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To present a standardized and reproducible approach for the surgical excision of deep endometriosis in the rectovaginal septum, represented by #ENZIAN A. Surgical video article. A tertiary referral center. The case of a patient with an isolated endometriotic nodule in the rectovaginal septum was used to illustrate the surgical technique, also referred to as the butterfly method. An Intuitive Xi DaVinci system was used at the tertiary referral center, IFEMEndo in Bordeaux, France. Patient consent was obtained. Step-by-step approach for the excision of endometriosis in the rectovaginal septum. This educational film presents a systematic approach dividing the surgical procedure into following six steps: 1. Adhesiolysis and identification of the decisive structures such as the sacrouterine ligament, ureter, and nervus hypogastricus on both sides. 2. Dissection of the Okabayashi pararectal space with preservation of the plexus hypogastricus. 3. Incision of the pararectal space medial to the sacrouterine ligament. 4. Dissection of the rectovaginal septum and detachment of the rectum in a caudal direction. 5. Resection of the entire endometriotic nodule, depending on the depth of invasion. 6. Closure by suturing when transvaginal resection was performed. We used the metaphor of the butterfly because it comprehensively and pictorially reflects the resection line of the endometriotic nodule in the rectovaginal septum. Surgical management of rectovaginal endometriosis can be challenging and requires as much as possible the preservation of autonomic nerves. A systematic approach enables the endoscopists to perform a safe and complete removal of the lesion. [ABSTRACT FROM AUTHOR]

To evaluate the intraoperative visual effect of treatment with GnRH-analogues and Dienogest in endometriosis. Retrospective observational study. Every laparoscopy from all the different disciplines in our hospital is documented on video and stored in a database. The study was approved by the local ethics committee. A total of 193 patients with histological proven endometriosis from 2007 to 2021 were included, who underwent 2-step surgical procedure. Indications were endometrioma before CO2-Laser therapy, missing consent because of emergencies or other surgeries from other disciplines, or high active and extended disease. When endometriosis was suspected in a surgery conducted by other disciplines, a gynecological surgeon was called during the surgery. Data and intraoperative videos were reviewed by 2 independent reviewers at one referral center. Only cases with available video of first and second look laparoscopy were included. We excluded patient who had prior hormonal treatment in the last 6 months. Lesions were classified according to the description of Khan et al. Statistical analysis was performed using SPSS (Version 27.0, IBM). Mann-Whitney U test (nonparametric analysis) and χ2 tests were applied. Percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. Significance level was set to p <.05. Seventy-seven received GnRH-analogues and 116 Dienogest for preoperative hormone down-regulation. The median duration of down-regulation with GnRH-analogues or Dienogest was 3 months. The mean age was 32.3 (SD 6.3) years for GnRH-analogues and 32.6 (SD 6.3) years for Dienogest, p =.619 respectively. The visible intraoperative effect will be demonstrated in the video. The effect of a hormonal treatment can be observed macroscopically in endometriosis. This can help to understand the in vivo response to the administrated treatment. This video is showing our past experience, as performing second-look laparoscopy is not state of the art anymore. [Display omitted] [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) in pregnancy, consisting of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major factor of maternal mortality. Several patient-specific risk factors along with the physiologic changes of pregnancy promote a state of hypercoagulability in pregnant women. Detailed assessment of all pregnant women can establish a risk profile that would guide clinical decisions, and balance potential therapeutic benefits with side effects. Differentiating between physiologic changes of pregnancy and symptoms of VTE can be challenging and warrants meticulous clinical evaluation. Timely and accurate diagnosis of VTE with proper imaging is essential for its management, and systemic anticoagulation remains the cornerstone of VTE prevention and therapy. Furthermore, advanced invasive treatment options such as inferior vena cava filters and thrombectomy can be considered for complex cases. Importantly, the risk of systemic anticoagulation should be balanced against the risk of VTE-associated morbidity and mortality for mother and fetus, and an informed decision should be made. In this review, we present an up-to-date overview of VTE management in pregnancy and the postpartum period. • Venous thromboembolism (VTE) comprises a major factor of maternal mortality. • Critical clinical evaluation is warranted for efficient differential diagnosis between physiologic changes of pregnancy and VTE that is often challenging. • Anticoagulation is the cornerstone of VTE therapy but more complex therapies can be utilized for individual cases with comorbidities. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the association of adenomyosis with fertility, pregnancy and neonatal outcomes. An electronic search was conducted using the MEDLINE, PubMed and Cochrane databases up to April 2020. Seventeen observational studies were included. Adenomyosis was significantly associated with a lower clinical pregnancy rate (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.51–0.94) and higher miscarriage rate (OR 2.17; 95% CI 1.25–3.79) after treatment with assisted reproductive technology (ART). The lower clinical pregnancy rate was more significant in the subgroup of patients with short down-regulation protocols. Similar associations were recorded after age adjustment. Adenomyosis was also significantly associated with an increased risk of pre-eclampsia, preterm delivery, Caesarean section, fetal malpresentation, small for gestational age infancy and post-partum haemorrhage, which was confirmed after correction for age and mode of conception. In conclusion, adenomyosis is associated with negative effects on fertility after ART. The potentially protective role of the ultra-long down-regulation protocols needs further evaluation in randomized controlled studies. Adenomyosis is also associated (independently of the mode of conception) with adverse pregnancy and neonatal outcomes. Proper counselling prior to ART and close monitoring of pregnancy in patients with adenomyosis should be recommended. [ABSTRACT FROM AUTHOR]

Objective: To describe the anatomical distribution and intraoperative morphology of endosalpingiosis.Design: Retrospective observational video study.Setting: Data and intraoperative videos were reviewed by two independent reviewers at one referral center. The study was approved by the local ethics committee.Patient(s): A total of 77 patients with histologically proven endosalpingiosis from 2007-2020.Intervention(s): None.Main Outcome Measure(s): The primary endpoints were anatomical distribution and macroscopic phenotype. The secondary endpoints were demographic and clinical characteristics as well as associated diseases.Result(s): Of the 77 patients with endosalpingiosis, the mean age was 40.2 years (standard deviation, 16.4 years), mean body mass index 24.1 kg/m2 (standard deviation, 5.7 kg/m2), 59.7% (n = 46) were nulligravide, 70.1% (n = 54) nulliparous, 22.1% (n = 17) suffered of infertility, and 53.2% (n = 41) had at least one previous abdominal or vaginal surgery. Endometriosis was associated in 53.2 % (n = 41) and malignancies in 28.6% (n = 22, 7 endometrial cancers, 1 uterine carcinosarcoma, 8 borderline ovarian tumors, 5 epithelial ovarian cancers, and 1 yolk sac tumor of the ovary). Anatomic distribution and varying intraoperative phenotypes were demonstrated in the video presentation.Conclusion(s): In the majority of this population, endosalpingiosis was located in the pelvis. The higher prevalence of specific gynecologic tumors is consistent with previous results. In phenotype, most lesions appear to be less spectacular than prominent in the literature. For further studies on the relevance as a risk factor for malignancy and consequently clinical recommendations, sound knowledge about endosalpingiosis of laparoscopists as initial diagnosticians is crucial. [ABSTRACT FROM AUTHOR]