Deep infiltrating endometriosis: Laparoscopic nerve-sparing surgery and use of neutral argon plasma

To present a minimally approach to the management of deep pelvic endometriosis by nerve-sparing surgery and use of neutral argon plasma for extensive endometriotic lesions.

This is a clinical case video of a 29 years-old patient, affected by deep pelvic endometriosis with primary dysmenorrhea, deep dyspareunia, chronic pelvic pain and dyschezia. Pelvic MRI shows a right ovarian endometrioma measuring 5 cm, a thickening of the right uterosacral ligament and a uterine torus nodule.

Laparoscopy video.

This laparoscopic surgery begins by an adhesiolysis of the sigmoid and a blue tube test to check the correct permeability of the tubes. A bilateral ureterolysis is performed before the excision of a torus lesion and adhesiolysis of the rectovaginal septum. A fine dissection of the uterosacral ligament by nerve-sparing surgery is realized to respect the hypogastric nerve in the Okabayashi space. Endometriosis nodules of the lumbo-ovarian ligaments and multiples endometriosis peritoneal implants, inaccessible to a complete excision, are destroyed by argon plasma vaporization. A cystectomy of the right endometrioma and an appendectomy are performed at the end.

The surgical management of deep infiltrating endometriosis is complex, with the recent contribution of new technical procedures such as nerve-sparing surgery to reduce postoperative urinary complications, or argon plasma for ablation of extended peritoneal implants or endometrioma to preserve ovarian function.