Excision Of Endometriosis Research Articles

A step-by-step approach to a frozen pelvis

To demonstrate a step-by-step approach for restoration of pelvic anatomy in frozen pelvis using a systematic approach to make the steps reproducible, safe, and time efficient. Video presentation. Academic medical center. A 30-year-old nulliparous woman with lifelong dysmenorrhea and 4 years of infertility who presented for the surgical management of stage IV endometriosis. An abdominopelvic survey was first in a systematic fashion to assess the extent of adhesive disease and evalaute for normal anatomy. Dissection was then started on the patient's left side to mobilize the sigmoid colon at the pelvic brim. Subsequently, the ureters were identified and bilateral ureterolysis was performed as the retroperitoneal spaces were explored. Once the ureters were safely dissected, the adnexa were mobilized bilaterally. Attention was then turned to the dissection of the medial pararectal spaces (Okabayashi's space) before the dissection of the rectovaginal space. With the restoration of anatomy, the remaining planned surgery was completed. Restoration of pelvic anatomy, excision of endometriosis, and resolution of symptoms. The patient had an uncomplicated procedure with complete excision of endometriosis and an estimated blood loss of 45 mL. She was discharged on the same day and had an uneventful postoperative period. At her follow-up appointment, she had resolution of symptoms and was initiated on medical hormone suppression therapy until ready for invitro fertilization. A frozen pelvis is a condition in which the pelvic organs are distorted and tethered to each other as a result of adhesive processes. This can obscure normal anatomical landmarks and surgical planes making dissection extremely difficult, thus increasing the risk of interoperative and postoperative complications. Although an uncommon surgical condition, it is not rare to come across in clinical practices, thus creating a challenge to reproductive surgeons as it is commonly seen with endometriosis-associated infertility. It is important for surgeons to be able to recognize the relevant anatomy and have the knowledge to open proper pelvic avascular spaces in the pelvis to mitigate these risks. Following this video's step-by-step approach can help restore pelvic anatomy for planned surgical procedures.

Laparoscopic Discoid Excision of Bowel Endometriosis Using Sutures for Closure

To demonstrate the technique of discoid excision of bowel endometriosis followed by closure of the bowel defect using sutures, without the application of the transanal stapler device. Stepwise demonstration of the technique with narrated video footage. Bowel endometriosis is a common pattern of deep endometriosis [1]. Discoid excision is 1 of the 3 surgical interventions applied to manage this pathologic entity, with shaving and segmental resection being the other 2 [2]. When discoid excision is performed, a transanal stapler device is used for bowel closure in most cases [3,4]. Only a few studies so far have reported the application of sutures for this purpose [5]. This video highlights the technique of bowel suturing after discoid excision. This video presents the technique of bowel discoid excision with the application of sutures to close the bowel defect (Supplemental Video 1). The key surgical steps are as follows: 1. Dissection of both ureters and development of pararectal spaces. 2. Recognition and preservation of the inferior hypogastric plexus and the hypogastric nerve. 3. Detachment of the nodule from the cervix. 4. Detachment of the nodule from the bowel, beginning with deep shaving and followed by discoid excision. 5. Thorough description of the bowel closure using 2 layers of Vicryl 3-0 sutures, the first being interrupted and the second continuous. The described technique of bowel closure using sutures may be a safe and effective alternative to the transanal stapler. Its advantage is that it can be performed when the pathology is located higher than 15 cm from the anal verge or the diameter of the nodule is more than 30 mm.

Diaphragmatic endometriosis: robotic approaches and techniques

To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. Endometriosis center. Patients undergoing excision of diaphragmatic endometriosis. Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. N/A. The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.

