basecamp

Endometriosis basecamp

Hysteroscopy basecamp

Wrist basecamp

Colorectal basecamp

Hernia basecamp

surgical intervention video

Laparoscopic Nissen fundoplication: a perfect case to start

Fundoplicatura de Nissen Laparoscópico para RGE

Fundoplicatura de Nissen laparoscópica: um caso perfeito para começar


腹腔镜尼森胃底折叠术：一个完美的开始


Fundoplicature de Nissen laparoscopique : un cas idéal pour commencer


LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic right hemicolectomy for stenosing caecal cancer 

LIVE хирургия: лапароскопическая гемиколэктомия по поводу стенозирующеяго рака слепой кишки

CIRURGIA INTERATIVA AO VIVO: demonstração totalmente abrangente de uma hemicolectomia direita laparoscópica para câncer de ceco estenosante

CHIRURGIE INTERACTIVE LIVE : hémicolectomie droite laparoscopique pour cancer caecal sténosant

Total laparoscopic hysterectomy: stepwise approach

Hystérectomie laparoscopique totale : approche par étapes

Laparoscopic resolution of an incarcerated Spigelian hernia and simultaneous multiple inguinal wall defects

Prise en charge laparoscopique d'une hernie de Spiegel étranglée et de la présence simultanée de multiples défects de la paroi inguinale

Prise en charge laparoscopique d'une hernie de Spiegel

Low Spiegel's hernia, laparoscopic resolution

Cure de hernie inguinale (technique TAPP) pour hernie fémorale étranglée avec entérectomie et anastomose primaire

Inguinal TAPP repair for strangulated femoral hernia with enterectomy and primary anastomosis

Live interactive surgery: laparoscopic TAPP approach for left inguinal hernia 

Laparoscopic Whipple procedure for the management of a pancreatic head tumor

Intervention de Whipple par voie d'abord laparoscopique pour prise en charge d'une tumeur de la tête du pancréas

video lecture

Ten golden rules for minimally invasive (MIS) groin hernia repair

Cure de hernie inguinale par voie d'abord laparoscopique : technique TAPP

Laparoscopic groin hernia repair: TAPP procedure

Œsophagectomie robotique transthoracique

Transthoracic robotic esophagectomy

Gastrectomie totale laparoscopique avec curage ganglionnaire D2 et dérivation gastrique Roux-en-Y pour le traitement d'un adénocarcinome gastrique peu différencié

Totally laparoscopic gastrectomy with D2 lymphadenectomy and intracorporeal Roux-en-Y esophagojejunostomy for a poorly differentiated adenocarcinoma of the gastric body

Lymphadénectomie pour cancer de l’œsophage

Lymphadenectomy in esophageal cancer

Salvage endoscopic submucosal dissection (ESD)

Minimally invasive Ivor Lewis esophagectomy for caustic esophageal stricture: a stepwise approach

Œsophagectomie mini-invasive (opération d'Ivor et Lewis) pour rétrécissement caustique de l'œsophage : approche par étapes

Dissection sous-muqueuse endoscopique périanale étendue au bas rectum pour traitement de la néoplasie intraépithéliale anale de type 3

Perianal extended to the lower rectum endoscopic submucosal dissection (ESD) for the treatment of anal intraepithelial neoplasia grade III

Endoscopic repermeabilization of a common bile duct (CBD) transection after laparoscopic cholecystectomy

Reperméabilisation endoscopique d'une transection de la voie biliaire principale après cholécystectomie laparoscopique

Échographie pancréatique par laparoscopie : instructions de base

Laparoscopic pancreatic ultrasound: basic instructionals

Severe acute pancreatitis: lessons learned

Pancréatite aiguë sévère : leçons à en tirer

Cure de hernies incisionnelles W3 avec toxine botulique par approche extrapéritonéale totale étendue ventrale (eTEP)

Resolution of W3 incisional hernias with botulinum toxin using ventral extended totally extraperitoneal approach (eTEP)

monthly focus

Spigelian hernias occur through the Spigelian fascia, which consists of the aponeurotic layer located between the rectus muscle medially and the lateral semilunar line laterally. The absence of the posterior fascia of the rectus muscle may contribute to the inherent weakness of this area. It is more common in women and typically affects middle-aged to elderly patients. Spigelian hernias should be repaired due to the risk of incarceration associated with their narrow neck. Surgical repair can be performed using laparoscopic techniques, offering advantages such as a faster recovery and a lower rate of complications as compared to conventional surgery.

Bibliography:

1\. Rupit Serrano, M. de J., Jaime Limón, Á. R., Palacio Vélez, F. (2017). Obstrucción intestinal secundaria a hernia de Spiegel estrangulada con contenido de íleon terminal, apéndice cecal, ciego y colon ascendente. Reporte de un caso \[Strangulated spigelian hernia with contents of the terminal ileum, cecal appendix, cecum and ascending colon. Report of a case]. Cirujano General, 39(3). ISSN 1405-0099.

2\. Faber Machado, Carlos Calle, Federico Lopez. Hernia de Spiegel como causa de obstrucción intestinal de íleon en una paciente anticoagulada por fibrilación auricular, abordaje laparoscópico. Reporte de caso Revista de Hernias y Heridas, 10.20960/rhh.184. Sociedad hispanoamericana de hernia.

Déchirure de la gaine postérieure après approche extrapéritonéale totale à vue améliorée (eTEP) : résolution laparoscopique et recommandations 

Small bowel occlusion (SBO) following repair of hernia and diastasis through a laparoscopic enhanced-view totally extraperitoneal  (eTEP) approach is a rare condition, with an incidence of 3%. It typically occurs due to excessive tension in the closure of the posterior sheath during the immediate postoperative period.

Bibliography:

1\. Gadea Mateo, R., Martí Cuñat, E., & Pou Santonja, G. (2021). Obstrucción intestinal tras hernioplastia totalmente extraperitoneal por hernia inguinal bilateral: una infrecuente complicación en el posoperatorio inmediato \[Intestinal obstruction after totally extraperitoneal bilateral inguinal hernia repair: an infrequent complication in the early postoperative period. Sociedad hispanoamericana de hernia. Https://hernia.grupo aran.com

2\. Shpitz B, Lansberg L, Bugayev N, Tiomkin V, Klein E. Should peritoneal tears be routinely closed during laparoscopic total extraperitoneal repair of inguinal hernias? a reappraisal. Surg Endosc Other Interv Tech. 2004;18(12):1771-3. DOI: 10.1007/s00464-004- 9001-z

Tear of the posterior sheath after enhanced-view totally extraperitoneal (eTEP) approach: laparoscopic resolution and recommendations 

Spiegel’s hernias (SpH) are an uncommon type of primary ventral hernias (PVHs), representing 0.1 to 2% of all ventral hernias (1). Patients with SpH may either be asymptomatic or present with a tumor in the lower middle abdomen, lateral to the rectus muscle, at the level of the so-called “SpH belt”, an area located between the anterior rectus maximus muscle medially and the semilunar line laterally, and between the umbilicus and the interspinous plane (2). Low SpHs are rare and must be differentiated from direct inguinal or supravesical hernias (3). They are located caudally to the inferior epigastric artery within Hesselbach’s triangle, close to the inguinal region. A finding of 8% of low SpHs has been reported in a series of inguinal hernia repairs (4).

This video has the following learning objectives: to recognize low Spiegel’s hernias (SpHs) as a differential diagnosis of inguinal hernia, to interpret CT-scan findings for the recognition of low SpHs, and to expose the main gestures used in the laparoscopic surgical approach to low SpHs.

Bibliography:

1\. Francesco A Polistina, Greta Garbo, Paolo Trevisan, Mauro Frego. Twelve years of experience treating Spigelian hernia. Surgery 2015 Mar;157(3):547-50. doi: 10.1016/j.surg.2014.09.027. Epub 2015 Feb 3. PMID: 25656692 DOI: 10.1016/j.surg.2014.09.027

2\. L Spangen. Spigelian hernia. World J Surg 1989 Sep-Oct;13(5):573-80. doi: 10.1007/BF01658873. PMID: 2683401 DOI: 10.1007/BF01658873

3\. Hannu Paajanen, Seppo Ojala, Antti Virkkunen. Incidence of occult inguinal and Spigelian hernias during laparoscopy of other reasons. Surgery 2006 Jul;140(1):9-12; discussion 12-3. doi: 10.1016/j.surg.2006.01.005. PMID: 16857436 DOI: 10.1016/j.surg.2006.01.005

4\. S Klimopoulos, C Kounoudes, A Validakis, G Galanis. Low spigelian hernias: experience of 26 consecutive cases in 24 patients. Eur J Surg 2001 Aug;167(8):631-3. doi: 10.1080/110241501753171272. PMID: 11716453 DOI: 10.1080/110241501753171272

Clinical case presentation:

This is the case of an obese 66-year-old female patient, chronic smoker, with a BMI of 34.7. Her medical history included diabetes mellitus type 2. In 2022, she was diagnosed with a large and reducible M3W2 primary ventral hernia associated with diastasis recti, 36mm at epigastric and 68mm at supraumbilical level, respectively. She presented at the emergency department with a 24-hour history of an umbilical painful and irreducible lump associated with nausea.

Diagnostic work-up:

Her serum chemistries showed 14.400 leukocytes /L, 65% of prothrombin time, and 190.85mg/dL of C-reactive protein. Abdominal X-ray did not show any abnormalities. Abdominal ultrasound showed a large umbilical sac, which contained the greater omentum with signs of suffering. There was no anesthetic contraindication for an emergent endoscopic surgery.

Treatment strategy:

An umbilical hernioplasty and diastasis recti correction were performed using the eTEP Rives-Stoppa (RS) technique. A 2/0 absorbable barbed suture was used to close the defect and correct the diastasis recti. A macroporous polypropylene mesh was implanted without fixation, which entirely covered the dissected area and not just the hernia area. No drains were used.

Patient outcomes:

The patient had an uneventful hospital stay and was discharged 36 hours after surgery. An umbilical subcutaneous seroma, M3-type IV, according to the Morales-Conde classification, developed at the second postoperative week and required puncture and aspiration in order to be resolved successfully. There was no evidence of recurrence neither clinically nor radiologically at 18 months of follow-up.

Conclusion:

There is a lack of scientific evidence about the use of the eTEP RS technique in the emergent treatment of complicated ventral hernia. The eTEP RS approach to this type of hernia is a promising abdominal wall reconstruction procedure. The procedure is reproducible and safe, with short hospital stay and low morbidity in the short and middle term.

Bibliography:

1\. Sholapur S, Shaikh A, C G A, Tandur A, Padekar HD, Bhandarwar A, Jagdale S. Intraperitoneal Onlay Mesh (IPOM Plus) Repair Versus Extended-View Totally Extraperitoneal Rives-Stoppa (eTEP-RS) Repair in Primary Ventral Hernias: Experience With 50 Cases in a Tertiary Care Hospital. Cureus. 2024 Apr 5;16(4): e57678. doi: 10.7759/cureus.57678. PMID: 38590981; PMCID: PMC10999782.

2 Shlomi Rayman, Eliyahou Gorgov, Dan Assaf, Idan Carmeli, Nadav Nevo, Jacob Rachmuth, Youri Mnouskin. Quality of life, post-operative complications, and hernia recurrence following enhanced-view Totally Extra-Peritoneal (eTEP) Rives-Stoppa for incisional and primary ventral hernia repair. Updates Surg 2023 Oct;75(7):1971-1978. doi: 10.1007/s13304-023-01572-x. Epub 2023 Jun 28. PMID: 37378814 DOI: 10.1007/s13304-023-01572-x

3\. B Ramana, E Arora, I Belyansky. Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias. Hernia 2021 Apr;25(2):545-550. doi: 10.1007/s10029-020-02216-4. Epub 2020 May 18. PMID: 32424727 DOI: 10.1007/s10029-020-02216-4

4\. Jacopo Andreuccetti, Alberto Sartori, Enrico Lauro, Lorenzo Crepaz, Silvia Sanna, Giusto Pignata, Umberto Bracale, Alberto Di Leo. Extended totally extraperitoneal Rives-Stoppa (eTEP-RS) technique for ventral hernia: initial experience of The Wall Hernia Group and a surgical technique update. Updates Surg 2021 Oct;73(5):1955-1961. doi: 10.1007/s13304-021-01067-7. Epub 2021 Apr 30. PMID: 33929701 DOI: 10.1007/s13304-021-01067-7

eTEP Rives Stoppa (eTEP RS) technique for a large incarcerated primary ventral hernia in an obese patient: expanding the indications for this approach to the emergency setting

Technique eTEP Rives Stoppa (eTEP RS) pour hernie ventrale primaire incarcérée de grande taille chez une patiente obèse : élargissement des indications de cette approche au contexte de l'urgence

In this live interactive surgery, Prof. Didier Mutter, MD, PhD, FACS, FRSM, Dr. Mihaela Ignat, MD, PhD, and Dr. Pietro Riva, MD demonstrate the laparoscopic management of a ventral hernia. This video presents the case of a patient with a left subcostal hernia secondary to a colectomy complicated by a previous anastomotic fistula. Imaging studies confirmed the presence of a double hernia sac on the left subcostal scar, with small bowel loop and omental encapsulation. Laparoscopic surgery was performed, with the placement of four ports creating a triangulation opposite the incisional hernia area. The author successively presents the different operating stages in the repair of an incisional hernia via a transabdominal approach, namely adhesiolysis, dissection and release of encapsulated hernia components, release of the retromuscular aspect of the anterior abdominal wall muscles over 5cm around the hernia edges, closure of the hernial orifice with a V-Loc™ running suture, repairing the abdominal wall. A dual parietal mesh was then inserted, with transparietal suturing with four cardinal stitches and additional fixation using double crown absorbable clips (double-crown mesh fixation technique). Postoperative outcomes were uneventful, and the patient was discharged home after 48 hours. The patient presented a strong abdominal wall at the 6-month follow-up.

Live interactive surgery: laparoscopic management of a ventral hernia

This educational video presents the case of a laparoscopic groin hernia repair using the transabdominal preperitoneal (TAPP) approach in a 60-year-old man with a symptomatic right inguinal hernia.

The patient experienced increasing discomfort and pain in the groin area, exacerbated by physical activity.

