Laparoscopic management of advance endometriosis with RV nodule and presacral neurectomy
by Jain Nutan, Jain Vandana, Jain Monika

Comprehensive Video Atlas of Laparoscopic Surgery in Infertility and Gynecology

by Nutan Jain
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In this video you are seeing a 30-year-old female patient with grade IV endometriosis. Patient present complaints is severe dysmenorrhea with secondary infertility. She also complained of dyspareunia. Her sonography showing retroverted enlarged globular uterus with signs of adenomyosis and adherent right ovary, which was tender on scanning. Her CA-125 was increased 214 IU/mL. PV examination: uterus retroverted and fixed, puckering and scarring in vaginal fornices, severe tenderness on examination. Patient laid in modified lithotomy position under GA. Four ports laparoscopy done, all ports are 5 mm except camera port which is 10 mm. On inserting the telescope, uterus is densely retroverted, fixed in pouch of Douglas. Mesentery of colon is fixed to left sided anterior abdominal wall by taking three to four prolene, 1-0 stitches to enhance the pelvic vision. This is routinely done to clear the bowel from the pelvis and enhance the vision of pouch of Douglas and adnexa. Right tube was looking dilated and edematous, which was stuck on the posterior surface of uterus while right ovary stuck anteriorly. Left tube and ovary comparatively free. Initially spill seen only from left tube on hydrotubation. Gentle adhesiolysis started using sharp and blunt hook scissors. During dissection a small right ovarian endometrioma drained of chocolate material and cyst wall completely fulgurated. Right tube and ovary were totally released from the back surface of uterus. All the endometriotic implants beneath the left ovary were fulgrated using a bipolar forceps. Uterosacral ligaments felt to be thickened, nodular and adherent to rectosigmoid with lot of puckering and scarring in rectovaginal space. Blunt and sharp dissection of rectovaginal space was carried out. Right side ureteral dissection done up to uterosacral ligament so that ureter could be mobilized laterally. Now with the help of harmonic ACE the rectovaginal nodule was excised safely. An unusual located right round ligament adenomyoma noticed which was enucleated and removed. Other endometriotic implants near round ligament were also fulgurated. At the end both tubes and ovaries were seen free from the uterus, bilateral spill seen. Normal tubo-ovarian relationship restored. To combat longstanding dysmenorrhea. Presacral neurectomy done by opening up the peritoneum over the sacral promontory. The fibrofatty loose areolar tissue in the presacral space was cleared and presacral nerve is exposed. It is a leash of nerve fibers coming down from the aortic bifurcation. It is lifted up from the sacral promontory and a long segment of nerve is transected. Hemostasis achieved. We have to be careful about the middle sacral vessels which can cause excessive bleeding in this space. Thorough suction irrigation and lavage done.

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