Design: A video demonstration of the surgical removal of suspected endometriosis lesions.

Setting: The surgery was performed in the operating room at a private teaching hospital.

Patients or Participants: The surgical video describes the case of a 43-year-old female who presented with a history of abnormal uterine bleeding and dysmenorrhea. She previously completed a trial of Depo-Provera for abnormal uterine bleeding. She declined further medication management and opted to undergo a laparoscopic hysterectomy and bilateral salpingectomy for definitive management of abnormal uterine bleeding. During the surgery, suspected endometriosis lesions were visualized and removed.

Interventions: The intervention involved a hysterectomy and bilateral salpingectomy, cystoscopy, and removal of suspected endometriosis lesions.

Measurements and Main Results: During the surgery, small bowel was noted to be adherent to the mid-uterine serosa with a collection of powder-burn lesions consistent with suspected prior surgical history and endometriosis. A second suspected powder-burn lesion was visualized during the dissection of the bladder flap, though with a more circumscribed appearance. The lesions were dissected from underlying structures and gross palpation of the lesions revealed that they were firmer than anticipated with endometriosis. The final histopathology revealed that the powder-burn lesions consistent with endometriosis were actually components of lead from a previous gunshot wound.

Conclusion: This case highlights the similarities in appearance between birdshot bullet fragments and endometriosis lesions. The multiple fragments produced by a birdshot explain why several fragments were visualized during the surgery. Previous studies have shown that gunshot wound victims with retained bullet fragments can have elevated blood levels. Therefore, blood lead level monitoring should be considered in patients like this one.