Design: N/A

Setting: High volume surgical practice in a tertiary academic hospital. Patient positioned in dorsal lithotomy.

Patients or Participants: This case describes a 38 year old gravida 0 woman with history of pelvic pain and biopsy proven 4cm deeply infiltrating rectovaginal nodule.

Interventions: On entry, the posterior cul-de-sac was found to be obliterated with the uterus scarred to the rectum and sigmoid bowel. The medial approach was taken to open up the pararectal space to approach laterally. To open the rectovaginal space, a combination of blunt and sharp dissection was used to take down the adhesions. Given the depth of the rectovaginal nodule, a colpotomy was made to safely dissect away the nodule from the vaginal tissue. Electrocautery was used to completely resect the nodule and then the colpotomy was closed with V-Loc suture.

Measurements and Main Results: This video shows key techniques in the dissection of a deeply infiltrative rectovaginal nodule, including knowing the key anatomical planes and borders of avascular spaces, starting the dissection laterally where there is healthy tissue, using probes to help delineate the rectum versus the vagina, the importance of preoperative planning, and avoiding electrosurgical instruments when close to the rectum.

Conclusion: Rectovaginal endometriosis can be challenging to manage surgically due to extensive scarring and distorted anatomy. This video provides key techniques to help surgeons navigate these often difficult cases.