After clinical evaluation, a laparoscopic TAPP procedure was indicated.

During surgery, a direct right inguinal hernia was identified, and the hernia sac was reduced back into the abdominal cavity. A mesh prosthesis was then placed to reinforce the defect. The TAPP approach allows for a bilateral exploration and minimally invasive repair with visual control, offering an effective solution for the management of inguinal hernias in active individuals. The patient had an uneventful recovery, and no signs of recurrence were observed during postoperative follow-up.

Bibliography:

1\. Houcine Maghrebi, Amin Makni, Amin Sebai, Faouzi Chebbi, Wael Rebai, Amin Daghfous, Rachid Ksantini, Mohamed Jouini, Montassar Kacem, Zoubeir Ben Safta. Outcomes of laparoscopic surgery for groin hernia repair: our experience in Tunisia \[Résultats de la chirurgie laparoscopique pour la hernie de l’aine: l’expérience Tunisienne]. Pan African Medical Journal. January 2018; 29(43). DOI: 10.11604/pamj.2018.29.43.14013. License CC BY 2.0.

2\. J Leroy, M Bailey, D Mutter, J Marescaux. Key steps of laparoscopic TAPP inguinal hernia repair. WebSurg. Epublication WebSurg.com, May 2015;15(05). URL: [https://websurg.com/doi/vd01en4474](https://websurg.com/doi/vd01en4474)

In this live interactive surgery, Dr. Bernard Dallemagne, MD demonstrates the laparoscopic management of a left inguinal hernia using the totally extraperitoneal (TEP) approach. This video shows a totally extraperitoneal (TEP) approach to a left inguinal hernia. The procedure began with a preaponeurotic incision and the creation of a dissection space using an atraumatic port and camera. A 30-degree scope was used. As soon as sufficient space was created, two additional ports were positioned, one port on the midline two fingerbreadths above the pubis, the second port also on the midline, halfway between the scope and the lowermost port, hence allowing for the progressive release of the retroperitoneal space. It was necessary to identify the epigastric artery to make sure that it was located underneath the scope. It was then possible to progressively free the hernial orifice, and to parietalize components of the spermatic cord. After complete dissection, a 15 by 13cm mesh was inserted, completely covering the dissection spaces. The benefit of the TEP approach was that no mesh fixation was required. As could be seen, exsufflation helped to perfectly fix the mesh to the posterior part of the anterior abdominal wall.

The patient was discharged home on the same day. Postoperative outcomes were uneventful, and the patient could resume physical activities after one month.

Live interactive surgery: laparoscopic TEP approach for left inguinal hernia 

In this live interactive surgery, Professor Didier Mutter, MD, PhD, FACS, FRSM demonstrates the laparoscopic management of a bilateral inguinal hernia using the transabdominal preperitoneal (TAPP) approach. This video presents the case of an overweight patient with a bilateral inguinal hernia (direct hernia on the left side, mixed, direct, and indirect on the right side). The author explains the principles of the TAPP approach to a bilateral inguinal hernia, outlines the bilateral exploration and dissection of this bilateral hernia pathology. A left approach was performed, with parietalization of the spermatic cord components, and complete lowering of the peritoneum, followed by a right approach. The two meshes, right-sided and left-sided, are placed superimposed at the level of the pubis, providing complete coverage of the anterior abdominal wall. The peritoneal defect was closed in an original fashion, using clips. The surgery was performed on an outpatient basis, and postoperative outcomes were uneventful.

Live interactive surgery: laparoscopic management of a bilateral inguinal hernia: TAPP approach 

Cure vidéolaparoscopique d'une hernie d'éventration à l'aide d'une prothèse rétromusculaire (technique eRives)

The authors present their technique of videolaparoscopic repair of incisional hernia with a retromuscular mesh, an endoscopic approach to perform the conventional Rives operation. Although this technique is frequently called “eTEP”, the authors prefer to call it “eRives”, since it follows the principles of the open Rives technique, and it is not preperitoneal, strictly speaking. The principles stated by Rives and Stoppa more than 50 years ago are still valid, namely midline reconstruction and implantation of a mesh in the retrorectus space are the pillars of a successful repair of a midline hernia. This video demonstrates a stepwise approach to an eRives operation for a M23W2R2 incisional hernia in a 63-year-old physically active man.

Bibliography:

1\. Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H, Weltz AS, Sibia US, Park A, Novitsky Y. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc 2018 Mar;32(3):1525-1532. doi: 10.1007/s00464-017-5840-2. Epub 2017 Sep 15.PMID: 28916960. [https://doi.org/10.1007/s00464-017-5840-2](https://doi.org/10.1007/s00464-017-5840-2)

2\. Salido Fernandez S, Fraile Vilarrasa M, Osorio Silla I, Georgiev Hristov T, Bernar de Oriol J, González-Ayora S, Pardo García R, Guadalajara Labajo H. Extended Totally Extraperitoneal (eTEP) Approach for Ventral Hernia Repair: Initial Results. Cir Esp (Engl Ed) 2020 May;98(5):260-266. doi: 10.1016/j.ciresp.2020.01.006. Epub 2020 Mar 12.PMID: 32172955. [https://doi.org/10.1016/j.cireng.2020.04.013](https://doi.org/10.1016/j.cireng.2020.04.013)

3\. Andre Luiz Gioia Morrell, Alexander Morrell, Alexander Charles Morrell-Junior, Jose Mauricio DE Freitas Mendes, Allan Gioia Morrell. Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias. Rev Col Bras Cir 2020 Oct 7:47:e20202622. doi: 10.1590/0100-6991e-20202622. eCollection 2020. PMID: 33053065 DOI: 10.1590/0100-6991e-20202622. [https://doi.org/10.1590/0100-6991e-20202622](https://doi.org/10.1590/0100-6991e-20202622)

Videolaparoscopic repair of incisional hernia with retromuscular mesh (eRives)

Acute inguinal hernias are common surgical emergencies conventionally managed through open surgery. Although several authors advocated for the laparoscopic approach in recent years, controversy persists among surgeons. The benefits of the laparoscopic technique extend beyond the elective context. Apart from detecting hidden and visible hernias and covering the entire myopectineal orifice (MPO), it also makes precise diagnosis possible, lessens the necessity for laparotomy, and lowers the incidence of wound infections. In this approach, intestinal viability is evaluated once the hernia has been identified and the strangulated content has been reduced. Save from cases of gangrenous perforation necessitating immediate intervention, hernia repair ensues. The subsequent reassessment of the strangulated bowel allows for revascularization, often obviating the need for bowel resection and unnecessary laparotomy. In this educational video, the authors present a case study of a 61-year-old woman with a strangulated femoral hernia. A laparoscopic transabdominal preperitoneal (TAPP) repair was performed, requiring segmental bowel enterectomy due to non-reversible ischemia. 

Bibliography:

1. Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc. 2020 Apr;34(4):1458-1464. doi: 10.1007/s00464-020-07449-z. Epub 2020 Feb 19. PMID: 32076858

2. Yang, G. (2017). Laparoscopy in emergency hernia repair. Annals Of Laparoscopic And Endoscopic Surgery, 2(6). doi:10.21037/ales.2017.05.05

In this live interactive surgery, Professor Didier Mutter, MD, PhD, FACS, FRSM demonstrates the laparoscopic management of a left inguinal hernia using a transabdominal preperitoneal approach (TAPP). This video shows the case of a 35-year-old male patient with a BMI of 26 presenting with a Nyhus IIIB indirect left inguinal hernia. A three-trocar transabdominal preperitoneal (TAPP) approach was performed. Exploration allowed to precisely identify the anatomical landmarks, namely gonadal vessels and deferent duct; the epigastric artery defining the indirect inguinal hernia, and the umbilical artery representing the most internal landmark of the dissection. Surgery was performed in a conventional manner, with the following operative steps: peritoneal opening, peritoneal lowering, approach to the space of Bogros medially, hernia sac parietalization, and release of the deferent duct and vascular pedicle. The triangle of Doom and the triangle of pain were identified. The procedure ended with the positioning of a 13 by 12 by 8cm recut mesh entirely covering the freed hernial orifices. Reperitonization was then performed to completely cover the hernial mesh.

One treatment option in the management of large abdominal wall defects is the use of botulinum toxin (BT) which produces a functional blockade that reaches its maximum effect between 4 and 6 weeks after administration. This causes the lateral abdominal muscles to elongate, allowing for a tension-free abdominal reconstruction. The repair of large defects represents a great challenge for abdominal wall surgeons, and the minimally invasive approach offers new opportunities.

Bibliography:

1\. Adriana Hernández López, Estefanía J. Villalobos Rubalcava. Botulinum toxin type A infiltration in the preoperative preparation of hernias with 10-15 cm defects. Rev Hispanoam Hernia 2016;4(2) 43-49. [https://doi.org/10.1016/j.rehah.2016.02.003](https://doi.org/10.1016/j.rehah.2016.02.003)

2\. Diego A Hipolito Canario, Ari J Isaacson, Jessica A Martissa, Jessica K Stewart. Ultrasound-Guided Chemical Component Separation with Botulinum Toxin A prior to Surgical Hernia Repair. J Vasc Interv Radiol 2021 Feb;32(2):256-261. doi: 10.1016/j.jvir.2020.09.013. Epub 2020 Dec 7. PMID: 33303339 DOI: 10.1016/j.jvir.2020.09.013

Focus sur la cure des hernies de la paroi abdominale

Focus on abdominal wall hernia repair (AWHR)

Excision laparoscopique d'une endométriose rectovaginale et résection intestinale discoïde

Deep endometriosis is a condition in which there is more than a 5mm depth of subperitoneal invasion. The bowel is involved in 5 to 12% of the overall endometriosis cases with sigmoid colon and rectum being the commonest, more than 90% (1). Rectal shaving, discoid resection, and segmental resection remain the standard technique for managing bowel endometriosis. Discoid resection is performed for lesions less than 3cm with less than a 50% involvement of bowel circumference. Rectal shaving performed in such cases is associated with medium-term recurrence rates of dysmenorrhea and dyspareunia (2). For a small nodule, full-thickness disc resection of the rectal wall can be performed safely. The rectal wall remains well vascularized and innervated after closure with sutures (3). Barbed sutures can be used safely to close the rectal wall in 2 layers without significantly increasing the rates of postoperative leak, abscess, and fistula formation (4).

Bibliography:

1. Meuleman C, Tomassetti C, D’Hoore A, et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update. 2011;17(3):311–326. doi: 10.1093/humupd/dmq057
2. Afors K, Centini G, Fernandes R, et al. Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. J Minim Invasive Gynecol. 2016;23:7. doi: 10.1016/j.jmig.2016.08.813
3. Roman H, Opris I, Resch B, Tuech JJ, Sabourin JC, Marpeau L. Histopathologic features of endometriotic rectal nodules and the implications for management by rectal nodule excision. Fertil Steril. 2009;92:1250-1252
4. Stuparich MA, Lee TTM. Discoid Resection of Rectosigmoid Endometriotic Nodules. J Minim Invasive Gynecol. 2018 Mar-Apr;25(3):388. doi: 10.1016/j.jmig.2017.09.024. Epub 2017 Oct 6. PMID: 28993241

Laparoscopic excision of rectovaginal endometriosis and discoid bowel resection

This video presents the reverse technique (RT) in laparoscopic surgery for deep endometriosis, highlighting its benefits over conventional techniques. Deep endometriosis, involving structures such as the rectum, poses significant surgical challenges. The RT begins with a dissection from healthy tissue towards diseased areas, enhancing precision and reducing complications. In this educational video, the authors demonstrate this technique showing the case of a 39-year-old woman with deep endometriosis involving the rectal wall. Surgery led to significant symptoms improvement and helped to reduce operative time and bowel injury. The RT, requiring specialized training, offers a promising approach to the management of complex endometriosis with improved outcomes and recovery.

Bibliography:

1\. Cabrera R, Tessmann Zomer M, Larrain D, Bourdel N, Canis M, Kondo W. Laparoscopic reverse technique for posterior rectovaginal deep endometriosis nodule step by step. J Minim Invasive Gynecol 2020. Mar-Apr;27(3):577-578. doi: 10.1016/j.jmig.2019.07.018. Epub 2019 Jul 25. PMID: 31352071

2\. Bendifallah S, Ballester M, Darai E. Surgical management of deep infiltrating endometriosis with bowel involvement and urinary tract involvement. Presse Med. 2017 Dec;46(12 Pt 1):1212-1217. doi: 10.1016/j.lpm.2017.09.006. Epub 2017 Nov 10. PMID: 29129414

Revolutionizing deep endometriosis surgery: the reverse technique approach

Révolutionner la chirurgie de l'endométriose profonde : approche par technique inversée

Objective: To show how cesarean scar pregnancy (CSP) can be managed safely and effectively through a laparoscopic fertility-preserving treatment. 

Design: Stepwise demonstration of the technique with narrated video footage. 

Setting: The surgical management of cesarean scar pregnancy remains challenging. Currently, there is no standard treatment for the management of CSP, and it is why it seems appropriate to describe and share one of the authors’ therapeutic techniques. 

This is the case of a 37-year-old woman referred to our center for suspected ectopic scar pregnancy. The patient reported abdominal pain in the hypogastrium. 

She had a history of delivering a child via a cesarean section. She was admitted to our center with positive beta-hCG. 

Physical exam showed little vaginal bleeding with pain on palpation in the hypogastrium.

Transvaginal sonography showed a gestational sac with trophoblastic tissue in relation to the cesarean section scar. The residual myometrium was 2mm thick, with a 12mm embryo of approximately 7.2 weeks. 

MRI showed a gestational sac implanted at the level of the cesarean section scar measuring 50 by 29 by 29mm, including the trophoblastic tissue. The trophoblast extended into the vesicouterine space. At that level, the residual myometrium was approximately 2mm. The bladder wall was preserved. 

It was decided to perform a laparoscopic resolution with uterine preservation due to the patient’s desire for future fertility. 

For the surgery, the patient was placed in a dorsal modified lithotomy position. The surgeon stood on the patient’s left side, the first assistant on the patient’s right side, and the second assistant between the patient’s legs. 

Main outcomes: The patient evolved favorably in postoperative care. Hospital discharge took place 24 hours after the surgery. 

