Endometriosis is a progressive illness characterised by continual irritation within the endometrial glands and stroma present in areas outdoors the endometrial cavity. Its prevalence in girls of reproductive age group is round 10% 1, 20-30% in girls identified with infertility, and 40-60% in girls with continual pelvic pain2. Endometriosis could be macroscopically labeled as superficial endometriosis (peritoneal or ovarian floor), deep infiltrating endometriosis or ovarian endometriomas3. Deep infiltrating endometriosis (DIE) is outlined histologically as a lesion penetrating the subperitoneal area and/or wall of the pelvic organs to a depth of at the least 5 mm4. It’s seen in about 20% of instances presenting with endometriosis5. It’s sometimes characterised by multifocal lesions, mostly within the posterior pelvic compartment buildings, with a lowering order of incidence, in uterosacral ligaments, rectosigmoid colon, vagina and urinary bladder6. Essentially the most extensively used classification for endometriosis by revised American Society for Reproductive Medication, allocates a two to eight occasions increased rating for deep endometriosis as in comparison with superficial lesions. Nonetheless, it has poor correlation with the depth of related pelvic pain7,8. Therefore, a brand new classification has been proposed for deeper lesions, the Adamyan classification, which divides rectovaginal endometriosis into three sorts: Retrocervical endometriosis (wherein the rectum is often freed from illness) Rectovaginal septum Bowel endometriosis (with infiltrative traits over the bowel thickness) This sort of classification could also be extra suitable with the surgical method of this disease9 PATHOPHYSIOLOGY Etiopathogenesis of endometriosis isn’t clear until date and theories like retrograde menstruation, mesothelial metaplasia, mullerian rests principle and lymphatic or haemogenous unfold have been steered in literature. Endometriosis is an ongoing continual inflammatory response triggered by cyclic bleeding within the present lesions that spreads by contiguity, thereby selling the infiltration. Such ongoing irritation could typically trigger easy muscle proliferation with fibrotic response surrounding it ensuing within the formation of a nodule10.Deep infiltrating endometriosis of the gut is outlined as a lesion that infiltrates at the least the muscularis propria layer of the intestinal wall11. CLINICAL SCENARIO A very good historical past and a radical medical examination is of utmost significance within the analysis of sufferers with endometriosis. Signs that counsel endometriosis embrace dysmenorrhea, dyspareunia, and continual pelvic ache. Additionally, vital to guage are digestive signs and menstrual or peri-menstrual urinary signs. Research demonstrated that painful symptomatology was particular to an anatomic web site or organ affected by the DIE implant12. Thus, dyspareunia was related to deep lesions involving the uterosacral ligaments, dyschezia suggests involvement of the posterior wall of the vagina, noncyclic pelvic ache and practical bowel signs had been related to intestinal involvement and practical urinary signs like dysuria or haematuria had been related to deep endometriotic lesions of the urinary tract. Generally these nodules also can current as a vaginal mass or prolong alongside the spherical ligament to the mons pubis. DIAGNOSIS Prognosis stays a significant problem within the medical context of deep infiltrating endometriosis and must have a meticulous information of pelvic anatomy and its pure historical past in addition to experience within the imaging methods. Transvaginal, transrectal, and rectal endoscopic ultrasound used to diagnose DIE have proven variable accuracy relying on the anatomical websites affected and the expertise of the investigators13-15.Rectovaginal endometriosis is finest identified via visualization of a hypoecogenic lesion between rectum and vagina on transvaginal ultrasound, for which research have proven excessive sensitivity and good correlation with laparoscopic findings16. Magnetic resonance imaging (MRI) stays the very best non-invasive technique to guage the areas affected by pelvic endometriosis17,18.The lesions of DIE are described on MRI as nodular or retractile fibrotic-like tissue that had been hypointense on T2-weighted photos and isointense to muscle on T1-weighted photos. Adhesions and oblique indicators of adhesions had been additionally described as hypointense peritoneal strands that converged to loculated fluid collections or organ displacements. If rectal involvement was suspected, the exact location (distance from the anorectal junction) was described and acknowledged whether or not or not