{"paper_id":"0f2ad396-025e-449a-af1e-dffc470e5c6e","body_text":"Review began\n 05/04/2025 \nReview ended\n 05/14/2025 \nPublished\n 05/16/2025\n© Copyright \n2025\nMore et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.84239\nLaparoscopic Optimal Excision of Deep\nRectovaginal Endometriosis: Tips and Techniques\nShweta More \n, \nKunal Rathod \n1.\n Obstetrics and Gynaecology, Queen’s Hospital, King George Hospitals, Barking, Havering and Redbridge University\nHospitals NHS Trust, London, GBR\nCorresponding author: \nShweta More, \nshwetaankushmore@gmail.com\nAbstract\nEndometriosis is a chronic progressive disease spectrum characterized by the presence of tissue resembling\nfunctioning endometrial glands and stroma outside the uterine cavity. These ectopic implants have a\npropensity to bleed, initiating an inflammatory response. One of the most severe forms is deep rectovaginal\nendometriosis, which is the most challenging entity to treat. The diagnostic evaluation of these patients\nrequires a transvaginal ultrasound and an MRI pelvis. Medical management may reduce the symptom\nseverity but does not cure the disease. These patients often need surgical excision of the endometriosis to\nmanage symptoms. We aim to describe the approach, principles, and detailed techniques of surgical removal\nof deep endometriosis. Complete excision of the deep rectovaginal endometriosis was achieved with\nsymptomatic relief. This case illustrates our presurgical evaluation and operative techniques in detail, which\nare crucial in the optimal removal of endometriosis.\nCategories:\n Obstetrics/Gynecology\nKeywords:\n deep rectovaginal endometriosis, discoid bowel resection, laparoscopy, ovarian suspension, ureterolysis\nIntroduction\nEndometriosis is a chronic progressive, clinical, and pathologic entity characterized by the presence of tissue\nresembling functioning endometrial glands and stroma outside the uterine cavity, affecting 7-11% of women\nof the reproductive age group \n[1]\n. These ectopic endometrial implants have a propensity to bleed under the\ninfluence of hormonal changes, and this triggers the inflammatory response in the adjacent areas. This\ninflammatory response is considered an important factor in the formation of pelvic adhesions. These\nadhesions can range from flimsy, thin, translucent to a severe condition called a frozen pelvis \n[1,2]\n. It\npresents in three distinct categories, like peritoneal, ovarian, and deep pelvic endometriosis. Deep\nendometriosis (DE) is identified when there is peritoneum infiltration by endometriotic tissue, more than 5\nmm \n[3]\n. The various locations for the pathology could be involving uterosacral ligament, bowel, bladder,\nureter, vagina, parametrium, and the diaphragm.\nDeep pelvic endometriosis is the most challenging entity to treat. Medical management may reduce the\nsymptom severity but does not cure the disease. These patients often need surgical excision to manage\nsymptoms of pain, subfertility, sexual problems, and bowel or urinary symptoms \n[4]\n. Surgical management\nof endometriosis involves both minimally invasive, laparoscopic, and robotic excision and open surgical\nexcision. However, laparoscopy has become the standard of care over the years in comparison to open\nsurgery \n[5]\n.\nThe basic principles of endometriosis excision surgery remain the same regardless of the surgical approach\nand location of the disease. Sound and safe operating techniques are crucial in the management and optimal\nremoval of endometriosis. Dissection of the avascular spaces in the pelvis is a key for safe endometriosis\nsurgery \n[5,6]\n. We aim to provide detailed surgical techniques for the excision of deep pelvic endometriosis.\nTechnical Report\nCase details\nA 31-year-old female had symptoms of dysmenorrhea, dyschezia, dyspareunia, and chronic pelvic pain. She\nreceived progesterone hormonal treatment in the past without any significant relief. Transvaginal (TVS)\nultrasound pelvis was performed, which showed endometriotic nodules affecting the bilateral uterosacral\nligament, pouch of Douglas, and right parametrium (Figure \n1A\n-\n1D\n). There was also an endometriotic nodule\naffecting the anterior wall of the upper rectum 12 cm from the anal verge, confined to the muscularis layer. \n1\n1\n \nOpen Access Technical Report\nHow to cite this article\nMore S, Rathod K (May 16, 2025) Laparoscopic Optimal Excision of Deep Rectovaginal Endometriosis: Tips and Techniques. Cureus 17(5):\ne84239. \nDOI 10.7759/cureus.84239\n\nFIGURE\n 1: A) TVS ultrasound image showing an endometriotic nodule\nin the right uterosacral ligament (green dotted arrow). B) TVS\nultrasound image showing an endometriotic nodule in the left\nuterosacral ligament (green dotted arrow). C) Endometriosis nodule in\nthe right parametrium (yellow arrow). D) Endometriosis nodule along\nthe anterior wall of the upper rectum (yellow arrow, green line outlines\nthe mucosa of the rectum).