Fertility- and Nerve-Sparing Laparoscopic Eradication of Deep Endometriosis with Anterior and Posterior Compartment Peritonectomy

Abstract

Study Objective To show anatomical and technical highlights of novel nerve-sparing laparoscopic eradication of deep endometriosis (DE) with anterior and posterior compartment peritonectomy. Design Stepwise demonstration of the technique. Setting An urban general hospital. Laparoscopic nerve-sparing techniques represented by the Negrar method have been described as resulting in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches. In addition, a recent paper showed that complete excision of DE with the posterior compartment peritonectomy could be surgical treatment of choice to decrease postoperative pain, improve fertility rate, and prevent future recurrence. However, a fertility- and nerve-sparing procedures are even more challenging than oncologic radical procedures because the pathology resembles advanced cervical cancer and ovarian cancer. Patients or Participants N/A Interventions After adhesiolysis and ovarian surgery, we developed retroperitoneal space at the level of promontory. The hypogastric nerve consists of the upper edge of pelvic plexus, so autonomic nerves were separated as a “nerve plane“ by sharp interfascial dissection of the loose connective tissue layers both above (between fascia propria of rectum and prehypogastric nerve fascia) and below (between prehypogastric nerve fascia and presacral fascia) the hypogastric nerve. As a result of these dissections, autonomic nerves in pelvis were separated like a sheet with surrounding fascia. We then completely resected all DE lesions including peritoneal endometriosis while avoiding injury to the nerve plane. Measurements and Main Results No patients (n=40) developed postoperative bladder, rectal, and sexual dysfunctions after the surgery. This nerve-sparing method is a modification of the technique of total mesorectal excision (TME) and total mesometrial resection (TMMR). We considered that this nerve-sparing technique is also applicable to segmental bowel resection and radical hysterectomy. Conclusion Our novel nerve-sparing surgery based on detailed meso-anatomy reproducibly simplify this complex procedure. Step-by-step technique help to perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete.