Excision of endometriosis – optimising surgical techniques

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Excision of Endometriosis – Optimising Surgical Techniques Fleischer K et al. Excision of endometriosis – optimising surgical techniques. TOG 2021;23:310–317. doi:10.1111/tog.12762

3 6 PDS 2-0 DISEASE ENTITIES: PERITONEAL, OVARIAN, SOSURE MNEMONIC STEPS SUTURE FOR OVARIAN SUSPENSION DEEP

DO N' T-M IS S FA C TS

1. SOSURE = Survey/sigmoid → Ovarian mobilisation → Suspension → Ureterolysis → Rectovaginal/pararectal entry → Excision (flexible framework, not rigid order)

2. 3 disease entities: peritoneal, ovarian, deep endometriosis

3. Sigmoid mobilisation: cut the "white line of Toldt" just medial to the peritoneum

4. Ovarian suspension: PDS 2-0, 4–5 cm below lateral ports, left 5–7 days, removed in the community

5. Uterine suspension > uterine manipulator for stable anteversion; manipulator still needed for tubal patency testing or hysterectomy

6. Ureterolysis: start in normal tissue, avoid energy near the ureter, keep adventitia intact; stent only if hydroureter or intraoperative concern

7. "Butterfly area" = bilateral sidewalls + uterosacral ligaments + torus uterinus; protect hypogastric nerves/inferior hypogastric plexuses during excision

SOSURE AT A GLANCE

S: Survey/sigmoid O: Ovarian mobilisation S: Suspension U: Ureterolysis R: Rectovaginal/pararectal

E: Excision

ABBREVIATION KEY

BSGE — British Society for Gynaecological Endoscopy PDS — polydioxanone suture (non-braided)

SOSURE — Survey/sigmoid, Ovarian mobilisation, Suspension, Vicryl — polyglactin 910 braided suture Ureterolysis, Rectovaginal/pararectal entry, Excision — mnemonic for PoD — Pouch of Douglas structured excision

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — Fleischer K et al. Excision of endometriosis – optimising surgical techniques. TOG 2021;23:310–317. doi:10.1111/tog.12762

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