Design: Case report illustrated with video.

Setting: The patient was under general anesthesia and positioned in lithotomy position, with arms alongside the body and legs abducted at 80 degrees in adjustable stirrups. Four punctures were performed: one for the optics inserted through the umbilical scar, and two incisions on the right and left flanks, along with a suprapubic puncture for auxiliary trocars. The cervix was manipulated using a disposable uterine manipulator.

Patients or Participants: A 42-year-old female presenting with intense chronic pelvic pain and symptoms consistent with Menopausal Syndrome. The pain proved refractory to analgesia, pelvic physiotherapy, and a gestrinone implant. She has a history of previous laparoscopy for deep endometriosis with rectal involvement. She had no comorbidities and had previously undergone two cesarean deliveries, with no desire for future reproduction. Physical examination revealed a positive internal obturator sign. MRI findings included a uterus measuring 69.1 cc and an irregular lesion in the left parametrial region measuring 1.6 x 1.2 x 0.7 cm, involving the course of the inferior hypogastric plexus and located 0.7 cm from the left ureter.

Interventions: Excision of the left parametrial endometriotic lesion, with extrinsic compression of the lumbosacral trunk and circumferential involvement of the ureter, followed by hysterectomy.

Measurements and Main Results: The procedure lasted 2 hours and was performed with minimal bleeding and preservation of vital structures. The patient had a good postoperative recovery and experienced complete improvement of pelvic pain in the late postoperative period.

Conclusion: Despite the challenges posed by the perimenopausal period, this case underscores the importance of individualized surgical approaches and the potential benefits of laparoscopic techniques in managing endometriosis, even in challenging clinical scenarios.