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Objective: Excisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction [1-4]. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus., Design: Using didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery., Setting: Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy., Interventions: Radical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE., Conclusion: The hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To describe a case of spontaneous hemoperitoneum in a woman affected by deep infiltrating endometriosis (DIE)., Design: Technical video showing laparoscopic management of a spontaneous hemoperitoneum in a patient with DIE., Setting: Minimally Invasive Gynecological Unit, Sant'Orsola Academic Hospital, Bologna, Italy., Intervention: A 35-year-old nulliparous woman was admitted to our gynecologic emergency room because of pelvic pain and a fainting sensation. She had a history of DIE and had been followed for 6 months by our outpatient clinics. The patient underwent an immediate laparoscopy because of the rapid worsening of clinical conditions. After blood suction and difficult adhesiolysis, a vascular lesion with a huge blood flow, close to the left utero-ovarian ligament, was detected. Selective coagulation was performed with good results. During the follow-up visit after 1 month, the patient reported good health. Written informed consent was obtained from the patient for publication of this case report., Conclusion: Spontaneous hemoperitoneum represents a rare and life-threatening complication associated with endometriosis. In patients with hemoperitoneum and a history of endometriosis, it is important to pay attention to the possible presence of uncommon bleeding localizations. Laparoscopy was useful and effective in this challenging situation, identifying the bleeding source and performing selective coagulation., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Intraperitoneal bleeding due to spontaneous rupture of hepatocellular carcinoma (HCC) is often a life-threatening condition as well as a poor prognostic sign in terms of the spread of neoplastic disease. Up to 12% of the patients with HCC are reported to develop this complication in Asia, while few cases have been observed to date in western countries, even in areas such as Italy where incidence of hepatocellular carcinoma is high. There is a lack of specific symptoms, therefore a correct diagnosis can be made only if the possibility of hepatocellular carcinoma rupture is taken into account in case of spontaneous hemoperitoneum and if imaging procedures are carefully focused on the liver. Once the presence of the malignant liver neoplasm is demonstrated, non surgical management, aimed solely at controlling the hemorrhage, can be considered. Herein we report 8 cases of spontaneous intraperitoneal bleeding observed in our Department. Our experience confirms that an exact diagnosis is rarely made before laparotomy and that long-term prognosis is poor even after surgical resection of the tumor: 5 of 7 patients who had hepatic resection developed an early recurrence and 4 of them died within one year.