Laparoscopic Excision of Obturator Nerve Endometriosis: A Stepwise Approach скачать в хорошем качестве

Laparoscopic Excision of Obturator Nerve Endometriosis: A Stepwise Approach

This video demonstrates a stepwise laparoscopic approach to excising endometriosis from the obturator nerve. The obturator nerve arises from the L2–L4 roots of the lumbar plexus, travels through the psoas muscle deep to the common iliac vessels, and exits via the obturator canal. It supplies the medial thigh with motor and sensory fibres. Obturator nerve endometriosis is a rare form of deep infiltrating endometriosis. It should be suspected in patients with cyclical leg pain or paraesthesia, thigh adduction weakness, or difficulty walking. MRI is the imaging modality of choice, and early treatment is essential to avoid chronic neuropathy. Safe excision of an obturator nerve nodule requires a clear understanding of pelvic spaces. In a lateral view of the pelvis, the obturator nerve lies in the iliolumbar space between the psoas muscle and the external iliac vessels; care is required to avoid the genitofemoral nerve. Endometriosis nodules may be found proximally in the iliolumbar space, distally in the obturator space, and medially within the lateral pararectal space. We present a 30-year-old woman with Stage 4 endometriosis identified on prior laparoscopy, reporting severe pelvic and leg pain. MRI revealed adenomyosis, a deep rectovaginal nodule, severe hydroureteronephrosis from a ureteric nodule, and a 1.6 cm lesion on the left obturator nerve. She had failed medical therapy and consented to laparoscopic excision of the obturator nodule, along with ureteral reimplantation and rectal disc excision. The excision followed six key steps: abdominal survey; sigmoid mobilisation when operating on the left; iliolumbar space dissection; pararectal space dissection with ureterolysis; obturator space dissection; and nodule release and excision. Initial survey showed Stage 4 disease with a rectovaginal nodule, a dilated left ureter, and deep disease in the left pelvic sidewall. After adequate sigmoid mobilisation, dissection began lateral to the left infundibulopelvic ligament to enter the retroperitoneum. The psoas muscle was identified with the genitofemoral nerve coursing superficially. Medial traction revealed the external iliac vessels and the medialised dilated left ureter and ovarian vessels. Dissection continued medial to the psoas and lateral to the external iliac vessels to develop the iliolumbar space, maintaining meticulous haemostasis as depth increased. The external iliac vessels were gently medialised to improve visualisation of the proximal obturator nerve. Lateral and medial dissection along the nerve delineated its course and the proximal margin of the lesion. Attention then turned medially. The dilated ureter was traced caudally to the transition point caused by deep infiltrating endometriosis, and the lateral pararectal (Latzko) space was developed. The round ligament was transected, and the anterior and distal margin of the lesion was delineated along the left round ligament toward the left perivesical space, identified by the obliterated umbilical ligament. The lesion was identified near the bifurcation of the external and internal iliac vessels. Dissection proceeded deeper until the obturator nerve was found medially within the obturator space, similar to the approach used for obturator lymph node dissection in gynaecologic oncology. A triangular lesion extending from the obturator nerve toward the left round ligament and the dilated left ureter was then gently released and excised from the nerve, avoiding thermal injury or traction trauma. The dissected obturator nerve was visualised both from the initial iliolumbar space and medially from the obturator space. The medialised lesion was excised in its entirety, completing this portion of the operation. The remainder of the planned surgery was then performed. At six weeks postoperatively, the patient reported resolution of leg pain and improved pelvic symptoms. Pathology confirmed active glandular endometriosis along the obturator nerve. Recognising rare forms of deep infiltrating endometriosis is essential. MRI is valuable for preoperative planning, and safe, complete excision of obturator nerve disease requires detailed knowledge of pelvic spaces, careful dissection, and a stepwise approach.