Surgical Management of Disseminated Peritoneal Leiomyomatosis

The objective of this video is to describe a case of disseminated peritoneal leiomyomatosis (DPL) mimicking deeply infiltrating endometriosis and discuss the preoperative workup, intraoperative approach, and postoperative considerations. We also illustrate key surgical techniques to optimize safe and complete resection, including use of indocyanine green (ICG) for ureteral identification and strategic use of retractors for improved visualization and mobilization of lesions.

Tertiary care, academic center with expertise in complex gynecologic surgery.

A 48-year-old patient with a remote history of laparoscopic hysterectomy for uterine fibroids that required morcellation, although it was unknown if this was performed in a contained fashion. She presented with chronic cyclical pelvic pain, urinary urgency, and tenesmus. She was started on progestin therapy for presumed endometriosis, with incomplete symptom relief.

Pelvic MRI revealed nodular thickening of bilateral round ligament remnants, a spiculated fibrotic lesion with hemorrhagic foci involving the right ovary and terminal ileum, and a lobulated mass abutting the bladder and vaginal cuff. Laparoscopic surgical excision was planned during which leiomyomatous lesions noted at the umbilicus, vaginal cuff, bladder, and round ligament remnants. Cystoscopy-guided ureteral instillation of ICG was used to aid ureteral identification, and rectal and vaginal retractors were used to delineate anatomy.

DPL is an uncommon and often misdiagnosed condition that may mimic deep endometriosis. Recognition of its iatrogenic association highlights the importance of contained morcellation during gynecologic surgery. Preoperative imaging and intraoperative identification of critical structures, such as the ureters, bladder and rectal borders, enable safe, complete excision with low risk of recurrence. VIDEO ABSTRACT.