Cancer Arising from Endometriosis

Study Objective Presentation of unique case of postmenopausal patient with previous total hysterectomy, salpingo-oophorectomy and excision of endometriosis who developed cancer originating from endometriosis. Design Case report Setting Endometriosis Referral center Patients or Participants This video presents a 78-year-old G1P1 female with a history of endometriosis who presented with post-coital vaginal bleeding. She had a history of a total abdominal hysterectomy at the age of 46 due to pelvic pain, and later underwent bilateral salpingo-oophorectomy and excision of endometriosis at the age of 56 due to continued pain. She was on hormonal supplementation with transdermal estrogen. Preoperative examination and imaging revealed a 5 cm friable mass at the vaginal cuff and a smaller pelvic mass in the left pelvic sidewall. Interventions The patient underwent multi puncture video laparoscopy. The left pelvic sidewall mass near the left ureter was carefully resected and found to be endometriosis on final pathology. The vaginal cuff mass was also resected. Measurements and Main Results Pathology reported endometriosis juxtaposed with well-differentiated endometrioid adenocarcinoma. Immunohistochemical tumor staining further confirmed gynecological origin. Conclusion The relationship between endometriosis and ovarian cancer has been established, although not fully elucidated. Therefore, among patients with a history of endometriosis, continued regular gynecologic follow up is recommended not only for recurrence but also for possible malignant transformation. Presentation of unique case of postmenopausal patient with previous total hysterectomy, salpingo-oophorectomy and excision of endometriosis who developed cancer originating from endometriosis. Case report Endometriosis Referral center This video presents a 78-year-old G1P1 female with a history of endometriosis who presented with post-coital vaginal bleeding. She had a history of a total abdominal hysterectomy at the age of 46 due to pelvic pain, and later underwent bilateral salpingo-oophorectomy and excision of endometriosis at the age of 56 due to continued pain. She was on hormonal supplementation with transdermal estrogen. Preoperative examination and imaging revealed a 5 cm friable mass at the vaginal cuff and a smaller pelvic mass in the left pelvic sidewall. The patient underwent multi puncture video laparoscopy. The left pelvic sidewall mass near the left ureter was carefully resected and found to be endometriosis on final pathology. The vaginal cuff mass was also resected. Pathology reported endometriosis juxtaposed with well-differentiated endometrioid adenocarcinoma. Immunohistochemical tumor staining further confirmed gynecological origin. The relationship between endometriosis and ovarian cancer has been established, although not fully elucidated. Therefore, among patients with a history of endometriosis, continued regular gynecologic follow up is recommended not only for recurrence but also for possible malignant transformation.

8747 Excision of Endometriosis in a Postmenopausal Patient

<h3>Study Objective</h3> We seek to demonstrate endometriosis excision in a postmenopausal patient status post hysterectomy and explore the important clinical features of postmenopausal endometriosis. <h3>Design</h3> Case study. <h3>Setting</h3> Urban academic tertiary care center. <h3>Patients or Participants</h3> One postmenopausal female with history of biopsy proven endometriosis experiencing persistent pelvic pain and deep dyspareunia following prior total laparoscopic hysterectomy and endometriosis excision procedures. <h3>Interventions</h3> Exam under anesthesia, bilateral salpingo-oophorectomy, lysis of adhesions, excision of endometriosis, partial peritonectomy, and cystoscopy. <h3>Measurements and Main Results</h3> Intra-op findings included abundant filmy adhesions and focal hemorrhagic lesions, which appeared consistent with endometriosis. Pathology showed fibrous serosal adhesions and associated hemosiderin laden macrophages compatible with clinical impression of endometriosis, though classical findings of endometrial glands and stroma were absent. The patient reported near complete resolution of her prior symptoms following the surgery, without use of narcotic medication, and overall satisfaction with the procedure. <h3>Conclusion</h3> Endometriosis is an estrogen-mediated chronic inflammatory condition that is benign but has a significant impact on the quality of life of many people. Though symptoms are typically seen in premenopausal individuals, cases of postmenopausal endometriosis have also been shown and are estimated to account for roughly 1-5% of all cases. It is hypothesized that extra-ovarian estrogen production from adipose tissue or endometriosis implants may contribute to or drive these processes, but the precise mechanism and etiology is not well understood. Surgical management is particularly important for postmenopausal patients, especially those with endometriomas, given the increased association with malignancy. Here we present a case of a patient with postmenopausal endometriosis status post TLH who experienced significant symptom improvement following surgical treatment with bilateral salpingo-oophorectomy, partial peritonectomy, lysis of adhesions and excision of endometriosis lesions. More research is needed to fully understand the etiology, impact, and appropriate treatment options for postmenopausal endometriosis.

