Department of Gynecology and Obstetrics, Aarhus University Hospital (Dr. Roman), Aarhus, Denmark, and IFEMEndo, Clinique Tivoli-Ducos, (all authors), Bordeaux, France.
Department of Gynecology and Obstetrics, Aarhus University Hospital (Dr. Roman), Aarhus, Denmark, and IFEMEndo, Clinique Tivoli-Ducos, (all authors), Bordeaux, France.
J Minim Invasive Gynecol. 2023 May;30(5):357-358. doi: 10.1016/j.jmig.2023.02.003. Epub 2023 Feb 9.
Deep endometriotic lesions may involve the deep parametrium, which is highly vascular and includes numerous somatic and autonomous nerves [1,2]. Surgeons who dissect in this area must always be prepared to deal with major bleeding and to master the different techniques of hemostasis. The goal of this video is to show the steps of laparoscopic excision of deep endometriotic lesion of the parametrium and the steps taken to control the bleeding encountered from one of the venous branches.
Surgical educational video.
Endometriosis referral center.
Excision of the endometriotic parametrial nodule and the release of the sacral plexus, with excision of the vaginal involvement, rectal disc excision, and segmental resection of the sigmoid colon. The video shows the excision of a deep endometriosis involving the right parametrium, mid rectum, sigmoid colon, and vagina. The excision of deep endometriosis of the parametrium followed the 10 steps previously described [1]. During this procedure, careful dissection of arteries and veins branching from the internal iliac vessels is a crucial step. However, injury of one or more of the vessels can still occur. The video presents the different techniques used to control the bleeding from a venous injury faced during the dissection around the nodule in the parametrium, including energy use, clips, hem-o-loks, and direct continuous pressure. Of note, hemostatic agents are available; however, we have not yet successfully used them in the circumstances in which large veins were injured. The ultimate solution in our case was the clamping of the injured vessels, allowing meticulous dissection and sectioning of all the feeding vessels, while taking care not to injure the sacral roots that were just beneath these veins. Total operative time was 4 hours.
Surgery of deep endometriosis involving the sacral plexus may be successfully done laparoscopically. Thorough knowledge of the deep pelvis anatomy is mandatory, and the surgeon should master various techniques of hemostasis, particularly on deep veins.
深部子宫内膜异位病灶可能累及深部子宫旁组织，该区域血管丰富，包含众多躯体和自主神经[1,2]。在此解剖区域进行手术的医生必须时刻准备处理大出血，并掌握不同的止血技术。本视频旨在展示腹腔镜下切除深部子宫旁子宫内膜异位症病灶的步骤，以及处理其中一条静脉分支出血时所采取的措施。
手术教学视频。
子宫内膜异位症转诊中心。
切除子宫内膜异位症子宫旁结节，并松解骶丛，同时切除阴道受累部位、直肠盘状突出、乙状结肠节段性切除。本视频展示了一例累及右侧子宫旁、直肠中段、乙状结肠和阴道深部子宫内膜异位症的切除过程。深部子宫旁子宫内膜异位症的切除遵循了先前描述的 10 个步骤[1]。在此过程中，仔细解剖发自髂内动脉的动脉和静脉分支是至关重要的一步。然而，仍有可能损伤一条或多条血管。视频介绍了在子宫旁结节周围解剖过程中处理静脉损伤出血时使用的不同技术，包括能量器械、夹子、Hem-o-loks 和直接持续压迫。值得注意的是，有止血剂可用；然而，我们尚未成功将其用于已损伤大静脉的情况下。在我们的病例中，最终的解决方案是夹闭损伤的血管，以便在小心解剖和切断所有供血血管的同时，注意不要损伤刚好位于这些静脉下方的骶神经根。总手术时间为 4 小时。
腹腔镜下处理累及骶丛的深部子宫内膜异位症是可行的。深入了解深部盆腔解剖结构是必需的，外科医生应掌握各种止血技术，尤其是深部静脉的止血技术。
