How we do it: Identification and Dissection of the Sacrospinous Ligament and Lumbosacral Spinal Root on a Patient with Endometriosis of the Pelvic Floor

Abstract

Video Objective Our aim is to raise awareness of pelvic floor endometriosis and describe a technique to dissect the pelvis until the pelvic floor muscles identifying the lumbosacral nerves and the main structures of the pelvis. Setting A 23-year-old woman with cyclic pelvic pain since menarche had a history of claudication and pain in the right lower limb accompanied by dyschezia. At the vaginal and rectal examination, the patient had a nodule in the region of the right sacrospinous ligament, fixed in the pelvis and painful to palpation. The MRI showed a right posterolateral vaginal wall lesion on the uterosacral ligament and the anterior wall of the rectum, that touched the levator ani muscle infiltrating the sacrospinous ligament. Interventions The medial dissection of the lesion was performed by developing the pararectal space, resecting the uterosacral ligaments, ureterolysis and identifying the hypogastric nerve. Then, during lateral dissection of the lesion, we identified the iliac vessels and the obturator nerve after pelvic lymphadenectomy. The lumbar trunk, the sacral root S1, the superior gluteal artery and the S2 and S3 roots were identified posteriorly. Thus, we identified the lesion extending from the paracolpus and the rectal wall to the sacrospinous ligament in contact with the levator ani muscle. With both sides dissected, it was possible to approach the lesion preserving noble structures such as the ureter, uterine artery and splanchnic nerves. Conclusion Although endometriosis on the pelvic floor is a rare condition, deeply infiltrating endometriosis is more often diagnosed in young woman such as our patient. Surgical techniques must be developed to asses those type of lesions and videos like this are a form to discuss different approaches to the pelvic floor.