8402 Two-Port Total Laparoscopic Hysterectomy and Excision of Simple Endometriosis in a Transgender Male Patient.

<h3>Study Objective</h3> To provide an overview of a two-port total laparoscopic hysterectomy with bilateral salpingo-oophorectomy in a transgender male patient and to demonstrate the feasibility of excision of simple endometriosis by this approach. <h3>Design</h3> Surgical video. The American College of Obstetricians and Gynecologists recommends vaginal approach to hysterectomy, whenever feasible; however, in the transgender male patient, the vaginal approach to hysterectomy may pose technical challenges due to limited vaginal access: vaginal atrophy (when on testosterone therapy), lack of uterine descensus due to nulliparity that is common, and often times infrequent or no vaginal intercourse. Moreover, the frequent desire for salpingo-oophorectomy in this population can make the vaginal approach a challenging one. When patients have history of dysmenorrhea and/or pelvic pain, laparoscopy offers an adequate intrabdominal survey to diagnose and treat endometriosis, which is precluded with vaginal access alone. <h3>Setting</h3> Academic hospital with a referral-based practice for the transgender male patient who desire gender affirming surgery. <h3>Patients or Participants</h3> 35-year-old nulligravid trans male with gender dysphoria and history of severe dysmenorrhea prior to beginning testosterone therapy, who desires gender affirming surgery by hysterectomy and bilateral salpingo-oophorectomy. <h3>Interventions</h3> A 5 mm umbilical trocar is used for a 30-degree camera to maximize visualization. A 5 mm suprapubic trocar for the single operative instrument is placed above the level of the uterus fundus. Success of a two-port hysterectomy is achieved by having excellent uterine manipulation to generate appropriate counter traction on the uterus. The hysterectomy is completed in the standard fashion, and the excision of simple endometriosis is completed with a single instrument by using blunt and sharp dissection. The vaginal cuff is closed vaginally. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> A two-port laparoscopic approach avoids placement of ancillary trocars on the appropriate patient. This technique can be also used in the appropriate cis-gendered patients. Excision of simple endometriosis can be feasible with the two-port approach.

8346 Polypoid Endometriosis: A Distinct Variant

<h3>Study Objective</h3> To examine a case study of polypoid endometriosis and perform a literature review. <h3>Design</h3> Case Report. <h3>Setting</h3> Academic institution <h3>Patients or Participants</h3> 1 Patient. <h3>Interventions</h3> Surgical resection. <h3>Measurements and Main Results</h3> A 34-year-old nulliparous woman with complex adnexal masses and severe left hydronephrosis presented for consultation. Menarche occurred at 12 years-old, followed by regular monthly menses lasting 5 days. The patient reported multiple emergency room visits for severe dysmenorrhea and was taking combined hormonal contraceptives with good effect since adolescence. Of note, she had discontinued her contraceptives as she was trying to conceive. Examination revealed a non-obese female with bilateral lower abdominal tenderness to palpation. Initial labs showed elevations in CA125, HE4, and CA19-9. Imaging demonstrated a complex 7cm right adnexal mass with severe left hydronephrosis secondary to enhancing fibrosis in the left hemipelvis. This was suspicious for deep infiltrating endometriosis. The patient underwent robotic bilateral ovarian cystectomy, excision of endometriosis, right salpingectomy, left ureteral reimplantation with psoas hitch, appendectomy, and cystoscopy. Stage IV endometriosis was noted intraoperatively. Intraoperative frozen pathology was benign. Her recovery was overall uncomplicated. Final pathology was consistent with polypoid endometriosis. Follow up imaging revealed recurrence of bilateral complex adnexal masses. <h3>Conclusion</h3> Polypoid endometriosis is an uncommon, distinct variant of endometriosis with histological features suggestive of an endometrial polyp. Unlike usual-type endometriosis, which commonly affects reproductive-aged women, polypoid endometriosis primarily affects older patients with a mean age of 52.5-years-old. Patients with polypoid endometriosis often present with mass effect or vaginal bleeding. It is characterized by a tendency to mimic neoplastic processes clinically, intra-operatively, and on gross examination. Polypoid endometriosis also demonstrates a high rate of recurrence after surgical excision, as seen in our case study. Given the ability of polypoid endometriosis to mimic malignancy, intraoperative frozen pathology may prevent a more extensive surgery and excessive resection in patients of childbearing age.

