Laparoscopic modified radical hysterectomy for women with stage IV AFS endometriosis and obliterated Douglas space: a technical note (with video).

Excision of deep infiltrating endometriosis has to be complete to prevent symptomatic recurrences but with more complications. The patients with obliterated Douglas space who wish a definitive treatment for their pain require a more complex hysterectomy to remove all the lesions. Laparoscopic modified radical hysterectomy may allow to perform safely this surgery following 9 steps. The dissection is standardized according to anatomical landmarks. The key steps are: extrafascial dissection of uterine pedicle by opening the pararectal spaces and paravesical space, nerve sparing, ureterolysis if needed, the retrograde dissection of rectovaginal space and the rectal step if needed. The rectal step depends on depth of rectal infiltration and on the number of nodules (rectal shaving, disc excision or rectal resection). This standardized procedure could help surgeons to achieve a complex radical surgery for patients with endometriosis and obliterated Douglas space.