Treatment of Endometriosis of Uterosacral Ligament and Rectum through the Vagina: Description of a Modified Technique

O. Camara; J. Herrmann; A. Egbe; A. Kavallaris; H. Diebolder; M. Gajda; I.B. Runnebaum

Disclosures

Hum Reprod. 2009;24(6):1407-1413. 

In This Article

Surgical Technique and Results

First, a clinical examination under general anaesthesia was performed in a dorsal lithotomy position. A 10 mm trocar was introduced through the umbilicus for the laparoscope (0°, Karl Storz, Tuttlingen, Germany), two 5 mm trocars were placed left and right in the lower abdomen and one 12 mm trocar in the supra pubic area. One 10 mm trocar was also placed in the left upper quadrant. A careful intra-abdominal inspection was carried out (Fig. 1).

Figure 1.

(AD) Presentation of bowel endometriosis—representative of all cases.

The proximal healthy left colon was mobilized laparoscopically (Fig. 2). The ureters and hypogastric nerves were identified. A low anterior resection was done. In order to gain access to the proximal colon stump through the vagina, the colon needed to be mobilized to the splenic flexure (Fig. 3). A division of the mesenteric vessels was not necessary. Transection of rectosigmoid 2 cm proximal to the lesion with an endo-GIA (Covidien Deutschland GmbH, Sugical, Gewerbepark 1, 93333 Neustadt/Donau, Germany) was performed. No Pfannenstiel incision was needed, and further mobilization of the specimen was done vaginally. The resection of the specimen with a TA stapler (Covidien Deutschland GmbH) was carried out (Fig. 4) in the vagina, and the specimen was removed. The specimen was removed transvaginally. A metallic grasper was introduced through the vaginal colpotomy to withdraw the stump of the proximal sigmoid colon. After resecting the staple line of the proximal sigmoid stump, the head of the circular stapler was inserted transvaginally into the open sigmoid colon. A purse-string suture was used to close the proximal sigmoid colon around the shaft of the stapler head (Fig. 5). The sigmoid stump was returned to the pelvis and the colpotomy incision closed with interrupted sutures. The circular stapler was inserted transanally. The colorectal anastomosis was carried out under laparoscopic control, using the circular stapler (diameter 29 mm). The anastomosis was checked for leakage and tension. The length of the largest abdomen wound was 12 mm.

Figure 2.

(A) Mobilization of the left proximal colon; (B) left colon flexure; (C) phrenic colonic ligament and (D) mobilized colon flexure.

Figure 3.

(A) Mobilization from the gerota fascia; (B) left para rectal dissection; (C) rectal endometriosis (nerve-sparing) and (D) right uterosacral dissection.

Figure 4.

(A,B) Resection of rectosigmoid segment with endo-GIA stapler (Tyco Germany); (C) transvaginal incision and (D) resected specimen with TA stapler (Tyco Germany).

Figure 5.

(A) Colon stump transvaginally; (B) purse-string suture grasper after the resection line was resected and stapled; (C) purse-string suture around the stapler head and (D) circular stapler connected for the anastomosis, before closing the device.

The intra- and post-operative courses were uneventful. No blood transfusions were needed. On the third day, food intake was allowed: at this time the patients had defecated. They were discharged on post-operative day 7. Pathological diagnosis from the resected specimen were compatible with the pre-operative findings (Fig. 6).

Figure 6.

Morphological sections of resected specimens at various magnifications. (A) Vagina haematoxylin and eosin (H&E) (200 ×); (B) rectum H&E (40 ×); (C) rectum H&E (100 ×); (D) rectum H&E (200 ×); (E) rectum H&E (200 ×)—haemorrhagic endometriotic foci and (F) rectum iron test (100 ×) haemosiderophages (blue).

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