A group of diseases caused by abnormal sexual differentiation and development is very rare in gynecologic clinics, and some of these patients require gonadectomy because they have Y chromosomes. The traditional surgical approach is to perform an open exploration followed by gonadectomy. We performed 13 cases of laparoscopic gonadectomy from July 2003 to August 2004 with satisfactory results, which are described below. I. Clinical data The average age of the 13 patients was 19.5 years (9-40 years), all of them contained Y chromosome or Y component, the social gender was female, and the gonads were located in the abdominal cavity or in the inguinal canal. Among them “17-αhydroxylase deficiency” 3 cases, all with chromosome 46, XY; “45, X/46, XY gonadal hypoplasia” 2 cases, all with chromosome 45, X/46, XY (1:2); “androgen insensitivity syndrome” 6 cases, all with chromosome 46, XY, of which 2 were “sisters” “gonadal dysgenesis” 1 case, chromosome 46, XY; “sex chromosome abnormalities” 1 case, chromosome 46, X, del(x)(qter-q11),q dominant band did not see fluorescence Y material, PCR amplification of Y chromosome, short arm end ZFY gene positive, indicating carrying Y chromosome fragment. Six of them had been operated in outside hospitals, one “gonadal hypoplasia” patient underwent left nephrectomy for left nephroblastoma, another “sex chromosome abnormality” patient underwent ureteral cyst removal surgery, and the remaining four cases underwent hernia repair for inguinal hernia or mass found. In these 4 cases, 2 cases were found “testis” but not resected, the testis was returned and hernia repair was performed, and in the other 2 cases, no mass was found and hernia repair was performed directly. Preoperative preparation was the same as that for general gynecological laparoscopic surgery. (1) A 1 cm longitudinal incision was made in the umbilicus and a 10-mm trocar was placed, and a 5-mm trocar was placed in both lower abdomens in the same way. (2) Exploration of the pelvic cavity to find and identify abnormal gonads. The abnormal development of the gonads is basically in 2 forms: striated and testicular. The striated gonads are located in the pelvic cavity at the level of the normal ovaries and are often associated with the fallopian tubes; the testicular gonads are located in the inguinal canal or outside the internal orifice. (3) Decompose the adhesions and expose the free gonads. If there are pelvic adhesions, the adhesions must be disassembled first to restore the normal pelvic structure. When separating, the area to be separated is first clamped with non-invasive forceps to give some tension to make the adhesions tense, and then cut along the transparent non-vascular area with tissue scissors, trying to avoid the tip of the scissors touching the normal tissue. If there are small blood vessels in the adhesion zone, bipolar electrocoagulation can be used at both ends, and then cut from the middle to reduce bleeding. If there are important organs near the adhesions such as small intestine, ureter, bladder, etc., use monopolar electrocoagulation carefully to avoid the spread of heat energy along the tissue leading to necrosis. Tight adhesions should not be broken down with brute force. (4) Excision of gonads. For striated gonads, lift them together with the fallopian tubes, clamp and electrocoagulate the pelvic funnel ligament and cut it off, gradually separate the fallopian tube tract to the horn of the uterus and cut it off by electrocoagulation. The uterus is preserved with a view to future development and perhaps the possibility of in vitro fertilization. For the underdeveloped testis, the testis is retracted by clamping out of the inguinal canal until the spermatic cord is pulled out, and the spermatic cord tract, the remnants of the Mullerian duct and the pelvic funnel ligament are electrocoagulated and severed. The ruptured peritoneum at the inguinal canal’s internal opening is closed with a titanium clip and or closed with absorbable sutures to prevent future inguinal hernias. (5) After removing the gonads, check carefully for completeness to prevent incomplete excision and the chance of cancer. (6) The incision should be sutured or glued together. The postoperative treatment and care were the same as general gynecological laparoscopic surgery, and the stitches were removed 5 days after surgery for those with incision sutures and not for those with adhesives. The