Total Laparoscopic Hysterectomy (TLH) in Extensive Endometriosis

Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. It is indicated in patients with deep infiltrative endometriosis (DIE) to treat severe chronic pelvic pain symptoms, heavy menstrual bleeding and adenomyosis recurrences. Before commencing surgery for extensive endometriosis cases, it is vital to conduct a comprehensive preoperative assessment, taking into account the severity of the condition, previous surgical history, and the preferences of the patient. The surgical approach involves meticulous dissection of pelvic structures, including the ureter, medial and lateral para-rectal space, and inferior hypogastric plexus, aiming for a nerve-sparing procedure. Careful dissection in rectovaginal space and dealing with intestinal endometriosis is the mandate of the case. This chapter highlights the role of our Comprehensive Canopy Concept, ‘The 3 Step Technique’ involving a posterior approach for uterine artery ligation, canopy concept for bladder dissection and anterior approach for contralateral uterine artery ligation. The importance of ureteric assessment, dissection, role of ICG and potential stenting in cases of parametrial endometriosis is emphasized.