Severe endometriosis involving the bowel – a colo-rectal surgeon’s approach

Endometriosis affects up to 10% of the female population, and the bowel is involved in up to 30% of those cases.1 The affected areas tend to be localized to the pelvic parts of the bowel, with sigmoid colon involvement in up to 73% of cases, and the rectovaginal septum containing deposits in 13% of affected patients.2 Surgery is used in severe cases that have not responded to medical treatment, such as those with deep-seated invasive disease, endometriomas, and cul-de-sac obliteration. The latter is defined as ‘extensive adhesions in the cul-de-sac, obliterating its lower portion and uniting the cervix or the lower portion of the uterus to the rectum’.3 The posterior vaginal wall is frequently involved in cul-de-sac obliteration, too. There is some evidence to suggest that rectovaginal septum endometriosis may initially originate from adenomyotic lesions of the uterus which invade the anterior wall of the rectum.4