Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis

We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.

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Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis

Authors

A Wattiez, J Leroy, E Faller, J Albornoz, P Messori

Abstract

We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.

Catégorie

live recorded

Mots-clés

Deep endometriosis excision, ureteral anastomosis, segmental rectosigmoid resection, transvaginal specimen extraction, transanal colorectal anastomosis

Type de vidéo

Vidéo chirurgicale

Durée

29'26''

Publication

2012-01

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E-publication

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3562.htm

Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis

1. Exposure 02'36''

Exposure of the pelvis reveals a big endometriotic nodule located on the right side of the pelvic wall. The T-lift™ device is used to fix the ovaries and improve pelvic exposure.

2. Dissection around endometriotic nodule 04'02''

Surgery begins with dissection of the right ureter, which is surrounded by fibrotic tissue. The dissection is very difficult and accidentally a hole is made in the medial wall of the right ureter. Urine leakage is then visible. The pararectal fossae are opened with blunt dissection in order to turn the endometriotic nodule around. Progressively, mobility of the rectum is obtained. A rectal probe is placed in order to confirm the rectal wall location and is then removed.

3. Deciding upon rectal resection 11'00''

The rectum is free and a big fibrotic nodule is visualized at the right lateral rectal wall. Low rectal resection below 7cm from the anal margin is associated with a high risk of functional problems and complications.

4. Dissection of right ureter in the ureteral canal 12'17''

The dissection is continued by the identification of the right uterine artery. Next, the bladder and the anterior aspect of the right ureter are dissected. During the ureter’s dissection, the preservation of the uterine artery is not always possible. At the end of the dissection, you can see that 2 holes have been made accidentally in the ureter.

5. Cystoscopy and double J stent insertion 15'03''

The double J stent is inserted in the distal part of the ureter. The fibrosis is so important that a resection is decided on. The stent is then moved through the proximal part of the ureter under visual control, until reaching the renal pelvis.

6. Disease resection 17'07''

The ureteral nodule is excised and the vagina is opened in order to resect the vaginal nodule. A T-lift™ device is placed in the abdominal wall to hold the uterus anteriorly and improve the exposure. Colpotomy is used for extraction of the endometriotic nodule from the pelvic cavity.

7. Ureteral anastomosis 20'34''

The anastomosis is carried out with 4 separate stitches of monofilament 6/0. It is important to avoid too much tension at the level of the suture.

8. Mobilization of sigmoid colon using vessel-sealing device 22'42''

Rectal examination by the colorectal surgeon concludes that the rectal nodule of endometriosis is located at 8cm from the anal margin. The colorectal surgeon decides to perform a segmental rectal resection. A 5mm Ligasure™ vessel-sealing device is used to dissect the lateral margins of the rectosigmoid bowel in order to prepare it for the resection and anastomosis.

9. Anvil preparation and trans-anal placement 25'03''

A Vicryl 0 suture is attached to the anvil. The anvil is then grasped with a flat forceps covered with a plastic tube and introduced through the rectum above the level of the nodule. This strategy reduces the amount of bowel descent needed to perform the anastomosis. Consequently, bowel devascularization is limited, which is not the case when the anastomosis is performed extracorporeally.

10. Division of rectum and transvaginal extraction 25'48''

The rectum is transected both caudally and cranially to the endometriotic nodule using an Endo-GIA™ linear stapler. The extraction of the specimen is performed through the vagina.

11. Anvil extraction and intracorporeal side-to-end colorectal anastomosis 27'08''

A small incision in the anti-mesenteric border of the sigmoid stump allows for the exteriorization of the anvil\'s caudal portion. A purse-string with a pre-shaped loop is made to tighten the anvil\'s shaft. The PCEEA 28 circular stapler is inserted through the anus into the caudal portion of the rectum and an intracorporeal side-to-end colorectal anastomosis is carried out. It is important to avoid twisting the colon and checking for the presence of the two borders of the anastomosed margins inside the stapler. A test of anastomotic tightness is carried out with air to demonstrate the absence of gas leakage.

12. Omentoplasty and vaginal closure 28'40''

The Ligasure™ vessel-sealing device is used to free a portion of the greater omentum. The vagina is closed using 3 separate stitches of polypropylene. The omentum is put around the ureteral anastomosis and fixed to the vaginal suture in order to protect the 3 sutured structures: ureter, vagina, and bowel.