Journal of the European Society for Gynaecological Endoscopy


Recommendations for the surgical treatment of endometriosis
Part 2: deep endometriosis

Working group of ESGE, ESHRE and WES, Joerg Keckstein 1, Christian M. Becker 2, Michel Canis 3, Anis Feki 4, Grigoris F. Grimbizis 5, Lone Hummelshoj 6, Michelle Nisolle 7, Horace Roman 8,9, Ertan Saridogan 10, Vasilios Tanos 11, Carla Tomassetti 12, Uwe A. Ulrich 13, Nathalie Vermeulen 14, Rudy Leon De Wilde 15

1 Endometriosis Centre Dres. Keckstein, Richard-Wagner Strasse 18, 9500 Villach, Austria;
2 Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital Womens Centre, OX3 9DU Oxford, UK;
3 Department of Gynaecological Surgery, University Clermont Auvergne CHU, Estaing 1 Place Lucie Aubrac, 63000 Clermont-Ferrand, France;
4 Department of Obstetrics and Gynecology, HFR Fribourg Hopital cantonal, 1708 Fribourg, Switzerland;
5 1st Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Tsimiski 51 Street, 54623 Thessaloniki, Greece;
6 World Endometriosis Society, London N1 3JS, UK;
7 Hôpital de la Citadelle, Department of Obstetrics & Gynecology, 4000 Liège, Belgium;
8 Endometriosis Centre, Clinic Tivoli-Ducos, Bordeaux, France;
9 Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark;
10 Reproductive Medicine Unit, Elizabeth Garrett AndersonWing Institute forWomen’s Health, University College Hospital, NW1 2BU London, UK;
11 Department of Obstetrics and Gynecology, Aretaeio Hospital, 2024 Nicosia, Cyprus;
12 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, 3000 Leuven, Belgium;
13 Department of Obstetrics and Gynaecology, Martin Luther Hospital, 14193 Berlin, Germany;
14 ESHRE, Central office - Meerstraat 60, BE 1852 Grimbergen, Belgium;
15 University Hospital for Gynecology, Carl von Ossietzky Universitat Oldenburg, 26129 Oldenburg, Germany.


endometriosis, laparoscopy, surgery, deep endometriosis, extrapelvic, frozen pelvis, hysterectomy, good practice recommendations

Published online: Mar 31 2020


Study question: How should surgery for endometriosis be performed?

Summary answer: This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

What is known already: Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

Study, design, size, duration: A working group of the European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

Participants, materials, setting, methods: This document focused on surgery for deep endometriosis, and is complementary to a previous document in this series focusing on endometrioma surgery.

Main results and the role of chance: The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

Limitations, reasons for caution: Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

Wider implications of the findings: These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

Study funding - Competing interest(s): The meetings of the working group were funded by ESGE, ESHRE and WES.

Dr. Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS, and NORDIC PHARMA, outside the submitted work; Dr. Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences, and Roche Diagnostics Inc, and other relationships or activities from AbbVie Inc, and Myriad Inc, during the conduct of the study; Dr. Tomassetti reports non-financial support from ESHRE, during the conduct of the study; non-financial support and other from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals, and Merck SA, outside the submitted work. The other authors had nothing to disclose.

Trial registration number: na

† This ESGE/ESHRE/WES document has not been externally peer reviewed. The manuscript has been approved by the Executive Committee of ESGE.
‡ This paper has been approved by the Executive Committees of the ESHRE and WES.
¶ This article has been co-published with permission in HROpen and FACTS, VIEWS & VISION in Obgyn.