The "Ureteral Raincoat". the Ceccaroni Ureteral Wrapping with Omental Free Flap after Parametrial Surgery for Deep Endometriosis

Study Objective

To describe an innovative minimally invasive technique consisting in the ureteral wrapping by omental free flap in order to reduce the risk of postoperative ureteral fistula. Secondary objective is to didactically demonstrate different ureterolysis settings during surgery for severe form of endometriosis.

Design

Didactic surgical video article. Patients’ consent to present and publish the video has been obtained.

Setting

Postoperative ureteral fistula still represents one of the most serious complications after ureteral surgery performed due to severe form of endometriosis. It is largely perceived as a frustrating event, since to date, no techniques or tools exist to avoid such risk and the extensive knowledge of the anatomy is not enough to prevent from this complication. Exploiting the intrinsic properties of the omentum, used as free flap to wrap the ureter, the risk of ureteral fistula can be reduced without increasing surgical risks for patients.

Patients or Participants

Women undergoing ureteral surgery due to severe form of endometriosis.

Interventions

Surgery starts with the omental retrieve, paying attention to tailor the amount of tissue harvested according to the length of ureter to be wrapped. Then, the caudad portion of the flap is secured to peritoneum of Douglas pouch. Once the omentum has been fixed, the flap is stretched and passed under the ureter. The cranial portion of the flap is fixed to pelvic peritoneum and the ureter is then progressively wrapped through an interrupted or running suture. Same surgical steps are performed on the contralateral ureter in case of bilateral ureteral wrapping.

Measurements and Primary Results

106 patients underwent ureteral wrapping from 2020 to 2025. Preliminary results showed no postoperative ureteral fistula with an additional operative time of 26 ± 2.3 minutes.

Conclusion

This minimally invasive technique can be considered safe and effective in reducing the risk of postoperative ureteral fistula although further randomized clinical trial are needed to confirm these results.