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Study Objective Review diaphragmatic endometriosis and important diaphragm anatomy for the purpose of treatment. Design Case Review. Setting Pt was brought to the operative room and placed in dorsal lithotomy position. General anesthesia was conducted. Three laparoscopic ports were placed. One was umbilical and two in the lateral abdominal aspects. Patients or Participants We present a 30-year-old nulligravid female with a history of chronic pelvic pain, catamenial pain with breathing, infertility, and Stage III endometriosis. Interventions Patient was taken to the operating room for excision of endometriosis, peritoneal stripping, appendectomy, and excision of diaphragmatic endometriosis in a joint case with general surgery. Measurements and Main Results N/A Conclusion This video successfully reviewed the symptoms, incidence, and etiology of diaphragmatic endometriosis. Appropriate imaging for diagnosis and pre-operative workup with MRI was overviewed. We also discussed the anatomy and innervation of the diaphragm as well as surgical considerations for removal of endometriosis of the diaphragm.

Video Objective To demonstrate successful ureterolysis technique when the ureter is abutting the cervix. Setting A 43 year-old multiparous woman with an enlarged fibroid uterus and abnormal uterine bleeding desired definitive surgical management. Her right ureter was abutting the cervix to within less than 0.5cm and required meticulous dissection to maintain its integrity. Interventions Several factors are considered to maintain ureteral integrity during hysterectomy. These include: 1- Identification and dissection of the ureter along the medial leaflet of the broad ligament; 2- In-depth knowledge of the anatomical variations of the parametric; 3- Judicious use of monopolar and bipolar electrosurgery; 4- In-depth understanding of the various effects of electrosurgery on tissues. Conclusion Understanding the course of the ureter is crucial during hysterectomy. When abutting the cervix, judicious use of monopolar and bipolar energy is key to maintain ureteral integrity.

Video Objective To describe a robotic approach for performing a sacrospinous ligament suspension. Setting A 78 year-old woman presented with stage 3 uterine prolapse with the sole complaint of vaginal pressure. She had no urinary or bowel dysfunction. Her gynecologic surgical history included anterior and posterior vaginal wall mesh-augmented repairs. On examination, she had uterovaginal prolapse with underlying palpable uterus and calcified fibroid and the leading edge of he cervix at +6 cm from the hymen. Anterior, posterior and introital measurements on POP-Q were normal. This represented an isolated stage 3 Uterine Prolapse. Interventions A robotic hysterectomy with bilateral salpingo-oophorectomy was completed. Uterosacral ligaments were attenuated and could not be utilized for vaginal apical support. Alternatively, a robotic right sacrospinous ligament suspension was attempted successfully. Steps for this procedure include: developing the right pararectal space, identifying the levator ani muscles and sacrospinous ligament followed by suspension of the vaginal cuff to the sacrospinous ligament using resorbable suture. This surgical clip demonstrates the technique. Conclusion A robotic approach can be utilized for vaginal apical suspension to the sacrospinous ligament when uterosacral ligaments are attenuated. Pelvic floor and sidewall anatomic knowledge is required for successful completion of this procedure.