Excision of endometriosis in the pouch of Douglas by combined laparovaginal surgery using the Maher abdominal elevator.

Twenty-one patients with stage 3 or 4 endometriosis in the pouch of Douglas had combined laparovaginal surgery using the Maher abdominal wall elevator. Opening the pouch of Douglas at the beginning of the operation allowed the combined surgery. Instruments were introduced through both the vagina and accessory laparoscopic incision. And a finger was placed in the vagina to palpate and detect abnormal tissue and assist in blunt dissection. The extent of pathologic tissue in the pouch of Douglas was easily identified. This approach allowed flexibility in maximizing the optimum route, vaginal or laparoscopic, to remove the uterus, and facilitated rectal surgery. The alternatives of laparoscopic and laparotomy surgery have limitations compared with combined laparovaginal surgery, particularly deep in the pelvic cavity.