Seven-Step Approach to an Obliterated Posterior Cul-de-Sac

INTRODUCTION: Deeply infiltrative endometriosis (DIE) is defined as endometriosis infiltration extending to >5 mm beyond the peritoneum. This type of endometriosis causes inflammation, fibrosis, and nodularity to surrounding tissue, and commonly affects the posterior cul-de-sac, leading to obliteration of normal anatomy. Pain is a common presenting symptom in patients with DIE, necessitating surgical management. Dense adhesive tissue is encountered, creating challenges in surgical approaches to resection of endometriosis and restoration of normal anatomic planes. OBJECTIVE: The objective of this video is to provide an overview of DIE and discuss surgical planning and approach when an obliterated posterior cul-de-sac is suspected or encountered. We will illustrate a seven-step approach for an obliterated posterior cul-de-sac, and finally discuss techniques used to optimize performance of this systematic approach. METHODS: In this video, we will discuss foundations of pelvic anatomy as this is essential to managing an obliterated posterior cul-de-sac. Adequate preoperative planning is also crucial, including ultrasound and MRI to assess the extent of the disease and assess if ureteral or bowel involvement is suspected. There are seven steps that are described in approaching the obliterated posterior cul de sac including releasing the rectosigmoid colon from the side wall, performing bilateral ureterolysis, restoring normal adnexal anatomy, approaching the rectovagainal septum from the pararectal space, releasing the rectum from the posterior uterus, excising endometriotic lesions, and performing bowel surgery if indicated. Each of these steps is demonstrated with various techniques to minimize injury to surrounding organs. RESULTS: Multiple different surgical scenarios are illustrated to show safe and effective approaches to an obliterated posterior cul de sac with distorted anatomy. The combination of the multiple steps allows for access to key structures via avascular spaces, which helps the surgeon maintain orientation throughout the case. CONCLUSIONS: In conclusion, a systematic approach can help in complex cases in which anatomy is difficult to recognize, knowledge of pelvic anatomy and recognition of avascular spaces can help avoid inadvertent injury to surrounding structures, and use of proper surgical technique can allow for safe dissection in challenging cases.