\nTVS: transvaginal\nPre-surgical evaluation/approach\nThe clinical history and previous medical and surgical treatments related to endometriosis need to be\nrecorded in detail. Therapeutic planning depends on many factors, including the age of the patient, her\ndesire for fertility or pain relief, the duration and intensity of her symptoms, the extent of disease, and\nprevious treatments that have been undertaken.\nThe endometriosis-focused multidisciplinary team discussion with radiology and colorectal team helped us\nto plan the safe surgical approach. Preoperative TVS ultrasound and MRI pelvis imaging were done to\nunderstand the extent of the disease to tailor the surgical planning. Preoperative bowel preparation is\nessential in all cases. \nStepwise description of surgical techniques\nAdequate Exposure of the Operative Field\nThe mobilization of the sigmoid colon from its embryonic attachment to the lateral pelvic wall was done to\nachieve clear operative visualization of the pelvic cavity, to prevent inadvertent injury to bowel loops, and\nto facilitate left ureterolysis (Figure \n2A\n). The gentle medial and caudal traction by the grasper led to the\nvisualization of the white line of Toldt. The process of the bowel loop mobilization was initiated at the most\ndistal site of the sigmoid colon, which is usually located at the pelvic brim. Following the retraction of the\nbowel, a peritoneal incision is made lateral and parallel to the descending colon (Figure \n2B\n).\n \n2025 More et al. Cureus 17(5): e84239. DOI 10.7759/cureus.84239\n2\n of \n6\n\nFIGURE\n 2: \nA) Mobilization of the sigmoid colon from its embryonic\nattachment to the lateral pelvic wall. B) Rectovaginal endometriotic\nnodule obliterating the pouch of Douglas (green circle). C) Dissection of\nthe left ureter along with its intact vasculature. D) Medial deviation of\nthe right ureter changing its course.\nUreterolysis\nThe aim of ureterolysis is to lateralize the ureter, which prevents injury to it during the surgery by keeping it\nunder the direct vision of the surgeon. It also acts as an important anatomical landmark to prevent large\nvessel injury on the lateral pelvic wall \n[7]\n. The dissection of the ureter was started at the plane where the\nureter enters the pelvic brim. A tent and incision were made in the normal peritoneum adjacent to the\ninvolved area. The inferior margin of the incision was grasped and deviated medially, and the ureter was\nseparated from the peritoneum bluntly (Figure \n2C\n). In this scenario, the right ureter deviated medially\ntoward fibrosed adipose tissue in the pararectal space and deep rectovaginal endometriosis complex (Figure\n2D\n). A careful dissection and lateralization of the right ureter was performed to reduce the risk of ureteric\ninjury (Figure \n3A\n). The important aspect of ureterolysis is to avoid the use of an energy source close to the\nureter to maintain its blood supply. Peri-ureteral vessels in the adventitial layer must remain intact to\nprevent ischemia and resultant fistula formation \n[7]\n.\n \n2025 More et al. Cureus 17(5): e84239. DOI 10.7759/cureus.84239\n3\n of \n6\n\nFIGURE\n 3: A) Medial deviation of the right ureter secondary to fibrosis\nof the rectovaginal endometriosis nodule (white arrow). B) Bilateral\novaries (white arrow) suspended to the anterior abdominal wall. C)\nPararectal avascular space dissection to mobilize the segment of the\nrectum and hypogastric nerve course (white arrow). D) Discoid\nresection of the rectum (white circle) due to partial thickness\ninvolvement.\nOvarian Suspension\nThe suture-mediated elevation of both ovaries was performed to the anterior pelvic wall using synthetic\nStratafix 2-0 on a round body needle (Figure \n3B\n). This allowed access to the ovarian fossa and lateral pelvic\nwall. It aids in maintaining the traction during dissection, which frees the hands of the operating\nsurgeon/assistant to perform other tasks \n[8]\n. These sutures were removed immediately after the procedure\nwas completed. \nPararectal and Presacral Space Dissection\nThe pararectal and presacral space is an avascular space that provides access to rthe ectovaginal pouch and\nthe dorsal aspect of the rectum to achieve complete excision of the disease \n[9]\n. The use of a rectal probe can\nfacilitate the pararectal space. Careful dissection was performed to prevent injury to the hypogastric nerve\nplexus (Figure \n3C\n).\nDiscoid Resection of the Bowel\nIf the endometriosis involves the partial thickness of the rectum, less than 3 cm, and a unifocal lesion,\ndissection of the nodule can be achieved by discoid resection of the bowel \n[10,11]\n. Discoid resection can be\nachieved by cutting peri-nodular with a scissor or circular stapler (Figure \n3D\n). After resection, the bowel\nedge was approximated at the right angle to the long axis of the bowel to avoid the tension on the sutures\n \n2025 More et al. Cureus 17(5): e84239. DOI 10.7759/cureus.84239\n4\n of \n6\n\nand stricture of the bowel. The bowel integrity was confirmed by performing the leak test at the end of the\nprocedure \n[12,13]\n. This test is performed by submerging the bowel loops into a pool of clear saline in the\nPOD. We checked for any air bubbles after putting air through the rectum. In the absence of any visible air\nbubbles, the test confirms the bowel integrity.