Laparoscopic rectosigmoid resection in case of deep endometriosis

Article Information: Publication Date:: 08/26/2004

Abstract

Introduction: Intestinal endometriosis is a disabling disease present in 6% to 30% of deep endometriosis cases. It can be the cause of abdominal bloating, constipation, intestinal cramping and painful bowel movements, defecation pain and intestinal stenosis up to intestinal occlusion. Colorectal endometriosis requires surgical treatment that can be performed by abdominal route or by laparoscopy. The present study describes the total laparoscopic rectosigmoid resection in case of deep endometriosis with bowel involvement. 

Material and Methods: Between January 2002 and January 2003 we performed six total laparoscopic endometriosis excision and intestinal resections with end-to-end rectosigmoid reanastomosis in cases of deep endometriosis with stenosis of sigma.

Operative technique: We started the procedures by firstly isolating and lateralizing the ureters and dissecting the rectovaginal septum endometriosis up to the posterior uterine wall. Then we performed the ovarian cystectomy,  removed the peritoneal implants and restored the cul-de-sac, obtaining the complete excision of pelvic nodules. Afterwards, the affected bowel segment was identified, mobilized and then excised. An end-to-end reanastomosis was obtained with the use of a circular stapler

Results: No major complications were observed and there had been no intestinal complications in any patients. All patients reported a significant pain symptoms relief and an improvement of their standards of life after surgery.

Conclusion: All authors agree that surgical treatment of deep endometriosis is recommended  when the disease causes a restriction of the standard of life. Surgery requires complete excision of all visible and palpable parts affected in order to obtain maximal pain relief and return to fertility. Total laparoscopic technique represents, according to us, the best procedure to remove pelvic and intestinal endometriosis because it allows a complete and less invasive approach.

Materials and Methods

Between January 2002 and January 2003 we performed six total laparoscopic endometriosis excisions and intestinal resections with end-to-end rectosigmoid reanastomosis in cases of deep endometriosis. All patients were in fertile age (median age was 35).

Symptoms reported from all patients were severe dysmenorrhoea, severe dyspareunia, chronic pelvic pain and pain during defecation. One patient reported cyclical rectal bleeding. All women lamented an important reduction of the quality of life before surgery.

Before surgery, all patients underwent gynaecological examination, pelvic ultrasonography in order to evaluate the presence of ovarian endometriosis cysts or endometriosis pelvic nodules, renal ultrasonography, in order to evaluate the presence of hydronephrosis and mono/bilateral ureteral stenosis and barium enema. This last revealed in all women the presence of a not mobile rectosigmoid tract with extended and persistent stenosis.

CA 125 plasma levels were significantly elevated in all cases (from 60 to 168 U/ml, median level was 96). All patients signed an informed surgical consent form before surgery.

At laparoscopy all patients presented nodular disease of the rectosigmoid colon with a circular stenosis of the sigma and obliteration of the cul-de-sac due to endometriosis

Operative Technique

After creating carbon dioxide (CO2) pneumoperitoneum, a 10 mm trocar was placed in the umbilical site to introduce laparoscope and camera. The suprapubic access routes (5-10 mm) were three: two were located lateral to the inferior epigastric arteries and one on the medial line

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We performed the ovarian cystectomy and the removal of the peritoneal implants of endometriosis; after that the cul-de-sac was freed by the obliterations and adhesions, obtaining the complete excision of pelvic nodules.

This step was preceded by the bilateral isolation and lateralization of the ureters and then by incision of the endometriosis rectovaginal septum up to posterior uterus wall.

This permitted the excision of the endometriotic nodule and the safe opening of the cul-de-sac. 

Afterwards, affected bowel segment was identified, bilateral peritoneal incisions were created along the bowel exposing the retroperitoneal connective attachments. 

In some cases the dissection of inferior mesenteric artery, obtained by electrocoagulation or surgical clips, was necessary in order to achieve a better mobilization. 