Beta-hCG was requested a month later and proved to be negative. Control MRI after three months showed the absence of residual isthmocele. 

Conclusion: It is crucial to offer scar ectopic pregnancy patients a minimally invasive treatment with fertility preservation. The use of tools to reduce intraoperative bleeding is essential, as in this case. 



Bibliogaphy:

1. Ron Maymon, Ran Svirsky, Noam Smorgick, Sonia Mendlovic, Reuvit Halperin, Karin Gilad, Josef Tovbin. Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy. J Ultrasound Med 2011 Sep;30(9):1179-84. doi: 10.7863/jum.2011.30.9.1179. PMID: 21876087 DOI: 10.7863/jum.2011.30.9.1179

2. Andrea Kaelin Agten, Giuseppe Cali, Ana Monteagudo, Johana Oviedo, Joanne Ramos, Ilan Timor-Tritsch. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche”. Am J Obstet Gynecol 2017 May;216(5):510.e1-510.e6. doi: 10.1016/j.ajog.2017.01.019. Epub 2017 Jan 20. PMID: 28115056 DOI: 10.1016/j.ajog.2017.01.019

3. Alkatout I, Honemeyer U, Strauss A, Tinelli A, Malvasi A, Jonat W, Mettler L, Schollmeyer T. Clinical diagnosis and treatment of ectopic pregnancy. Obstet Gynecol Surv 2013 Aug;68(8):571-81. doi: 10.1097/OGX.0b013e31829cdbeb. PMID: 23921671 DOI: 10.1097/OGX.0b013e31829cdbeb

4. Rehan M Riaz, Todd R Williams, Brian M Craig, Daniel T Myers. Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging 2015 Oct;40(7):2589-99. doi: 10.1007/s00261-015-0472-2. PMID: 26070747 DOI: 10.1007/s00261-015-0472-2

Cesarean scar pregnancy: laparoscopic fertility-preserving treatment

Grossesse sur cicatrice de césarienne : traitement laparoscopique de préservation de la fertilité

Endometriosis is a chronic inflammatory disease with different treatment options. It occurs in women who can be either symptomatic or not (and when symptomatic with a variable range of severity) and may seek for pregnancy or not. To date, no preoperative factors have been found to identify patients who may respond better to surgical treatment of endometriosis [1]. As a result, ESHRE guidelines recommend to choose the most appropriate treatment option, according to symptoms and desire for future pregnancy, with a “shared decision-making approach” [1]. In this authoritative lecture, Prof. Renato Seracchioli reported some preoperative features, which can be used to identify women who can benefit from surgery, and to provide clinical cases for a surgically tailored management of endometriosis. First, a series of factors related to disease, patient and center, were identified as they are useful to define the expected benefits and potential disadvantages of the surgical treatment for each patient. Disease-related factors included endometriotic ultrasound features, ENZIAN/rASRM/AAGL stage; patient-related factors included symptoms (such as pain, bowel function, infertility), previous surgery (endometriosis or not), co-morbidities (CSS, dolichocolon), compliance to therapy, age; and center-related factors included a referred center for endometriosis, the surgeon’s experience, and the rate of complications in the referred center. More severe endometriosis has been associated with stronger pain relief after laparoscopic surgery and, consequently, some authors have proposed a pain score >7 (according to the Visual Analog Scale) as one of clinical criteria to choose surgery [2]. A higher prevalence of central sensitization has been reported among women with endometriosis; as a result, the identification of a central contribution to pain might preoperatively predict a poor pain response after surgery [3]. Surgery for endometriosis should be performed in a referred center where surgeons have experience with retroperitoneal dissection and nerve-sparing surgery [4], allowing to obtain a clinical benefit with a low surgical risk. In conclusion, age, individual preferences, desire for pregnancy, impact on quality of life (QoL) and symptoms, ultrasound features of endometriotic lesions, risk of surgical treatment have to be considered and balanced to build up the most appropriate surgical treatment.

Bibliography:

1. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.

2. Kho RM, Andres MP, Borrelli GM, Neto JS, Zanluchi A, Abrão MS. Surgical treatment of different types of endometriosis: Comparison of major society guidelines and preferred clinical algorithms. Best Pract Res Clin Obstet Gynaecol. 2018 Aug;51:102-110. doi: 10.1016/j.bpobgyn.2018.01.020. Epub 2018 Feb 16. PMID: 29545114.

3. Raimondo D, Raffone A, Renzulli F, Sanna G, Raspollini A, Bertoldo L, Maletta M, Lenzi J, Rovero G, Travaglino A, Mollo A, Seracchioli R, Casadio P. Prevalence and Risk Factors of Central Sensitization in Women with Endometriosis. J Minim Invasive Gynecol. 2023 Jan;30(1):73-80.e1. doi: 10.1016/j.jmig.2022.10.007. Epub 2022 Oct 29. PMID: 36441085.

4. Zakhari A, Mabrouk M, Raimondo D, Mastronardi M, Seracchioli R, Mattei B, Papillon-Smith J, Solnik MJ, Murji A, Lemos N. Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery. J Minim Invasive Gynecol. 2020 May-Jun;27(4):813-814. doi: 10.1016/j.jmig.2019.08.001. Epub 2019 Aug 3. PMID: 31386912.



Disclosures: Prof. Renato Seracchioli, MD, PhD has conflicts of interest to declare, receiving advisory board meeting fees and lecture fees from Medtronic, as well as lectures fees from Olympus. However, these industrial companies were never committed to the elaboration and running organization of Prof. Renato Seracchioli’s lectures and videos. There is neither commercial publicity nor commercial promotion in Prof. Renato Seracchioli’s lectures and videos. 

Prof. Renato Seracchioli, MD, PhD declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Renato Seracchioli has no financial affiliations that would affect the content of his presentations.

Clinical diagnosis, decision-making counselling in endometriosis

In this authoritative lecture (part 1), Prof. Caterina Exacoustos focuses on the ultrasound diagnosis of endometriosis and endometrioma, including ultrasound mapping of the anterior and posterior compartments.&#x20;

Disclosure: Prof. Caterina Exacoustos, MD, PhD has no conflict of interest to disclose. Prof. Caterina Exacoustos, MD, PhD declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Caterina Exacoustos has no financial affiliations that would affect the content of her presentations.

Ultrasound diagnosis of endometriosis: eyes do not see what mind does not know (Part 1)

In this part 2 lecture (sequel to part 1), Prof. Caterina Exacoustos looks into ultrasound mapping of the lateral compartment, advantages in preoperative diagnosis, considering key anatomical structures (i.e., lateral spaces, anterior parametrium, paracervix, posterior lateral space), addressing US characteristics to diagnose adenomyosis, considering complications in pregnancy and delivery, adenomyomectomy, and providing take-home messages.&#x20;

Prof. Caterina Exacoustos, MD, PhD has no conflict of interest to disclose. Prof. Caterina Exacoustos, MD, PhD declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Caterina Exacoustos has no financial affiliations that would affect the content of her presentations.

Ultrasound diagnosis of endometriosis: eyes do not see what mind does not know (Part 2)

This key lecture focuses on the role that magnetic resonance imaging (MRI) plays in the diagnosis and staging of deep pelvic endometriosis. Recommended MRI protocols are reviewed and pertinent findings on T2- and T1-weighted imaging are discussed. T2-weighted imaging provides the anatomical information required to identify the pathology within the pelvis. Dr. Freeman demonstrates how T2-weighted images allow for the detection of anatomical distortion / adhesions, fibrosis and muscle invasive lesions within the bladder and bowel. T1-weighted imaging with and without fat suppression enables the differentiation of lesions containing fat and blood products. Endometriomas sometimes have a typical appearance on T2-weighted imaging with ‘T2 shading’ seen within a cyst; this radiological sign describes the change in signal intensity of the cyst contents from light grey to dark grey. On T1-weighted imaging, the chronic blood contents within an endometriotic cyst are high signal intensity and usually become even higher signal intensity on T1-weighted fat suppressed imaging.

Using multiple MRI examples, the most common imaging findings of deep pelvic endometriosis are illustrated within the posterior, anterior, and middle pelvic compartments.

MRI plays an essential role in a multidisciplinary team setting. The MR images can be discussed among the multiple surgical teams including gynecology, colorectal surgery, and urology, enabling an effective surgical planning.

Bibliography:

1\. Bourgioti C, Preza O, Panourgias E, Chatoupis K, Antoniou A, Nikolaidou ME, Moulopoulos LA. MR imaging of endometriosis: Spectrum of disease. Diagn Interv Imaging. 2017 Nov;98(11):751-767. doi: 10.1016/j.diii.2017.05.009. Epub 2017 Jun 23. PMID: 28652096.

2\. Burkett BJ, Cope A, Bartlett DJ, Burnett TL, Jones T, Venkatesh SK, VanBuren WM. MRI impacts endometriosis management in the setting of image-based multidisciplinary conference: a retrospective analysis. Abdom Radiol (NY). 2020 Jun;45(6):1829-1839. doi: 10.1007/s00261-020-02417-6. PMID: 32002570.

3\. Coutinho A Jr, Bittencourt LK, Pires CE, Junqueira F, Lima CM, Coutinho E, Domingues MA, Domingues RC, Marchiori E. MR imaging in deep pelvic endometriosis: a pictorial essay. Radiographics. 2011 Mar-Apr;31(2):549-67. doi: 10.1148/rg.312105144. PMID: 21415196.

4\. Foti PV, Farina R, Palmucci S, Vizzini IAA, Libertini N, Coronella M, Spadola S, Caltabiano R, Iraci M, Basile A, Milone P, Cianci A, Ettorre GC. Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights Imaging. 2018 Apr;9(2):149-172. doi: 10.1007/s13244-017-0591-0. Epub 2018 Feb 15. PMID: 29450853; PMCID: PMC5893487.

Disclosures: Dr. Sue Freeman, MD has no conflict of interest to disclose. Dr. Freeman declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Dr. Freeman has no financial affiliations that would affect the content of her presentations.

MRI diagnosis of endometriosis: what a gynecologist needs to know

Objective: Deep endometriosis (DE) infiltrating the rectum may be managed via full-thickness disc excision, with the objective of preserving rectal function and preventing a low anterior rectal resection syndrome. Transanal staplers may be successfully used to remove the rectal wall disc and to concomitantly perform rectal suture. The objective of this lecture video is to discuss the indications and the feasibility of the technique.

Intervention: The video presents disc excision of deep endometriosis infiltrating the rectum using a transanal circular stapler, following 10 steps: 1) Nodule dissection and rectum releasing; 2) Rectal shaving; 3) Removal of adipose tissue on the lateral rectal wall; 4) Placement of a suture on the shaved area; 5) Introduction of a transanal circular stapler closed; 6) Stapler opening at nodule’s level; 7) Knot-tying procedure; 8) Stapler closure and firing; 9) Stitches placed to reinforce the stapled line; 10) Bubbles’ test. From 2009 to 2034, Prof. Horace Roman performed this procedure in 460 patients; mean disc diameter was 40+/-8mm; microscopic foci were found on disc edges in 25.7% of cases, the rate of rectal recurrences was 1.5% whereas the leakage rate was 4.4%. No postoperative bowel stenosis was noted. The use of robotic assistance allows to increase the feasibility of disc excision in large nodules in the middle and low rectum.

Conclusion: Disc excision using a transanal circular stapler is a standardized and reproducible procedure. The learning curve may be short, as colorectal surgeons routinely use the stapler to perform a laparoscopic colorectal anastomosis.

Keywords: endometriosis; bowel; rectum; disc excision; transanal stapler; full-thickness.

Bibliography:

1\. Roman H, Dennis T, Forestier D, François MO, Assenat V, Tuech JJ, Hennetier C, Merlot B. Disk Excision Using End-to-End Anastomosis Circular Stapler for Deep Endometriosis of the Rectum: A 492-Patient Continuous Prospective Series. J Minim Invasive Gynecol. 2023 Feb;30(2):122-130. doi: 10.1016/j.jmig.2022.10.009. Epub 2022 Nov 2. PMID: 36334913.

2\. D'Ancona G, Merlot B, Denost Q, Roman H. Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned. Fertil Steril. 2023 May;119(5):886-888. doi: 10.1016/j.fertnstert.2023.01.048. Epub 2023 Feb 7. PMID: 36758889.

3\. Roman H, Darwish B, Bridoux V, Chati R, Kermiche S, Coget J, Huet E, Tuech JJ. Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients. Fertil Steril. 2017; 107:977-986

4\. Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, Collinet P, Tuech JJ. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 2018; 33:47–57

Disclosures: Prof. Horace Roman, MD, PhD has conflicts of interest to declare, receiving personal fees for involvement in masterclasses and workshops from Olympus, Johnson & Johnson, Medtronic, Plasma Surgical Ltd, Intuitive Surgical, Gedeon Richter, and Nordic Pharma. However, these industrial companies were never committed to the elaboration and running organization of Prof. Roman’s lectures and videos. There is neither commercial publicity nor commercial promotion in Prof. Roman’s lectures and videos.

Prof. Horace Roman, MD, PhD declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Roman has no financial affiliations that would affect the content of his presentations.

Conservative approach to rectosigmoid endometriosis (shaving and disc resection):  a stepwise technique

In this authoritative lecture, Prof. Mario Malzoni outlines segmental bowel resection with endometriosis, describing a stepwise approach, including preoperative work-up, indications for surgery, segmental bowel resection with the NOSE technique, complications, results, and take-home messages.&#x20;

Disclosures: Prof. Mario Malzoni, MD has no conflict of interest and no financial ties to disclose. Prof. Malzoni declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Malzoni has no financial affiliations that would affect the content of his presentations.

Segmental bowel resection with endometriosis: step-by-step approach

The coexistence of endometriosis and adenomyosis brings to chronic pelvic pain, and the persistence of post-excision pain leading to the execution of a hysterectomy. Patients with a long history of pelvic pain consider hysterectomy at the end of their journey as the definitive treatment for endometriosis and pelvic pain. Hysterectomy with coexistence of endometriosis has a higher risk of complications. Consequently, patients need appropriate counselling to be empowered of the decision-making option for surgery with an awareness of risks and benefits.

