Design: Video case report

Setting: Academic tertiary hospital

Patients or Participants: 35-year-old female with chronic right lower quadrant pelvic pain, fibroid uterus, right ovarian cyst desiring permanent sterilization. Medical history included Castleman's disease, BMI of 58, type 1 diabetes, and asthma. Previous surgeries: diagnostic laparoscopy converted to open with periiliac lymph node dissection and resection of a sigmoid colon mass consistent with Castleman's disease. A diagnostic laparoscopy for suspected right ovarian torsion findings of right adnexal mass with no torsion and solid consistency. Procedure was concluded but pain symptoms persisted post operatively.

Interventions: Robotic-assisted excision of endometriosis, right salpingo-ophorectomy, left salpingectomy, cystoscopy with ureteral indocyanine green injection

Measurements and Main Results: A right adnexal mass with retroperitonealized appearance and densely adherent to the pelvic sidewall was found. The infundibulopelvic ligament was ligated, retroperitoneal dissection was performed, and extensive ureterolysis due to the severe nature of the patient's fibrosis. During the procedure, injury occurred to the internal iliac vein, which was successfully repaired using a 4-0 Prolene figure-of-eight suture. Pressure was dropped and no extra bleeding was found. Left salpingectomy was completed. Case concluded.

Conclusion: The case highlights the need for a coordinated and multidisciplinary approach in the care of patients with multiple comorbidities, including morbid obesity, endometriosis, and Castleman's disease. Effective intraoperative communication and collaboration are critical in managing life-threatening surgical complications.