Study Objective The objective of this study was to describe an approach to deep endometriosis in the frozen pelvis. Given it's high complexity, these cases must be thoroughly studied by every pelvic surgeon. Design Video description of tips and tricks to navigate through the frozen pelvis. Setting N/A. Patients or Participants The surgery was performed in a 20 years oldwoman who suffered from extensive retrocervical endometriotic lesions with obliteration of the pouch of Douglas. She presented with dysmenorrhea, dyspareunia, dyschezia and tenesmus. Her diagnosis was made through physical examination, ultrasound and MRI. She had an endometrioma in her left ovary and a lesion on the intestinal wall with 1.6 cm of infiltration and 3.5cm of extension, totaling 32% of the intestinal loop diameter. Interventions We start the surgery through the development of the avascular anatomical spaces. To loosen the intestinal lesion of the uterine wall, we traction the rectum centrally and posteriorly, and dissect towards the rectovaginal septum, passing the lesion area. In cases of endometriosis with extension to the ovarian pit, we like to remove the posterior leaflet of the broad ligament in conjunction with the uterosacral ligament while the assistant surgeon keeps the ureter and hypogastric nerve apart. Finally, after circumventing all the lesion and preserving the pelvic innervation, the excess fibrotic process must be resected by shaving the intestinal wall to reduce the lesion size and allow the discoid resection. Measurements and Main Results We conclude that the surgical technique in complex frozen pelvis cases must be flawless. Usually, the anatomy is very distorted and is more demanding to the surgeon. Thus, the correct use of energy devices and the help of the surgical assistant is key for successful outcome. Conclusion In summary, describe useful tips and tricks that equip the surgeon to navigate through the complex anatomy of a frozen pelvis. The objective of this study was to describe an approach to deep endometriosis in the frozen pelvis. Given it's high complexity, these cases must be thoroughly studied by every pelvic surgeon. Video description of tips and tricks to navigate through the frozen pelvis. N/A. The surgery was performed in a 20 years oldwoman who suffered from extensive retrocervical endometriotic lesions with obliteration of the pouch of Douglas. She presented with dysmenorrhea, dyspareunia, dyschezia and tenesmus. Her diagnosis was made through physical examination, ultrasound and MRI. She had an endometrioma in her left ovary and a lesion on the intestinal wall with 1.6 cm of infiltration and 3.5cm of extension, totaling 32% of the intestinal loop diameter. We start the surgery through the development of the avascular anatomical spaces. To loosen the intestinal lesion of the uterine wall, we traction the rectum centrally and posteriorly, and dissect towards the rectovaginal septum, passing the lesion area. In cases of endometriosis with extension to the ovarian pit, we like to remove the posterior leaflet of the broad ligament in conjunction with the uterosacral ligament while the assistant surgeon keeps the ureter and hypogastric nerve apart. Finally, after circumventing all the lesion and preserving the pelvic innervation, the excess fibrotic process must be resected by shaving the intestinal wall to reduce the lesion size and allow the discoid resection. We conclude that the surgical technique in complex frozen pelvis cases must be flawless. Usually, the anatomy is very distorted and is more demanding to the surgeon. Thus, the correct use of energy devices and the help of the surgical assistant is key for successful outcome. In summary, describe useful tips and tricks that equip the surgeon to navigate through the complex anatomy of a frozen pelvis.
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