LAUSR

STUDY OBJECTIVE To describe the surgical approaches and excisional techniques employed in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall. DESIGN A technical video showing the excision of advanced lateral DIE. SETTING An academic tertiary care hospital. PATIENTS A 32-year-old gravida 2, para 1 presented for definitive surgical management of endometriosis-associated pelvic pain. Intraoperative findings revealed severe retroperitoneal fibrosis tethering the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament and ureter. INTERVENTIONS Laparoscopic management of DIE involving the lateral pelvic side wall. MEASUREMENTS AND MAIN RESULTS We demonstrate the surgical methods 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 utilized a non-traditional surgical approach by tunneling under the external iliac vascular to tackle the dissection from a lateral to medial direction in order to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule. CONCLUSION Extreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical in order to overcome unexpected lateral pelvic side wall endometriosis as the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master these difficult endometriotic resections.