Total Laparoscopic Hysterectomy in Severe Endometriosis

PROGRAM:

1. Welcome and Introduction

Overview of the session and learning objectives.

2. Case Presentation

1. Patient: 45-year-old woman referred from the reproductive medicine clinic.
   
   
2. Clinical Background:
   

   • History of secondary subfertility.

   • One previous vaginal delivery (8 years ago).

   • Diagnostic laparoscopy revealed obliteration of the pouch of Douglas and left adnexa.

   • MRI showed adenomyosis, a left ovarian endometrioma adhered to the recto-sigmoid, and deep infiltrating endometriosis.

   • After multidisciplinary discussion (including colorectal team), the decision was made to proceed with Total Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy and excision of endometriosis.

3. Surgical Procedure – Steps
   
   1. Diagnostic Laparoscopy
      Assessment of the extent of disease, adhesions, and organ involvement.

   2. Adhesiolysis
      Systematic and careful dissection of pelvic adhesions using sharp and energy-based techniques.

   3. Ureterolysis
      Mobilization of ureters where necessary to prevent injury and ensure anatomical clarity.

   4. Bladder Dissection
      Separation of the bladder from the uterus and cervix, particularly in fibrotic or infiltrated planes.

   5. Rectovaginal Space Dissection
      Mobilization of the rectum from the posterior cervix and vagina. Excision of nodules if present.

   6. Ligation of Uterine Vessels
      Skeletonization and sealing at the uterine isthmus with ureter identification.

   7. Colpotomy
      Circumferential incision at the vaginal cuff using energy devices.

   8. Specimen Removal
      Transvaginal extraction or morcellation (if no malignancy suspected), with endobag to prevent spillage.

   9. Vaginal Cuff Closure
      Performed laparoscopically or transvaginally using delayed absorbable sutures.

   10. Final Inspection
       Hemostasis check and assessment for possible ureteral or bowel injury.

4. Closing remarks