7897 Bladder Injury Caused by Uterine Manipulator

<h3>Study Objective</h3> This video demonstrates identification and management of a bladder injury caused by a uterine manipulator <h3>Design</h3> Surgical video <h3>Setting</h3> Academic medical center <h3>Patients or Participants</h3> A 34-year-old G0 with endometriosis, bilateral endometriomas, and subserosal fibroids desiring fertility underwent a robotic-assisted abdominal exploration with excision of endometriosis and myomectomy. Uterine manipulator was placed at the start of the case. Exposure to the surgical field was limited by inadequate uterine manipulation, which was thought to be attributed to the significant adhesive disease. At the start of the anterior compartment dissection, it was suspected that the uterine manipulator tip may have perforated into the bladder. A 3mm perforation was confirmed on cystoscopy. <h3>Interventions</h3> A bladder flap was further developed but the defect was too caudal to be accessed in this plane. The space of Retzius was entered and intentional cystotomy was made. The bladder injury was repaired transvesically with 2 sutures of 2-0 PDS. An additional suture was placed in the vagina to close the vaginal aspect of defect. The cystotomy was closed in a traditional 2-layer fashion. <h3>Measurements and Main Results</h3> Repeat cystoscopy confirmed a watertight closure of the bladder injury and the intentional cystotomy repair. The retropubic space was reperitonealized. The patient did well post-operatively with bladder decompression with foley catheter for 10 days. Subsequent CT cystogram showed no leakage of urine. The catheter was removed after the post-op imaging and a voiding trial. <h3>Conclusion</h3> This case highlights a rare complication of uterine manipulator use. There are benefits of using uterine manipulators especially in cases of advanced endometriosis and laparoscopic hysterectomy are well known and hence used readily in minimally invasive gynecologic surgery. It is therefore important to be aware of potential complications and have knowledge of how to address them.

Nerve-Sparing Laparoscopic Segmental Bowel Resection for Deep Endometriosis: The Negrar Method

<h3>Study Objective</h3> to demonstrate a nerve-sparing technique during laparoscopic segmental bowel resection for deep endometriosis. <h3>Design</h3> A step-by-step demonstration of surgical procedure of laparoscopic segmental bowel resection. <h3>Setting</h3> In several cases, segmental bowel resection may be necessary to achieve complete removal of the disease and significantly improve the quality of life. Laparoscopic complete excision of deep-infiltrating endometriosis can seriously affect bladder, rectal, and sexual function. The goal of the nerve-sparing approach is to better identify the visceral neural fibers and surgical landmarks. <h3>Patients or Participants</h3> patients who underwent nerve-sparing laparoscopic complete excision of endometriosis with segmental bowel resection (‘‘The Negrar Method''). <h3>Interventions</h3> Our surgical nerve-sparing bowel resection technique proceeds in 5 steps: Step 1 Development of the medial pararectal space (Okabayashi's space) and development of the lateral pararectal space (Latzko's space) and isolation of the ureteral course Step 2 Opening of the presacral space, development of avascular spaces, and identification and preservation of pelvic sympathetic fibers of the inferior mesenteric plexus, superior hypogastric plexus, upper hypogastric nerves. Step 3 Development of the rectovaginal space Step 4 The previously skeletonized inferior mesenteric vessels are transected Step 5 Rectal resection and colorectal anastomosis <h3>Measurements and Main Results</h3> The Nerve-sparing technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. <h3>Conclusion</h3> This kind of surgery requires uncommon surgical skills and anatomical knowledge; we believe that it should be performed only in selected reference centers.

