STUDY OBJECTIVE To examine the efficacy and safety of laparoscopic presacral neurectomy (LPSN) as the initial surgical treatment of midline pelvic pain and dysmenorrhea; and to evaluate its effectiveness in conjunction with procedures to relieve lateral pelvic pain, such as excision of endometriosis and lysis of adhesions. DESIGN A preoperative and postoperative self-rating with which patients classified pain on an ordinal scale of 0 to 5. A x<SUP>2<SUP> analysis of the data was performed. SETTING A private hospital in Savannah, Georgia. PATIENTS Twenty-seven women, age 15 to 41 years, who experienced severe midline dysmenorrhea and/or pain; 12 also had significant lateral pain. INTERVENTIONS Laparoscopic presacral neurectomy was the primary intervention. Other procedures, including lysis of adhesions, excision and vaporization of endometriosis, and appendectomy were completed as adjuncts to LPSN. MEASUREMENTS AND MAIN RESULTS Ratings were completed by patients 5 to 35 months after surgery. Twenty-two women reported no midline pain, three had significant reduction of pain, and two had persistence of severe pain. Two of the 12 women with lateral pain reported that pain persisted. CONCLUSIONS The LPSN is safe and effective as an initial surgical intervention for treating midline dysmenorrhea and pelvic pain, and when it is performed by experienced laparoscopic surgeons with adequate training.