Video article retrorectal endometriotic lesion involving sacral roots: Surgical technique for nerve-sparing excision and pain relief

OBJECTIVE: To present a laparoscopic nerve-sparing technique for the excision of a retrorectal fibrotic lesion involving the sacral roots (S2-S4), with additional dissection of the lumbosacral trunk based on the patient's left-sided sciatic-type pain. DESIGN: Demonstration of the surgical technique with narrated video. SETTING: Tertiary referral center specialized in advanced pelvic surgery and neuropelveology. PATIENT: A 35-year-old nulliparous woman with disabling chronic pelvic pain and left-sided sciatica-like neuralgia. Pelvic MRI demonstrated retrorectal laminar fibrosis involving the left sacral roots (S2-S4) and mesorectal fascia. INTERVENTION: Laparoscopic nerve sparing dissection of the retrorectal space was performed with identification and preservation of the hypogastric and pelvic splanchnic nerves. Because of the neuropathic symptoms, dissection was extended to expose and decompress the lumbosacral trunk and sciatic nerve. Complete excision of the fibrotic plaque was achieved, followed by rectal shaving and reinforcement suture. CONCLUSION: Symptom-guided neuropelveological surgery enables safe and effective excision of fibrotic retrorectal lesions while preserving major pelvic nerves. When clinically indicated, targeted dissection of the lumbosacral trunk improves pain control and functional outcomes in patients with neuropathic pelvic pain.