 Hi everyone. So, this time we are going to show you a case in which it was suspected to be a cancer of the ovary, it was suspected multi septate complex ovarian cyst. But on entering the abdomen on a diagnostic scope it turned out to be a complex ovarian mass which was actually endometriosis. So, it was a left side ovarian endometriosis, there were implants, the chocolate cyst and the usual presentation was the adhesions that are actually very, very precarious and very difficult to understand in endometriosis. So, this whole video is about tackling difficult scenarios again, how to do a safe dissection in a case of endometriosis doing it laparoscopically. So, the most important step as we all know in endometriotic surgery is to enter the retropyrtonium and do all the dissection by the retropyrtonial approach. So, what we are doing here is we are identified, we have identified and held the ovarian ligament with our left hand forceps and what lies medial to the ovarian ligament or the infundible pelvic ligament which has the gonadal and the ovarian vessels is the ureter. So, we are trying to dissect and go into the retropyrtonium layer by layer by just incising the pelvic peritonium first and then the underlying fascia and fat and then to look for the ureters which will lie somewhere medial to the infundible pelvic ligament. So, as we are going ahead our first step in endometriosis as you can see in this case the left ovary and the fibril and the fallopian tubes are stuck to the left peritonium, the para rectal peritonium, the rectum and the left utero sacral and so is the rectum attached on to the right recto sacral obliterating the recto uterine pouch. Now, we have identified the ureter on the left side which is you can see the pedestalsis. This ureter always lies medial to the infundible pelvic ligament. You can subscribe to our YouTube channel in which we have also detailed on the pelvic anatomy, how to do a radical hysterectomy also about the pelvic arterial anatomy identifying the internal iliac artery, the external iliac artery because ultimately if your anatomy is perfect then you can actually tackle such scenarios in your practice and these scenarios do not inform you before they encounter before you encounter them in your practice. This in this case we had we planned to do a diagnostic scopy and then probably a leprotomy for CA ovary, carcinoma of the ovary, the CA-125 was high, the ovarian cyst had papillary projections on MRI and ultrasound. We thought it to be a malignancy of the ovary but on a diagnostic scopy turned out to be endometriosis so we are proceeding with laparoscopy. We have just cut the round ligament on the left side. We are trying to mobilize the whole of the specimen so that we can release the adhesions. So, this is the part of the rectum which has obliterated the whole pouch of Douglas. You cannot see the pouch of Douglas perfectly clearly. Now you can see the attachments of the or the adhesion pulling the rectum and the above overlying peritoneum to the right utero sacral. So, you cannot see the right side of the utero sacral properly. In this it is very difficult to do a routine laparoscopic hysterectomy that we usually do hence it is very important to delineate the important structures. You can see the chocolate cystic fluid flowing down. So, it is very important as I was saying very important to identify all the vital structures. Go in the retroperitoneum, identify the external the internal iliac arteries as we have shown how to delineate them in our previous YouTube videos. You can again subscribe to those YouTube videos our channel so that you can get regular updates. So, in our previous videos we had detailed on how to identify the external iliac, the internal iliac artery and the veins and the ureters safely. So, again we are identifying the right infundible pelvic ligament and the medial to the infundible pelvic ligament lies the ureters. As you can see the right side of the ureter the infundible pelvic ligament is held high up and we are trying to isolate the infundible pelvic ligament on the right side so that we can ligate it. So, you can see the infundible pelvic ligament as marked by the arrow and you can see the ureters medial to the infundible pelvic ligament somewhere here. So, you can see the ureters over here you can see the infundible pelvic ligament being gothrized and cut. So, this is the harmonic HD1000i it is the latest harmonic very useful has very good maneuverability. The claws are very much like a maryland which help you to dissect each layer and tissue by tissue and also has very effective coagulation and cutting a very high end instrument very useful instrument. So, what we are doing over here is the approach to endometriosis is by going into the retroperitonium first. So, we do not go right directly into the pouch of Douglas or the peritonium inside but we incise a little part of the peritonium then go behind in the retroperitonium and look for the plane that is the lus aeola tissue and the fat we all know that the fat belongs to the rectum. So, we stay above the fat the fat goes down we are staying above the fat in doing so we are keeping the the ureters laterally. So, we are lateralizing the ureters in order to make our dissection very safe and once we have cut this part of the peritonium as you can see now we go into the retroperitonium and bring down as much as rectum as you can and then again incise little bit of the peritonium and then again push the rectum down you can see the lus aeola fatty tissue coming up over here yes now you can see that now you can do a blunt dissection how we are going to do the blunt dissection and going to push all the fibro fatty tissue down. So, you are pushing the rectum down by pushing the fat down you are pushing the rectum down by doing all the dissection medial to the ureter you are actually dissecting medial