Bibliography:

1\. Prevalence of adenomyosis in women undergoing surgery for endometriosis. Di Donato N, Montanari G, Benfenati A, Leonardi D, Bertoldo V, Monti G, Raimondo D, Seracchioli R. Eur J Obstet Gynecol Reprod Biol. 2014

2\. Excisional endometriosis surgery with hysterectomy and bilateral salpingo-oophorectomy versus excisional endometriosis surgery alone for pelvic pain associated with deep endometriosis N Manobharath, J Lewin, M Hirsch, J Naftalin, A Vashisht, A Cutner, E Saridogan Facts Views Vis Obgyn 2023

3\. Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures. Seracchioli R, Mabrouk M, Mastronardi M, Raimondo D, Arena A, Forno SD, Mariani GA, Billi AM, Manzoli L, O'Guin WM, Lemos N.J Minim Invasive Gynecol. 2019

4\. Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy. Uccella S, Marconi N, Casarin J, Ceccaroni M, Boni L, Sturla D, Serati M, Carollo S, Podesta' Alluvion C, Ghezzi F. Arch Gynecol Obstet. 2016

Disclosures: Dr. Nadine Di Donato, MBBS, ATSM has no conflict of interest to disclose. Dr. Di Donato declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Dr. Di Donato has no financial affiliations that would affect the content of her presentations.

Hysterectomy with posterior deep endometriosis (DE) and other bowel endometriosis (ileum, caecum, and appendix)

Deep endometriosis (DE), characterized by the presence of endometrial-like tissue out of the uterine cavity, poses signiﬁcant challenges in the management of subfertility in affected women. The intricate relationship between DE and infertility requires a nuanced approach to treatment, particularly when considering assisted reproductive technologies (ART) and surgical interventions. This presentation will review the critical aspects of DE’s impact on natural fertility, ART pregnancy rates, and the strategic decisions surrounding the excision of endometriosis in the context of improving fertility outcomes.



The link between DE and subfertility is well documented, with DE adversely affecting natural fertility and the success rates of ART. The presence of DE may lead to anatomical distortions and inﬂammatory changes, thereby compromising egg quality, fertilization, and implantation processes. The role of DE in natural conception and ART outcomes is a subject of ongoing research, with evidence suggesting that the excision of endometriosis may play a pivotal role in enhancing fertility prospects.



The decision to excise DE in the setting of infertility is complex and multifaceted. Surgical intervention aimed at removing endometriotic lesions has been associated with improved fertility outcomes, including increased rates of spontaneous conception and higher success rates in subsequent ART cycles.

However, the question of whether to routinely offer surgery to individuals with DE and subfertility remains controversial. Factors such as the extent and location of endometriosis, patient age, and the severity of infertility symptoms must be carefully weighed against the potential risks and beneﬁts of surgery.



Timing is crucial when considering surgery to improve fertility in patients with DE. Surgical intervention is generally recommended when endometriotic lesions cause signiﬁcant pain, are suspected of contributing to mechanical infertility, or when ART has been unsuccessful. The decision to operate should be tailored to the individual’s clinical proﬁle, considering the likelihood of achieving pregnancy post-surgery versus the potential impact on ovarian reserve and the risks associated with surgical complications.



Beyond fertility considerations, there are other compelling reasons to recommend surgery for DE, including the management of chronic pelvic pain, the removal of large or symptomatic endometriomas, and the prevention of disease progression. The risk of deep infiltrating endometriosis (DIE) worsening after ART or during pregnancy further underscores the importance of a carefully considered surgical approach.



In conclusion, the management of subfertility in couples affected by DE requires a personalized strategy, which balances the potential beneﬁts of surgical intervention against the risks. Surgery for DE appears to increase the likelihood of both spontaneous and assisted conception. However, the impact of DIE on ART outcomes and the risk of disease exacerbation post-ART or during pregnancy necessitate a cautious and individualized approach. Despite the tolerable rate of complications and the lack of direct correlation between pregnancy rates and surgical complications, tailoring the indication for surgery is essential. Ultimately, the treatment plan should be jointly decided upon by the patient, their partner, and the healthcare team, ensuring that the couple is fully informed and actively involved in the decision-making process.



Disclosures: Prof. Francisco Carmona Herrera, MD, PhD has conflicts of interest to declare, receiving consultancy honoraria from Adamed, Gedeon Richter, Medtronic, Myovant, Organon, Theramex. However, these industrial companies were never committed to the elaboration and running organization of Prof. Carmona’s lectures and videos. There is neither commercial publicity nor commercial promotion in Prof. Carmona’s lectures and videos. 

Prof. Carmona, MD, PhD declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Carmona has no financial affiliations that would affect the content of his presentations.

Patients with subfertility and deep endometriosis (DE): what should we offer to the couple?

patientes atteintes de subfertilité et d'endométriose profonde : que proposer au couple ?

Background: Urinary tract endometriosis (UTE) involves the bladder and/or the ureters and affects 1 to 6% of women with endometriosis. Its prevalence increases to 19-53% among patients with deep endometriosis (DE). Bladder involvement occurs in 70 to 85%. Ureteral involvement accounts for 9 to 23% of UTE cases.

Learning objectives: To gain a good knowledge of UTE, including prevalence and symptoms; To learn how to recognize UTE; to know how to establish an accurate diagnosis, along with treatment options.

Frequent symptoms of bladder endometriosis include frequency, urgency, hematuria, recurrent abacterial cystitis, discomfort when the bladder is full. Diagnosis should consider clinical history, pelvic examination (i.e., uterus extremely anteflexed, detrusor nodule palpated medially). Regarding imaging studies, transvaginal ultrasound has a high sensivity (72.7%) and a high specificity (97%) for bladder endometriosis, in expert hands. Magnetic resonance (MR) is a second-line imaging technique, although it depends on the different centers. Cystoscopy is useful to estimate the distance between ureteral orifices and nodule borders.

Regarding decision-making, in endometriotic patients, medical/surgical treatment depends on patient’s age, desire for pregnancy, extent of the disease, and recurrence. In case of bladder endometriosis, laparoscopic cystectomy allows for a complete lesion removal.

Regarding ureteral endometriosis, the distal portion of the left ureter is the most affected region. Extrinsic disease (60%) occurs in case of large endometrioma/nodule of the uterosacral ligament which “compresses the ureter” or in case of fibrosis involving the ureter. Intrinsic disease (40%) occurs in case of endometriosis infiltrating the parametrium and the rectovaginal septum. The surgical treatment (i.e., ureterolysis/ureteral reimplantation) of ureteral endometriosis is mandatory in case of hydronephrosis.

Conclusions: An accurate disease map is highly recommended in order to plan the most appropriate surgery with a multidisciplinary team.

Bibliography:

1\. Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P. Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation.Eur Urol. 2017 May;71(5):790-807. doi: 10.1016/j.eururo.2016.12.015. Epub 2016 Dec 28. PMID: 28040358 Review.

2\. Philip CA, Froc E, Chapron C, Hebert T, Douvier S, Filipuzzi L, Descamps P, Agostini A, Collinet P, von Theobald P, Roman H, Dubernard G. Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group). J Minim Invasive Gynecol. 2021 Nov;28(11):1889-1897.e1. doi: 10.1016/j.jmig.2021.04.020. Epub 2021 May 6. PMID: 33964459

3\. Hernández Gutiérrez A, Spagnolo E, Hidalgo P, López A, Zapardiel I, Rodriguez R. Magnetic resonance imaging versus transvaginal ultrasound for complete survey of the pelvic compartments among patients with deep infiltrating endometriosis. Int J Gynaecol Obstet. 2019 Sep;146(3):380-385. doi: 10.1002/ijgo.12894. Epub 2019 Jul 15.PMID: 31220340

4\. Mabrouk M, Raimondo D, Arena A, Iodice R, Altieri M, Sutherland N, Salucci P, Moro E, Seracchioli R. Parametrial Endometriosis: The Occult Condition that Makes the Hard Harder. J Minim Invasive Gynecol. 2019 Jul-Aug;26(5):871-876. doi: 10.1016/j.jmig.2018.08.022. Epub 2018 Aug 31. PMID: 30176361

Disclosures: Dr. Emanuela Spagnolo, MD, PhD has no conflict of interest to disclose. She declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device Industry. Dr. Spagnolo has no financial affiliations that would affect the content of her presentations.

Urinary tract involvement with endometriosis (anatomical and functional) diagnosis, and decision-making

The surgical management of bladder endometriosis represents a critical focus within the broader context of endometriosis treatment, addressing the complex challenges raised by this invasive form of the disease.

Bladder endometriosis, characterized by the presence of endometrial-like tissue within or on the bladder, significantly impacts patient quality of life through symptoms such as pelvic pain, urinary urgency, frequency, and sometimes hematuria. This authoritative lecture delved into the intricacies of diagnosing bladder endometriosis, emphasizing the importance of a multidisciplinary approach, which incorporates clinical examination, ultrasound imaging, and MRI for accurate diagnosis.

The core of the discussion centered on the surgical options available to manage bladder endometriosis, outlining the criteria for patient selection of surgical techniques, and for potential benefits and risks associated with each surgical approach. Two primary surgical interventions were highlighted: conservative surgery aiming to remove endometrial lesions while preserving the bladder and reproductive organs, and radical surgery, which may involve partial cystectomy of the bladder base or dome with or without hysterectomy.

Key to the lecture was the comparison of outcomes between different surgical techniques, with a focus on patient symptom relief, recurrence rates, and impact on fertility. The role of postoperative medical management in reducing symptom recurrence and preserving organ function was also discussed, alongside the necessity for ongoing research into minimally invasive techniques which promise improved patient outcomes with reduced morbidity.

This overview aimed to equip surgeons with the appropriate knowledge to make informed decisions in the management of bladder endometriosis, ultimately enhancing patient care and quality of life.

Bibliography:

1\. Mathew Leonardi, Mercedes Espada, Rosanne M Kho, Javier F Magrina, Anne-Elodie Millischer, Luca Savelli, George Condous. Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment. Diagnostics (Basel) 2020 Sep 30;10(10):771. doi: 10.3390/diagnostics10100771. PMID: 33007875 PMCID: PMC7650710 DOI: 10.3390/diagnostics10100771

2\. Umberto Leone Roberti Maggiore, Simone Ferrero, Massimo Candiani, Edgardo Somigliana, Paola Viganò, Paolo Vercellini. Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation. Eur Urol 2017 May;71(5):790-807. doi: 10.1016/j.eururo.2016.12.015. Epub 2016 Dec 28. PMID: 28040358 DOI: 10.1016/j.eururo.2016.12.015

3\. Gioia Villa, Mohamed Mabrouk, Manuela Guerrini, Giuseppe Mignemi, Giulia Montanari, Elena Fabbri, Stefano Venturoli, Renato Seracchioli. Relationship between site and size of bladder endometriotic nodules and severity of dysuria. J Minim Invasive Gynecol 2007 Sep-Oct;14(5):628-32. doi: 10.1016/j.jmig.2007.04.015. PMID: 17848326 DOI: 10.1016/j.jmig.2007.04.015

4\. Anna Kołodziej, Wojciech Krajewski, Łukasz Dołowy, Lidia Hirnle. Urinary Tract Endometriosis. Urol J 2015 Sep 4;12(4):2213-7. PMID: 26341760

Disclosures: Prof. Mohamed Mabrouk, MD, PhD has conflicts of interest to declare, receiving consultancy honoraria for education from Medtronic, and being a mentor in robotic surgery for CMR Surgical. However, these industrial companies were never committed to the elaboration and running organization of Prof. Mabrouk’s lectures and videos. There is neither commercial publicity nor commercial promotion in Prof. Mabrouk’s lectures and videos.

Prof. Mohamed Mabrouk, MD, PhD declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Mabrouk has no financial affiliations that would affect the content of his presentations.

Surgery for bladder endometriosis: counselling and step-by-step approach

Ureteric endometriosis, a challenging and often underdiagnosed condition, requires a multidisciplinary approach for effective management. This presentation explores the critical aspects of ureteric endometriosis, emphasising the importance of accurate diagnosis, surgical expertise, and collaborative care. The condition is primarily characterised by endometriotic lesions affecting the ureters, leading to complications such as hydroureteronephrosis and potential kidney damage. Early recognition through imaging modalities such as transvesical ultrasound scanning (TVUSS), MRI, and CT urograms is vital, particularly in patients with posterior compartment deep endometriosis (DE).

The presentation outlines a structured surgical approach and highlights the importance of comprehensive preoperative planning and intraoperative collaboration with urologists and colorectal surgeons. Essential surgical principles such as minimising thermal injury, respecting the adventitia, and ensuring complete excision of all visible lesions are stressed to prevent complications and improve patient outcomes.

In addition, the presentation addresses the high litigation risks associated with ureteric injuries in gynaecological surgery and underscores the need for meticulous surgical techniques and thorough postoperative follow-up. The SOSURE protocol (Survey & Sigmoid mobilisation / Ovarian mobilisation / Suspension of the uterus and the ovaries / Ureterolysis / Rectovaginal and/or pararectal space entry / Excision of all visible or palpable lesions) is presented as a comprehensive strategy for managing complex cases. This presentation aims to enhance the surgical management of ureteric endometriosis, ensuring optimal patient care and reducing the incidence of adverse outcomes.

Bibliography:

1\. Charles-André Philip, Elise Froc, Charles Chapron, Thomas Hebert, Serge Douvier, Laurence Filipuzzi, Philippe Descamps, Aubert Agostini, Pierre Collinet, Peter von Theobald, Horace Roman, Gil Dubernard. Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group). J Minim Invasive Gynecol. 2021 Nov;28(11):1889-1897.e1. doi: 10.1016/j.jmig.2021.04.020. Epub 2021 May 6.

2\. João Alves, Marco Puga, Rodrigo Fernandes, Anne Pinton, Ignacio Miranda, Elias Kovoor, Arnaud Wattiez. Laparoscopic Management of Ureteral Endometriosis and Hydronephrosis Associated With Endometriosis. J Minim Invasive Gynecol. 2017 Mar-Apr;24(3):466-472. doi: 10.1016/j.jmig.2016.11.018. Epub 2017 Jan 12. PMID: 28089810.

