8761 Batwing Endometriosis: Radiographic Findings and Surgical Approach

Abstract

<h3>Study Objective</h3> To present radiographic findings suggestive of deep infiltrating endometriosis of the uterosacral ligaments and posterior torus uterinus (referred to as batwing endometriosis) and review surgical considerations and approach to excision of disease. <h3>Design</h3> Description of imaging findings and surgical technique. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients with batwing endometriosis on preoperative pelvic magnetic resonance imaging (MRI) and concordant intraoperative findings. <h3>Interventions</h3> Preoperative pelvic MRI and laparoscopic or robotic excision of endometriosis with and without hysterectomy. <h3>Measurements and Main Results</h3> Batwing endometriosis can often be associated with an obliterated posterior cul-de-sac and present significant challenges during laparoscopy. Here we review a systematic approach to aid with restoration of this space and focus on relevant anatomy to consider. The following important steps are discussed: methods for navigating ureterolysis, ways to shave disease and preserve neurovascular and ligament support, and finally, techniques to consider with vaginal cuff closure for concurrent hysterectomy. In addition to highlighting batwing endometriosis on MRI, key pelvic structures are identified including the ureter, uterine vessels, and pararectal space which all aid in dissection. <h3>Conclusion</h3> Identification of batwing endometriosis on preoperative pelvic MRI may improve surgical planning. Knowledge of important anatomic considerations and surgical steps allows for safe and effective excision for patients with batwing endometriosis.