to the ureter to lateralize the ureter to the right side. So, there are two important structures in any hysterectomy one is the rectum the bladder and of course the both ureters on the side and that is what we are going to show in this video how to delineate the anatomy how to identify the ureters and push them down and when the pouch of Douglas the utrosacral that is the usual area where endometriosis has maximum adhesions and difficulty in doing the dissection in this area. So, now what we are doing is identifying our ureter you can see the right side of the ureter over here and we are dissecting all the fibro fatty tissue from all around the ureter pushing the ureter down away from our specimen away from the dissection you can see the cervix coming up over here and all this rectum and the fat of the rectum is being pushed down. So, the moment we go into this plane we are in the wrong plane but when we go in this plane we are in the right plane and this plane is identified by first going into the retroperitonium and pushing all this fibro fatty tissue down and then incising the rest of the pelvic peritonium in this part and you can see the tunnel of the ureter the tunnel of the ureter is created and we are just going to go medial to the ureter so that we can push the ureter to the right side and lateralize the ureter away from our uterus and the cervix whereas the utrine vein which comes from below the ureter so you can see the dissection of the utrine vein again separating separating out the attachments from the ureter so once you know that the ureter is away from your specimen again it makes lot of things much much simpler and much easier now again we are going to the right plane now we know that we have pushed the rectum down so now we can cut this part of the peritonium again I am just seeing whether I can mobilize the left ovary or not so I again see that it is very difficult to do it still there is lot of adhesion of the left side of the ovary with the left uterus sacral and the peritonium of the rectum and the left pelvic peritonium and these adhesions will go on slowly and steadily as and when we proceed and we mobilize these specimen from all sides so this is not a frozen pelvis I would not say that this is a frozen pelvis but yes the adhesion the adhesions that we have with the rectum as you can see we are again pushing the fatty part of the rectum down and once the rectum is pushed down we incise the pelvic peritonium that is the recto uterine pouch or the peritonium exposing the cervix and the posterior wall of the vagina now all this in cases of endometriosis is done by first entering the pelvis by the retroperitonial approach pushing all the fibro fatty tissue down and then only incising the overlying peritonium so again you can see before incising the peritonium we we are now pushing the fat of the rectum and the loose aerial tissue down and then we incise the overlying peritonium now if you can appreciate we can see the posterior wall of the vagina you can see the blunt dissection when we do the blunt dissection we are in the right plane because then there is no bleeding again we have pushed the rectum down and incising the overlying peritonium that is the pouch of Douglas now the rest of the u-cut posterior u-cut that is from the pelvic peritonium up to the pouch of Douglas has been done from the right side now and now we have to incise the same peritonium starting from the left side up to the pouch of Douglas and in turn by doing so we will also try to identify the left side of the ureter and also try to mobilize the left ovary which is the complex mass the chocolate cyst away from the peritonial attachments now if I have pushed I have asked the assistant surgeon to push the uterus on the right side pull the rectum behind and incising right above the ureter so this is the ureter what we have incised and overlying the ureter the pelvic peritonium is what we are going to incise now by doing so the specimen the right the left side of the ovary also get mobilized see now you can see the pouch of Douglas clearly now slowly and steadily we know that the ureter is down here we know the fat belongs to the rectum as always and we will try to push this peritonial attachment with the ovary above towards the specimen above and leave the ureter down again incise the peritonium go into this retroperitonial lose areola tissue which is the avascular plane and connect this posterior u cut right going above and then curve medially as I can show you with my cursor and meet the posterior u cut overlying this cervix which is the the peritonium that we had cut from the right side this is an unedited video of how to tackle difficult scenarios especially in endometriotic surgery which is a very difficult surgery for any surgeon or gynecologist so now we have totally separated out the underlying ureter over here from the infundible pelvic ligament on the left side so the left-sided endop in fundable pelvic ligament is cauterized coagulated and cut with HD 1000 harmonic the overlying ovary has its attachments with the overlying pelvic peritonium and underline this attachment is the ureter you can see such close is the attachments or the adhesions of the overlying adnexa the left-sided nexa with the ovary it is very important to separate out these vital structures before going ahead into the pelvis and taking the parametric so you can see the the ureters are pushed down so if i'm pushing the ureters down as well as lateralizing the ureter onto the left side i've also completed the posterior u cut this is the tunnel part of the ureter the same we had seen on the right side and what crosses above the tunnel is nothing but the uterine artery we are coagulating it and cutting that eventually so again i know my plane of dissection is safe if you can appreciate this is the uterine artery which crosses above the ureter