2 Methods for Identification and Preservation of Hypogastric Nerve During Laparoscopic Die (Deep Infiltrating Endometriosis) Surgery

Abstract

Video Objective In this video, we are going to introduce two methods for proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery. Setting Single institute, single surgical team's experience. Interventions USL is the mostly frequently involved area of pelvic endometriosis. Hypogastric nerves just lie between USL and pelvic ureter, locate in the Okabayashi pararectal space. They are frequently involved (either direct infiltration, or just encasement by surrounding tissue fibrosis) by the DIE lesions. En-bloc excision of USL DIE lesions frequently result in inadvertent hypogastric nerve injury, or even pelvic plexus injury. Proper identification and preservation of the hypogastric nerves is mandatory during nerve-sparing DIE surgery. We develop two methods to identify the hypogastric nerve within the USL DIE complex. (1) “Contralateral nerve traction test”: If we can clearly identify and isolate the hypogastric nerve on the more healthy side, by gentle pulling on this side hypogastric nerve, we can see the contralateral hypogastric nerve move on the other side. Thus we can have a good mapping of the course of hypogastric nerve within the DIE complex. (2) “Antegrade tracing from pre-sacral region”: If we move upward to the pre-sacral region, starting dissection from the virgin site, proximal part of hypogastric nerve can be easily identified. Antegrade tracing along the hypogastric nerve, un-roofing and bi-half the overlying DIE USL tissue, the whole course of hypogastric nerve can be safely traced and the nerve can be well-preserved. Conclusion Proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery is important. By this two simple methods and concepts (“contralateral nerve tract test” and “antegrade tracing”), we can minimize the risk of inadvertent nerve injury.