3\. Mobolaji O Ajao, Jon I Einarsson. Management of Endometriosis Involving the Urinary Tract. Semin Reprod Med. 2017 Jan;35(1):81-87. doi: 10.1055/s-0036-1597124. Epub 2016 Dec 7. PMID: 27926970.

4\. Marco Scioscia, Angelo Molon, Gaetano Grosso, Luca Minelli. Laparoscopic management of ureteral endometriosis. Curr Opin Obstet Gynecol. 2009 Aug;21(4):325-8. doi: 10.1097/GCO.0b013e32832e0798. PMID: 19512927.

5\. Kyle Fleischer, Ahmed El Gohari, Matthew Erritty, Vasileios Minas, Shaheen Khazali. Excision of endometriosis – optimising surgical techniques. The Obstetrician & Gynaecologist: Volume 23, Issue 4. October 2021. Pages 310-317. [https://doi.org/10.1111/tog.12762](https://doi.org/10.1111/tog.12762)

Disclosures: Dr. Shaheen Khazali, MD, MRCOG MSc has conflicts of interest to declare, receiving honoraria from Medtronic. However, this industrial company was never committed to the elaboration and running organization of Dr. Khazali’s lectures and videos. There is neither commercial publicity nor commercial promotion in Dr. Khazali’s lectures and videos. Dr. Shaheen Khazali, MD, MRCOG MSc declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device Industry. Dr. Khazali has no financial affiliations that would affect the content of his presentations.

Ureteric endometriosis: step-by-step management 

Deep infiltrating endometriosis (DIE) can involve pelvic organs. Pelvic nerves can also be involved. They are subsequently responsible for urinary and bowel disorders. Extensive dissection in the pelvic posterior compartment may lead to autonomic nerve injury and urinary dysfunction. Understanding the potential functional complications in deep endometriosis surgery is mandatory to prevent them by making a nerve-sparing approach, and when they occur, it is essential to promptly diagnose them and address them in a multidisciplinary manner. In this way, patient morbidity can be reduced.

Bibliography:

1\. Elias Kovoor, Joseph Nassif, Ignacio Miranda-Mendoza, Gerlinde Lang-Avérous, Arnauld Wattiez. Long-term urinary retention after laparoscopic surgery for deep endometriosis. Fertil Steril. 2011 Feb;95(2):803.e9-12. doi: 10.1016/j.fertnstert.2010.07.1043. Epub 2010 Aug 24. PMID: 20739020

2\. Marcos Ballester, Gil Dubernard, Estelle Wafo, Laura Bellon, Gérard Amarenco, Jeremie Belghiti, Emile Daraï. Evaluation of urinary dysfunction by urodynamic tests, electromyography and quality of life questionnaire before and after surgery for deep infiltrating endometriosis. Eur J Obstet Gynecol 2014. PMID: 24965994 DOI: 10.1016/j.ejogrb.2014.05.041

3\. Gil Dubernard, Roman Rouzier, Emmanuel David-Montefiore, Marc Bazot, Emile Daraï. Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gynecol 2008 Mar-Apr;15(2):235-40. doi: 10.1016/j.jmig.2007.10.009.

4\. Possover M. Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 2014 Mar;101(3):754-8. doi: 10.1016/j.fertnstert.2013.12.019. Epub 2014 Jan 11.

Disclosures: Dr. Filipa Osorio, MD has no conflict of interest to disclose. Dr. Osorio declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Dr. Osorio has no financial affiliations that would affect the content of her presentations.

Urinary dysfunction after endometriosis surgery: how to prevent, diagnose, and manage? 

Endometriomas are present in a significant proportion of women with endometriosis, and surgical treatment may be required due to pain or subfertility. Concern over their appearance, raising the possibility of cancer, may also be a reason to operate on patients, and this would need to be managed based on ultrasound (and/or MRI) findings, as well as on local protocols for the management of such patients. Ovarian torsion and rupture requiring surgery are very rare for endometriomas.

Excisional surgery (cystectomy) is usually the most commonly used approach as it is associated with a lower cyst and pain recurrence, and a higher chance of spontaneous conception in infertile women as compared to bipolar coagulation. Laser vaporization has also been shown to have similar recurrence rates to cystectomy in the long term; however, recurrences are more common after one year. Cystectomy reduces ovarian reserve as measured by anti-Müllerian hormone (AMH) levels, and this can potentially make ovarian stimulation more difficult in future in vitro fertilization (IVF) cycles. The detrimental impact of surgery on ovarian reserve may be lower following ablative approaches including laser and plasma energy vaporization.

Initial surgical steps for both excisional and ablative approaches involve an initial assessment of pelvic and abdominal structures, followed by cyst mobilization and drainage. These steps are then followed by either finding the plane between the cyst wall and the ovarian cortex before excision or using an ablative technique to destroy the inner cyst surface using laser, plasma energy or electrosurgery. Targeted coagulation or suturing is required following cystectomy for hemostasis. Anti-adhesion measures are recommended following endometrioma surgery. Sclerotherapy is a relatively recent approach to endometrioma treatment. It can be performed via ultrasound-guided aspiration or laparoscopic drainage. The initial claim is that it may better preserve ovarian reserve, but long-term data are missing.

Bibliography:

1\. Working group of ESGE, ESHRE and WES; Saridogan E, Becker CM, Feki A, Grimbizis GF, Hummelshoj L, Keckstein J, Nisolle M, Tanos V, Ulrich UA, Vermeulen N, De Wilde RL. Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma. Hum Reprod Open. 2017 Dec 19;2017(4):hox016.

2\. Froyman W, Landolfo C, De Cock B, Wynants L, Sladkevicius P, Testa AC, Van Holsbeke C, Domali E, Fruscio R, Epstein E, Dos Santos Bernardo MJ, Franchi D, Kudla MJ, Chiappa V, Alcazar JL, Leone FPG, Buonomo F, Hochberg L, Coccia ME, Guerriero S, Deo N, Jokubkiene L, Kaijser J, Coosemans A, Vergote I, Verbakel JY, Bourne T, Van Calster B, Valentin L, Timmerman D. Risk of complications in patients with conservatively managed ovarian tumours (IOTA5): a 2-year interim analysis of a multicentre, prospective, cohort study. Lancet Oncol. 2019 Mar;20(3):448-458.

3\. Hart R, Hickey M, Maouris P, Buckett W, Garry R. Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review. Hum Reprod. 2005 Nov;20(11):3000-7.

4\. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012 Sep;97(9):3146-54.

Disclosures: Prof. Ertan Saridogan, MD, PhD, FRCOG has conflicts of interest to declare, receiving honoraria from Arthrex, Intuitive Surgical, Karl Storz, Medtronic, and Hologic. However, these industrial companies were never committed to the elaboration and running organization of Prof. Saridogan’s lectures and videos. There is neither commercial publicity nor commercial promotion in Prof. Saridogan’s lectures and videos.

Prof. Saridogan, MD, PhD, FRCOG declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device Industry. Prof. Saridogan has no financial affiliations that would affect the content of his presentations.

Surgery for ovarian endometriomas: when and how? 

Chirurgie des endométriomes ovariens : quand et comment ?

The parametrium is the area surrounding the cervix. It is divided into the anterior, lateral, and posterior parametrium. In terms of endometriosis surgery, the posterior parametrium is the most pertinent region since endometriotic lesions are most common in this area. A pelvic MRI is very helpful preoperatively to fully delineate the location of the lesion and for appropriate preoperative planning. It is also crucial to counsel the patient on the risk of urinary, sexual, and bowel dysfunction. There is also a significant risk of neurogenic pain if the endometriosis involves large somatic nerves. The basic procedural steps include ureterolysis, identification of the hypogastric nerve and its lateralization, dissection of the internal iliac vein and adjacent structures. A stepwise delineation of the surgical procedure will be described and demonstrated.

Bibliography:

1\. Marcello Ceccaroni, Matteo Ceccarello, Ivano Raimondo, Giovanni Roviglione, Roberto Clarizia, Francesco Bruni, Daniele Mautone, Maria Manzone, Enrico Facci, Lorenzo Rettore, Roberto Rossini, Elisa Bertocchi, Giuliano Barugola, Giacomo Ruffo, Fabio Barra. "A Space Odyssey" on Laparoscopic Segmental Rectosigmoid Resection for Deep Endometriosis: A Seventeen-year Retrospective Analysis of Outcomes and Postoperative Complications among 3050 Patients Treated in a Referral Center. J Minim Invasive Gynecol 2023 Aug;30(8):652-664. doi: 10.1016/j.jmig.2023.04.005. Epub 2023 Apr 26.

Disclosures: Prof. Einarsson, MD, PhD, MPH has the following potential conflict of interest to disclose, being a consultant for Arthrex. He also has the ownership of Freya Healthcare, a startup company developing several medical devices. However, these industrial companies were never committed to the elaboration and running organization of Prof. Einarsson’s lectures and videos. There is neither commercial publicity nor commercial promotion in Prof. Einarsson’s lectures and videos.

Prof. Einarsson, MD, PhD, MPH declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device Industry. Prof. Einarsson has no financial affiliations that would affect the content of his presentations.

Parametrial endometriosis surgery: preoperative counselling and step-by-step approach

In this authoritative lecture, Prof. Vito Chiantera outlines endometriosis-related nerve entrapments, addressing the surgical strategy and technique (i.e., laparoscopic neuronavigation, nerve-sparing, neurolysis, necessity of nerve resection or neuromodulation, LION procedure) and providing take-home messages.&#x20;

Disclosures: Prof. Vito Chiantera, MD, PhD has no conflicts of interest to disclose. Prof. Chiantera declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device Industry. Prof. Chiantera has no financial affiliations that would affect the content of his presentations.

Endometriosis-related nerve entrapments: surgical strategy and technique 

Recurrence of endometriosis is defined as relapse of pain, clinical detection of an endometriotic lesion, or evidence of recurrence found during repeat surgery. Recurrence of endometriosis is common, necessitating surgical interventions aimed at symptom relief and fertility preservation. This presentation reviews the current landscape of surgical approaches for recurrent endometriosis.

The optimal surgical management of recurrent endometriosis remains controversial. Challenges include the high variability in disease presentation, the risk of complications, adhesion formation, and the potential for disease recurrence. Additionally, the decision to pursue surgery must be balanced against its potential impact on fertility and quality of life.

Future directions in the surgical management of recurrent endometriosis include refining surgical techniques and integrating adjunctive therapies to improve outcomes. In addition, personalized treatment strategies tailored to individual patient needs are crucial in optimizing outcomes and enhancing the quality of life for individuals with recurrent endometriosis.

Bibliography:

1\. Marcello Ceccaroni, Valentina Elisabetta Bounous, Roberto Clarizia, Daniele Mautone, Mohamed Mabrouk. Recurrent endometriosis: a battle against an unknown enemy. Eur J Contracept Reprod Health Care 2019 Dec;24(6):464-474. doi: 10.1080/13625187.2019.1662391. Epub 2019 Sep 25. PMID: 31550940 DOI: 10.1080/13625187.2019.1662391

2\. Manuel Maria Ianieri, Daniele Mautone, Marcello Ceccaroni. Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature. J Minim Invasive Gynecol 2018 Jul-Aug;25(5):786-793. doi: 10.1016/j.jmig.2017.12.025. Epub 2018 Jan 31. PMID: 29357317 DOI: 10.1016/j.jmig.2017.12.025

3\. Elizabeth Taylor, Christina Williams. Surgical treatment of endometriosis: location and patterns of disease at reoperation. Fertil Steril 2010 Jan;93(1):57-61. doi: 10.1016/j.fertnstert.2008.09.085. Epub 2008 Nov 11. PMID: 19006792 DOI: 10.1016/j.fertnstert.2008.09.085

4\. Gabriele Centini, Karolina Afors, Rouba Murtada, István Máté Argay, Lucia Lazzeri, Cherif Youssef Akladios, Errico Zupi, Felice Petraglia, Arnaud Wattiez. Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate. J Minim Invasive Gynecol 2016 Jan;23(1):113-9. doi: 10.1016/j.jmig.2015.09.015. Epub 2015 Sep 30. PMID: 26427703 DOI: 10.1016/j.jmig.2015.09.015

Disclosures: Dr. Karolina Afors, MBBS, MRCOG has the following conflicts of interest to declare, receiving specialist consulting fees for Medtronic and Besins Healthcare, fees as Medical Director for Medherant, and fees as Chief Medical Officer (CMO) for Sirona Health. However, these industrial companies were never committed to the elaboration and running organization of Dr. Afors’s lectures and videos. There is neither commercial publicity nor commercial promotion in Dr. Afors’s lectures and videos.

Dr. Afors declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Dr. Afors has no financial affiliations that would affect the content of her presentations.

Surgery for recurrent deep endometriosis 

Although there is no cure for endometriosis, research and clinical experience have provided clinicians with several different strategies to manage its symptoms.

Steroid hormones play a key role in the pathophysiology of endometriosis. The first medical treatment of choice for endometriosis-related pain has subsequently been hormonal treatment, either via suppression of ovarian activity or direct action on steroid receptors and enzymes in the lesions. It is therefore crucial to understand the different components in such medications, and how they work, to find the right “tool in the box”. Notably, none of the hormonal treatments are free of side effects and such findings must also be conveyed to patients.

One third of patients lack adequate response, and progesterone resistance is a potential explanation for this. Even so, one must bear in mind that all pain contributors are essential when treating chronic pain, ranging from those strictly organic to those with a greater neuropsychological component.

The type of medical treatment to select is dependent upon the type of pain the patient presents with. Neuropathic pain has different treatment options starting from nociceptive pain. Familiarity with different types of pain is necessary to tailor the most appropriate medical treatment plans for each patient.

The prospects for future medications for endometriosis-related pain is bright, and it is believed that, in the near future, personalized treatment will be attainable for patients with endometriosis. Tailored medical treatment in addition to surgery and evidence-based lifestyle interventions give a strong belief for a better outcome in this patient group.