medially from lateral to medial you can see the reflection of the uterine artery over here yeah so now you can see it much more clearly this is the uterine artery which crosses from the internal iliac to the medial side you can see the the ureter also curving towards the uterosecral so we have to be very careful with the uterosecral over here because in endometriosis the uterosecral pulls everything into itself that is where the ureters also get pulled in the rectum also gets pulled in so now this part of the pouch of Douglas or the pelvic peritoneum is going to get cut and as you all know that the fat belongs to the rectum belongs to the rectum so we push all the fat down to the rectum all the fat should be considered as a part of rectum to perform a safe surgery now we have achieved that plane of dissection you can see the loose fibro ureola tissue over here so we're going to just cut that loose fibro ureola tissue pull the rectum down give a good traction on the uterus above and the rectum down so you can subscribe to our youtube channel for other youtube videos such as the pelvic anatomy pelvic anatomy for rectal surgeries for gyne oncologists for gynex surgeons how to identify the internal iliac artery and the uterine artery at origin so you can see the posterior vaginal wall over here and all the loose ureola tissue is being separated out from the posterior vaginal wall anteriorly and we're taking all the we're taking down all the fibro fatty tissue keeping in mind that ureter is running lateral and we slowly and steadily release all the attachments along the ureter as well this is the area of the uterus sacral where everything gets pulled in and we have first separated out the rectum and its attachment and then the ureter now we go back and the fourth vital structure apart from the two ureters and the rectum is the bladder and we're just going to push the bladder down again in size the overlying bladder peritoneum where the peritoneum covers the bladder and makes a u-turn and covers the uterus just in size that peritoneum wait for two minutes let all the carbon dioxide and under pressure go in seep into these spaces and they do half of the job that that you need to do so at the end what you have to do is just in size and push in size and push the structures because you know that you are going to dissect in the right plane so again we're just in sizing and pushing the bladder down this part of the surgery can be safely performed with the monopolar forceps you can see we are staying right above the uterine artery it's a very safe area to be in to be above just above the uterine artery as you all know that the ureters will run always underneath the uterine artery so relatively a very safe area this is usually performed to push the bladder pillars laterally and also which assists in pushing the bladder away from the cervix so we have pushed the whole bladder down now we do the regular dissection create the pedicles on both the sides it's a this is a surgery for for chocolate cysts of the ovary which we thought was suspected ovarian malignancy so we're developing the pedicles on the left side and then on the right side now these instruments have made our life much easier the harmonic thousand and also the ligature both of these are extremely valuable and extremely important instruments in taking the uterine vessels either near the uterus or they can also be taken with these vessels without ligating them at the origin now you can see that the demarcation of paracolpus from the cervix we're just going to develop these pedicles you can see the ureters over here you can see the uterine artery coming right above the ureters and crossing medially onto the cervix and go above parallel to the cervix and the uterus to meet the ovarian vessels from above just going to do the paracolpus dissection again ensuring by blood dissection to push the whole of the bladder down just to be on the safer side ensuring it yet already pushed all of the uterus already behind and down on the same dissection that was done on the left side has to be repeated again on the right side also now yet again ensuring that the whole of the bladder is down just just to be sure so you can see the bladder pillars have gone down the whole of the bladder is already pushed down we're not used to using much of retractors from below that is the uterine manipulators and the vaginal cuffs in onco surgeries we don't use that very often but in such surgeries like the endometriosis surgery when the adhesions are even much more presently in this video the adhesions were not as much as we generally see in lot of endometriosis but then when the adhesions are very strong then the use of these uterine manipulators and vaginal cuffs are very important as they help in giving you a good traction and having a very good dissection between the tissues between the vagina the cervix and the rectum or the bladder when the adhesions are very dense in cases of frozen pelvis when we have encountered these cases I presently feel that endometriotic surgeries it's very important to show videos which are unedited because how we retract tissues how we dissect between the tissue is very important and that can only be seen in edited videos unedited videos I'm sorry rather than the edited videos which do not actually send the right message across so now what we are doing is we are developing this pedicle of uterine artery so uterine pedicles are being developed right up to the vagina and the cervix I think the vagina is already we are at that intersection and we'll do a colpotomy yeah so the colpotomy is done and and the surgery is finished by doing a intracorporeal suturing we cannot go into the details of it so that was all about endometriotic surgery you can subscribe to our youtube channel for other videos as well and here we come to the end of the video thank you very much