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Totally laparoscopic approach for recto-vaginal endometriosis

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Totally laparoscopic approach for recto-vaginal endometriosis

作者群

J Leroy, J Marescaux

關鍵字

rectovaginal endometriosis,laparoscopy

媒體類型

手術影片

期間

10'00''

刊物

2004-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1590.htm

Totally laparoscopic approach for recto-vaginal endometriosis

1. Trocar placement 00'07''

This is the case of a young woman with a history of endometriosis with symptomatic involvement of the rectum. Here we show the position of the ports. Five ports are used in our typical fashion for sigmoidectomy. The symptoms are pain during menstruation, dyspareunia, and cyclic diarrhea. The endometriosis is identified at the level of the rectosigmoid junction on the posterior side of the vagina. We see the intimate relationship between the sigmoid and the inferior portion of the uterus. We begin dissection of the sigmoid using a Harmonic scalpel.

2. Dissection of sigmoid colon 01'10''

Continued dissection in these tissue planes aids in the mobilization of the tissue itself. The dissection is adjacent to the left ureter as is seen here. The left ureter is again visualized as is noted.

3. Left ureter 02'26''

Dissection continues medial to the ureter and adjacent to the rectum and posterior inferior portion of the uterus and posterior portion of the superior wall of the vagina. During the dissection, a portion of the superior wall of the vagina is noted to be significantly involved with the endometriosis. This portion is excised with the specimen. It is noted that 12 to 34% of patients with pelvic endometriosis have bowel involvement as well as significant involvement of other pelvic organs. As you can see here, the posterior wall of the vagina is open. The vaginal wall is closed with interrupted sutures. Along with the patient’s bowel rest postoperatively, the patient will have the appropriate measures regarding sexual function in the weeks to come in the postoperative period as well. The adhesions created by endometriosis are very dense and difficult to dissect. We have found that the Harmonic scalpel significantly aids in the dissection over other techniques. The dissection of the sigmoid is continued with the Harmonic scalpel to free the rectosigmoid junction above the nodule of endometriosis that is fixed to the anterior wall of the colon. As you can see, we have a stagnant operative field with our small bowel being maintained out of harm’s way during the entire procedure.Tricks such as these as well as patient positioning in the beginning aid in the successful completion of the procedure and the timeliness of the procedure. An area below the involved segment of the rectum is now seen and is freed from the surrounding normal tissue. It is this area where the Endo-GIA will be fired. Almost complete circumferential dissection is completed.

4. Rectosigmoid division 07'05''

The Endo-GIA is now able to be advanced across the rectum and fired. We now mobilize the sigmoid colon with a medial dissection technique. The 10mm Ligasure device is very useful in this dissection. As the patient’s disease only warns this small section of sigmoid and proximal rectum to be excised, our dissection only is limited to that. Lateral attachments are then taken down and the sigmoid colon is noted to be relatively free and will likely not require further mobilization more proximal in the left colon to able to perform a tension-free anastomosis. We enlarge the suprapubic incision to 4cm and advance the dissected segment through it.

5. Sigmoid extraction 09'00''

It is then excised. In typical fashion we utilize the purse-string device and a 28mm anvil from the end-to-end stapling device to prepare the colon for anastomosis. The purse-string device has a secondary function in that we use it to clamp the wound protector to maintain our pneumoperitoneum.

6. Anastomosis 09'37''

Proper orientation of the colon is appreciated prior to firing of the EEA device. As the patient is young and wishes for continued fertility, utilization of medication for her disease by her gynecologist will be attempted now that significant disease has been removed from the pelvis. After a pool of irrigant has been placed in the pelvis, a syringe insufflates via the anus into the rectum to maintain that an airtight anastomosis has been performed. Our procedure is now complete.