Damage Control in Frozen Pelvis: Advanced Endometriosis Surgery With Deep Parametrial Disease and Double Circular Rectal Resection

Show the possibility of nerve maintenance in cases of deep parametrial endometriosis and the feasibility of performing extensive nodulectomy with the double stapling technique. Step by step technique video. Baía Sul Hospital – Brazil. A 39-year-old woman with infertility and chronic pelvic pain. Ultrasound revealed extensive thickening affecting the torus, uterosacral ligaments, and bilateral ovarian fossae, approximately 3.5 cm x 1.5 cm. Retraction of the rectal wall, with two areas: the first lesion 8 cm from the anal verge, 1.4 cm x 0.4 cm, 10% diameter, the second 1.3 cm from the first lesion, 4.0 cm x 0.7 cm until the submucosa, 35% circumference. Together, representing 7 cm. Extension to the right lateral compartment, infiltrating the posterior leaflet of the broad ligament near the uterine vessels, causing ureteral angulation. First release of the left colon, exposure of the left hypogastric nerve and ureter. On the right, the peritoneum was transversely opened at the promontory level for the release of the right ureter and hypogastric nerve. To remove right parametrial disease, the right uterine artery section was required. Aggressive shaving of the rectal lesion, leaving a 4.0 cm nodular area - release of the mesorectum from the sides of the loop, the passage of the Z-point, covering the lesion from proximal to distal. The first disc stapling was performed with partial removal of the lesion. A second staple was chosen, where the Z-point covers the previously stapled area and the remaining lesion. Rubber test, over-suturing, and fluorescence evaluation. Two bowel segments, 3.5 × 3cm and 5.5 × 2.7cm – muscularis propria up to the submucosa endometriosis. Free margins. Nerve sparing is feasible in lateral compartment treatment with functional preservation. The double circular stapling technique allows the removal of extensive nodular lesions safely.