Bibliography:

1\. Endometriosis: Etiology, pathobiology, and therapeutic prospects Philippa T K Saunders, Andrew W Horne. PMID: 34048704 DOI: 10.1016/j.cell.2021.04.041

2\. Progesterone Resistance in Endometriosis: Current Evidence and Putative Mechanisms. Ping Zhang 1, Guoyun Wang 2 PMID: 37108154  DOI: 10.3390/ijms24086992

3\. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Andrew Zakhari 1 2, Emily Delpero 1 2, Sandra McKeown 3, George Tomlinson 4 5, Olga Bougie 6, Ally Murji 1 2 7 PMID: 33020832 DOI: 10.1093/humupd/dmaa033

4\. Cetera GE, Merli CEM, Facchin F, Viganò P, Pesce E, Caprara F, Vercellini P. Non-response to first-line hormonal treatment for symptomatic endometriosis: overcoming tunnel vision. A narrative review. BMC Womens Health. 2023 Jun 30;23(1):347. doi: 10.1186/s12905-023-02490-1. PMID: 37391793; PMCID: PMC10311799.

Disclosures: Dr. Guri Majak, MD, PhD has conflicts of interest to declare, receiving lectures and proctorship fees from Intuitive Surgical, lectures and courses fees from Olympus, and lectures fees as an expert-group member for Gedeon Richter; she also received honoraria from Medtronic. However, these industrial companies were never committed to the elaboration and running organization of Dr. Majak’s lectures and videos. There is neither commercial publicity nor commercial promotion in Dr. Majak’s lectures and videos.

Dr. Majak, MD, PhD declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Dr. Majak has no financial affiliations that would affect the content of her presentations.

Medical management of endometriosis: evolving strategies and treatment plans

Endometriosis surgery is complex, especially in advanced stages, and it could be associated with a high morbidity.

To prevent complications, either intraoperative or postoperative, it is recommended to preoperatively identify the different lesions, the size, the degree of infiltration, and the repercussion on adjacent organs. By using transvaginal sonography or magnetic resonance imaging, a preoperative mapping and a deep pelvic endometriosis index are easily obtained. It also allows to organize a multidisciplinary surgical procedure if needed, and to predict the risk of postoperative complications and the length of hospital stay. An appropriate multidisciplinary team organization will allow the optimization of the surgical procedure and will decrease the risk of complications.

Intraoperatively, the detection of minor and major complications is crucial and possible by following the different rules described in the literature. For example, in case of complex rectal perforation, a general surgeon must be called in order to repair the bowel. A similar collaboration is required in urological complications related to complex ureterolysis, in cases of large deep endometriotic nodules. If not detected intraoperatively, complications must be diagnosed as early as possible during the first 48 postoperative hours.

In conclusion, to prevent complications, a preoperative mapping and a thorough knowledge of the surgical rules are needed. Care must be taken to detect the complications as early as possible, and a multidisciplinary team should be involved for patient management.

Bibliography:

1\. Carole Abo, Salwa Moatassim, Noemie Marty, Mathilde Saint Ghislain, Emmanuel Huet, Valérie Bridoux, Jean Jacques Tuech, Horace Roman. Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril 2018 Jan;109(1):172-178.e1. doi: 10.1016/j.fertnstert.2017.10.001. PMID: 29307394 DOI: 10.1016/j.fertnstert.2017.10.001

2\. Working group of ESGE, ESHRE, and WES; Joerg Keckstein, Christian M Becker, Michel Canis, Anis Feki, Grigoris F Grimbizis, Lone Hummelshoj, Michelle Nisolle, Horace Roman, Ertan Saridogan, Vasilios Tanos, Carla Tomassetti, Uwe A Ulrich, Nathalie Vermeulen, Rudy Leon De Wilde. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open. 2020 Feb 12;2020(1):hoaa002. doi: 10.1093/hropen/hoaa002. eCollection 2020. PMID: 32064361 PMCID: PMC7013143 DOI: 10.1093/hropen/hoaa002

3\. Cristina Maciel, Hélder Ferreira, Dusan Djokovic, Jimmy Kyaw Tun, Jörg Keckstein, Stefania Rizzo, Lucia Manganaro. MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report. Insights Imaging. 2023 Jul 5;14(1):120. doi: 10.1186/s13244-023-01466-x. PMID: 37405519 PMCID: PMC10323073 DOI: 10.1186/s13244-023-01466-x

4\. Maria Alexandra Rocha, Gonçalo Mendes, Luis Ferreira Castro, Sofia Mesquita, Bernardo Lobão Teixeira, Mariana Madanelo, João Aragão Vital, Miguel Marques-Monteiro, Nuno Vinagre, Beatriz Oliveira, Martinha Magalhães, Paulo Príncipe, Hélder Ferreira, Miguel Silva-Ramos. Outcomes of Urinary Tract Endometriosis-Laparoscopic Treatment: A 10-Year Retrospective Study. J Clin Med. 2023 Nov 9;12(22):6996. doi: 10.3390/jcm12226996. PMID: 38002610 PMCID: PMC10672564 DOI: 10.3390/jcm12226996

Disclosures: Prof. Michelle Nisolle, MD, PhD has no conflict of interest to disclose. Prof. Nisolle declares that she is fully committed to maintaining professional autonomy and independence in relation with the medical device industry. Prof. Nisolle has no financial affiliations that would affect the content of her presentations.

Surgical complications in endometriosis: anticipation, management, and recovery

In this authoritative lecture, Professor Helder Ferreira Carvalho, MD, PhD, MBA delves into endometriosis, characterized by the presence of endometrial-like tissue outside the uterus, which affects approximately 1 in 10 women of reproductive age. This condition leads to significant complications such as chronic pain, infertility, and psychological challenges. Traditional surgical methods, including laparotomy and conventional laparoscopy, have limitations which can hinder patient outcomes. In contrast, robotic surgery offers notable benefits: improved precision, reduced tissue damage, quicker recovery, lower infection rates, and enhanced suturing accuracy. However, challenges remain, including high costs and a steep learning curve for surgeons. The session emphasizes the importance of patient perspectives and shared decision-making in treatment planning. Conclusively, while robot-assisted laparoscopy is increasingly playing a significant role in managing endometriosis, the future potential of integrating artificial intelligence (AI) with robotics promises further advancements in patient care. Professor Ferreira Carvalho, MD, PhD, MBA does not have any conflicts of interest to disclose.&#x20;

Transforming endometriosis management: advances in surgical innovations and robotics

Deep infiltrating endometriosis often involves the rectosigmoid colon, requiring advanced surgical management. Conventional approaches, such as segmental and discoid resections, carry significant risks. The previously described ‘en bloc’ hysterectomy technique combines hysterectomy with segmental rectal resection. This video introduces a novel surgical approach, the modified ‘en bloc’ hysterectomy, designed for cases requiring hysterectomy with concurrent intestinal involvement classified as #Enzian C2, enabling hysterectomy with intestinal discoid resections. This approach reduces the need for radical intestinal resection, minimizes complications, and enhances visualization of healthy structures, decreasing the risk of fistula formation and intestinal injury while reducing intraoperative time.



Introduction:

Deep infiltrating endometriosis (DIE) is characterized by the presence of endometrial-like tissue infiltrating beyond the superficial peritoneum. It is a complex disease which affects not only the reproductive organs but also adjacent structures such as the intestinal tract. It is estimated that between 5 to 37% of patients with DE present with rectal involvement, as one of the most common extragenital locations. Not only does this condition cause severe pelvic pain, but it can also trigger severe digestive symptoms such as constipation, pain during bowel movements, and, in some cases, partial bowel obstruction. Endometriosis excision surgeries with intestinal involvement present high complication risks, reaching 10 to 22% when colorectal resection is required. This is why such procedures should be performed by highly trained surgeons with an extensive knowledge of pelvic anatomy. When the intestine is compromised by endometriosis, the surgical approach will depend on different factors such as the size of the lesion and the extent and depth of parietal involvement. Different strategies may be considered, ranging from conservative techniques such as rectal shaving and discoid resections to a radical approach such as segmental resection.

Discussion:

As mentioned earlier, the intestinal approach will depend on the size of the lesion and the extent of the intestinal wall involvement. The discoid resection involves the excision of a disc-shaped portion of the anterior bowel wall. This procedure is mainly used for deep, yet localized lesions, #Enzian C1-C2, meaning less than 3cm in size. This technique is associated with less morbidity compared to segmental resections. Rather than removing a full intestinal segment, a disc of affected tissue is excised, minimizing damage to intestinal structures, and preserving function. It allows for a quicker recovery with a lower risk of complications such as infections and postoperative obstructions.

The segmental resection technique is used when the disease significantly affects a large portion of the bowel circumference, #Enzian C3, or when there are multiple deep lesions, meaning a multifocal disease. In this case, a complete intestinal segment is removed, and a primary anastomosis is performed to reconnect the healthy ends. Segmental resection carries a higher risk of complications, such as fistulas or dehiscence.

In intestinal endometriosis surgery, the priority is to adopt a conservative approach, aiming to preserve intestinal function. However, this approach is valid only if the complete removal of the disease can be ensured. Residual endometriotic tissue leads to persistence of the pathologic tissue, raising the risk of recurrence of symptoms and subsequently worsening patient quality of life. Consequently, the surgical intervention applied to each patient is carefully evaluated based on the severity of the intestinal involvement, thereby being an individualized decision.

The article entitled “A novel Technique for En Bloc Hysterectomy in the Treatment of Deep Endometriosis #Enzian C3 bowel nodules” published in 2023 by Cabrera R. and Kondo W. describes the “EBH” technique for the treatment of deep endometriosis with rectosigmoid involvement, specifically #Enzian C3 nodules. This technique involves the simultaneous resection of the uterus and the affected portion of the rectosigmoid through a segmental resection, reducing surgical time and providing a more efficient approach.

The benefit of the “EBH” technique is that it reduces the risk of complications by first accessing healthy planes of the rectovaginal space until Denonvilliers’ fascia is clearly visualized, before heading to the compromised areas, as it is clearly exposed in the video. This ensures better visualization and careful separation of the structures, minimizing the risk of intestinal injury during the dissection.

To perform the “EBH” technique, specific criteria must be met, such as ensuring that the intestinal nodule is at least 7cm from the anal margin. This is because a sufficient healthy distal margin is required to create the stapling line below the nodule.

In this video, we developed a modified ‘en bloc’ hysterectomy technique, as we are performing a hysterectomy combined with a conservative procedure, such as discoid resection instead of segmental resection. Although the surgery uses an ‘en bloc’ approach until the step of the anterior colpotomy with the intestinal nodule adherent to the posterior uterine surface; once the healthy space of the rectovaginal septum is dissected and identified between the posterior uterine surface and the bowel, the uterus is carefully separated from the intestine, allowing to perform a discoid resection of the affected bowel. This modified technique allows for intestinal-sparing surgery in patients where radical intestinal resection is not required, while still maintaining the previously and already published benefits of ‘en bloc’ hysterectomy for DE surgery.

The “EBH” technique is safer than the conventional approach to manage DE involving the rectum and posterior uterine surface. This technique allows the surgeon to mobilize the uterus more effectively. Once the anterior portion of the hysterectomy has been completed, the dissection of the rectovaginal septum becomes significantly easier. This increased mobility provides better visualization and access to the diseased area. This dissection is performed with the rectum and uterus still intact as a single unit, reducing tension and minimizing the risk of accidental bowel perforation. Once the rectovaginal space is adequately dissected, the rectum can be safely separated from the uterus without excessive traction or manipulation. This step is crucial, as direct attempts to separate the rectum from the posterior uterus at the start of the surgery, as in the conventional technique, often result in an increased risk of bowel perforation due to the fixed and adherent nature of endometriotic nodules.

 

Conclusion:

The modified ‘en bloc’ hysterectomy technique offers an effective low-risk surgical approach in patients with DE and intestinal involvement classified as #Enzian C1-C2. This technique emphasizes function preservation and minimizes complications, ensuring a better visualization of vital structures, and significantly reducing intraoperative time. It is a promising option for DE cases, which require intestinal resection.

Bibliography:

1\. Ramiro Cabrera Carranco, William Kondo, Andres Vigueras Smith, Eder Gabriel Rivera Rosas, Ulises Armando Menocal Tavernier. A novel technique for en bloc hysterectomy in the treatment of deep endometriosis Enzian C3 bowel nodules to optimize – video step by step approach \[Internet]. ISGE. 2023 \[citado el 28 de octubre de 2024]. Available on: [https://www.isge.org/2023/12/a-novel-technique-for-en-bloc-hysterectomy-in-the-treatment-of-deep-endometriosis-enzian-c3-bowel-nodules-to-optimize-video-step-by-step-approach/](https://www.isge.org/2023/12/a-novel-technique-for-en-bloc-hysterectomy-in-the-treatment-of-deep-endometriosis-enzian-c3-bowel-nodules-to-optimize-video-step-by-step-approach/). DOI: 10.36205/trocar4.vid20231

2\. Emile Daraï, Marcos Ballester, Elisabeth Chereau, Charles Coutant, Roman Rouzier, Estelle Wafo. Laparoscopic versus laparotomic radical en bloc hysterectomy and colorectal resection for endometriosis. Surg Endosc 2010 Dec;24(12):3060-7. doi: 10.1007/s00464-010-1089-8. Epub 2010 Jun 8. Available on: [http://dx.doi.org/10.1007/s00464-010-1089-8](http://dx.doi.org/10.1007/s00464-010-1089-8). PMID: 20532571 DOI: 10.1007/s00464-010-1089-8

3\. Gael Darlet, Arnaud Fauconnier, Joy Bloomfield, François Margueritte. Laparoscopic modified radical hysterectomy for women with stage IV AFS endometriosis and obliterated Douglas space: a technical note (with video). J Gynecol Obstet Hum Reprod 2023 May;52(5):102571. doi: 10.1016/j.jogoh.2023.102571. Epub 2023 Mar 11. Available on: [https://linkinghub.elsevier.com/retrieve/pii/S2468784723000387](https://linkinghub.elsevier.com/retrieve/pii/S2468784723000387). PMID: 36907512 DOI: 10.1016/j.jogoh.2023.102571

Deep endometriosis with intestinal involvement: laparoscopic modified 'en bloc' hysterectomy for #Enzian C1-C2 bowel nodules

Endométriose profonde avec atteinte intestinale : hystérectomie laparoscopique modifiée « en bloc » pour nodules intestinaux #Enzian C1-C2

Excision discale d'un nodule intestinal avec neuropréservation et myomectomie avec ligature temporaire de l'artère utérine dans un cas d'endométriose infiltrante profonde sévère

Background: Deep endometriosis (DE), particularly involving C2 #Enzian nodules, presents a significant surgical challenge due to its location and the complexity of surrounding anatomical structures. The reverse technique for disc excision has emerged as a promising approach, offering a method to improve surgical outcomes and reduce operative time. However, a standardized protocol is necessary to ensure consistency across surgical teams and to facilitate the training of fellows in this advanced technique.

