Approach to the Obliterated Cul-De-Sac

Last updated:

Video Description

This video describes a laparoscopic approach to the obliterated cul-de-sac in the setting of endometriosis

Presented By

male doctor avatar
Dr. Devon Evans
male doctor avatar
Dr. Michael Suen
male doctor avatar
Dr. Vincent della Zazzera
male doctor avatar
Dr. Sukhbir Sony Singh


University of Ottawa, The Ottawa Hospital

See Also

Watch on YouTube

Click here to watch this video on YouTube.

Video Transcript: Approach to the Obliterated Cul-De-Sac

This video describes a surgical approach to the obliterated cul-de-sac. We present an important preoperative consideration, anatomic landmarks, and an approach to the cul-de-sac to help optimize your excision while minimizing harm.

Preoperatively, high quality imaging is critical. Expert ultrasound radiologists can tell us much more than the presence or absence of endometriomas. Here we use dynamic ultrasound to demonstrate the sliding sign anteriorly and posteriorly, which predicts that there’s no compartment obliteration.

Here we demonstrate the negative sliding sign or uterine immobility in the posterior compartment. 

The positive and negative sliding signs are shown side by side for comparison here. This test has proved greater than 90% sensitive and specific for the obliteration of the anterior and posterior compartments.

The rectovaginal disease can also be identified with a more detailed static assessment. And deep nodular infiltration into the bowel can be predicted by the moose antler sign demonstrated here.

With expert guided imaging, cases like this should not come as a surprise in the OR. 

We’ll now move on to the relevant anatomic landmarks. It’s critical to have a strong understanding of the relevant anatomy to inform your approach to the obliterated cul-de-sac.

The classically taught borders of the pararectal space include the bowel medially, the internal iliac artery laterally, the cardinal ligament or uterine artery caudally, and the sacrum cephalad.

However, when the rest of the anatomy between the bowels and major vessels is considered, it becomes clear that this area can be further defined.

Specifically, isolation of the uterosacral ligament defines an avascular space lateral to the bowel and an avascular medial to the ureter. These spaces can be considered the medial and lateral pararectal spaces.

These spaces are demonstrated here in an interoperative image of developed left lateral and medial pararectal spaces. On the right, the lateral space has developed, but the medial space between the bowel and uterosacral is not.

Here is another interoperative image of completely dissected left lateral and medial and right lateral and medial pararectal spaces.

We’ll now describe our surgical approach to the obliterated cul-de-sac. We advocate for a five-step approach, including optimizing visualization. Identifying relevant anatomy. Developing the pelvic spaces. Excising the rectovaginal nodule. And finally, confirming the integrity of the bowel.

We’ll now apply these principles to a case. She was a 38-year-old G1A1 with infertility, pelvic pain, and bowel symptoms. She had a fixed retroverted uterus and uterosacral nodularity. Imaging revealed a small endometrioma, a negative posterior sliding sign, and a rectovaginal nodule. 

Equipped with good preoperative imaging and a systematic approach we proceeded with the case. 

We began our survey with bilateral hydrotubation to confirm tubal patency and performed a survey of the disease.

Of note, the extent of her rectovaginal disease may not have been apparent had we known to look for it, thanks to our expert guided preoperative imaging. 

We then optimized our visualization by performing temporary oophoropexy and bilateral ureterolysis.

Next, we identified the relevant anatomy to help define the pararectal spaces. Here we’ve developed all of the relevant avascular spaces except the right medial pararectal space bordered by the uterosacral laterally and bowel medially.

This space can be opened bluntly. 

Once the pararectal space is opened, it can be developed further to define the two avascular spaces bordered by the uterosacral ligament, bowel, and ureter. 

The medial and lateral pararectal spaces are now developed adequately to proceed with the case. 

With the bowel free, the dissection plane can be identified as the rectovaginal nodule. It’s well away from the ureter, separated by the medial avascular space, the uterosacral ligaments, and the lateral avascular space. 

The dissection plane should be in the middle of the nodule so as to avoid injury to the uterus or bowel during the dissection.

Once the nodule is divided, the rest of the nodule on the bowel and uterus can be excised.

We demonstrate the restoration of normal anatomy. And next approach is the excision of the remaining nodule on the rectosigmoid colon. This is achieved using the shaving technique, which is better illustrated in another case.

Finally, we excise the remaining nodule on the uterosacral ligament.

Uterosacral nodularity palpable preoperatively is no longer palpable on vaginal examination. 

This marked the end of the procedure, and we performed a bowel insufflation test to confirm bowel integrity after the excision of the rectovaginal nodule. 

All anatomy was restored. An absorbable adhesion barrier was left in the pelvis. 

To summarize, after preoperative evaluation, we used a five-step approach to the cul-de-sac. Optimized visualization, identified relevant anatomy, developed the pelvic spaces, excised the nodule, and confirm the integrity of the bowel.