8740 Preparing for the Operating Room: What to Expect at Time of Surgery for Patients with History of Endometriomas

<h3>Study Objective</h3> This study aims to examine if history or presence of endometriomas is an independent risk factor for adhesive disease, longer operative time, and higher blood loss in patients undergoing endometriosis surgery. <h3>Design</h3> Our study was a retrospective chart review which reviewed the endometriosis cases of two surgeons at our institution from March 2018 to March 2021. A report was generated using CPT codes billed for the surgeries performed. 11 CPT codes were used to ensure we captured all endometriosis cases. These codes included any procedure of the ovary, fallopian tube, excision of endometriosis, or laparoscopic appendectomy. Charts were then reviewed and included in the study if endometriosis was confirmed on pathology. Comparisons were made using Wilcoxon rank sum and Chi-Squared tests. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The query resulted in 3,106 matches for the 2 surgeons using the 11 CPT codes queried with 1,120 individual surgical cases. Of these patients, 389 had endometriosis confirmed on pathology and were included in the analysis. We analyzed three outcome variables at time of surgery including presence of adhesions, case length, and blood loss in the setting of one risk factor, prior surgical or image history of endometrioma. There was a higher percentage of patients with a prior surgical or image history of endometrioma also having adhesions (76.47%), compared to those who did not (45.52%) (p<0.001). The median case length (372 min vs 221 min) and median blood loss (50cc vs 25cc) were both statistically significantly higher amongst patients with prior surgical or image history of endometrioma compared to those who did not. <h3>Conclusion</h3> Of patients undergoing surgery for endometriosis, those with endometriomas or a history of endometriomas had a higher rate of adhesions, longer case length, and greater blood loss compared to those who did not. This information will help improve surgical preparation, expectations, and counseling.

7585 A Systematic Approach to Endometriosis Lesion Mapping and Radical Excision

<h3>Study Objective</h3> To illustrate a systematic approach to laparoscopic endometriosis lesion mapping and radical wide field excision. Significant variation exists regarding the optimal approach to surgical management of endometriosis with attempts for standardization being fairly recent. We hereby contribute to these efforts by presenting our approach to radical, wide-field endometriosis excision in our institution. <h3>Design</h3> Edited surgical video demonstrating laparoscopic radical wide field endometriosis excision. <h3>Setting</h3> Academically affiliated community hospital. <h3>Patients or Participants</h3> Surgical videos of multiple surgical cases from our practice <h3>Interventions</h3> Laparoscopic radical wide field excision of endometriosiss. <h3>Measurements and Main Results</h3> As illustrated in this video, important considerations are the non-contact, mm by mm dissection along the avascular planes, use of the perirectal tissue fat as an insulator and landmark for dissection, as well as the deliberate use of rectal and vaginal probes in order to delineate anatomy and optimize dissection geometry. <h3>Conclusion</h3> With a systematic approach to radical wide field excision of endometriosis, both in high and low ASRM stage disease, via a lateral to medial approach and clockwise progression from the left pelvic brim to the left pelvic sidewall and so on, virtually all cases will be completed safely and efficiently.

Surgical Management of Endometriosis of the Bladder and Ureter

<h3>Study Objective</h3> To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy. <h3>Design</h3> Surgical video. <h3>Setting</h3> Academic tertiary referral center for endometriosis. <h3>Patients or Participants</h3> The first patient was a 38-year-old G3P3 with a history of hysterectomy presenting with dysuria had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. The second patient was a 25-year-old nulliparous woman with history of stage IV endometriosis with DIE into the bowel and both ureters causing subsequent hydronephrosis requiring bilateral ureteral stents and subsequently bilateral percutaneous nephrostomy tubes. <h3>Interventions</h3> In the first case, a cystoscopy was performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. Conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and two-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, cystoscopy was performed with injection of ICG to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had indwelling foley catheter for bladder decompression during recovery. <h3>Measurements and Main Results</h3> Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each foley catheter. Patient two had office stent removal 6 weeks postoperative. <h3>Conclusion</h3> Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.