Objective: The authors aim to propose a standardized procedure for the reverse technique in disc excision of C2 #Enzian nodules. The focus is on optimizing surgical efficiency, minimizing complications, and establishing a training framework for fellows in deep endometriosis surgery.

Methods: The reverse technique involves a stepwise approach where the nodule is approached from the posterior aspect, allowing for better visualization and control of the surrounding tissues.

Measurements and main results: Under general anesthesia, the patient was placed in a dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. The pneumoperitoneum was established using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10mm trocar at the umbilicus for the 0-degree laparoscope; a 5mm trocar at the right anterior superior iliac spine; a 5mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10cm inferior to the umbilical trocar; and a 5mm trocar at the left anterior superior iliac spine.

The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). Toldt fascia and retroperitoneum is dissected to find pelvic key structures (step 4). Vasopressin administration and myomectomy with intracorporeal suture (step 5). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using an ultrasonic scalpel (step 5). Reverse technique: the lesion is separated from the retrocervical area, and the posterior vaginal fornix is resected, leaving the disease attached to the anterior surface of the rectum (step 6). The lesion is shaved off the anterior rectal wall using an ultrasonic scalpel. (step 7). A debulking of the disease was achieved, leaving just the intramural nodule (step 8). The anterior rectal wall was resected using a 31mm transrectal stapler (step 9). A pneumatic test was performed to check the integrity of the suture (step 10).

Reverse technique: The laparoscopic reverse technique is an alternative approach to manage retrocervical or rectovaginal nodules infiltrating the anterior rectal wall. In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed in the conventional technique. This allows the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall due to the increased bowel mobility. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide on the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection).

Bibliography:

1\. Cabrera R, Tessmann Zomer M, Larrain D, Bourdel N, Canis M, Kondo W. Laparoscopic reverse technique for posterior rectovaginal deep endometriosis nodule step by step. J Minim Invasive Gynecol 2020 Mar-Apr;27(3):577-578. doi: 10.1016/j.jmig.2019.07.018. Epub 2019 Jul 25. PMID: 31352071

2\. Kanno K, Yanai S, Sawada M, Sakate S, Andou M. Nerve-sparing surgery for deep lateral parametrial endometriosis. Fertil Steril 2022 Nov;118(5):992-994. doi: 10.1016/j.fertnstert.2022.08.004. Epub 2022 Sep 25. PMID: 36171149.

3\. Kondo W, Bourdel N, Tessman Zomer M, Slim K, Botchorischvili R, Rabischong B, Mage G, Canis M. Surgery for deep infiltrating endometriosis: technique and rationale. Front Biosci (Elite Ed) 2013 Jan 1;5(1):316-32. doi: 10.2741/e618. PMID: 23276992

Nerve-sparing disc excision of endometriotic nodule and myomectomy using advanced techniques for severe deep infiltrating endometriosis

This video presents a laparoscopic surgical procedure performed in a 33-year-old female patient with deep endometriosis affecting the left parametrium, which resulted in ipsilateral hydronephrosis. The patient’s symptoms, imaging, and diagnosis indicated significant ureteral obstruction due to extrinsic compression by a parametrial endometriotic nodule. Given the severity of the condition, the surgical intervention was necessary to prevent further renal damage and alleviate the patient’s symptoms.

The surgery involved a delicate excision of a left parametrial endometriotic nodule and ureterolysis to relieve the ureteral compression, restoring the normal function of the left kidney. Key anatomical landmarks were identified and preserved, and the procedure was performed using advanced laparoscopic techniques to ensure minimal invasiveness, quick recovery, and optimal outcomes.

The video demonstrates the stepwise approach to managing complex cases of deep infiltrating endometriosis (DIE), offering valuable insights into surgical techniques for gynecologic surgeons. Special attention was given to the identification and preservation of critical structures, such as the ureter and hypogastric nerve, ensuring both safety and effectiveness. The procedure was successfully completed without complications, and the patient’s postoperative outcomes were uneventful. This educational resource provides essential tips for performing complex laparoscopic surgeries in endometriosis cases, with a focus on maintaining anatomical integrity and surgical precision.

Bibliography:

1\. Seracchioli R, Mabrouk M, Manuzzi L, Guerrini M, Villa G, Montanari G, Fabbri E, Venturoli S. Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol. 2008 Jul-Aug;15(4):435-9. doi: 10.1016/j.jmig.2008.03.005. PMID: 18588850.

2\. Seracchioli R, Mabrouk M, Mastronardi M, Raimondo D, Arena A, Forno SD, Mariani GA, Billi AM, Manzoli L, O'Guin WM, Lemos N. Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures. J Minim Invasive Gynecol. 2019 Nov-Dec;26(7):1340-1345. doi: 10.1016/j.jmig.2019.01.010. Epub 2019 Jan 29. PMID: 30708116.

3\. Querleu D, Cibula D, Abu-Rustum NR, Fanfani F, Fagotti A, Pedone Anchora L, Ianieri MM, Chiantera V, Bizzarri N, Scambia G. International expert consensus on the surgical anatomic classification of radical hysterectomies. Am J Obstet Gynecol. 2024 Feb;230(2):235.e1-235.e8. doi: 10.1016/j.ajog.2023.09.099. Epub 2023 Oct 1. PMID: 37788719.

4\. Kobylianskii A, Thiel P, McGrattan M, Barbe MF, Lemos N. Key Anatomical Concepts, Landmarks, and Proposed Terminology for Nerve-Sparing Gynecologic Surgery: A Narrative Review. J Minim Invasive Gynecol. 2024 Aug;31(8):641-652. doi: 10.1016/j.jmig.2024.05.013. Epub 2024 May 17. PMID: 38761917.

Minimally invasive surgery for deep infiltrating endometriosis: laparoscopic excision of an endometriotic nodule of posterolateral parametrium involving the ureter and the hypogastric nerve

Chirurgie mini-invasive pour endométriose profonde : excision laparoscopique d'un nodule endométriosique du paramètre postéro-latéral impliquant l'uretère et le nerf hypogastrique

Préservation de la fertilité dans l'endométriose : approche laparoscopique avec laser Argon

Endometriosis is a common condition affecting fertility in women, with up to 44% of patients presenting with ovarian endometriomas (1). Standard treatment options, such as cystectomy, are effective but can result in reduced ovarian reserve and fertility. Alternative approaches, including the use of the Argon laser for endometrioma treatment, may provide better outcomes for fertility preservation by minimizing damage to ovarian tissue (2).

This surgical video demonstrates a follicle-sparing technique using the Argon laser in the treatment of deep infiltrating endometriosis (DIE) and bilateral endometriomas in a nulligravida patient who has been attempting to conceive for three years. MRI findings revealed a 55mm right-side endometrioma, bilateral “kissing ovaries,” and rectosigmoid involvement. Despite a poor ovarian reserve (AMH at 0.55ng/mL), the authors prioritized a fertility-sparing approach.

Initially, alcoholization of the endometrioma was planned. However, during ultrasound-guided puncture, the cyst was ruptured, leading to the decision to switch to Argon laser treatment. Laparoscopic exploration revealed the rupture and the presence of a chocolate-colored fluid, characteristic of endometriomas.

During the procedure, endometriotic nodules were excised, followed by rectal shaving and precise Argon laser photocoagulation of the internal surfaces of the endometriomas. This technique offered controlled ablation of pathological tissue, preserving ovarian function while maintaining hemostasis. The laser’s 4,000-volt ionized plasma application allowed for the precise destruction of tissue without damaging surrounding healthy structures (3). Postoperative follow-up demonstrated excellent healing, with a significant regression of endometriomas and an improvement in the patient’s endometriosis fertility index (EFI) (4). The patient was referred to a fertility clinic for in vitro fertilization (IVF) with hypothetically increased chances of success.

This video highlights the efficacy of the Argon laser in treating endometriomas while preserving ovarian tissue, making it a valuable tool for fertility preservation in women with endometriosis.

  

Bibliography:

1\. Seraji S, Ali A, Demirel E, Akerman M, Nezhat C, Nezhat FR. Association between Ovarian Endometriomas and Stage of Endometriosis. J Clin Med. 2024 Aug 2;13(15):4530. doi: 10.3390/jcm13154530. PMID: 39124796; PMCID: PMC11313643.

2\. Keye WR Jr, Hansen LW, Astin M, Poulson AM Jr. Argon laser therapy of endometriosis: a review of 92 consecutive patients. Fertil Steril. 1987 Feb;47(2):208-12. doi: 10.1016/s0015-0282(16)49992-9. PMID: 2949998.

3\. Gale P, Adeyemi B, Ferrer K, Ong A, Brill AI, Scoccia B. Histologic characteristics of laparoscopic argon beam coagulation. J Am Assoc Gynecol Laparosc. 1998 Feb;5(1):19-22. doi: 10.1016/s1074-3804(98)80005-4. PMID: 9454871.

4\. Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril. 2010 Oct;94(5):1609-15. doi: 10.1016/j.fertnstert.2009.09.035. PMID: 19931076.

Fertility preservation in endometriosis: a laparoscopic approach with Argon laser

Focus on gynecologic surgery: treatment of endometriosis

Section antérieure droite hépatique par laparoscopie pour une tumeur du foie chez un enfant de 14 ans

This video presents the case of a laparoscopic liver right sectionectomy in a 14-year-old girl. Laparoscopic liver resections are not well-reported in pediatric oncology due to the low frequency of liver tumors in children. Published data are limited by several case series, and left lateral sectionectomy represents the most common indication. The resection of central liver segments is believed to be the most difficult type of resection, especially using a minimally invasive approach. Glissonian pedicle isolation according to Takasaki’s technique allows to reduce intraoperative blood loss and to provide a more precise anatomical hepatectomy. This video may be useful to pediatric surgeons and oncologists.

Bibliography:

1\. Moritz Schmelzle, Felix Krenzien, Wenzel Schöning, Johann Pratschke. Laparoscopic liver resection: indications, limitations, and economic aspects. Langenbecks Arch Surg 2020 Sep;405(6):725-735. doi: 10.1007/s00423-020-01918-8. Epub 2020 Jul 1. PMID: 32607841 PMCID: PMC7471173 DOI: 10.1007/s00423-020-01918-8

2\. Maciej Murawski, Marcin Łosin, Andrzej Gołębiewski, Katarzyna Sinacka, Irena Zabolska, Ewa Iżycka-Świeszewska, Piotr Czauderna. Laparoscopic resection of liver tumors in children. J Pediatr Surg 2021 Feb;56(2):420-423. doi: 10.1016/j.jpedsurg.2020.08.037. Epub 2020 Sep 17. PMID: 33046224 DOI: 10.1016/j.jpedsurg.2020.08.037

3\. Gabriele Calaminus, Dominik T Schneider, Dietrich von Schweinitz, Heribert Jürgens, Nacera Infed, Stefan Schönberger, Thomas A Olson, Peter Albers, Christian Vokuhl, Raimund Stein, Leendert Looijenga, Jalid Sehouli, Martin Metzelder, Alexander Claviez, Michael Dworzak, Angelika Eggert, Birgit Fröhlich, Nicolas U Gerber, Christian P Kratz, Jörg Faber, Thomas Klingebiel, Dieter Harms, Ulrich Göbel. Age-Dependent Presentation and Clinical Course of 1465 Patients Aged 0 to Less than 18 Years with Ovarian or Testicular Germ Cell Tumors; Data of the MAKEI 96 Protocol Revisited in the Light of Prenatal Germ Cell Biology. Cancers (Basel) 2020 Mar 6;12(3):611. doi: 10.3390/cancers12030611. PMID: 32155835 PMCID: PMC7139559 DOI: 10.3390/cancers12030611

4\. Claudius Conrad, Satoshi Ogiso, Yosuke Inoue, Nairuthya Shivathirthan, Brice Gayet. Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective. Surg Endosc 2015 Aug;29(8):2410-7. doi: 10.1007/s00464-014-3924-9. Epub 2014 Nov 13. PMID: 25391984 DOI: 10.1007/s00464-014-3924-9

Laparoscopic hepatic right anterior sectionectomy for a liver tumor in a 14-year-old child

Cystojéjunostomie par voie d'abord laparoscopique pour kyste biliaire intrahépatique solitaire congénital chez un nourrisson d'un an

Congenital solitary liver cysts are rare conditions, typically asymptomatic in infancy, and often discovered incidentally during imaging studies. The etiology remains unclear. However, hypotheses suggest that obstruction of aberrant bile ducts, possibly due to infection or vascular disruption during the fetal period, may contribute to cyst formation. Such cysts may present as simple cysts or intrahepatic biliary cysts.

The authors report the case of a full-term female infant with an antenatal suspicion of choledochal cyst. Postnatal abdominal ultrasound and MRI revealed an intrahepatic cystic mass crossing liver segments IVa, VII, and Vb, raising questions about a possible connection between the cyst and the right intrahepatic bile duct. The cyst could not be classified under the Todani classification. The infant remained asymptomatic since birth, with no abnormalities on physical examination.

At 20 months of age, the patient underwent a laparoscopic intervention. Intraoperative cholangiography confirmed the diagnosis of a solitary intrahepatic biliary cyst. A Roux-en-Y cystojejunostomy was performed. The procedure was uneventful, and the patient was discharged on postoperative day 3, remaining asymptomatic thereafter.

This case highlights the diagnostic challenges of congenital solitary liver cysts. Intraoperative cholangiography is crucial to define the anatomical relationship between the cyst and the biliary tree. Total excision is recommended for accessible solitary cysts, while internal drainage procedures, such as cysto-enterostomy or Roux-en-Y hepaticojejunostomy, are effective alternatives when excision is not feasible. These approaches ensure a safe and effective biliary system reconstruction.

