Temporary Uterine Artery Occlusion and Surgical Techniques for Stage 4 Endometriosis

Abstract

<h3>Study Objective</h3> To describe a surgical approach to minimize intraoperative blood loss and improve visualization for stage 4 endometriosis. <h3>Design</h3> Video presentation for surgical management of stage 4 endometriosis. <h3>Setting</h3> The procedure was performed with robot assisted laparoscopy in dorsal lithotomy position. <h3>Patients or Participants</h3> A 39-year-old patient G0 with stage 4 endometriosis and prior failed In Vitro Fertilization. <h3>Interventions</h3> In this Video we describe the surgical approach used for Stage 4 endometriosis after prior failed In Vitro Fertilization. Intraoperatively, Initial survey of the pelvis showed both small and large bowel adhesions to the posterior aspect of the uterus as well as obliteration of the cul-de-sac. We begin by opening the pelvic sidewall bilaterally, parallel and lateral to the infundibulopelvic ligament identifying the pararectal space. The ureters are identified bilaterally and are tagged with a vessel loop for easier identification and manipulation for ureterolysis. Further dissection into the pararectal space is performed to identify the uterine arteries at their origin and are temporarily ligated with vascular bulldog clamps. Ureterolysis is then performed followed by mobilization of the rectum using a lateral to medial approach towards the central pathology. The anatomy of the adnexa is then restored bilaterally and a bilateral salpingectomy was then performed due to hydrosalpinx to improve future attempts of In Vitro Fertilization. The vascular bulldog clamps are then removed at the end of the procedure. <h3>Measurements and Main Results</h3> Patient had significant improvement in pain post operatively and is pending In Vitro Fertilization. <h3>Conclusion</h3> Temporary uterine artery ligation during extensive endometriosis surgery could improve blood loss and visualization intraoperatively and can be utilized during pelvic side wall dissection and identification of critical anatomy.