Endometriosis is a chronic progressive disease spectrum characterized by the presence of tissue resembling functioning endometrial glands and stroma outside the uterine cavity. These ectopic implants have a propensity to bleed, initiating an inflammatory response. One of the most severe forms is deep rectovaginal endometriosis, which is the most challenging entity to treat. The diagnostic evaluation of these patients requires a transvaginal ultrasound and an MRI pelvis. Medical management may reduce the symptom severity but does not cure the disease. These patients often need surgical excision of the endometriosis to manage symptoms. We aim to describe the approach, principles, and detailed techniques of surgical removal of deep endometriosis. Complete excision of the deep rectovaginal endometriosis was achieved with symptomatic relief. This case illustrates our presurgical evaluation and operative techniques in detail, which are crucial in the optimal removal of endometriosis.