Bibliography:

1\. Tutku Soyer 1, Ibrahim Karnak, Mehmet Emin Senocak. Congenital solitary intrahepatic biliary cyst in a newborn: report of a case. Surg Today 2007;37(6):521-4. doi: 10.1007/s00595-006-3442-z. Epub 2007 May 28. [https://pubmed.ncbi.nlm.nih.gov/17522776/](https://pubmed.ncbi.nlm.nih.gov/17522776/) PMID: 17522776 DOI: 10.1007/s00595-006-3442-z

2\. Anil Kumar Yadav, Jianghua Zhan, Shujian Zhang, Nita Yadav. Congenital solitary intrahepatic biliary cyst in infant: A rare case report. Journal of Pediatric Surgery Case Reports Volume 30, March 2018, Pages 64-67. [https://www.sciencedirect.com/science/article/pii/S2213576617302348?via%3Dihub](https://www.sciencedirect.com/science/article/pii/S2213576617302348?via%3Dihub)

3\. M B Macken, J R Wright Jr, H Lau, M C Cooper, E B Grantmyre, D L Thompson, M K O'Brien. Prenatal sonographic detection of congenital hepatic cyst in third trimester after normal second-trimester sonographic examination. J Clin Ultrasound 2000 Jul-Aug;28(6):307-10. doi: 10.1002/1097-0096(200007/08)28:6\<307::aid-jcu8>3.0.co;2-7. [https://pubmed.ncbi.nlm.nih.gov/10867671/](https://pubmed.ncbi.nlm.nih.gov/10867671/) PMID: 10867671 DOI: 10.1002/1097-0096(200007/08)28:6\<307::aid-jcu8>3.0.co;2-7

Laparoscopic Roux-en-Y cystojejunostomy for a congenital solitary intrahepatic biliary cyst in a 1-year-old infant

Primary hyperhidrosis is an idiopathic condition characterized by excessive sweat secretion, which has a significant impact on psychosocial well-being and overall quality of life. The palms, axillae, and soles are areas that are most commonly affected.

The authors report the clinical case and video of a 15-year-old girl followed in outpatient consultation for primary palmar and plantar hyperhidrosis. She underwent a thoracoscopic bilateral sympathectomy at the age of 14, targeting the T3-T4 levels, which resulted in significant improvement of palmar hyperhidrosis. However, due to persistent plantar hyperhidrosis, which continued to significantly affect her quality of life, a bilateral retroperitoneal lumbar sympathetic blockade was proposed and performed.

The retroperitoneal space was created and insufflated on both the right and left sides of the patient, and the sympathetic chain was identified at the L3 and L4 levels, along the medial aspect of the psoas muscle. The blockade was then performed using the Hem-o-Lok™ polymer ligation system. There were no intraoperative or postoperative complications, with minimal blood loss estimated. The patient presented with dry feet immediately after surgery.

Retroperitoneal lumbar sympathetic blockade is a safe and effective procedure for pediatric patients with plantar primary hyperhidrosis.

Bibliography:

1\. Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis. Sonia O Lima, Vanessa R de Santana, Daisy P Valido, Renata L B de Andrade, Leticia M Fontes, Victor Hugo O Leite, José M Neto, Jéssica M Santos, Lucas L Varjão, Francisco P Reis. J Vasc Surg 2017 Dec;66(6):1806-1813. doi: 10.1016/j.jvs.2017.05.126. PMID: 29169540 DOI: 10.1016/j.jvs.2017.05.126

2\. Retroperitoneoscopic lumbar sympathectomy for the treatment of primary plantar hyperhidrosis. Kyung Jae Hur, Hyong Woo Moon, Yong Hyun Park, Woong Jin Bae, Hyuk Jin Cho, U-Syn Ha, Ji Youl Lee, Sae Woong Kim, Sung-Hoo Hong. BMC Surg 2021 Nov 12;21(1):397. doi: 10.1186/s12893-021-01393-y. PMID: 34772374 PMCID: PMC8590320 DOI: 10.1186/s12893-021-01393-y

Retroperitoneal lumbar sympathetic blockage in a pediatric primary plantar hyperhidrosis

 Blocage rétropéritonéal du sympathique lombaire dans une hyperhidrose plantaire primaire chez l'enfant

A teenage boy presented with abdominal pain and a 3cm non-transfixing wound in the right umbilical region. He had fallen on his bike’s handlebars while cycling down a slope at high speed, without a helmet.

A CT-scan of the chest and abdomen found single air bubbles, intraperitoneal effusion, right common iliac artery dissection with focal subocclusive tight stenosis. The radiologists assured that the air bubbles were not specific; as a result, the patient was admitted to the pediatric surgery department. However, after a 2-day monitoring, and as strong pain persisted, a new CT-scan of the chest and abdomen showed a large amount of pneumoperitoneum, increased diffuse peritoneal effusion, perforation of the lower gastric wall, and a large left pneumothorax. An exploratory laparoscopy using the AirSeal® insufflation system, a valveless low-pressure device, highlighted a 3cm long open wound in the lower gastric wall. The stomach was sutured, and the abdominal and left pleural cavities were drained. The child was discharged home on postoperative day 14. After a 6-week and a 4-month follow-up, postoperative outcomes were uneventful.

Bibliography:

1\. Koirala DP, Shrestha BM, Kansal A, Poudel D, Neupane S, Dahal GR. Perforation of gastroesophageal junction, stomach, and diaphragm following blunt abdominal trauma: A near miss: A case report. Int J Surg Case Rep. 2021 Mar 17;81:105786. PMID: 33887842 PMCID: PMC8041729 DOI: 10.1016/j.ijscr.2021.105786

2\. Stringel G, Xu ML, Lopez J. Minimally Invasive Surgery in Pediatric Trauma: One Institution’s 20-Year Experience. JSLS 2016 Jan-Mar;20(1):e2015.00111. doi: 10.4293/JSLS.2015.00111. PMID: 26877626 PMCID: PMC4744998 DOI: 10.4293/JSLS.2015.00111

3\. George AK, Wimhofer R, Viola KV, Pernegger M, Costamoling W, Kavoussi LR, Loidl W. Utilization of a novel valveless trocar system during robotic-assisted laparoscopic prostatectomy. World J Urol. 2015 Nov;33(11):1695-9. PMID: 25725807 DOI: 10.1007/s00345-015-1521-8

4\. Tytgat SHAJ, Zwaveling S, Kramer WLM, van der Zee DC. Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma. Injury. 2012 Sep;43(9):1442-4. PMID: 21129741 DOI: 10.1016/j.injury.2010.11.002

Laparoscopic repair of gastric perforation after blunt trauma in an adolescent using the AirSeal® insufflation system: a case report and literature review

Traitement laparoscopique d'une perforation gastrique après traumatisme contondant chez un adolescent à l'aide du système d'insufflation AirSeal® : rapport de cas et revue de la littérature

Introduction: 

Chylothorax is a rare postoperative complication of congenital heart surgery. A staged treatment is the general principle to manage this serious complication. However, a failure of conservative therapy requires surgical ligation to prevent continued fluid and protein losses. 

Materials and methods:

This is the case of an 8-month-old girl with Down syndrome, weighing 7.7 Kg. She presented with chylothorax following a cardiac procedure, refractory to conservative management. 

Surgery was facilitated using a selective endotracheal intubation. 

A methylene blue colored cream was administered preoperatively to visualize the thoracic duct during the surgical procedure. 

A video-assisted thoracoscopic surgery was performed to treat the chylothorax in our patient. The procedure was performed in the right chest using four ports. 

The duct was controlled via a direct thoracoscopic application of clips and fibrin glue, at the level of the diaphragm, and using a mechanical and chemical pleurodesis. 

Postoperative outcomes:

No intraoperative complication was observed. Operating time was 2 hours. Oral intake was allowed on postoperative day 5. Chest tubes were removed on postoperative day 7. There was no recurrence at 2 months of follow-up. 

Conclusion:

Thoracoscopic duct ligation is a safe and effective procedure, facilitated by means of selective intubation in our case. 



Bibliography:

1. Thoracoscopic Thoracic Duct Ligation: How I Teach It. Evgeny V Arshava , Kalpaj R Parekh. Ann Thorac Surg, 2020 May;109(5):1330-1334. PMID: 32035916 DOI: 10.1016/j.athoracsur.2020.01.004 

2. Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review. Ioana Baiu, MD, MPH, Elorm Yevudza, BS, and Joseph B. Shrager, MD. Ann Thorac Surg, 2020 Apr;109(4):1294-1301. PMID: 31593652 DOI: 10.1016/j.athoracsur.2019.08.104 

3. Thoracoscopic pleural clipping for the management of congenital chylothorax. Margaret E Clark, Russell K Woo, Sidney M Johnson. Pediatr Surg Int, 2015 Dec;31(12):1133-7. PMID: 26276425 DOI: 10.1007/s00383-015-3760-6 

Thoracoscopic management of postoperative chylothorax

Traitement thoracoscopique d'un chylothorax postopératoire

Introduction:

Morgagni hernia is a rare congenital defect of the anteromedial portion of the diaphragm. This video demonstrates the robot-assisted repair of a Morgagni-Larrey diaphragmatic hernia using a laparoscopic approach.

Materials and methods:

The patient was a 17-month-old girl, weighing 11 kg. She was found to have a Morgagni-Larrey diaphragmatic hernia discovered as an incidental finding.

A thoracic radiography demonstrated the presence of an anterior diaphragmatic hernia, which was confirmed with a barium enema and a CT-scan.

The child underwent a laparoscopic repair of the hernia with the assistance of a robotic system.

The hernia sac contents were reduced. The diaphragmatic defect was then primarily closed using a 2/0 Ethibond suture in an interrupted fashion.

Results:

There was no intraoperative complication. Operating time was 3 hours. Oral intake was authorized on postoperative day (POD) 1. She was discharged on POD2. There was no recurrence at 6 months of follow-up.

Conclusion:

Robotic assistance offers improved vision and most particularly easiness for suturing and knot-tying. Despite the low weight of the child, the limited intra-abdominal space and decreased distance between ports did not pose any problem.

 

Bibliography:

1\. C Nistri, L Marinelli, A Di Giacomo, L Bonariol, M Massani. Robotic repair of a giant Larrey-type congenital left-sided diaphragmatic hernia in a young woman. A case report and literature review. Int J Surg Case Rep. 2022 Sep:98:107507. doi: 10.1016/j.ijscr.2022.107507. Epub 2022 Aug 13. PMID: 36027832 PMCID: PMC9424357 DOI: 10.1016/j.ijscr.2022.107507

2\. Colin G Knight, Kelly M Gidell, David Lanning, Attila Lorincz, Scott E Langenburg, Michael D Klein. Laparoscopic Morgagni hernia repair in children using robotic instruments. J Laparoendosc Adv Surg Tech A 2005 Oct;15(5):482-6. doi: 10.1089/lap.2005.15.482. PMID: 16185121 DOI: 10.1089/lap.2005.15.482

3\. M Anderberg, C Clementson Kockum, E Arnbjornsson. Morgagni hernia repair in a small child using da Vinci robotic instruments--a case report. Eur J Pediatr Surg 2009 Apr;19(2):110-2. doi: 10.1055/s-2008-1038500. Epub 2008 Jul 15. PMID: 18629776 DOI: 10.1055/s-2008-1038500

Robotic assisted repair of Morgagni-Larrey hernia in a 17-month-old girl

Cure d'une hernie de Morgagni-Larrey assistée par robot  chez une fillette de 17 mois

Traitement d'un neuroblastome du médiastin postérieur chez l'enfant par voie thoracique bilatérale

This video presents the case of a neuroblastoma of the posterior mediastinum. Neuroblastoma of the posterior mediastinum most often involves the thoracic aorta, intercostal arteries, and it often spreads into the spinal canal. This localization is classically the most frequent location site of neurogenic tumors. The patient underwent a one-step operation to remove a tumor from two hemithorax. This video may be useful to pediatric oncologists and surgeons.

Bibliography:

1\. Badiu Tișa I, Samașca G, Aldea C, Lupan I, Farcau D, Makovicky P. Ganglioneuroblastoma in children. Neurol Sci. 2019 Sep;40(9):1985-1989. doi: 10.1007/s10072-019-03932-1. Epub 2019 May 30. PMID: 31147856.

2\. Dingemann C, Ure B, Dingemann J. Thoracoscopic procedures in pediatric surgery: what is the evidence? Eur J Pediatr Surg. 2014 Feb;24(1):14-9. doi: 10.1055/s-0033-1350060. Epub 2013 Jul 12. PMID: 23852720.

Bilateral thoracoscopic approach in a child with posterior mediastinal neuroblastoma

Hepatobiliary ascariasis (HA) is a rare condition associated with significant morbidity. The laparoscopic extraction of Ascaris lumbricoides from the biliary tract is a safe approach in patients who do not improve with anthelminthic treatment and when endoscopic retrograde cholangiopancreatography (ERCP) is not feasible or when not all nematodes can be removed using this method. In this video, the author presents the technique used in pediatric patients with HA. 

Bibliography: 

1. Khuroo MS, Rather AA, Khuroo NS, Khuroo MS. Hepatobiliary and pancreatic ascariasis, World J Gastroenterol. 2016 Sep 7;22(33):7507-17. doi: 10.3748/wjg.v22.i33.7507. PMID: 27672273 PMCID: PMC5011666.

2. Canes M, Seaton C, Mawson J, Goldfarb DM, Kang KT. Biliary ascariasis and trisomy 21 in a child newly arrived to Canada. CMAJ. 2022 Oct 3;194(38):E1318-E1321. doi: 10.1503/cmaj.220089. PMID: 36191940 PMCID: PMC9529569.

3. Roy K, Das J, Mukherjee D, Kundu R. Pancreatic-Biliary Ascariasis in an Infant. Journal of Nepal Paediatric Society, October 2017, 37(1), 98-100. https://doi.org/10.3126/jnps.v37i1.16501

4. Hajaji K, Aljohary H, Althani H. Laparoscopic Management of Billiary Ascariasis: A Case Report and Review of Literature. World Journal of Laparoscopic Surgery. September-December 2010;3(3):113-115. doi: 10.5005/jp-journals-10007-1094

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