{"paper_id":"f2bcfa92-84fa-4c6e-9af0-c679faaca9c9","body_text":"The aim of the study was to demonstrate how to identify and preserve the inferior hypogastric nerve (IHN) during gynecological laparoscopic surgeries, in cases where the nerve is not infiltrated by pathological processes such as deep endometriosis. The IHN is liable to injury during gynecological surgery, which may lead to vaginal and cervical hypoesthesia, diminished vaginal lubrication, urinary retention, or anorectal dysfunction.[ 1 ]\n\nNarrated surgical  video . Institutional Board Review approval is not required, patient consent was obtained.\n\nA 40-year-old patient with chronic pelvic pain. Imaging suggested the presence of a 4-cm right ovarian hemorrhagic cyst. No evidence of deep endometriosis was detected on imaging or laparoscopy. Excision of the Douglas pouch peritoneum histologically confirmed the presence of superficial endometriosis.\n\nLaparoscopic removal of ovarian cyst (not demonstrated) and excision of Douglas pouch peritoneum.\n\nRoutine 4-port laparoscopy was performed. We focus on the patient’s left side: Initially, a superficial incision is made on the peritoneum, at the level of the ureter crossing the left common iliac vessels. Using blunt and sharp dissection, the ureter is mobilized carefully, with its vascular supply intact, and pushed laterally, off of the posterior leaf of the broad ligament.\nThe IHN derives from the superior hypogastric plexus and is located 2 cm below and parallel to the ureter, in the meso-ureter, and 2 cm superior and parallel to the uterosacral ligament.[ 2 3 ] To identify and preserve its fibers, following ureterolysis, the peritoneum is lifted at the level of the pelvic brim and dissection continued superficially, and caudally, until the fibers of the IHN are visualized [ Figure 1 ]. In cases of peritonectomy for superficial peritoneal endometriosis, the nerve can be fully visualized and kept intact, by gently pushing its fibers off the affected peritoneum that will, subsequently, be excised. Having lateralized the IHN, blunt dissection is continued medially to the nerve, until the left uterosacral ligament is identified medially to it. Should the ligament also need to be excised, it can be done safely with minimal risk of injuring the nerve.\nFibers of the left inferior hypogastric nerve (green) in relation to the left ureter (yellow) and the posterior peritoneal leaf of the broad ligament (pale blue).\nhttp://www.apagemit.com/page/video/show.aspx?num=1393&kind=2&page=1\nThe total operative time (excision of Douglas pouch peritoneum and right ovarian cystectomy) was 65 min and the estimated blood loss was 20 mL. The patient was discharged home on postoperative day 1 and made an uneventful recovery. At the 3-month follow-up, she was pain-free, with negative imaging.\n\nIdentification and preservation of the IHN are feasible and reproducible by following the surgical steps described here.\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 their identity, but anonymity cannot be guaranteed.\nConceptualization, GG; Methodology, Software, Validation, AD; Formal Analysis, Investigation, Resources, Data Curation, GG; Writing – Original Draft Preparation, GG, MA, AP; Writing – Review and Editing, GG, AD; Visualization, GG; Supervision, AD; Project Administration, Funding Acquisition. All authors have read and agreed to the final version of the manuscript.\nData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\nThere are no conflicts of interest.","source_license":"CC0","license_restricted":false}