\nPost-operative follow-up\nThe post-operative period was uneventful, and the patient was discharged after 24 hours with analgesic and\nlaxative support. Clinical follow-up was done at two weeks and eight weeks at the gynecology and colorectal\nsurgery clinic. It showed improvement in the symptoms with normal bowel and bladder function. The\nhistopathology confirmed endometriosis of the area and two-thirds involvement of the rectal wall without\nmucosal involvement.\nDiscussion\nDeep rectovaginal endometriosis is one of the most severe forms of endometriosis and affects between 3.8%\nand 37% of all patients with endometriosis \n[1,2]\n. It is considered a stage four according to the American\nSociety of Reproductive Medicine (ASRM) classification \n[3]\n. Patients usually present with symptoms of\nchronic pelvic pain, especially around the menstrual period, dyschezia, or severe dyspareunia. Further\napproach in these suspected patients involves clinical examination paired with diagnostic imaging, like\ntransvaginal ultrasound and MRI pelvis. Diagnostic imaging plays a vital role in surgical planning. Medical\nmanagement can give temporary relief from symptoms while waiting for surgery. These patients often need\neducation and support for their emotional and psychological well-being. Surgery for recto-vaginal\nendometriosis is associated with plenty of technical challenges and calls for thorough evaluation \n[4,5]\n.\nThese patients should be treated in specialized centers under a multidisciplinary team approach.\nPreoperative planning, opening pelvic avascular spaces during the dissection, and a stepwise systematic\napproach are key for successful surgery \n[6,7]\n. Endometriosis lesions with superficial involvement of the\nrectal wall are preferably treated with local laparoscopic excision in the form of shaving, while segmental\nrectal resection is needed in the case of severe, circumferential infiltration with stenosis. For intermediate\ndisease, the current practice is discoid resection \n[10-12]\n. The recurrence rate of endometriosis is\nconsiderably lower with segmental resection and discoid excision than with rectal shaving \n[12,13]\n. \nRecent studies have demonstrated the importance of the nerve-sparing laparoscopic approach while\nperforming excision for DE \n[14]\n. It helps to preserve the bowel, bladder, and sexual function by avoiding\niatrogenic injury to pelvic autonomic nerves. The careful dissection of the presacral and pararectal space is\nhelpful to prevent iatrogenic injury to pelvic autonomic nerves \n[14,15]\n.\nConclusions\nThe laparoscopic approach for deep endometriosis demands high-level surgical skills, which has a long\nlearning curve but provides superior visualization of the posterior cul-de-sac. The surgical approach allows a\nhigh degree of magnification of peritoneal surfaces, which aids in the identification of subtle lesions and\nalso provides a detailed anatomical view of blood vessels, nerves, and the ureter. This leads to precise\nexcision of the endometriotic nodules. Good preoperative workup with transvaginal ultrasound and MRI\npelvis, along with a focused multidisciplinary approach, aids in surgical planning for best results. Optimal\nexcision of the endometriosis has a significant impact on the patient’s quality of life as it improves the pain.\nIn our experience, a stepwise approach during the laparoscopic surgery of deep endometriosis gives the best\noutcome and reduces the surgical morbidity. This stepwise surgical approach is a reproducible skillset that\ncan be transferred to junior laparoscopic surgeons while dealing with deep endometriosis surgery.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nShweta More, Kunal Rathod\nDrafting of the manuscript:\n  \nShweta More\nCritical review of the manuscript for important intellectual content:\n  \nKunal Rathod\nDisclosures\nHuman subjects:\n Consent for treatment and open access publication was obtained or waived by all\nparticipants in this study. \nAnimal subjects:\n All authors have confirmed that this study did not involve\n \n2025 More et al. Cureus 17(5): e84239. DOI 10.7759/cureus.84239\n5\n of \n6\n\nanimal subjects or tissue. \nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all\nauthors declare the following: \nPayment/services info:\n All authors have declared that no financial support\nwas received from any organization for the submitted work. \nFinancial relationships:\n All authors have\ndeclared that they have no financial relationships at present or within the previous three years with any\norganizations that might have an interest in the submitted work. \nOther relationships:\n All authors have\ndeclared that there are no other relationships or activities that could appear to have influenced the\nsubmitted work.\nReferences\n1\n. \nHanda V, Van Le L: \nTe Linde's operative gynecology\n. Wolters Kluwer, Philadelphia; 2020.\n2\n. \nGiudice L, Kao L: \nEndometriosis\n. 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