Arcus taurinus: the 'mother and father' of all LUNAs

Objective This paper reviews the surgical management of pelvic pain due to endometriosis, and describes a new operation, the so called 'arcus taurinus procedure'. Background In 1954, Joseph Doyle from Massachusetts described the procedure of paracervical uterine denervation by transection of the uterosacral ligaments. He carried out this procedure in an attempt to interrupt the pain fibres contained in the cervical division of the Lee-Frankenhauser plexus. In the 1980s, the pioneers of minimal access surgery began to perform Doyle's operation laparoscopically. However, randomized controlled trials have shown that this procedure does not confer any additional benefit to ablation or excision of endomtriotic tissue, and the operation has been recently been refined. The uterosacral ligaments are now completely excised or ablated, a crater between the ligaments is formed, and the rectovaginal septum opened. This more extensive operation has been called an 'arcus taurinus', or 'bull's horn' procedure. These procedures were initially intended to relieve pain by denervating the pelvis. However, cytoreduction of endometriosis also relieves pain, and the uterosacral ligaments and rectovaginal septum can be infiltrated with endometriosis that may not be macroscopically visible. Conclusion Therefore, it is likely that the relief of painful pelvic symptoms is due to a combination of denervation, and cytoreduction of endometriosis. In this context, the arcus taurinus procedure is truly 'the mother and father' of all laparoscopic uterine nerve ablations.