Deep infiltrating endometriosis: Laparoscopic nerve-sparing surgery and use of neutral argon plasma

OBJECTIVE: To present a minimally approach to the management of deep pelvic endometriosis by nerve-sparing surgery and use of neutral argon plasma for extensive endometriotic lesions. DESIGN: This is a clinical case video of a 29 years-old patient, affected by deep pelvic endometriosis with primary dysmenorrhea, deep dyspareunia, chronic pelvic pain and dyschezia. Pelvic MRI shows a right ovarian endometrioma measuring 5 cm, a thickening of the right uterosacral ligament and a uterine torus nodule. SETTING: Laparoscopy video. INTERVENTION: This laparoscopic surgery begins by an adhesiolysis of the sigmoid and a blue tube test to check the correct permeability of the tubes. A bilateral ureterolysis is performed before the excision of a torus lesion and adhesiolysis of the rectovaginal septum. A fine dissection of the uterosacral ligament by nerve-sparing surgery is realized to respect the hypogastric nerve in the Okabayashi space. Endometriosis nodules of the lumbo-ovarian ligaments and multiples endometriosis peritoneal implants, inaccessible to a complete excision, are destroyed by argon plasma vaporization. A cystectomy of the right endometrioma and an appendectomy are performed at the end. CONCLUSION: The surgical management of deep infiltrating endometriosis is complex, with the recent contribution of new technical procedures such as nerve-sparing surgery to reduce postoperative urinary complications, or argon plasma for ablation of extended peritoneal implants or endometrioma to preserve ovarian function.