Incidental Finding of Stage IV Endometriosis during Laparoscopic Hysterectomy for Fibroid Uterus

Abstract

Study Objective To describe the surgical techniques used to assist management of incidental stage IV endometriosis during laparoscopic hysterectomy of a large, multi-fibroid uterus. Design N/A Setting A 38-year-old G2P2 with past medical history significant for fibroids and iron-deficiency anemia and past surgical history of two cesarean sections presented to clinic requesting definitive management of heavy bleeding and pain. She had a pelvic ultrasound which demonstrated multiple uterine fibroids, with the largest having maximum dimension of 7.2cm. She also underwent an MRI, which again identified numerous uterine leiomyomata, but also demonstrated a complex left ovarian cyst measuring 5.4cm, not seen on the prior ultrasound. Patients or Participants N/A Interventions The patient was scheduled for a total laparoscopic hysterectomy with bilateral salpingectomy, possible oophorectomy. Given proper pre-operative planning, the surgery was able to be kept laparoscopic despite complete obliteration of the posterior cul-de-sac and right adnexa being completely adherent to the sidewall due to presence of endometrioma. This video shows the techniques used and identifies tips used to safely perform a laparoscopic hysterectomy in the setting of dense adhesions and incidental finding of stage IV endometriosis. Measurements and Main Results N/A Conclusion This patient was incidentally found to have stage IV endometriosis, which complicated her already challenging surgery given a multifibroid uterus and history of two intra-abdominal procedures. Pre-operative planning and careful surgical technique is essential when faced with severe adhesions.