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The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. Design: Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. Setting: Private hospital in Curitiba, Paran a, Brazil. Interventions: A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1−4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh...

We describe two cases of diaphragmatic endometriosis treated using the robotic assisted laparoscopic approach, in which an incidental tension pneumothorax occurred during the initial inspection and assessment of diaphragmatic lesions. We demonstrate the importance of early diagnosis of this complication and report successful resolution using the thoracic drainage technique. In case one, after the pneumoperitoneum was installed, during the cavity assessment and inspection, small endometriotic lesions were observed in the tendon portion of the diaphragmatic surface. We observed a sudden increase in maximum airway pressures and a reduction in tidal volume, associated with arterial hypotension and hemodynamic instability and bulging of the diaphragm, which led to the diagnosis of a tension pneumothorax. In case two, diaphragmatic endometriotic lesions were also observed after hepatic mobilisation and following visualisation of the endometriotic lesions, an abrupt decrease in the capnography values was observed, consistent with hypertensive pneumothorax. In both cases, even after deflation of the abdominal cavity, hemodynamic instability persisted. We treated both cases with thoracic drainage, which immediately normalised respiratory parameters and resulted in hemodynamic stabilisation, and the surgical procedures were continued. During laparoscopic procedures for the treatment of diaphragmatic endometriosis, the endometriotic lesions can behave as communication hole in the tendon portion of the diaphragmatic surface and the changes in ventilatory patterns and haemodynamic instability should alert the medical team to the development of an incidental tension pneumothorax. The early identification of this complication in both cases allowed rapid intervention for chest drainage and allowed the surgical procedure to continue.