Fully laparoscopic segmental rectosigmoid resection with Natural Orifice Specimen Extraction (NOSE) for bowel endometriosis

We report the case of a 45-year-old woman, G2P2, who presents with rectal bleeding, constipation and subocclusive syndrome caused by rectosigmoid endometriosis. The laparoscopic exploration revealed a sigmoid stuck by a few adhesions to the lateral abdominal wall underneath the left ovary and obliteration of the left uterosacral ligament and rectovaginal septum. A segmental bowel resection was performed with all necessary steps for mechanical bowel anastomosis carried out laparoscopically. The transvaginal specimen extraction obviated the need to create an abdominal incision. There were no complications and the patient presented a clinical remission following surgery. This surgical technique has the advantage of a shorter division of the mesentery, which enables a better vascularization of the bowel.

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Fully laparoscopic segmental rectosigmoid resection with Natural Orifice Specimen Extraction (NOSE) for bowel endometriosis

Authors

A Wattiez, J Leroy, S Maia, A Vázquez Rodriguez, P Trompoukis, J Alcocer

Abstract

We report the case of a 45-year-old woman, G2P2, who presents with rectal bleeding, constipation and subocclusive syndrome caused by rectosigmoid endometriosis. The laparoscopic exploration revealed a sigmoid stuck by a few adhesions to the lateral abdominal wall underneath the left ovary and obliteration of the left uterosacral ligament and rectovaginal septum. A segmental bowel resection was performed with all necessary steps for mechanical bowel anastomosis carried out laparoscopically. The transvaginal specimen extraction obviated the need to create an abdominal incision. There were no complications and the patient presented a clinical remission following surgery. This surgical technique has the advantage of a shorter division of the mesentery, which enables a better vascularization of the bowel.

Keywords

laparoscopic, segmental rectosigmoid resection, Natural Orifice Specimen Extraction, NOSE, bowel endometriosis

Media type

Surgical video

Duration

08'03''

Publication

2011-07

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E-publication

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3139.htm

Fully laparoscopic segmental rectosigmoid resection with Natural Orifice Specimen Extraction (NOSE) for bowel endometriosis

1. Introduction 00'20''

We report the case of a 45-year-old woman, G2P2, who presents with rectal bleeding, constipation and subocclusive syndrome caused by rectosigmoid endometriosis.

2. Exposure by sigmoid adhesiolysis and ovary suspension 00'35''

The procedure was started by the adhesiolysis of the sigmoid colon in order to expose the left ureter. To achieve better exposure, a transparietal suspension of the ovaries was carried out by passing a straight needle armed with a monofilament suture.

3. Dissection of pararectal fossa and rectovaginal space 00'53''

The peritoneum covering the mesentery of the rectosigmoid colon was opened in an avascular area. Care was taken at this point to identify the left ureter. Careful dissection was continued into the left pararectal fossa up to the levator ani muscle, respecting the inferior hypogastric plexus that was affected by the disease. After identification of the right ureter, the dissection was continued on the right pararectal fossa. The rectovaginal space was then dissected. A dry gauze was inserted into the peritoneal cavity to clean it, and once the uterine manipulator was removed, a transparietal uterine suspension was performed.

4. Retrorectal dissection 02'17''

Retrorectal dissection using a 5mm Ligasure™ device was begun in the avascular plane between the presacral fascia and the mesorectum to achieve a mesorectal excision.

5. Division of the rectum 03'09''

The rectum was transected caudal to the endometriotic lesion using a 60mm Endo-GIA™ linear stapler further assisted by a 45mm one. In order to gain access to the sigmoid stump through the vagina, the take down of the splenic flexure was performed.

6. Transvaginal exteriorization of the colon 03'59''

A CCL culdotomy extractor was placed into the vagina, and its posterior vault was opened with a monopolar hook dissector. Once an Endoloop suture was placed on the sigmoid stump, the colon was gently exteriorized through the vagina by pulling the free end of the thread with a grasper introduced transvaginally.

7. Anvil insertion 04'22''

The anvil of a circular stapler was previously prepared by the surgeon. A polypropylene suture was threaded through the tip of the anvil. Once the anvil was introduced through the suprastenotic incision of the colon that was previously exteriorized, it was pushed in the proximal colon under laparoscopic control.

8. Division of the colon and transvaginal specimen extraction 04'44''

The sigmoid stump was transected cranial to the lesion using a 60mm Endo-GIA™ linear stapler proximal to the lesion. The gauze was also removed through the vagina.

9. Anvil extraction 04'56''

A gauze soaked in povidone-iodine was transvaginally introduced into the peritoneal cavity to clean the anvil\'s tip. A micro-incision on the antimesenteric border of the sigmoid stump allowed the anvil\'s exteriorization. A purse-string with a pre-shaped loop to tighten the anvil shaft was performed. The tip was then removed transvaginally with the gauze in a bag.

10. Laparoscopic closure of colpotomy 05'38''

The colpotomy incision was closed laparoscopically with an interrupted 2/0 Polysorb™ suture, showing no leakage during the control test.

11. Intracorporeally end-to-side colorectal anastomosis 06'27''

At this point of the surgery, the surgeon should check if the freeing of the left colon needed to be completed, in order to obtain a tension-free anastomosis at the level of the upper rectum. The PCEEA 28 circular stapler was then inserted into the anus and an intracorporeal end-to-side colorectal anastomosis was created, paying attention not to twist the colon. The two doughnuts of tissue were controlled. An air-test was carried out. It did not show any leakage. Upon completion of the anastomosis, the abdominal cavity was thoroughly irrigated, and the patency of the anastomosis was checked. In this surgical technique, all necessary steps for mechanical bowel anastomosis were performed laparoscopically, and the transvaginal access allowed for specimen extraction, obviating the need to create an abdominal incision.