Secrets for a Successful Surgical Systematization in the Treatment of Posterior Compartment Endometriosis

Abstract

Study Objective Demonstrate the secrets of the laparoscopic systematization in the treatment of posterior compartment endometriosis. Design Video demonstrating the systematic technique step by step (Canadian Task Force classification III) Setting: Surgery performed in 30-year-old patient, G0P0, with progressive dysmenorrhea, dyspareunia, menometrorrhagia and infertility. Upon vaginal and rectal touch, palpable thickening of the uterosacral ligaments was noticed with pain on mobilization. The MRI scan showed a low T2 signal lesion over the uterosacral ligaments, resulting in extrinsic damage to the right ureter. Patients or Participants N/A Interventions The nerve sparing laparoscopic excision systematization technique was the following: 1) Carry out the inspection of the cavity without targeting the central disease at first. 2) Mobilization of the sigmoid colon, identifying the line of separation between the mesosigmoid and the parietal peritoneum, above the paracolic gutters. 3) Exposure of the left pararectal fossa, keeping the ureter and mesoureter as the lateral limit and the rectum as the medial limit, dissecting caudally until we surpass lesion. 4) Fixation of the ovaries, exposing the posterior leaflet of the broad ligament. 5) Left ureterolysis begins at level of the promontory, with craniocaudal and lateromedial movements over the ureter, until the proximity with the posterior leaflet of the broad ligament. We then lateralize the ureter to expose the left uterosacral ligament 6) Resection of the left uterosacral ligament, keeping the ureter and hypogastric nerve lateralized - exposing the rectovaginal space. 7) Target the rectovaginal septum from lateral to medial, facilitating the identification of the mesorectum, dissected in a posterior direction. The same steps are performed in the right hemi-pelvis respecting their anatomical differences. Measurements and Main Results: The lesions were excised without complications and with minimal blood loss. Conclusion The surgical systematization proposed is a viable and reproducible technique and may offer greater damage control.