Tigers in the Sidewall: Surgical Approaches to Excision of Lateral Deep Infiltrating Endometriosis.

OBJECTIVE: To describe the surgical approaches and excisional techniques used in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall. DESIGN: A technical video showing the excision of advanced lateral DIE. SETTING: An academic tertiary care hospital. INTERVENTIONS: A 32-year-old woman, gravida 2, para 1, presented for definitive surgical management of endometriosis-associated pelvic pain. Intraoperative findings revealed severe retroperitoneal fibrosis tethering the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament, and ureter. The patient underwent laparoscopic management of the DIE involving the lateral pelvic side wall. We demonstrate the surgical methods and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we used a nontraditional surgical approach by tunneling under the external iliac vascular to tackle the dissection from a lateral to medial direction to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule. CONCLUSION: Extreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical to overcome unexpected lateral pelvic side wall endometriosis because the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master these difficult endometriotic resections.