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


Hum Reprod. 2009;24(6):1407-1413. 

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Symptomatic deep pelvic endometriosis seems to be progressive, and radical excision gives good results. Several surgical approaches and techniques can be used (laparoscopic, abdominal, vaginal or combinations thereof). Redwine et al. (1996) reported that laparoscopically assisted transvaginal segmental rectosigmoid resection for endometriosis is simpler than a laparoscopic intra-corporeal segmental resection technique and is less costly than a laparotomy segmental resection. Brouwer and Woods (2007) carried out 137 segmental excisions of the rectum in 213 rectal procedures between 1995 and 2005. A small Pfannenstiel incision was needed for the anastomosis and retrieval of the specimen. Darai et al. (2007) treated 71 patients with 12.6% major complications. To allow the colon to be exteriorized and resected, one incision had to be enlarged to a length of 4 cm. Out of 71 patients, 6 rectovaginal fistulas occurred. Jerby et al. (1999) reported one colovaginal fistula in 30 laparoscopic interventions of colorectal endometriosis. Anaf et al. (2000) reported the treatment of five cases, each with a supra pubic incision of up to 5 cm in order to exteriorize the sigmoid lesion. Hand-sewn anastomosis was also performed. Jatan et al. (2006) reported the treatment between 1996 and 2004 of 95 patients with pelvic endometriosis involving the rectum. Fourteen patients had segmental low anterior resection. Abrao et al. (2005) treated eight patients in a pilot study. Their technique combines transvaginal access with mechanical intestinal anastomoses, performed using linear and circular staplers. The anastomosis is carried out via the vaginal route, and only the colon mobilization is undertaken laparoscopically. One case report from Breitenstein et al. (2006) used a transvaginal approach for synchronous sigmoid resection and hysterectomy. A transvaginally inserted grasper removed the resected sigmoid colon after vaginal hysterectomy. The stapler head is inserted transvaginally, and the purse-string suture performed laparoscopically. The colorectal anastomosis using a circular transanal stapler is also performed laparoscopically. The first series from Jena using laparoscopy (Kavallaris et al., 2003), including 50 patients between 1997 and 2001, was a combined approach with a mini-laparotomy. In our modified method described here, the first step is to mobilize the left colon to the left colonic flexure. This allows the colon stump to be withdrawn to the vagina together with the resected tissue in a hybrid of a NOTES and laparoscopy procedure. The purse-string suture is made transvaginally. The colorectal anastomosis is performed laparoscopically. In our opinion, this technique is safe and has also shortened the length of operating time. Ghezzi et al. (2008) reported on a new technique for laparoscopic rectosigmoid resection in 33 patients with endometriosis. Segmental colorectal resection with a combined laparoscopic–transvaginal approach, thus avoiding the extension of port-site incisions, was found to represent a viable option for the treatment of bowel endometriosis. Trocar configuration included a 10 mm, 0° umbilical laparoscope, two 5 mm ancillary trocars (one suprapubic and one lateral to the left epigastric artery) and a 10 mm working port in the right lower abdominal quadrant. In our series, a 10 mm trocar was introduced through the umbilicus for the laparoscope, 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. Landi et al. (2006) performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non-nerve-sparing technique (controls n = 20) and a nerve-sparing technique (cases n = 25). The aim of the Landi study was to evaluate the role of the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function. The nerve-sparing technique yielded a higher proportion of satisfaction (87.7 versus 59%) when compared with the group without nerve-sparing. In the present report, for all four cases our modified technique was nerve-sparing.

Although rectovaginal surgery for endometriosis is associated with major complications, such as rectovaginal fistula, the risk remains low. However, this is very demanding surgery that requires a high level of skill in specialized tertiary care endometriosis clinics and experienced bowel surgeons in attendance. Complications reported on laparovaginal procedures vary between 0 and 13%. In the largest series of segmental excision of the rectum, Woods et al. (2003) reported complication rates of 13%. In general, reported complications were anastomotic bleeding, anastomotic stricture, anastomotic leak, bladder dysfunction, pelvic haematoma, blood transfusion or conversion to laparotomy.

There is a little risk of infection, but it must be emphasized that no cases of post-surgical infection occurred. Abrao et al. (2005) reported no complications in a pilot study on eight patients. Our approach to prevent rectovaginal fistula or anastomosis dehiscence is to have no tension and no fatty tissue in between the anastomosis. In these four cases, we did not encounter any rectovaginal fistula and our modified technique is under further evaluation.


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