J. Albornoz

Surgical strategy in endometriosis

Endometriosis is a common disease affecting young women. Its clinical manifestations include pain and infertility, and it can dramatically affect quality of life. Treatments should be tailored to address the wishes of women according to the specific characteristics of the disease. Although many questions remain unanswered, strong evidence supports the use of laparoscopic surgery to improve pain and infertility. The systematisation of strategy is essential to make surgery more reproducible, safer and less time-consuming. Nevertheless, even in the most expert hands, complications may occur. Further investigations are needed to compare the different approaches. Outcomes must, however, include pain, fertility, organ dysfunction, and quality of life.

Totally Laparoscopic Intracorporeal Anastomosis With Natural Orifice Specimen Extraction (NOSE) Techniques, Particularly Suitable for Bowel Endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

A New Technique of Laparoscopic Intracorporeal Anastomosis for Transrectal Bowel Resection With Transvaginal Specimen Extraction

STUDY OBJECTIVE To show a new technique of laparoscopic intracorporeal anastomosis for transrectal bowel resection with transvaginal specimen extraction, a technique particularly suited for treatment of bowel endometriosis. DESIGN Step-by-step explanation of the technique using videos and pictures (educative video). SETTING Endometriosis may affect the bowel in 3% to 37% of all endometriosis cases. Bowel endometriosis affects young women, without any co-morbidities and in particular without any vascular disorders. In addition, affected patients often express a desire for childbearing. Radical excision is sometimes required because of the impossibility of conservative treatment such as shaving, mucosal skinning, or discoid resection. Bowel endometriosis should not be considered a cancer, and consequently maximal resection is not the objective. Rather, the goal would be to achieve functional benefit. As a result, resection must be as economic and cosmetic as possible. The laparoscopic approach has proved its superiority over the open technique, although mini-laparotomy is generally performed to prepare for the anastomosis. INTERVENTIONS Total laparoscopic approach in patients with partial bowel stenosis, using the vagina for specimen extraction. CONCLUSION This technique of intracorporeal anastomosis with transvaginal specimen extraction enables a smaller resection and avoidance of abdominal incision enlargement that may cause hernia, infection, or pain. When stenosis is partial, this technique seems particularly suited for treatment of bowel endometriosis requiring resection. If stenosis is complete, the anvil can be inserted above the lesion transvaginally.

Laparoscopic Sigmoidectomy for Endometriosis With Transanal Specimen Extraction

STUDY OBJECTIVE To describe a more conservative and less invasive surgical approach to laparoscopic colorectal segmental resection for treatment of endometriosis. DESIGN Video of elective sigmoidectomy to treat colorectal endometriosis. SETTING Tertiary referral center for laparoscopic gynecologic surgery at the University Hospitals of Strasbourg, France. PATIENT A 29-year-old woman with dysmenorrhea, constipation, and cyclic diarrhea and two sigmoid endometriotic lesions evident at colonoscopy. INTERVENTION The conservative surgical strategy, possible in cases of benign lesions such as endometriosis, consists of dividing the mesentery close to the digestive tract to preserve the vascular-lymphatic vessels and the surrounding sympathetic and parasympathetic nerves. The less invasive approach consists of natural orifice specimen extraction via the transanal route. MEASUREMENTS AND MAIN RESULTS The postoperative course was favorable. The conservative technique enables preservation of the superior rectal vessels, which contribute to 80% of the vascularization of the rectum, to maintain the best vascularization, essential for intestinal anastomosis. Transanal specimen extraction maximizes the benefits of laparoscopy by sparing the abdominal wall from incision and its associated complications. CONCLUSION A conservative surgical approach should be used in segmental bowel resection for treatment of endometriosis. Moreover, the segmental bowel resection can be safely performed with transanal specimen extraction, with great advantages for the patient.

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmoceles characteristics and surgeon expertise.