{"paper_id":"925f8766-b80b-412b-9b91-27c015a6521a","body_text":"CASE\nA 28-year-old woman presented with primary infertility and severe dysmenorrhea of 3-year duration. On examination, vitals were within normal limits, and mild pallor was present. Bimanual pelvic examination showed normal sized anteverted uterus with restricted mobility and motion tenderness. A tender nodule of approximately 2 cm × 2 cm was felt in the anterior felt. Similar Nodule felt in right lateral fornix also. Bilateral fornyceal fullness and tenderness were present. Abdominopelvic ultrasound (USG) revealed bilateral ovarian endometriomas (rounded, regular margins, homogeneous echotexture, and hypoechoic, containing diffuse areas of low echogenicity or debris; 45 mm × 23 mm in the right ovary and 22 mm × 13 mm in left ovary). Bilateral ovaries were adherent to the posterior surface of the uterus (sliding sign negative). Two endometriotic nodules (EN) were present; one in the vesico-uterine region – 21 mm × 14 mm and another in the right periovarian region – 22 mm × 17 mm.\nBased on clinical and USG findings [Figure 1], a diagnosis of severe endometriosis was made, and laparoscopic management was done. Intraoperative findings [Figure 2] were similar to the USG findings in terms of the presence, size, and location of endometriosis. Bilateral ovarian cystectomy and adhesiolysis with EN excision with ureterolysis till its insertion into the urinary bladder was done. The blunt dissection technique was followed to separate ovaries from the uterus and the ovarian fossa initially to reach the dense and completely stuck part of the adhesion, which later cleared, and ureterolysis was done with sharp dissection. Postoperative recovery period of the patient was uneventful, and she had subsequent normal menstrual cycles with a significant decrease in pain. She was free of complaints on follow-up period of 6 months and trying to conceive naturally since then.\nDISCUSSION\nEndometriosis, an ectopic endometrium-like tissue that affects women of reproductive age, is frequently accompanied by persistent pelvic pain/infertility and commonly involve fallopian tubes, uterus outer surface, ovaries, and the ligaments surrounding the uterus.[,] Various classifications, such as rASRM classification and the Enzian classification, are used in the case of endometriosis, of which the former one is currently the best known and widely used throughout the world. It is based on the organs involved and depth.[] In the present case, the rASRM score was 54, i.e. severe endometriosis (Calculated as follows: involvement: right ovary deep ~ 4 cm, left ovary deep ~ 2 cm, two ENs ~ 2 cm, i.e. 20 + 16 + 4 + 4 = 44; Adhesions: Bilateral ovaries dense up to third enclosure and bilateral fallopian tubes flimsy, i.e. 4 + 4 + 1 + 1 = 10, no involvement of pouch of Douglas).\nThe USG is routinely used in diagnosis. According to International Deep Endometriosis Analysis protocol, USG should be done by 4-step approach: (1) routine evaluation of uterus and adnexa for presence of adenomyosis and endometriomas; (2) evaluation of site-specific tenderness and ovarian mobility by transvaginal scan; (3) dynamic USG to assess pouch of Douglas with “sliding sign;” and (4) assessment of anterior and posterior compartments for the presence of DIE nodules (urinary bladder, uterosacral ligaments, vaginal vault, and bowel, including rectum, rectosigmoid junction, and sigmoid colon).[] In the present case, the same was followed to reach the diagnosis. The similarity in USG and intraoperative findings in the present case underscores the utility of USG examination in diagnosis and preoperative planning, as it is more accessible, less invasive, and has good reproducibility.[] In case of deep infiltrating endometriosis involving vital structures such as bowel, bladder, ureters, and blood vessels, magnetic resonance imaging can be done as it is highly useful, offering precise, noninvasive diagnosis and surgical planning, by mapping lesion location, depth, and extent, guiding surgeons for complete resection and potentially avoiding extra diagnostic laparoscopies.[]\nEndometrioma and nodule removal is usually the mainstay of treatment and improves fertility and overall outcome. Considering the gaining access to the pelvis and abdomen, laparoscopic route is preferred.[] The various techniques for the dissection are employed, such as blunt and sharp dissection. To release the ovaries from the uterus and ovarian fossa, blunt dissection is usually carried out. For ureters, the pararectal space is developed by dissecting between the pelvic sidewall and the posterior leaf of the broad ligament with blunt dissection, and dense adhesions or an involved area of ureters can be cleared with sharp dissection.[] In some cases of deep infiltrating endometriosis involving the rectum, bowel, and bladder, with obliteration of the pouch of Douglas or enclosure of the Fallopian tubes and ovaries by dense adhesions, radical surgery is required.[]\nWe present this case with patient’s consent. Institutional Review Board clearance is exempted as it is a single case, and consent from the patient is taken to publish the de-identified information and images.\nEthical statement\nThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.\nAuthor contributions\nAS, MW, RP, and PP managed the case and collected relevant data. AS drafted the manuscript with direction from MW, RP, and PP. AS, MW, RP, and PP critically evaluated the manuscript. All authors approved the final version of the manuscript.\nData availability statement\nData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\nFinancial support and sponsorship\nNil.\nConflicts of interest\nThere are no conflicts of interest.\nREFERENCES\n1.\nSmolarz B, Szyłło K, Romanowicz H. Endometriosis: Epidemiology, classification, pathogenesis, treatment and genetics (review of literature). Int J Mol Sci 2021;22:10554.2.\nChauhan S, More A, Chauhan V, Kathane A. Endometriosis: A review of clinical diagnosis, treatment, and pathogenesis. Cureus 2022;14:e28864.3.\nHaas D, Shebl O, Shamiyeh A, Oppelt P. The rASRM score and the Enzian classification for endometriosis: Their strengths and weaknesses. Acta Obstet Gynecol Scand 2013;92:3–7.4.\nPiessens S, Edwards A. Sonographic evaluation for endometriosis in routine pelvic ultrasound. J Minim Invasive Gynecol 2020;27:265–6.5.\nYoung SW, Jha P, Chamié L, Rodgers S, Kho RM, Horrow MM, et al. Society of radiologists in ultrasound consensus on routine pelvic US for endometriosis. Radiology 2024;311:e232191.6.\nAlonzo L, Cannella R, Gullo G, Piombo G, Cicero G, Lopez A, et al. Magnetic resonance imaging of endometriosis: The role of advanced techniques. J Clin Med 2024;13:5783.7.\nZanelotti A, Decherney AH. 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