The Optimal Surgical Approach for Deep Infiltrating Endometriosis Involving Pelvic Nerves (type 1 and 2)

OBJECTIVE: Excision of deep infiltrating endometriosis in the parametrium involving pelvic nerves can be challenging and requires good anatomical knowledge and surgical strategy [1]. Based on our experience, we have identified two important types of nodule in this compartment, differing in location and the pelvic structures involved, and therefore propose this new classification. This video aims to show a standardized, reproducible method for each type. SETTING: The surgeries were performed with the DaVinci Xi system at the IFEMEndo center in Bordeaux, France. Illustrations were produced with Blender and After Effects. PARTICIPANTS: The patients gave consent for publication of the video. The study was approved by the local ethics committee. INTERVENTIONS: Type 1 nodules are situated medially at the origin of the uterosacral ligaments, with surrounding structures including the ureter, rectum, and sacral roots. These nodules require a medial pelvic approach, starting with ureterolysis and dissection of the rectum and rectovaginal septum if needed. After identifying the hypogastric nerve, the internal iliac vessels are dissected and ligated when necessary. Caudally, the sacral roots and the inferior hypogastric plexus are then located and must be preserved as much as possible during the resection of the nodule. Type 2 lesions are found laterally on the pelvic sidewall. The approach begins laterally from the external iliac vessels and proceeds into the lumbosacral space. Identification of the obturator nerve and vessels is followed by further dissection towards the lumbosacral trunk and sciatic nerve. On the anterior side of the nodule, we may encounter the bladder. The lesion is then progressively removed from the sacral roots, sacrospinous ligament, pudendal nerve, and pelvic sidewall. CONCLUSIONS: According to our experience, deep infiltrating endometriosis of the parametrium involving the sacral root or lumbosacral trunk and sciatic nerve are two distinct types. A systematic approach helps minimize the risk of inadvertent injury to critical pelvic structures. VIDEO ABSTRACT.