a 44-year - old , para 2 , female with chronic pelvic pain was admitted for microlaparoscopic conscious pain mapping to evaluate the cause of her pain .
the patient had undergone a cesarean hysterectomy in 1979 during her last delivery secondary to having multiple large leiomyomata . over the next decade
, she suffered from chronic right - sided pelvic pain that was unrelieved with conservative medical therapy including hormonal therapy , nonsteroidal anti - inflammatory drugs , and narcotic medications .
a laparotomy with bilateral salpingo - oophorectomy and appendectomy were performed , which revealed endometriosis .
, the patient underwent 14 laparoscopic surgeries at various centers with minimal to no improvement .
although many of the operative reports describe fulguration of endometriosis and lysis of adhesions , others reported normal findings .
after an extensive history and physical examination were obtained and a review of the available medical records and videotape of her most recent laparoscopy was conducted , she was offered the option of undergoing micro - laparoscopic conscious pain mapping .
prior to surgery , the patient was familiarized with the conscious pain mapping procedure and pain scoring system .
she was asked to rate her pain on a scale of 0 , no pain , to 4 , severe pain .
the procedure was conducted in the outpatient surgery center of a private community hospital . with the patient in the supine position ,
conscious sedation ( atropine 0.2 mg , ondansetron hydrochloride 4 mg , midazolam hydrochloride 1 mg , and fentanyl citrate 350 g given slowly and titrated at 50  g increments to effect ) was administered intravenously .
periumbilical and suprapubic blocks were administered at operative sites of 10 ml of 1% lidocaine with epinephrine 1:100,000 buffered with sodium bicarbonate ( 10:1 dilution ) .
a pneumoperitoneum was created with carbon dioxide using the insuflow device ( georgia biomedical inc . ,
macon , ga ) after inserting a veress needle and 2-mm cannula . after advancing a 2-mm microlaparoscope ( minisite , us surgical corp . , norwalk , ct ) into the peritoneal cavity ,
a second 2-mm cannula was placed in the suprapubic region and a 2-mm manipulating probe directed into the pelvic cavity .
diagnostic microlaparoscopy and conscious pain mapping were performed by systematic probing of the pelvic cavity and obtaining intraoperative patient feedback regarding the presence or absence of pain .
inspection of the pelvis confirmed a previous hysterectomy , bilateral salpingo - oophorectomy and appendectomy .
the posterior cul - de - sac had a few small  powder - burn  endometriosis lesions that produced a minimal pain score of 1 ( out of 4 ) .
however , the patient had old sutures with granulation tissue ( figure 1 ) over the right pelvic brim with a pain mapping score of 4 ( figure 2 ) .
this exquisitely painful area was probed a second time to authenticate its role as the pain focus .
fulguration of the site was performed with 2-mm monopolar cautery scissors at a power setting of 40 w spray coagulation ( figure 3 ) .
she tolerated both the diagnostic and operative components of her surgery under local anesthesia with conscious sedation . at the scheduled 2-week and 6-month postoperative visits , she reported being completely pain - free without the use of analgesics .
chronic pelvic pain accounts for approximately 10% to 15% of a woman 's visits to the gynecologist , up to 50% of diagnostic laparoscopies , and many hysterectomies each year .
interestingly , a variable percentage of patients have no pathologic findings with the traditional laparoscopic approach under general anesthesia .
physical examination sometimes provides confusing and minimally useful data for evaluating chronic pelvic pain . in a large study of 1194 patients with chronic pelvic pain ,
normal pelvic examinations were found in 749 patients . not surprisingly , in 479 patients with chronic pelvic pain and a normal examination , 63% had abnormal findings during diagnostic laparoscopy . however
, 17.5% of the study patients with an abnormal pelvic examination had a normal diagnostic laparoscopy .
it is for this latter subgroup of patients that conscious pain mapping may provide more clinical information than with traditional laparoscopy under general anesthesia .
she subsequently underwent a bilateral salpingo - oophorectomy and appendectomy without symptom relief . over a period of 12 years , she underwent 14 laparoscopies , all performed under general anesthesia .
although some of these operative reports describe the presence of endometriosis , adhesions , or both of these , none addressed the sutures in the right pelvic brim .
further confusing the patient 's clinical picture is the fact that no consistent relationship existed between the severity of endometriosis and pelvic pain .
the  burned out  endometriosis lesions seen during conscious pain mapping produced a low pain score of 1 .
once electrosurgery to fulgurate the lesion over the right pelvic brim was performed , the patient 's pain score dropped from a severe 4 ( out of 4 ) to an insignificant score of 1 .
it is critical to perform conscious pain mapping in patients with chronic pelvic pain who have undergone unsuccessful surgical attempts to resolve their pain .
 chronic pelvic pain is a debilitating , life - altering syndrome that negatively affects a woman 's quality of life and personal relationships . many women continue to suffer with pelvic pain despite having undergone multiple medical and surgical treatments . 
 unfortunately , some women are incorrectly labeled as having psychological illness when organic disease may be present . 
 i report a case of a woman who underwent multiple pelvic and abdominal surgeries before the cause of her pain was identified through microlaparoscopic conscious pain mapping . 
CASE REPORT
DISCUSSION
CONCLUSION