it was current. Nonetheless, MRI is poor to evaluate the depth of infiltration of a lesion within the intestinal wall, which is finest assessed by ultrasonography. The urinary tract must be investigated (renal ultrasonography, Uro-MRI, IVU) as and when wanted reminiscent of when giant retroperitoneal lesions are suspected. Colonoscopy has a restricted function to diagnose nodular lesions of DIE that trigger obstructive GI signs on account of mass impact from the extrinsic wall of the intestines. MANAGEMENT Medical remedies are efficient for ache reduction and to stop postoperative recurrence, however are ineffective for restoration of fecundity19. Nonetheless, for deep infiltrating endometriosis, surgical administration is the best choice, on account of excessive incidences of recurrence when medical therapy is used alone20,21. SURGICAL MANAGEMENT Indications: Failed medical administration Recurrence of signs after discontinuation of medical administration Infertility on account of endometriosis GI tract or urinary tract obstruction Cyclic rectal bleeding or haematuria Surgical procedure for rectovaginal endometriosis : The nodules within the rectovaginal septum are first remoted from the vaginal tissue by the use of sharp dissection. To attenuate blood loss and to maintain the surgical subject clear, vasopressin infiltration and ultrasonic power sources can be utilized. Following such dissection, vaginal defects, if any, could be sutured. The rectal side of the nodule often infiltrates the superficial serosa or often the superficial muscularis layer. This nodule could be shaved off the rectosigmoid with out an enterotomy. The superficial defect within the rectosigmoid could be sutured with interrupted sutures of 2-Zero or 3-Zero Polyglactin 910 in a single layer. Surgical procedure for bowel endometriosis: Strategies for intestinal lesions of DIE embrace: 1. Rectal shaving with or with out mucosal skinning For this process, it’s essential to discover a clear aircraft within the thickness of the muscular layer of the gut, past which there aren’t any extra endometriotic lesions. Mucosal skinning means preservation solely of the intact mucosal layer with handbook suturing of the sectioned bowel wall. Historically, gynecologists first separate the posterior floor of the nodule from the anterior wall of the rectum, after which carry out the separation of the lesion from the posterior vaginal fornix and from the retrocervical area. Alternatively, one could use a surgical method referred to as a “reverse” approach, wherein,first the anterior floor of the nodule is free of the posterior floor of the uterus and vagina. The mobility obtained after liberating the anterior face of the nodule permits higher publicity of the nodule in the course of the dissection of probably the most troublesome space to be handled, which is in touch with the rectum. On the finish of the process, if the shaving was deeper, with opening of the muscular layer or under, suturing is completed with 3-Zero or 4-Zero monofilament (polypropylene) suture in a single aircraft with steady or separated stitches. 2. Discoid resection Discoid Resection entails wedge resection of the anterior wall of the rectum, in complete thickness. This method is reserved for single lesions of DIE situated on the anterior wall of the rectosigmoid colon, with deep infiltration past the muscle layer, which are smaller than 30mm in diameter and occupying lower than one-third of the intestinal circumference22 Right here too, two methods that can be utilized: Resection of the endometrial nodule with chilly scissors, adopted by rectal restore by handbook suturing; Resection of the endometrial nodule utilizing a round stapler inserted transanally Double stapling could be accomplished for bulkier lesions to get good surgical outcomes. Within the first approach with handbook suturing, two restore sutures are positioned adjoining to the lesion, in wholesome intestinal wall, and the anterior intestinal wall is resected in a wedge with a transverse incision into the intestinal lumen utilizing chilly scissors or ultrasonic power. The defect space within the anterior intestinal wall is then repaired in two planes : one, the entire aircraft, encompasses the complete wall thickness with steady sutures ; and the opposite, the sero-muscular aircraft, makes use of steady or separated 3-Zero or 4-Zero monofilament(polypropylene) sutures23. Within the approach utilizing staplers, a monofilament (2-Zero mononylon) suture is handed into the lesion laparoscopically and left free within the cavity with the lengthy ends. Guided laparoscopically, the round stapler is inserted transanally, till it’s past the lesion. It’s gently opened, observing