The Retroperitoneal Approach to Endometriosis

STUDY OBJECTIVE: To demonstrate principles of laparoscopic management of deeply infiltrating endometriosis requiring retroperitoneal entry. DESIGN: Step-by-step demonstration and explanation of technique using videos from patients with deeply infiltrating stage IV endometriosis who failed medical management (Canadian Task Force classification IIIB). This study was exempt from Institutional Review Board review. SETTING: Large academic medical center. INTERVENTIONS: Laparoscopic surgical excision of endometriosis requiring retroperitoneal dissection. CONCLUSION: Surgical excision of endometriosis is an essential tool for the management of symptomatic disease. Chronic inflammation may lead to distorted anatomy and limit the ability to identify pelvic landmarks, precluding the use of blunt dissection. High surgical morbidity may result from unintentional injury to the ureters or retroperitoneal pelvic vessels. Knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum, ureterolysis using blunt and sharp dissection, identification of pelvic vasculature, and judicious application of electrosurgery. With appropriate technique, the rate of intraoperative complications, including bowel, bladder, and ureteral injury as well as hematoma and bleeding, is approximately 1%. Postoperative complications, including drop in hemoglobin, urinary retention, cystitis, and abdominal wall hematoma, are usually minor, and reoperation rates are well under 1%. Thorough dissection of the retroperitoneum facilitates complete excision of endometriosis with minimum morbidity.