LAUSR

Study Objective To describe the surgical techniques used to assist management of incidental stage IV endometriosis during laparoscopic hysterectomy of a large, multi-fibroid uterus. Design N/A Setting A 38-year-old G2P2 with past medical history significant for fibroids and iron-deficiency anemia and past surgical history of two cesarean sections presented to clinic requesting definitive management of heavy bleeding and pain. She had a pelvic ultrasound which demonstrated multiple uterine fibroids, with the largest having maximum dimension of 7.2cm. She also underwent an MRI, which again identified numerous uterine leiomyomata, but also demonstrated a complex left ovarian cyst measuring 5.4cm, not seen on the prior ultrasound. Patients or Participants N/A Interventions The patient was scheduled for a total laparoscopic hysterectomy with bilateral salpingectomy, possible oophorectomy. Given proper pre-operative planning, the surgery was able to be kept laparoscopic despite complete obliteration of the posterior cul-de-sac and right adnexa being completely adherent to the sidewall due to presence of endometrioma. This video shows the techniques used and identifies tips used to safely perform a laparoscopic hysterectomy in the setting of dense adhesions and incidental finding of stage IV endometriosis. Measurements and Main Results N/A Conclusion This patient was incidentally found to have stage IV endometriosis, which complicated her already challenging surgery given a multifibroid uterus and history of two intra-abdominal procedures. Pre-operative planning and careful surgical technique is essential when faced with severe adhesions.