Methods: A comprehensive review was conducted to examine the current literature on the surgical management of complex endometriosis. Emphasis was placed on specific indications, technical considerations, anatomical challenges, multidisciplinary strategies, and outcomes related to hysterectomy in this context.

Results: While medical therapy is the first-line treatment for endometriosis-associated pain, a subset of patients remains refractory. In these cases, hysterectomy may be required to achieve definitive symptom relief. However, surgical management can be challenging due to distorted pelvic anatomy, dense adhesions, and the potential involvement of adjacent organs. A pathophysiology-informed approach, combined with multidisciplinary planning, is essential to minimize intraoperative risks and enhance outcomes.

Conclusions: Hysterectomy for endometriosis should be informed by a comprehensive understanding of the disease’s pathophysiology and the potential surgical complexities involved, in order to optimize patient outcomes.