the formation of a groove between the anvil and the stapler. The 2 ends of the suture are grasped with a needle holder and pulled vertically downward with a purpose to introduce the fibrotic space of the anterior wall of the rectum into the groove of the round stapler. When the lesion is ideally positioned, the round stapler is closed with the anterior wall of the rectum inside. Throughout this closure, the stapler must be lowered in order that its finish is anteriorized, thereby avoiding the stapling of the posterior intestinal wall.The stapler is fired, and the anterior wall of the rectum is stapled and lower. After cautious elimination of the stapler, one can view the discoid of anterior rectal wall contained in the round stapler. 3. Segmental resection Segmental resection of the bowel entails resecting the section of the bowel affected by DIE. Theoretically, this method affords “certainty” about full resection when histopathology confirms illness free margins however it has an instantaneous operative morbidity, and a extra important long-term morbidity. Surgical procedure for urinary tract endometriosis : Urinary tract endometriosis is a variation of retroperitoneal deeply infiltrating endometriosis. It entails adenomyotic nodules infiltrating the bladder and pelvic (particularly terminal portion) a part of ureter. Bladder endometriosis generally often infiltates the muscularis dome and trigonal side of the bladder often not invading the mucosa though the nodule with push and protrude into the cavity of the urinary bladder. It causes ulceration of the bladder mucosa resulting in cyclical hematuria and dysuria though it numerous girls it tends to be asymptomatic. The nodule often is an extension of endometriosis alon the lateral parametrium therefore is often asymmetrically positioned on the bladder. The lesion must be bipsied to distinguish it from bladder malignancy. Ureteric endometriosis happens due to proximity of the terminal ureters to the uterosacral ligaments. The adenomyotic tissue infiltrates the parametrium and fully or partially encircles the ureters constricting them. These lesions are often unilateral. The endometriosis often doesn’t infiltrate the seromuscular layer of the ureters. Excision of bladder endometriosis often requires stenting of the one or each uteters relying on the scale and placement of the lesion. The bladder is lower vertically to show the cavitary side of the lesion and in addition visualize the ureteric orifices. The nodule is excised with roughly 1cm of wholesome tissue to cut back recurrence. The defect within the bladder wall is closed with 2 layers of steady sutures of 2-Zero or 3-Zero Polyglactin 910. Therapy of ureteric endometriosis entails launch of ureteric tissue from the fibrous tissue encircling it after stenting the ureters. The dissection begins on the pelvic brim the place the dilated proximal portion of the ureter guides dissection. Care must be taken to proceed parallel to the ureter to cut back thermal injury and avioid transection of the troubled portion of the ureter. For the reason that illness typically entails the terminal portion of the ureter, the dissection has to increase upto the insertion of the ureter into the bladder. The spherical ligamament could also be lower and the uterine artery clipped & lower to entry the distal portion of the ureter. The ureter must be fully free of all elements to launch it from the endometriotic tissue and the diseased parametrial tissue fully excised to cut back recurrence. Excision of ureter with finish to finish anastomosis or re-implantation isn’t wanted. That is thought-about with in depth involvement of the ureter with endometriosis when it comes to size or infiltration of the sero-muscular layer inflicting irremediable constriction of the lumen. Following surgical procedure, the ureteric catheter is eliminated after 6-Eight weeks and ureteric wall integrity confirmed by fluoroscopy. OUTCOME Relating to fertility outcomes, being pregnant charges after laparoscopic process for rectovaginal endometriosis therapy varies from 44.Four to 72%24,25As regards bowel endometriosis, radical excision of those lesions can present an enchancment of 91-100% of the bowel signs26,27. CONCLUSION Deep infiltrating endometriosis is probably the most under-diagnosed type of endometriosis. The medical implications of this are apparent in the truth that superficial fulguration of those implants end in failure of major surgical procedure and recurrence of illness and signs. Therefore, a radical understanding of the illness course of with detailed medical and radiologic analysis adopted by aggressive multidisciplinary administration is required to deal with this debilitating illness