Wise Techniques for Excision of Severe Ureteric and Rectal Endometriosis

Abstract

Video Objective To provide logical steps and demonstrate wise techniques to minimise complications during laparoscopic surgery for severe ureteric and rectal endometriosis. Setting A 40 year old para 2 (normal vaginal deliveries) with no significant past medical history, presented with 2 year history of dysmenorrhea, abdominal bloating with constipation. Her pelvic ultrasound showed a 13 cm left endometrioma. Recently, she also developed urinary frequency, urgency and nocturia, consistent with the pressure effect of her large cyst. Abdominal palpation revealed an 18 week size mass and pelvic examination demonstrated a tender fixed uterus. Her CA 125 was within normal range (21 U/ml). The diagnosis is severe endometriosis. Interventions The patient underwent laparoscopic excision of endometriosis including ovarian cystectomy. Conclusion Stage 4 endometriosis was confirmed by laparoscopy. Surgical steps and techniques to manage severe endometriosis are discussed as follow: The first step of surgery is to decompress the large ovarian cyst in order to obtain adequate space for the surgical working field. During decompression, we used an endo-loop to prevent spillage of the large endometrioma. The next step is to normalize pelvic anatomy with good dissection technique. In this case, an active bleeding point was very close to the left ureter on the pelvic side wall. Due to the risk of thermal damage to the ureter, direct surgical diathermy on the pelvic side wall without identifying the ureter should be avoided. Therefore, to achieve temporary haemostasis and gain an optimal surgical view, the assistant used a grasper to clamp the bleeding point during ureterolysis. To avoid rectal injury, the use of a rectal probe during rectovaginal adhesiolysis to delineate the rectum is a wise technique. In addition, appropriate uterine manipulation is important to delineate the uterosacral ligaments, so we have anatomical landmarks to safely excise endometriotic nodules.