Introduction: A 44 yo nulligravid,with chronic pelvic pain, dysmenorrhea, hematochezia. Infertility for 3 years. Her BMI: 34. PMH: Sagittal Sinus Thrombosis managed with anticoagulant therapy, peri-rectal abscess drainage, laparotomy for treatment of bowel endometriosis and b/l ovarian cystectomy. TVUS showed b/l ovarian endometriomas. CT urogram showed left hydroureter.

Method:Large bilateral adnexal masses like kissing ovaries were noted. The masses were plastered to the bowel and pelvic side wall. Significant inflammation from possible previous leakage of the ovarian endometrioma, and her surgical history may have contributed to the frozen pelvis. The mass contents are aspirated, thereby decompressing the cyst for easier excision. Bowel adhesions are freed from the adnexa by blunt & sharp dissection. First, the IP ligament is desiccated & cut close to the pelvic side wall. This allows a retroperitoneal access to decompress the left hydroureter. Later the round ligament is desiccated & cut. Owing to her high BMI and small pelvis adequate pneumoperitoneum was difficult to achieve. Therefore, debulking the mass provided the room to manipulate. Part of the mass is secured to exteriorize it later. Vesico-vaginal space and vesico-cervical spaces were created. Uterine vessels are desiccated and cut. Circumferential colpotomy was done. Rectovaginal septum endometriosis is excised by performing partial vaginectomy. Bowel endometriosis is removed by shaving technique. Vaginal cuff is closed.

Conclusion: In high risk patients with extensive endometriosis sharp/ blunt dissections and CO₂ laser can be used for adhesiolysis. Surgical planes must be created with special attention to avoid damage to the important pelvic structures.