The Fine Balance between Radical and Functionally Conservative Excision of Endometriosis

<h3>Study Objective</h3> Present 3 different cases of deep endometriosis where we attempted radical but functionally conservative excision. <h3>Design</h3> Video compilation of 3 cases. <h3>Setting</h3> University hospital. <h3>Patients or Participants</h3> We present 3 different cases of deep infiltrating endometriosis. <h3>Interventions</h3> Surgical techniques in endometriosis. <h3>Measurements and Main Results</h3> The first case includes a 37-year-old nulliparous female with advanced endometriosis involving the right dorsolateral parametrium. Vascular clips were used to temporarily clip the uterine artery while completing the dissection of endometriotic nodule tethered to the uterine artery and ureter. Clips were removed after the dissection was complete. Our second case demonstrates the principle of dissecting diaphragmatic endometriotic nodule while avoiding entry to the pericardium. Our third case demonstrates managing cecal endometriosis with partial cecectomy to preserve the ileocecal valve. <h3>Conclusion</h3> Balance between complete excision and preserve organ function in cases with advanced endometriosis should be attempted. These techniques ensure that patients have a faster post-operative recovery. Resection of endometriosis using these conservative approaches have satisfactory symptom relief while decreasing long term morbidity.

Upper Vaginectomy for Rectovaginal Endometriosis: Manual Guidance for Deep Rectovaginal Dissection

<h3>Study Objective</h3> The objective of this video is to demonstrate a robotic-assisted excision of a rectovaginal endometriosis nodule. <h3>Design</h3> This case involves a 31-year-old nulligravid patient with dysmenorrhea, dyschezia, and dyspareunia. <h3>Setting</h3> This surgery was performed at an academic tertiary care center. The patient was in the dorsal lithotomy position and the robot was docked from the patient's left side. <h3>Patients or Participants</h3> The patient had a palpable rectovaginal nodule, which was confirmed with magnetic resonance imaging. <h3>Interventions</h3> The patient underwent diagnostic laparoscopy which showed bilateral pelvic sidewall endometriosis and cul-de-sac obliteration. The ovaries and fallopian tubes were normal. Pelvic sidewall dissection with extensive peritoneal stripping was required to remove all of the endometriosis implants. Bilateral uterosacral ligaments were excised. Within the posterior cul-de-sac, the rectocervical nodule was not visible due to tethering of the rectum. The rectovaginal space was carefully dissected with monopolar scissors. Despite opening the left para-rectal space, the nodule was still not visible. An assistant placed a single digit into the posterior fornix to mobilize the nodule to guide the surgeon. The surgeon dissected the rectovaginal space until the fibrosis was visualized abdominally. Chocolate cyst fluid was expelled, consistent with deep infiltrating endometriosis. Full-thickness entry into the vagina was required, and the colpotomy was closed with running barbed suture. After complete excision of endometriosis, a flat-tire test was performed to confirm rectal integrity. The surgery was then completed. <h3>Measurements and Main Results</h3> The patient did well and was discharged home from the recovery room. She had significant improvement in her pain, and her recovery proceeded without complications. <h3>Conclusion</h3> This surgical video demonstrates the importance of careful pre-operative planning and intra-operative use of resources to accomplish complete excision of endometriosis. Surgeons often need to be creative when tissue planes are obscured, and the target pathology is not clearly visible.

Robotic Nerve Sparing Uterosacral Ligament Suspension

<h3>Study Objective</h3> To demonstrate a technique for robotic assisted nerve sparing uterosacral ligament suspension. <h3>Design</h3> Description and demonstration of a novel surgical technique. <h3>Setting</h3> Tertiary care academic center. <h3>Patients or Participants</h3> A 49-year-old woman, who presented with AUB -A, pelvic pain, and vaginal bulge, was diagnosed with stage 2 pelvic organ prolapse, adenomyosis and endometriosis. <h3>Interventions</h3> Robotic assisted hysterectomy and excision of endometriosis for treatment of her pelvic pain and AUB. Robotic approach was recommended for prolapse repair due to the other underlying conditions; however, decision was made to perform uterosacral suspension over mesh augmentation. Mobilization of the ureter and dissection of the inferior hypogastric nerve was performed. Suspension of the vaginal cuff was performed using barbed sutures. A total of 6 suspension sutures were placed incorporating the uterosacral ligaments to the anterior and posterior vaginal cuff. Obliteration of the enterocele was performed using this method. Care was taken not to include the inferior hypogastric nerve in these suspension sutures performing a nerve sparing uterosacral ligament suspension. <h3>Measurements and Main Results</h3> At 6 weeks, patient suffered no perioperative complications and had excellent apical suspension. Continued follow-up is ongoing. <h3>Conclusion</h3> Identification and avoidance of the inferior hypogastric nerve while performing uterosacral ligament suspension is a safe, feasible procedure and may prevent morbidities.

