Laparoscopic resection of rectovaginal endometriosis involving segmental bowel resection and anastomosis: pre‐operative planning, intra‐operative decision making, description of technique, and tips and tricks for a successful outcome.

BACKGROUND Severe endometriosis with rectal involvement requires careful pre-operative investigation and planning. Methodical history taking and pre-operative discussion with the patient is key to establishing their wishes, aims, and expected outcomes of treatment options. Even with extensive prior investigation, the optimal surgical management can not always be determined until the time of laparoscopy. SETTING Multidisciplinary team at the Chelsea and Westminster Hospital Endometriosis Centre, London. Surgery carried out at the Lister Hospital, Chelsea. VIDEO We present the case of a 31 year old patient with rectovaginal endometriosis, her pre-operative workup and laparoscopy with description of the steps and decision making leading to a laparoscopic segmental bowel resection with anastomosis. We demonstrate a systematic assessment of findings at laparoscopy, decision making prior to undertaking a segmental bowel resection, and the techniques employed in full excision of her endometriosis by a joint team of gynaecologists and colorectal surgeons. The steps involve: bilateral ureterolysis and pelvic sidewall dissection; ovarian suspension; adhesiolysis; pararectal space dissection, and segmental bowel resection with anastomosis. We describe the surgical technique and anatomical landmarks at each step by both the gynaecology and colorectal teams including post operative sigmoidoscopy and leak test. CONCLUSIONS Clear understanding of the patients' objectives are paramount prior to any surgery for endometriosis where, even with extensive investigation, the optimal surgical management is not always certain. A systematic assessment of anatomy and pathology combined an understanding surgical technique ensures a good outcome and patient satisfaction.