Table II.

— Principles for identifying and treating deep endometriotic lesions.

☐ Identify all important anatomical structures (ureters, colon, small bowel, major vessels, adnexae, uterus, bladder, nerves).
☐ Identify the lesions.
☐ Signs of deep endometriosis include:
	☐ fibrosis, with or without characteristic dark spots
	☐ (dense) adhesions
	☐ distortion of anatomical structures, infiltrations
	☐ reduced tissue elasticity
	☐ haemorrhagic cystic structures
☐ Perform easy steps first as this will facilitate difficult ones.
☐ Divide adhesions and restore pelvic anatomy in addition to complete excision of endometriosis.
☐ Free and isolate the lesions.
☐ Start the dissection in areas free of disease.
☐ Optimise exposure by using manipulators, ovariopexy, and additional ports, if necessary.
☐ Aim for complete excision whenever reasonable and possible. *

* When deciding that a part of the disease may be left behind, the surgeon should remember that if an extensive dissection has been performed to access this part of the disease, reoperation will be extremely difficult and sometimes almost impossible. If excision is considered to be too risky, it is likely to be even more difficult and dangerous if a reoperation is needed due to recurrent pain or other severe symptoms (such as stenosis of the bowel or ureter). Ideally, surgeons would be prepared to manage all aspects of the disease.