33: Laparoscopic excision of deep infiltrating rectovaginal endometriosis: tips and tricks to ensure a complete, safe excision

The objective of this video is to demonstrate a technique for identification and complete resection of deep infiltrating endometriosis of the rectovaginal space. Endometriosis is a complex disorder present in up to 10 percent of reproductive-aged women. Deep infiltrating endometriosis extends at minimum 5 mm beneath the surface of the peritoneum and is particularly difficult to control with medical management or lesion ablation. Safe surgical excision can be especially challenging in the rectovaginal space, where the extent of involvement of the vagina and rectum can be difficult to delineate. This demonstrated surgical technique begins with an exam under anesthesia, during which endometriotic implants are visually and digitally confirmed. The border of these implants is marked intravaginally. After a total laparoscopic hysterectomy is completed, a rectal sizer is inserted to determine the area of the rectum posteriorly. The rectovaginal nodule is then resected laparoscopically using a bipolar sealing device across the previously outlined borders. Final confirmation of excision of all endometriotic implants is performed prior to vaginal cuff closure. A careful examination under anesthesia at the start of the procedure can therefore allow for identification and delineation of deep infiltrating endometriosis involving the rectovaginal space in order to guide subsequent complete laparoscopic resection and optimally preserve healthy vaginal tissue. The use of a marking pen to outline the posterior border of a rectovaginal nodule prior to the start of surgery is a quick and easy step that can help to ensure a complete excision of the lesion while maintaining as much healthy vaginal tissue as possible.