Design: A patient with suspected stage IV endometriosis on imaging was consented for total laparoscopic hysterectomy, bilateral saplingectomy and endometriosis resection. The patient was counseled on ovarian preservation and consented for possible bilateral or unilateral oophorectomy. The patient's recovery was uncomplicated, and she followed-up in office two weeks post operatively.

Setting: The patient was positioned in dorsal lithotomy within the operating room prior to surgical intervention.

Patients or Participants: A singular patient is depicted in this surgical video.

Interventions: Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, bilateral ureterolysis, and endometriosis resection was performed prior to restoration of optimal pelvic anatomy.

Measurements and Main Results: N/A

Conclusion: In this video we demonstrate a surgical approach to the total laparoscopic hysterectomy in a patient with stage IV endometriosis and obliterated cul-du-sac prior to restoration of optimal pelvic anatomy. Surgical treatment of endometriosis can be challenging due to anatomy distortion and indistinct tissue planes. Proper treatment relies on the surgeons' level of experience and comfort with retroperitoneal dissection. Our surgical approach highlights the importance of ureterolysis in these difficult endometriosis cases. Finally, performing colpotomy prior to restoring the bowel anatomy in the posterior cul-du-sac can allow for easier dissection of rectosigmoid colon adhesions.