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Study Objective To show a systematic approach to perform resection of deep infiltrating endometriosis of the bowel and bladder in the setting of posterior cul-de-sac obliteration and intentional cystotomy creation. Design Step-by-step video demonstration of the technique. Setting A university tertiary care hospital. Patients or Participants A 28-year-old gravida 0 with a history of several years of severe dysmenorrhea, pelvic pain, and dyspareunia. She had been managed with hormonal medical therapy and physical therapy with little improvement in her symptoms. Pelvic ultrasound and MRI was significant for 0.8 × 1 cm rectal nodule located between the posterior wall of the uterus and anterior wall of the rectum, suggestive of deep infiltrating endometriosis. Interventions Studies have shown that surgery can improve pain in the context of deep infiltrating endometriosis. Moreover, deep infiltrating endometriosis has been associated with infertility with retrospective and prospective nonrandomized studies showing that resection improves spontaneous conception rates. Laparoscopy with resection of deep infiltrating endometriosis is performed using a conservative fertility sparing endometriosis surgery with bowel discoid resection. Deep infiltrating endometriosis of the bladder is performed with repair of therapeutic cystotomy. Measurements and Main Results We describe three phases of deep endometriosis nodule excision. First, opening pelvic avascular spaces, restoring anatomy, and identifying important anatomical structures. Second, resection of deep infiltrative endometriosis lesions with relevant vital structures properly identified and lateralized. Third, ensure integrity of our repair and hemostasis. At postoperative follow up, the patient reported improvement in pain symptoms. She had no bowel or bladder dysfunction postoperatively. Conclusion Management of deep infiltrating endometriosis begins in the preoperative period and continues beyond the immediate postoperative period. Appropriate preoperative evaluation, systematic and skilled intra-operative surgical technique, and appropriate postoperative follow up are important steps necessary to perform safe and effective fertility sparing endometriosis surgery. |
