Complex Case of Bilateral Endometriomas and Uterine Fibroids in a Patient with Advanced Endometriosis

Study Objective: to demonstrate a step-wise approach for a complex case of bilateral endometrioma removal, endometriosis excision and uterine myomectomy in a patient with stage 4 endometriosis, to review methods for minimizing blood loss during laparoscopic myomectomy and to review different surgical tips and tricks for approaching similar complex cases. Video. Hospital Operating Room. 26yo G0 with pelvic pain and abnormal uterine bleeding who was found to have an enlarged fibroid uterus and bilateral endometriomas. Laparoscopic excision of bilateral ovarian endometriomas, myomectomy and endometriosis excision was performed. Endometrioma excision was performed first, using different surgical techniques to minimize compromise of ovarian cortex and performing a purse-string suture for hemostasis and to restore ovarian anatomy. Pexy of the ovaries was performed to optimize visualization of the pelvis. Cytotec and laparoscopic bulldog clamps were placed to minimize blood loss during myomectomy. Endometriosis excision was achieved after lysis of adhesions and identification of pelvic anatomy. When faced with a complex case, a sequential approach optimizes excision of all pelvic disease. Beginning the case with endometrioma excision and pexy of the ovaries allows for better visualization of the pelvis. The use of different techniques like preoperative cytotec administration, vascular clamps and vasopressin can help minimize blood loss.