8761 Batwing Endometriosis: Radiographic Findings and Surgical Approach

<h3>Study Objective</h3> To present radiographic findings suggestive of deep infiltrating endometriosis of the uterosacral ligaments and posterior torus uterinus (referred to as batwing endometriosis) and review surgical considerations and approach to excision of disease. <h3>Design</h3> Description of imaging findings and surgical technique. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients with batwing endometriosis on preoperative pelvic magnetic resonance imaging (MRI) and concordant intraoperative findings. <h3>Interventions</h3> Preoperative pelvic MRI and laparoscopic or robotic excision of endometriosis with and without hysterectomy. <h3>Measurements and Main Results</h3> Batwing endometriosis can often be associated with an obliterated posterior cul-de-sac and present significant challenges during laparoscopy. Here we review a systematic approach to aid with restoration of this space and focus on relevant anatomy to consider. The following important steps are discussed: methods for navigating ureterolysis, ways to shave disease and preserve neurovascular and ligament support, and finally, techniques to consider with vaginal cuff closure for concurrent hysterectomy. In addition to highlighting batwing endometriosis on MRI, key pelvic structures are identified including the ureter, uterine vessels, and pararectal space which all aid in dissection. <h3>Conclusion</h3> Identification of batwing endometriosis on preoperative pelvic MRI may improve surgical planning. Knowledge of important anatomic considerations and surgical steps allows for safe and effective excision for patients with batwing endometriosis.

How to Remove Endometriosis? Removing All Peritoneum from the Pelvic Compartment: En Bloc Peritonectomy, a Demonstration of the Technique

<h3>Study Objective</h3> Demonstrate the en bloc pelvic peritonectomy technique for the treatment of all grades of endometriosis. <h3>Design</h3> Edited video of a standard procedure for complete excision of endometriosis. <h3>Setting</h3> Three-port laparoscopic surgery. <h3>Patients or Participants</h3> 28-year-old patient with 3 years of infertility, pelvic pain, and dyspareunia. <h3>Interventions</h3> A systematized surgical procedure by en bloc peritonectomy of the posterior and anterior compartment of the pelvis, for the most complete removal of endometriosis possible. <h3>Measurements and Main Results</h3> The video demonstrates that the technique is feasible and reproducible for surgeons who have a deep understanding of the anatomy and layers of the pelvis (fasciae). <h3>Conclusion</h3> En bloc peritonectomy of the pelvis appears to be an effective and safe way to completely remove endometriosis at all stages of the disease, both as an isolated technique in mild to moderate cases, as well as a step in the technique of removing intestinal disease or deeper infiltration in the lateral pelvic wall. With this technique the ideal removal of endometriosis is possible, with complete preservation of the anatomy and function of the pelvic organs.

