Management of a Large Endometriotic Nodule of the Right Parametrium Involving the Sacral Roots, Vagina, Rectum, and Sigmoid Colon, with Intraoperative Bleeding.

STUDY OBJECTIVE

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.

DESIGN

Surgical educational video.

SETTING

Endometriosis referral center.

INTERVENTIONS

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.

CONCLUSION

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.