other 2 cases had only one side of the gonads removed laparoscopically because of serious abdominopelvic adhesions after the previous operation, and the other side had to be removed openly or in the groin. The bleeding volume was mostly 5-20 ml in 11 patients, 30 ml in others (related to separation of pelvic adhesions), with an average of 13 ml. The operative time was mostly 30-40 minutes (50 minutes in one case with a combined laparoscopy and hysteroscopy), with an average of 35 minutes. One case was discharged 1-2 days after surgery. one case with contralateral conversion to open surgery lasted 75 minutes with 30 ml of bleeding and was discharged in 4 days. Another case with contralateral conversion to inguinal resection had an operative time of 30 minutes, bleeding of 10 ml, and was discharged in 1 day. Discussion 1. Indications for surgery Testes with poor development (such as primitive gonads containing Y chromosome) or abnormal location (such as cryptorchid) are prone to malignant transformation and tumor. Malignant changes are mainly germ cell tumors (asexual cell tumors and seminoma), gonoblastoma and supportive cell tumors, while other malignant tumors such as endodermal sinus tumors, embryonal carcinoma and choriocarcinoma are rare. In 1993, our hospital summarized 9 cases of “45, X/46, XY gonadal insufficiency” 3 cases of tumors occurred, the literature reported an incidence of 10-20%; in 1995, 12 cases of “XY simple gonadal insufficiency” 8 cases of gonads had tumors, the literature reported an incidence of 30-60%, is the most likely to occur tumors Our hospital statistics “androgen insensitivity syndrome” 29 cases, 4 cases of tumors, Scully summarized the incidence of 6-9%, Manuel et al. reported the malignancy rate of 3-5% at the age of 20 years and up to 30% at the age of 50 years. The cause of deterioration may be related to abnormal gonadal tissue and intra-abdominal environment promoting each other for induction, or may be related to genetic mutations. Therefore, the gonads should be removed with all three of the following: (1) chromosomal examination proves the presence of Y chromosome or a fragment of Y chromosome; (2) the gonads are located in the abdominal cavity or in the groin; (3) the gonads are unable to perform endocrine and reproductive functions. 2. How to identify abnormal gonads under laparoscopic surgery (1) Preoperative diagnosis and evaluation are very important. Combining physical examination, ultrasound, sex hormone level and chromosomal examination, we can generally make a clear diagnosis and have a clear concept of the location and shape of the gonads. On examination, special attention is paid to the presence of a movable mass in the groin, the development of the vulva and vagina, and the presence of a uterus in the pelvis. Sex hormone levels are measured to help understand whether the gonads are functioning or whether the body is responding to hormones. Chromosomal examination helps to determine their true sex. (2) Careful intraoperative search for possible hiding places of abnormal gonads. If the testes are considered preoperatively, the focus is on finding the inguinal canal at the internal orifice and attempting to pull the ligaments that pass into it is often successful. If striated gonads are considered, look carefully for slender fallopian tubes and an underdeveloped primordial uterus; the thin fish-white strips that run parallel to the fallopian tubes are likely to be abnormal gonads. 3. Pros and cons of laparoscopic surgery The most prominent advantage of laparoscopic surgery is that it is minimally invasive and the patient recovers quickly and with less pain. Laparoscopic exploration is more advantageous than open because the magnified images make the laparoscopic search for the gonads more clear and accurate. The scope of laparoscopic exploration involves the whole abdominal cavity, thus, also avoiding the disadvantage of enlarging the incision required for open surgery to expand the scope of exploration. Laparoscopy is competent for the breakdown of general adhesions, but is risky for extensive, tight adhesions. This is related to the inherent characteristics of laparoscopic surgery: high instrument dependence and operator skill dependence. We had one patient converted to open and one to inguinal incision, both for this reason. Minimally invasive procedures have the potential to lead to megatrauma if used inappropriately.