Introduction/Background Laparoscopic hysterectomy with bilateral salpingoophorectomy represents the gold standard technique in endometrial cancer. An unusual situation such an associated deep endometriosis freezing the pelvis may occur making the procedure a challenge even for very expert surgeons.
Methodology A 48-year-old patient referred to our center with a histological diagnosis of endometrioid endometrial cancer G1, FIGO Ia, MMS (mismatch repair stability), p53 wild-type. The pre-clinical staging performed with transvaginal ultrasound and magnetic resonance, showed besides a picture of retro-cervical and rectum endometriosis and multiple pelvic adhesions. According to the guidelines the surgical planning is laparoscopic hysterectomy and bilateral salpingoophorectomy.
Results The operation situs showed an extremely complex situation, thus the so-called frozen pelvis. Neither the uterus nor the adnexa were identifiable. The anterior compartment was overturned by the bladder that was cranially stretched totally covering the uterine fundus. The posterior compartment was even more subverted by strong adhesions and fibrosis that brought the sigma to cover the uterus until the fundus. The adnexa were inextricably embedded to the sigma, the pararectal tissue, the posterior broad ligaments and uterosacral ligaments. During the procedure a large endometriosis nodule was detected between the uterosacral ligaments and the broad posterior ligament infiltrating the retro cervical tissue, pararectal tissue e anterior rectal wall at two different levels creating a clepsydra rectal stenosis. The ureters appeared medialized form the fibrosis without sign of infiltrating endometriosis.
Conclusion Our surgical approach requires carefully evaluation and systematic and replicable steps that will help mostly in any situation. This video will show, with a step by step short description, how to perform a challenging mini-invasive surgery.
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