Laparoscopic rectal shaving for rectocervical endometriotic nodule

  • Abstract
    This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
  • 00'19" Clinical case
    This is the case of a 32-year-old G0P0 woman who presented with severe dysmenorrhea, severe dyspareunia, and constipation. After pelvic examination and transvaginal ultrasonography, endometriosis was diagnosed, and a laparoscopic nerve-sparing rectocervical nodulectomy for endometriosis nodules was decided upon.
  • 00'44" Pelvic exploration
    Pelvic exploration showed that the rectum was attached to the posterior aspect of the uterus.
  • 00'58" Dissection of the pararectal fossa
    First, a left ureterolysis was performed followed by a pararectal fossa opening. The left hypogastric nerve was identified and held with a bipolar dissector. The same procedure was performed on the right side. The pararectal fossa was then dissected and the right hypogastric nerve was identified.
  • 02'24" Freeing of the left sacrouterine ligament
    The left sacrouterine ligament was divided using a bipolar forceps and scissors.
  • 03'15" View before nodulectomy
    The rectocervical attachment, the uterus, both fixed ovaries, the left ureter, and the hypogastric nerve could be visualized. A 10mm trocar was introduced into the umbilicus; 5mm trocars were placed in the left and the right sides laterally 5cm below the umbilical midline, and a 30-degree telescope was used. A rectal probe was inserted in order to visualize rectal movement during the dissection of the rectovaginal space and while checking the rectum with a methylene blue test.
  • 03'54" Freeing of rectum and rectovaginal space dissection
    The rectum was pulled and the dissection was performed in a stepwise approach using a bipolar dissector and scissors. Since the right ureter was close to the nodule, a right ureterolysis was carried out with gentle movements. The dissection was continued until the healthy rectal wall was reached.
  • 05'24" Rectal shaving
    The rectal nodule was pulled up and shaved with cold scissors. Bipolar energy could be used too, if necessary.
  • 06'37" Final view
    The final panoramic view showed that the rectum was totally free. The nerve and the ureter were visible. The rectum was then checked using a methylene blue test and no complication was evidenced.
  • Related medias
    This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.