Laparoscopic Excision of Rectovaginal Septum Endometriosis

INTRODUCTION: Endometriosis affects 10–15% of the female population. Of those individuals, it has been suggested that up to 37% have rectovaginal endometriosis. Laparoscopic excision of endometriosis is associated with prolonged operating times and may have up to 4.7% postoperative complication rate. One study found that up to 9% of patients with excisions involving the rectum experienced complications postoperatively. OBJECTIVE: The goal of this video is to illustrate key anatomy and steps for ureterolysis and dissection of rectovaginal septum endometriosis. To demonstrate surgical considerations and techniques for excision of rectovaginal endometriosis with laparoscopic approach. METHODS: Our patient is a 46-year-old G3P2012 with a history of biopsy proven vaginal endometriosis. She was previously on medical management with oral contraceptives, progestin injection, and gonadotropin-releasing hormone antagonist that never provided complete resolution of bleeding. She was then lost to follow-up for years prior to re-presenting with persistent, worsening vaginal bleeding. A 4-cm exophytic, friable lesion in the posterior vaginal fornix was identified on physical exam and the patient elected to proceed with definitive surgical management. A surgical video of her laparoscopic hysterectomy, bilateral salpingo-oophorectomy and endometriosis resection with upper posterior vaginectomy are presented. RESULTS: The laparoscopic dissection was completed successfully. She developed urinary retention on postoperative day 0, that resolved on postoperative day 1, with no other complications. Pathology confirmed endometriosis and the patient had completed resolution of vaginal bleeding and pain at her 6-week postoperative visit. CONCLUSIONS: Extensive preoperative planning and multidisciplinary procedures allow for safe surgery. Key strategies for laparoscopic excision include preoperative ureteral stents, extensive dissection of the vesicovaginal space to allow for tension free vaginal cuff closure after partial vaginectomy, and use of assisting devices (end-to-end anastomosis sizers) can be used to delineate rectal tissue planes for safe dissection.