By using the linear stapler, we dissected the rectosigmoid colon under the stenotic tract and, with a small incision (2-3 cm) on the abdominal wall in the point of the suprapubic trocar, we delivered the affected tract of bowel outside the abdomen and we excised it.

A circular running suture was performed around the proximal segment of sigma and the head of a circular stapler was positioned on the margin of the resection. At this point the bowel was reinserted in the abdomen. The rectal introduction of the circular stapler permitted to obtain a safe end-to-end reanastomosis.

Results

Mean operating time was 147.2 ± 34.1 minutes.

No major complications were observed and there were no intestinal complications in any patients. Average drop in haemoglobin was 1.6 ± 1.1 g/dl and the estimated blood loss during surgery was 290 ± 162 ml. No patient required blood transfusion during or after surgery.

All patients were discharged home on postoperative day 7 in good general conditions. They were also instructed in a gradual diet. No hormonal therapy was prescribed. 

All patients showed a return to regular bowel function and a complete defecation pain remission within 30 days.

Follow-ups took place at 30, 90 days, 6 months, and 1 year after operation. 

CA 125 plasma levels during follow-up appeared significantly reduced.

All patients reported a significant pain symptoms relief and an improvement of their quality of life, with important reduction of dysmenorrhoea, dyspareunia and chronic pelvic pain.

Discussion

Pelvic endometriosis occurs in 5 to 10% of the female population.

The main lesions are represented by ovarian cyst and pelvic nodules, while bowel involvement is present in 6 to 30% of deep endometriosis and it is predominantly localized in the pelvic parts of the colon and rectum, close to the uterus. 

In our experience and according to international literature, intestinal endometriosis is frequently associated to rectovaginal septum endometriosis.

Clinical presentations vary from the asymptomatic where the disease is noted at the time of surgery to complete intestinal obstruction.

The presence of intestinal endometriosis should be suspected in any woman of child bearing age who presents gastrointestinal symptoms and a prior history of known endometriosis or intestinal stricture in the absence of an intraluminal mass.

The most frequent symptoms are abdominal bloating, constipation, intestinal cramping and painful bowel movements, defecation pain and intestinal stenosis up to intestinal occlusion. Cyclical rectal bleeding is a rare presentation and occurs when the lesion infiltrates the bowel mucosa. 

Medical treatment rarely yields satisfactory long-term results.

All authors agree that surgical treatment of deep endometriosis is recommended when the disease causes an impairment of the quality of life. Surgery requires complete excision of all visible and palpable nodules affected in order to obtain maximal pain relief and return of fertility.

Many authors have suggested partial rectosigmoid resection by laparotomy with good results (Regenet N et al, 2001).

In the last 10 years the development of laparoscopic techniques allowed a less invasive approach for deep endometriosis.

Laparoscopic intracorporeal segmental resection and anastomosis of the lower colon for endometriosis was described for the first time in 1991 (Redwine D and Sharpe D, 1991).

According to Redwine, laparoscopically assisted transvaginal segmental colon resection compared with laparotomy segmental colon resection, resulted in a shorter hospitalization, equivalent operating room charges and significantly lower total hospital charges (Redwine D et al, 1996).

Total laparoscopic technique represents, in our opinion, the best procedure to remove pelvic and intestinal endometriosis because it allows a complete and less invasive approach.

Furthermore, laparoscopy permits an image magnification and a clearer and nearer vision compared to laparotomy and to transvaginal assisted approach . 

Laparoscopic intestinal resection represents in our experience the best technique to treat intestinal stenosis with sub occlusion due to endometriosis, being safe, feasible and effective.

Laparoscopic excision of severe pelvic endometriosis and laparoscopic rectosigmoid resection appear to be highly effective in reducing pelvic pain and restoring fertility in patients desiring a pregnancy.

References:

Reprinted with kind permission from TheTrocar.com

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