Frozen Pelvis – Stepwise Approach to Multifocal Endometriosis

Abstract

<h3>Study Objective</h3> To demonstrate the step-by-step approach to the treatment of endometriosis. The idea is to systematize all the steps to make this surgery more reproducible, safe and less time consuming. <h3>Design</h3> Case report for surgical technique and description of the procedure using video. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> A 36-year-old woman with a complaint of metrorrhagia for 2 years. She had one pregnancy with a normal delivery. The patient denied comorbidities and previous surgery. On the bimanual vaginal examination, it was possible to palpate a painful nodule in the retrocervical region as well as bilateral thickening of the uterus sacral ligaments, it was also possible to notice that the uterus had reduced mobility. The vaginal ultrasound described an area of tissue thickening next to the anterior uterus, measuring 1.8 × 0.7 × 1.4cm and another on the posterior measuring 3 × 1 × 2.6cm, determining an adherent process with the rectosigmoid 10cm from the anal border. It was also visualized a hypoechoic thickening on the anterior wall of the rectosigmoid affecting the external muscle itself and involving 15% of the circumference, measuring 2.7 × 0.6 × 1cm and 12 cm from the anal border. Thickening areas are noted near the distal ileum, measuring about 2 × 1.2 × 1.4cm, with signs of impairment of the distal portion of the cecal appendix. <h3>Interventions</h3> We performed a laparoscopic resection of deep endometriosis with bowel shaving and appendectomy. <h3>Measurements and Main Results</h3> We could restore the pelvic anatomy that was distorted by stage 4 endometriosis with bowel involvement without prejudice to the patient's function. <h3>Conclusion</h3> We should be conservative towards function considering that most patients with endometriosis are young and operate only symptomatic lesions.