DIE generally obliterates the planes laterally and anteriorly along the rectum and thus, a posterior approach is used initially to avoid dense adhesions. Dissection beneath the upper rectum, just adjacent to the rectal mesentery to avoid inadvertent injury to nerve fibers emanating from the sacral promontory, allows access to the presacral space. Throughout the dissection, the left ureter, which has typically been dissected by the gynecologic surgeon, is traced medially as it traverses under the sigmoid and into the pelvis to avoid injury. With care to preserve the inferior mesenteric artery, the total mesorectal plane is completely dissected posteriorly beyond the coccyx. The lateral dissections are then completed until the rectum is released circumferentially. The final dissection is anteriorly as this is the area typically involved with endometriosis. Once the adhesions between the uterus ovaries are released, and the anterior rectum is visi­ble, an assessment can be made as to whether a “shaving” technique of DIE is safe and feasible, or whether a formal resection is indicated. In our practice, the lesion is shaved if less than 30 % of the anterior wall of the rectum is involved. Visual haptics can facili­tate the identification of the borders of the nodule of DIE. DIE is often fibrous and dense, creating a hard nodule, while the borders of the normal rectum are much softer in appearance. If a shaving approach is feasible, a sharp dissection is completed with a robotic scissor and interrupted 2-0 polyglactin 910 stitches are placed to imbricate the thinned area of rectum. If the endometriosis is invasive to the point where a full thick­ness excision is needed, but <30 % of the lumen is involved, a discoid resection is completed and interrupted 2-0 polyglactin 910 stitches are placed to close the defect. An intraoperative sigmoidoscopy is subsequently completed for both the shaving and discoid resection approaches to ensure an airtight repair.

bowel resection for DIE experienced at least one major complication [48]. Among the most common is rectovaginal fistula. Patients are also at risk for pelvic infection and the need for reoperation should be counseled as such. Close follow-up by both the gynecologic and colorectal services postoperatively is imperative for optimal out­comes. With appropriate patient selection as well as coordinated and standardized care, a multidisciplinary approach to the management of DIE can optimize surgical out­comes and potentially lead to sustained remission of symptoms.