Laparoscopic hysterectomy for deep infiltrating endometriosis: anterior colpotomy first technique.

Background: Deep infiltrating endometriosis, particularly involving the rectovaginal space, represents one of the most challenging surgical benign gynaecologic conditions. While hysterectomy is a definitive option in women without fertility desire, these procedures are technically complex and associated with higher risks of complications. The anterior colpotomy first technique has been developed as an alternative approach to simplify dissection and improve surgical safety in such advanced cases. Objectives: Stepwise video demonstration of laparoscopic hysterectomy for deep infiltrating endometriosis involving rectovaginal space by the anterior colpotomy first technique. Participant: A 47-year-old woman presented with dysmenorrhea, dyspareunia and dyschezia unresponsive to medical treatment. Transvaginal ultrasound and magnetic resonance imaging (MRI) revealed bilateral 5 cm endometriomas, 2 cm endometriotic nodules on both utero-sacral ligaments, and a 4 cm nodule in the Douglas pouch. A further 3 cm superficial endometriotic nodule on the rectosigmoid colon was also revealed on MRI. According to the Enzian classification, the score was A3, B2/2, C3. Laparoscopic hysterectomy, bilateral salpingo-oophorectomy and endometriotic excision of lesions were planned. Operation time was 210 minutes, and blood loss was 50 mL. On the postoperative fourth day patient was discharged. The patient remained pain-free at 25 months follow-up. Intervention: Surgical steps for anterior colpotomy first technique could be divided into following steps: 1) entry into retroperitoneum, 2) ligation of uterine artery at the branching point from hypogastric artery, 3) development of vesicouterine space, 4) dissection of ureter and transection of lateral parametrium, 5) combining lateral and anterior compartments, 6) anterior colpotomy, 7) developing rectovaginal space from lateral to midline, 8) completion of posterior colpotomy, 9) excision of endometriotic nodule and leaving nodule on rectosigmoid colon, 10) completion of hysterectomy, 11) rectal shaving and resection of endometriotic lesions, 12) Bubble test, assessment of ureteral integrity and ladder filling with saline. In this technique, it is more feasible to do anterior colpotomy first and to develop rectovaginal space from lateral sides towards midline instead of dealing with the posterior compartment at the beginning of surgery. Ultimately endometriotic nodule between the rectosigmoid colon and the uterus is cut, leaving the endometriotic nodule on the rectosigmoid colon. Conclusions: Laparoscopic hysterectomy with anterior colpotomy first technique makes complicated hysterectomies easier in patients with deep infiltrating endometriosis. What is New?: This video article presents a stepwise demonstration of the anterior colpotomy first technique for laparoscopic hysterectomy in deep infiltrating endometriosis. By prioritising anterior colpotomy and developing the rectovaginal space from lateral to midline, this approach simplifies complex dissections, reduces the risk of rectal injury, and offers a safer, more reproducible strategy for advanced endometriosis cases.