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Presented by Kristen Pepin, MD, and Jon I. Einarsson, MD, PhD, MPH Brigham and Women’s Hospital, Boston
The video details a laparoscopic excision of endometriosis nodule of the rectum. The patient is a 35-year-old G1P1 with a history of chronic pelvic pain and infertility.
A year prior to this procedure, she had undergone an incomplete laparoscopy where extensive endometriosis was noted between the rectum and the vagina. On exam, she had a 2 cm mass that was palpable in the rectovaginal septum. Upon entry, a complete obliteration of the posterior cul-de-sac is noted.
The procedure is begun by removing filmy adhesion tethering the sigmoid to the left pelvic sidewall. This dissection is carried cranially to allow for adequate mobilization of the sigmoid. This allows for the ureter to be identified at the level of the pelvic brim as is seen here.
This dissection is then carried down into the pelvis so that the ureter can be seen at the level of the tethered ovary. Using sharp dissection, the left ovary is separated from the underlying rectum. A dissection of the rectum of the posterior uterus is also begun. The ovary can then be bluntly mobilized out of the posterior cul-de-sac. The left ovary is temporarily sutured to the round ligament to keep it out of the surgical field.
The right ovary is bluntly mobilized off the pelvic sidewall. The right ureter is identified trans peritoneally. The retroperitoneum is entered just below the level of the ureter to allow for its complete dissection on the right pelvic sidewall. Rectal attachments to the posterior uterus are carefully taken down with sharp dissection.
The rectum is found to have more than one attachment and the first attachment is freed. This allows for better visualization of the rectum and the remaining nodule. Dissection is carried laterally to free the nodule from any attachments on either sidewall.
The nodule is then carefully dissected off the posterior uterus. Electrosurgery is safely used at the interface of the nodule and the posterior uterus. Throughout the dissection, the surroundings are constantly evaluated to avoid injury. Here the mass must be further mobilized off the right pelvic sidewall.
A hand is placed in the vagina to help delineate any healthy vaginal tissue from the nodule. The right ovary is also temporarily tethered out of the way. With care to avoid the ureter, the peritoneum overlying the right pelvic sidewall, where the ovary was once tethered, is removed in its entirety. A rectal probe is placed.
Sequentially the endometriosis nodule is removed from its lateral attachments. The nodule is then freed of its attachments to the rectum itself. Despite a careful dissection there still is some residual nodule left. This is carefully grasped with the tenaculum and dissected off the rectum using cold scissors.
This leaves a viable area of the muscularis layer exposed. This area is oversewn in multiple layers without narrowing the rectal lumen. This is tested by passing an EEA sizer through the rectum after the first layer.
The suture used here is a barbed PDO suture. Similar to the right side, the peritoneum overlying the left pelvic sidewall is also excised. The excision is now complete, and a rectal leak test is done.
The patient was discharged at post-op days zero, had a routine post-op course, and reported significantly improved pain at her post-op visit. All specimens removed were notable for endometriosis.