the JSGOE website. Chairperson: Shigeo Akira Secretary-General: Yasuhisa Terao Members of the Guideline Formulation Committee (Alphabetical order by last name): Kaoru Abiko, Tsukasa Baba (Subcommittee Chair of Malignant Diseases), Atsushi Fukui, Tomonori Hada, Shigenori Hayashi, Akifumi Horie, Yu Horibe (Managing Secretary of Benign Diseases), Masao Ichikawa, Yoshiki Ikeda, Hiroshi Ishikawa, Tetsuya Ishikawa, Ken Ishitani, Chiaki Izumiya, Iwao Kikuchi, Michio Kitajima, Michiko Kodama, Kaori Koga, Hiroaki Komatsu, Haruhiro Kondo, Yukiyo Kumazawa, Jun Kumakiri (Subcommittee Chair of Benign Diseases), Keiji Kuroda, Masanori Maruyama, Hirotaka Masuda, Motoki Matsuura, Keiko Mekari, Mikio Mikami, Kiyonori Miura, Taisuke Mori, Keisuke Murakami, Tomoyuki Nagai, Kazunori Nagasaka, Yasuko Nagasaka, Hidekatsu Nakai, Yuya Nogami, Hidetaka Nomura, Tatsuru Ohara, Yoshiaki Ohta, Shuichi Ono, Juichiro Saito (Vice-chair of Benign Diseases), Nobutaka Takahashi, Yasushi Takai, Hiroto Tajima, Tomohito Tanaka, Fuminori Taniguchi, Satoru Tanimura, Yoshito Terai (Vice-chair of Malignant Diseases), Masafumi Toyoshima (Managing Secretary of Malignant Diseases), Akira Tsuchiya, Tomoka Usami, Kota Umemura, Wataru Yamagami, Hiroshi Yoshida, Osamu Yoshino Members of the Guideline Evaluation Committee (Alphabetical order by last name): Daisuke Aoki, Hironori Asada, Takuma Fujii, Tasuku Harada, Osamu Hiraike, Akira Iwase, Hiroyuki Kanao, Mari Kitade, Hiroaki Kobayashi, Izumi Kusuki, Masaki Mandai, Etsuko Miyagi, Takashi Murakami, Satoru Nagase, Osamu Nishii, Masahide Omichi, Zenko Ryo, Yukihiro Terada, Hidemichi Watari, Yoshihito Yokoyama. Conceptualization, M.T. and S.A.; Methodology, M.T.; Investigation, S.A., J.K., and T.B.; Resources, S.A. and M.M.; Writing – Original Draft Preparation, M.T., J.K., T.B., J.S., Y.T., Y.H., and Y.T.; Writing – Review & Editing, M.T.; Visualization, M.T.; Supervision, S.A.; Project Administration, S.A.; Funding Acquisition, S.A., M.M. All authors have read and agreed to the final version of the manuscript. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. There are no conflicts of interest.

The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) pioneered the development of guidelines for endoscopic surgery in obstetrics and gynecology. The first edition of these guidelines was published in the December 2008 issue of the society’s journal.[ 1 ] These guidelines were subsequently incorporated into the comprehensive textbook, “Skill-up for Endoscopic Surgery in Obstetrics and Gynecology,” published in 2010.[ 2 ] The 2013 Edition of the JSGOE guidelines, aligned with the “Medical Information Network Distribution Service (Minds) guidelines for the preparation of clinical practice guidelines 2007,”[ 3 ] expanded its scope to include a new section dedicated to laparoscopic surgery for malignant conditions.[ 4 ] The 2019 edition marked a significant methodological advancement by introducing the grading of recommendations assessment, development, and evaluation (GRADE) system,[ 5 ] which rigorously assesses the quality of evidence across studies, primarily based on patient outcomes, and determines the strength of recommendations separately from the assessed evidence quality. Following this revision, the “Skill-up for endoscopic surgery in obstetrics and gynecology” was also updated to its third version,[ 6 ] featuring a wealth of videos and photographs to provide clear, visual explanations of the surgical techniques therein. These guidelines have been instrumental in improving the safety and therapeutic efficacy of gynecological endoscopic surgery. The 2024 edition,[ 7 ] recognizing the population of certified laparoscopic surgeons in Japan, is predicated on the assumption that such certified surgeons or people with equivalent expertise will perform these procedures. This latest revision offers a contemporary evaluation of novel surgical procedures, drawing upon the most up-to-date global evidence, and provides recommendations for their clinical application. Notably, the sections on malignant tumors and robot-assisted surgery have been significantly expanded to reflect recent advancements in these rapidly evolving fields of endeavor. The guidelines comprise 40 clinical questions (CQ), 14 background questions (BQ), 2 future research questions (FRQ), and 7 informative columns [ Tables 1 - 3 ]. This manuscript represents a secondary publication of the “JSGOE Guidelines for Endoscopic Surgery in Obstetrics and Gynecology 2024” originally published in Japanese by JSGOE (Primary reference: JSGOE, ed. JSGOE Guidelines for Endoscopic Surgery in Obstetrics and Gynecology. KANEHARA & Co., LTD.; 2024. ISBN: 978-4-307-30157-2). Background questions, future research questions, and columns BMI: Body mass index, FRQ: Future research question, BQ: Background question Clinical questions of part I ↑Weak recommendation, ↑↑Strong recommendation. RRSO: Risk-reducing salpingo-oophorectomy, CQ: Clinical questions, AIS: Adenocarcinoma in Situ, HSIL/CIN3: High-grade Squamous Intraepithelial Lesion/Cervical Intraepithelial Neoplasia Grade 3, FIGO: International Federation of Gynecology and Obstetrics Clinical questions of part II ↑Weak recommendation, ↑↑Strong recommendation. CQ: Clinical questions While many Asian countries currently do not have specialized guidelines tailored to endoscopic surgical procedures, this publication offers a comprehensive, evidence-based resource addressing benign and malignant conditions. A key strength of these guidelines is the incorporation of the GRADE system, which provides a transparent, structured, and internationally recognized methodology for evaluating evidence and formulating recommendations. By carefully balancing the quality of evidence with clinical benefits, risks, patient values, and resource utilization, the GRADE system ensures that these guidelines are adaptable to the diverse set of healthcare systems across Asia. This robust approach enhances the credibility and applicability of the recommendations, offering a practical tool for enhancing surgical decision-making and ameliorating patient outcomes. Moreover, this tool’s focus on cutting-edge techniques (such as robotic-assisted surgery) and its adaptability to evolving technologies position it as a vital reference for advancing minimally invasive gynecologic surgery throughout the continent. By fostering cross-border collaboration, knowledge sharing, and standardization, these guidelines serve as a cornerstone for improving surgical quality and patient care across Asia.