Design: Video abstract

Setting: University hospital operating room

Patients or Participants: One patient with Stage IV endometriosis and chronic pelvic pain who presents for hysterectomy and resection of endometriosis

Interventions: Total laparoscopic hysterectomy, ureterolysis, resection of endometriosis, bowel shaving, enterolysis

Measurements and Main Results: Patient underwent ultrasound that showed positive sliding test, then intraoperatively she underwent extensive enterolysis and anatomy restoration with bilateral ureterolysis in order to perform resection of endometriosis and hysterectomy

Conclusion:

• Mobilize the sigmoid colon off its attachments to expose the left adnexa and underlying structures
• Ureterolysis is advisable ,the ureter should be followed down to the cardinal ligament and the crossing with the uterine vessels. When covered with endometriotic lesions, dissection of the ureter will be necessary to prevent injury
• As the presence of dense adhesion between the rectum and other structures may obscure the DE, complete dissection of these adhesions is mandatory.
• Use of EEA sizer can be helpful to delineate and manipulate the rectum
• Adhesiolysis is performed with cold scissors, blunt dissection or thermal instruments with minimal collateral thermal spread.