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Totally Laparoscopic Rectal Resection And Hysterectomy For Deep Infiltrating Endometriosis With Natural Orifice Specimen Extraction
Posted in Lectures on 9 April 2019

Raquel Bravo (Gastrointestinal Surgeon Consultant)
Ana Otero (Gastrointestinal Surgeon Consultant)
Hospital Clínic, Barcelona (Spain)

We report a case of a 36-year-old female with a 12-month history of chronic pelvic pain, dyschezia and rectal bleeding. These symptoms were refractory to hormonal, antispasmodic and opioid therapy. Magnetic resonance imaging detected a 2 x 2 cm nodule invading the rectal wall 10 cm from the dentate line. So we decided to perform an exploratory laparoscopy to resect the affected area.
We found the nodule at the uterine posterior wall invading the rectal anterior wall. The nodule was invading to the rectum in a large area so we proceeded with segmental resection.

We performed an anterior dissection in order to carry out the segmental resection of the rectum. We can see how the fibrous tissue makes surgical maneuvers difficult. It is important to be careful to avoid inadvertent injuries. In this case we used the hook to perform the dissection. The dissection progressed carefully, first on the anterior side, to then progress on to the posterior and lateral sides.

It is important to be careful not to injure the surrounding structures such as the ureter and vessels that may be retracted near the affected area due to fibrosis. To help the release of the rectum a uterine mobilizer can be used that helps us to have traction to separate the anterior side of the rectum from the posterior side of the vagina.

We continued with the dissection, passing the area affected by the endometrioma, until we found a rectal wall with no injury in order to perform the section and create a safe anastomosis. Once we founnd rectal wall in good condition, we proceeded to section the mesorectum by means of the hook and ligasure in order to perform the resection.

We performed the rectum section using a 60 mm EndoGIA and a 30 mm EndoGIA. At the same time we introduced the anvil of the mechanical suture device through the vagina in order to create the circular anastomosis.
We then just released the sigma to be able to perform the suture. At this moment we made an incision in the colon to introduce the anvil. Previously we had made a suture on the tip of the anvil to use the guide wire at the time of insertion into the colon. Finally, we closed and sectioned the colon with another 60 mm EndoGIA, obtaining the surgical specimen.

The specimen is removed through the vagina, performing in this way a totally laparoscopic procedure with natural orifice specimen extraction.

Finally we created the end to end circular anastomosis and closed the vagina, completing the surgery.

Outcomes

The total operative time was 100 minutes, the postoperative stay was uneventful and the patient was discharged on day four. The pathological report showed an endometrioma 4 x 4 cm length predominantly involving colonic muscularis propria.
Laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. In addition natural orifice specimen extraction avoid potential complications of abdominal incisions.