8453 Low Anterior Resection in Stage IV Endometriosis in a Post Hysterectomy Patient

<h3>Study Objective</h3> To demonstrate technique in resection of stage IV endometriosis in a post-hysterectomy patient, including parametrial dissection, ureterolysis, rectovaginal mobilization, and low anterior resection with reanastamosis. <h3>Design</h3> A narrated surgical video. <h3>Setting</h3> An endometriosis-focused surgical practice in the private setting. <h3>Patients or Participants</h3> The patient is a 40-year-old woman with three previous laparoscopies, including hysterectomy and bilateral salpingoopherectomy. She was notably told after her most recent laparoscopy that she had no residual disease. Patient presented for consult with severe dyschezia, dyspareunia, and pelvic pain. Exam findings were concerning for severe rectovaginal endometriosis at the pelvic cuff. <h3>Interventions</h3> The patient was taken to OR for diagnostic laparoscopy, and ultimately a full excision of endometriosis was performed, including parametrectomy, ureterolysis, and low anterior colon resection with stapled reanastamosis. <h3>Measurements and Main Results</h3> 6 months postop the patient reports near complete relief of her symptoms, and substantially improved quality of life. <h3>Conclusion</h3> Low anterior resection in stage IV endometriosis may be necessary even after hysterectomy for endometriosis. A previous negative laparoscopy does not rule out high grade disease, as inexperienced physicians may under diagnose even severe disease. Hysterectomy and salpingoopherectomy does not resolve pre-existing rectovaginal endometriosis, and symptoms may persist or even worsen despite this treatment.

8442 Isthmocele Repair in Unusual Presentations

<h3>Study Objective</h3> To demonstrate unusual clinical presentations and surgical management of isthmocele. <h3>Design</h3> Surgical video. Two cases are presented of women with unusual presentations undergoing isthmocele repair. One video demonstrates a robot-assisted and hysteroscopic repair, while the other is a laparoscopic and hysteroscopic repair. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> A 30-year-old G1P1and a 33-year-old G1P1 were referred to a minimally invasive gynecologic surgeon for pelvic pain and abnormal uterine bleeding. <h3>Interventions</h3> The first patient was referred for evaluation of dysmenorrhea and dyspareunia. She had a known history of an emergent cesarean delivery. MRI demonstrated findings concerns for isthmocele. She underwent a hysteroscopy, robotic-assisted excision of endometriosis and isthmocele repair. The second patient was referred 3 months after her delivery for abnormal uterine bleeding. She presented with persistent abnormal uterine bleeding. Her cesarean was complicated by a left extension and postoperative hemorrhage leading to IR coiling of her left uterine artery and a take-back exploratory laparotomy for hemoperitoneum. MRI report described myometrial blood products continuous with the endometrial lining. She underwent a concomitant hysteroscopy and laparoscopic isthmocele repair. Given the left lateral location of her defect near the uterine insertion of the uterine artery, the left uterine artery was clipped at its origin during the surgery as a precautionary measure. The clip was later removed upon completion of the repair. During her surgery, an endometrioma was noted to overly the c-section scar defect. Both patients had full recoveries and were cleared for pregnancy 6 months after the repair. <h3>Measurements and Main Results</h3> Office hysteroscopy after both the procedures demonstrated no further appreciable defects. <h3>Conclusion</h3> Isthmocele presentations vary. Isthmoceles should remain high on a differential when working up a patient with post-partum pelvic pain and abnormal bleeding. Concomitant use of hysteroscopy during laparoscopic or robotic repair of isthmocele is recommended.

7404 Tips and Tricks for Diagnostic Laparoscopy for Endometriosis

<h3>Study Objective</h3> The objective of this video is to provide Obstetricians and Gynecologists (Ob/Gyns) with tips and tricks for effective preoperative planning, minimally invasive surgical evaluation and treatment, and postoperative management for endometriosis. <h3>Design</h3> Narrated video. <h3>Setting</h3> Endometriosis is a prevalent disease that can be effectively treated with surgical excision. It is important for all Ob/Gyns to be able to effectively evaluate for and treat endometriosis via laparoscopy. <h3>Patients or Participants</h3> Patients with endometriosis. <h3>Interventions</h3> This video describes 1) preoperative evaluation for endometriosis through history, physical exam, and imaging 2) when further preoperative evaluation is required 3) when consultation with a minimally invasive gynecologic surgeon and/or other specialists such as colorectal or urology is recommended 4) tips and tricks for effective minimally invasive surgical excision of endometriosis 5) postoperative management of endometriosis. <h3>Measurements and Main Results</h3> This video can serve as a resource for Ob/Gyns to effectively evaluate for and treat endometriosis. <h3>Conclusion</h3> Endometriosis is a prevalent and debilitating disease that all Ob/Gyn's will encounter in practice. It is imperative that Ob/Gyns are able to effectively surgically evaluate for and treat endometriosis.