Tigers in the Sidewall: Surgical Approaches to Excision of Lateral Deep Infiltrating Endometriosis |
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| Affiliation: | 1. Department of Gynecology, Pôle de gynécologie-obstétrique (Drs. Paté, Hauss, Faller, Lecointre, and Akladios), Strasbourg University Hospital, Strasbourg, France;2. Department of Emergency, Pole urgence-reanimation-SAMU-SMUR (Dr. Colin), Strasbourg University Hospital, Strasbourg, France;1. Department of Gynecology and Obstetrics (Drs. Bendifallah, Vesale, and Daraï);2. Department of Radiology (Drs. Thomassin-Neggara and Bazot), Tenon University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France;3. Department of Surgery (Dr. Tuech);4. Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis (Dr. Abo), Rouen University Hospital, Rouen;5. Endometriosis Center (Dr. Roman), Clinique Bordeaux Tivoli-Ducos, Bordeaux, France;6. Endometriosis Center (Dr. Roman), Aarhus University Hospital, Aarhus, Denmark;7. Departments of Gynecology and Obstetric (Dr. Vesale) Centre hospitalier Sud Francilien, Corbeil Essonne, France;1. Department of Obstetrics and Gynecology, Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia, Brescia, Italy (Drs. Ciravolo, Donarini, and Rampinelli);2. Department of Obstetrics and Gynecology, Fondazione Poliambulanza, Brescia, Italy (Dr. Visenzi);3. Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy (Mr. Odicino);1. Endometriosis Centre Charité, Department of Gynaecology, Charité, Campus Virchow Clinic, Berlin, Germany (Drs. Abesadze, Sehouli, Mechsner, and Chiantera);2. University of Palermo, Palermo, Italy (Dr. Chiantera). |
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| Abstract: | ObjectiveTo describe the surgical approaches and excisional techniques used in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall.DesignA technical video showing the excision of advanced lateral DIE.SettingAn academic tertiary care hospital.InterventionsA 32-year-old woman, gravida 2, para 1, presented for definitive surgical management of endometriosis-associated pelvic pain. Intraoperative findings revealed severe retroperitoneal fibrosis tethering the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament, and ureter. The patient underwent laparoscopic management of the DIE involving the lateral pelvic side wall. We demonstrate the surgical methods and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we used a nontraditional surgical approach by tunneling under the external iliac vascular to tackle the dissection from a lateral to medial direction to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule.ConclusionExtreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical to overcome unexpected lateral pelvic side wall endometriosis because the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master these difficult endometriotic resections. |
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