A colposcopic approach to an endometriotic nodule in the recto vaginal septum under laparoscopic control

The surgical treatment of endometriotic nodules in the recto vaginal septum is aimed at removing the deeply infiltrating fibro muscular and abnormal glandular tissue, in order to relieve pelvic pain. The laparoscopic approach to the recto vaginal septum is difficult and potentially dangerous. We describe a new mode of access using a combination of laparoscopy and colposcopy. A 20-year-old woman presented with dyspareunia and dyschezia. Vaginal examination revealed a tender nodule, measuring 1.5 2 2 cm, in the posterior vagina wall. The endometriotic deposit was positioned at the top of the recto vaginal septum, extending into the posterior vaginal fornix. An air-contrast barium enema and vaginogran (lateral view) excluded a lesion that had penetrated the full thickness of the rectal wall. We carried out colposcopic CO₂ laser ablation of the nodule under laparoscopic control. 'Chocolate fluid' spilled from the lesion and the entire nodule was vaporised until normal tissue was reached. The patient was reviewed 3 and 6 months following the operation, and her symptoms had resolved. The colposcope allows an approach into an area of the pelvis that is usually difficult to access.