P. Messori

Is Ileostomy Always Necessary Following Rectal Resection for Deep Infiltrating Endometriosis

OBJECTIVE To verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement. DESIGN Retrospective study (Canadian Task Force classification III). SETTING Tertiary referral center. PATIENTS Forty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection. INTERVENTION Segmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared. MEASUREMENTS AND MAIN RESULTS Sigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%). CONCLUSION A protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.

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.