To demonstrate that the anatomical site called Toldt's fascia, commonly referred to as a layer of physiologic adhesions in the left iliac fossa, is actually an embryologic remnant that hides endometriotic lesions.

Design:

Edited video with three examples of laparoscopic endometriosis excision dissection showing how to identify hidden lesions in Toldt's fascia.

Setting:

Three-port laparoscopic surgery for en-bloc excision

Patients or Participants:

Three regular cases with different degrees of endometriosis underwent surgery for endometriosis excision due to pelvic pain. The ages of the patients were 14, 25, and 32 years.

Interventions:

A systematic surgical approach by en bloc peritonectomy of the posterior compartment of the pelvis to remove the endometriosis. As part of this procedure, the authors systematically explore the peritoneal embryological fold called Toldt's fascia from lateral to medial in the left iliac fossa, releasing and exploring the retroperitoneum in this area to release the nerve entrapment of the somatic nerves (for example, iliohypogastric, ilioinguinal, and genitofemoral nerves).

Measurements and Main Results:

The video demonstrates that this anatomical site is not just a commonly called physiological adhesion, but actually hides lesions of probable embryologic origin of endometriosis.

Conclusion:

Described by Carl Toldt, an Austrian anatomist, this area is sandwiched between two layers of mesothelium derived from the mesothelial cells of the primitive visceral and parietal peritoneum. The probable embryologic origin of endometriosis caused by Mullerian duct defects and the endometriosis path track left by them, with rotation of the colon formation during the gastrulation period, may explain the frequent presence of endometriosis in this location in the left side of the pelvis. The surgical systematization and careful exploration of this site may be a useful tool in endometriosis excision surgeries to reduce the disease persistence rates for all degrees of endometriosis, especially those with chronic pelvic pain.