Laparoscopic Resection Technique of Sacral Roots Endometriosis

Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Conclusion: Transmural rectal endometriotic nodules less than 3cm in size may be amenable to resection with primary repair in select patients. Preoperative bowel prep is not recommended. After closure, checking for an airtight closure and adequate lumen caliber is essential. Open Communications 22: Endometriosis (3:05 PM − 4:05 PM) 3:26 PM Surgical Pelvic Neuroanatomy: An Overview of Commonly Encountered Nerves in Benign Gynecologic Surgeries and Safe Dissection Techniques Wu CZ,1,* Urbina P,2 Klebanoff J,3 Moawad G4. 1Minimally Invasive Gynecologic Surgery, George Washington University Hospital, Washington DC, DC; 2Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC; 3George Washington University, Washington, DC; 4 MIGS, George Washington University Hospital, Washington, DC *Corresponding author. Video Objective: A thorough understanding of the natural course and functions of the nerves in the pelvis is critical in complex benign gynecological surgery to avoid injury and morbidity to the patient. This video reviews how to locate and safely dissect common nerves found in the pelvis that may be encountered in complex gynecological cases. Setting: Multiple patients at a large academic center with a robust team of minimally invasive gynecologic surgeons. Many patients have extensive adhesions or severe endometriosis. Interventions: Multiple nerves, such as the superior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves, sacral nerve roots, and the genitofemoral nerves, are dissected out during the course of the surgery. Simple surgical techniques, such as traction-countertraction and blunt dissection are employed. Conclusion: In complex gynecologic surgeries, the disease process may require extensive dissections in to the retroperitoneal spaces, where critical pelvic nerves are at risk for injury. With increased knowledge of the natural course of the nerves as well as having an array of dissection techniques, the surgeon can decrease the risk of inadvertent nerve injury and patient morbidity. If the disease is severely involved in areas where fragile nerves are, consideration needs to be given for a nerve preservation.

Open Communications 22: Endometriosis (3:05 PM − 4:05 PM)

S81 Open Communications 22: Endometriosis (3:05 PM − 4:05 PM) 3:40 PM 2 Methods for Identification and Preservation of Hypogastric Nerve During Laparoscopic Die (Deep Infiltrating Endometriosis) Surgery Sun CH*. OB/GYN, Lucina Women & Children Hospital, Kaohsiung City, Taiwan *Corresponding author. Video Objective: In this video, we are going to introduce two methods for proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery. Setting: Single institute, single surgical team’s experience. Interventions: USL is the mostly frequently involved area of pelvic endometriosis. Hypogastric nerves just lie between USL and pelvic ureter, locate in the Okabayashi pararectal space. They are frequently involved (either direct infiltration, or just encasement by surrounding tissue fibrosis) by the DIE lesions. En-bloc excision of USL DIE lesions frequently result in inadvertent hypogastric nerve injury, or even pelvic plexus injury. Proper identification and preservation of the hypogastric nerves is mandatory during nerve-sparing DIE surgery. We develop two methods to identify the hypogastric nerve within the USL DIE complex. (1) “Contralateral nerve traction test”: If we can clearly identify and isolate the hypogastric nerve on the more healthy side, by gentle pulling on this side hypogastric nerve, we can see the contralateral hypogastric nerve move on the other side. Thus we can have a good mapping of the course of hypogastric nerve within the DIE complex. (2) “Antegrade tracing from pre-sacral region”: If we move upward to the pre-sacral region, starting dissection from the virgin site, proximal part of hypogastric nerve can be easily identified. Antegrade tracing along the hypogastric nerve, un-roofing and bi-half the overlying DIE USL tissue, the whole course of hypogastric nerve can be safely traced and the nerve can be well-preserved. Conclusion: Proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery is important. By this two simple methods and concepts (“contralateral nerve tract test” and “antegrade tracing”), we can minimize the risk of inadvertent nerve injury. Open Communications 22: Endometriosis (3:05 PM − 4:05 PM) 3:47 PM

3:33 PM Laparoscopic Resection Technique of Sacral Roots Endometriosis In
acio W Jr*. Gynecology, S~ ao Luis Hospital, S~ ao Paulo, Brazil *Corresponding author. Video Objective: To describe a surgical procedure, performed to completely resect an endometrioc lesion that tackles s2 sacral root. Setting: A 34 years old patient, previously submitted to surgery for deep endometriosis, with recurrence, that led to a strong intensity burning pain, on the right medial buttock during the menstruation time, with no irradiation, alteration of motor function or bowel and urinary habits. Interventions: It was performed laparoscopic surgery for the complete resection of the endometriotic lesion. Conclusion: The complete resection of the endometriosis lesions of sacral nerves, through the appropriate technique, performed by an experienced surgeon, leads to the cure of the symptoms and preserves the nerve fuction.

Ureterolysis, Vasolysis and Neurolysis: The Trifecta in Deep Infiltrating Endometriosis Peters A,1,* Rindos NB,2 Lee TT3. 1OB/GYN and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA; 2Minimally Invasive Surgery, University of Pittsburgh Medical Center, Magee Womens Hospital, Pittsburgh, PA; 3UPMC, Pittsburgh *Corresponding author. Video Objective: To describe the surgical approaches and techniques employed in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall. Setting: A 32-year-old gravida 2, para 1 presented for definitive surgical management of pelvic pain due to endometriosis at an academic tertiary care center. Intraoperatively, severe retroperitoneal fibrosis tethered the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament and ureter together. Interventions: We demonstrate the surgical method and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we tunneled