Setting Up for Success: A Step-Based Approach to Excision of Deep Infiltrating Endometriosis Involving the Pelvic Nerves

Presented by:

Sara-Michelle Gratton

Affiliations:

The Ottawa Hospital

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What is Excision of Deep Infiltrating Endometriosis Involving the Pelvic Nerves? 

Excision of deep infiltrating endometriosis involving the pelvic nerves is a complex laparoscopic procedure used when endometriosis extends into or around nerves such as the sacral nerve roots, sciatic nerve, or pudendal nerve. Surgery aims to remove the disease, relieve pain and neurologic symptoms, and preserve nerve function wherever possible. Here’s what it involves:

• Preoperative Evaluation: Symptoms, neurologic findings, previous treatments, and surgical history are carefully reviewed to determine the extent and potential impact of nerve involvement.
• Advanced Imaging and Planning: MRI and expert radiologic review are used to map endometriosis and its relationship to nerves, blood vessels, and other pelvic structures. Additional tools such as three-dimensional modeling may be used for particularly complex cases.
• Retroperitoneal Dissection: The retroperitoneal spaces are systematically developed to establish normal anatomical landmarks and safely approach the affected nerves.
• Nerve Identification: Relevant sacral nerve roots and branches of the pelvic nervous system, including the sciatic or pudendal nerves when involved, are carefully identified.
• Nerve-Sparing Dissection: Endometriotic lesions and surrounding fibrosis are meticulously separated from neural structures while attempting to minimize manipulation and injury to healthy nerves.
• Excision of Deep Endometriosis: Diseased tissue is removed from the affected pelvic compartments while protecting nearby ureters, blood vessels, bowel, and pelvic organs.
• Restoration of Anatomy: Adhesions and fibrosis are addressed to restore normal relationships between nerves and surrounding pelvic structures where possible.
• Final Assessment: The operative field is inspected for bleeding and the integrity of exposed neural and surrounding structures is reassessed before completing surgery.

This highly specialized approach combines detailed preoperative mapping with precise nerve-sparing dissection to treat endometriosis involving some of the pelvis’s most sensitive anatomical structures.

What are the Risks of Excision of Deep Infiltrating Endometriosis Involving the Pelvic Nerves?

Surgery involving the pelvic nerves carries additional risks because even small injuries to neural structures can potentially affect movement, sensation, and pelvic organ function.

• Nerve Injury: Direct injury, traction, thermal damage, or disruption of a nerve’s blood supply can cause temporary or permanent neurologic deficits.
• Motor or Sensory Changes: Injury to the sacral roots or sciatic nerve may result in leg weakness, numbness, altered sensation, neuropathic pain, or difficulty walking.
• Bladder or Bowel Dysfunction: Damage to nerves controlling pelvic organs can lead to urinary retention, changes in bladder sensation, constipation, or other bowel dysfunction.
• Sexual Dysfunction: Injury to pelvic autonomic or pudendal nerves may affect genital sensation or sexual function.
• Vascular Injury and Bleeding: Major pelvic blood vessels lie close to many of the relevant nerves and can be injured during deep retroperitoneal dissection.
• Ureteral or Bowel Injury: Extensive endometriosis can distort normal anatomy and involve structures adjacent to the affected nerves, increasing the risk of unintended injury.
• Incomplete Excision or Recurrence: Disease directly involving critical nerve tissue may not always be safely removable, and endometriosis or associated symptoms can recur.
• Persistent Neuropathic Symptoms: Pain, numbness, or other neurologic symptoms may persist even after successful removal of visible disease, particularly when longstanding nerve damage is present.
• General Surgical Risks: Infection, blood clots, anesthesia-related complications, postoperative adhesions, and conversion to open surgery are possible.

Detailed preoperative mapping, systematic retroperitoneal dissection, clear identification of neural anatomy, and meticulous nerve-sparing technique help reduce these risks while allowing treatment of complex nerve-involving endometriosis.