F. Vianello, MD

 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. 

 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.

 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

 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.

 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.

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       

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

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.

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.       

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.       

Articles

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.

F. Vianello, MD

Articles

Laparoscopic rectosigmoid resection in case of deep endometriosis