Laparoscopic treatment of a complex recurrent deep endometriosis

Deep endometriosis is a rare condition (1 to 5% of all cases). Treatment should aim at symptom relief and the recovery of the organ function. We present a case of a 30-year-old patient with severe endometriosis. The MRI showed a recto-vaginal nodule invading the serosa of the rectum wall. Double-J stents were put in place before the surgery as the ureters were also compromised.

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Laparoscopic treatment of a complex recurrent deep endometriosis

Authors

A Wattiez, J Leroy, J Marescaux

Abstract

Deep endometriosis is a rare condition (1 to 5% of all cases). Treatment should aim at symptom relief and the recovery of the organ function. We present a case of a 30-year-old patient with severe endometriosis. The MRI showed a recto-vaginal nodule invading the serosa of the rectum wall. Double-J stents were put in place before the surgery as the ureters were also compromised.

Media type

Surgical video

Duration

19'05''

Publication

2006-11

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E-publication

WeBSurg.com, Nov 2006;6(11).
URL: http://www.websurg.com/doi-vd01en1841.htm

Laparoscopic treatment of a complex recurrent deep endometriosis

1. Start of procedure 00'16''

The procedure begins with port placement.

2. Trocar placement 00'20''

There is the umbilical port for the optic. There are two lateral ports, medially to superior anterior iliac spines. There is a lateral port for the assistant at the same level as the optic and a suprapubic port which can be enlarged for the bowel section. The next step is to create an exposure.

3. Exposure of the pelvis 00'43''

This is done by dissecting the adhesions between the sigmoid colon and the lateral abdominal wall. The technique here is the following: the assistant pulls the tissues and the traction counter-traction technique is used. There is bipolar diathermy for hemostasis and scissors for sharp dissection. Here the sigmoid colon is dissected and the dense adhesions are dissected as well.

4. Dissection of sigmoid colon 01'25''

The sigmoid colon is densely adherent to the back of the uterus. You can see the left ovary which is adherent to the sigmoid as well and the rectum is densely adherent to the back of the uterus as well. Clinical information for this patient is: this is a 30-year-old lady with severe endometriosis. The MRI showed that there is a nodule in the rectovaginal space in close proximity to the ureter. This is why the ureteric stents were inserted bilaterally prior to the procedure. The rectovaginal nodule does not extend into the muscular layer of the rectum but it is attached to the serosal surface of the rectum. The structure on the left is the obliterated umbilical artery. The dissection continues to expose the rectum and the technique here is to stay as close to the uterus to avoid inadvertent bowel injury. Once you see the plane, it is easy to just continue to develop this plane. Here we are trying to visualise the ureter as this is an essential part of the operation for rectovaginal endometriosis. The ureterolysis is performed by blunt dissection. This is the right side and the ureter is identified here by lifting the peritoneum and developing the retroperitoneal space.

5. Identification of right ureter 04'39''

The pararectal space is opened and the rectum is dissected off laterally and posteriorly.

6. Opening of pararectal space 05'20''

Here is an example of using the ultrasonic device for dissection. It provides dissection and hemostasis at the same time. Here there’s a flexible retractor is used to retract the uterus. You can see now that there are dense adhesions between rectum and uterus that require sharp dissection. This is all endometriosis which in this patient resulted in fibrosis and adhesions. The dissection of adhesions is performed so we can carry out a segmental resection. This is the left pararectal space and the healthy tissues are visible. The rectum is prepared. Dissection is continued posteriorly as well. Here you can see the use of the Ligasure device, which provides hemostasis and dissection at the same time.

7. Resection of sigmoid colon 07'24''

This is the Endo-GIA stapler and the sigmoid resection is performed. You can see the ureter on the left and the ureter is being dissected off the diseased rectum. There is a small visible defect on the ureter but this is a necessary step because both ureters are diseased and the dense fibrosis encircles the ureters. Now the rectal stump is lifted up and the dissection continues inferiorly. You can see the nodule because of its brown colour and dense fibrosis.

8. Endometriotic nodule 08'31''

The rectovaginal space is being developed by using sharp dissection. Here you can see the use of the Ligasure device again, which is very useful in this situation because it gives minimal lateral thermal injury. The rectal stump is being prepared to perform the distal part of the resection. It is very important not to compromise the vascular supply of the rectum. Here the vaginal examination is being performed to see the limits of the vagina. The Endo-GIA stapler is being applied again and the resection is completed. Here there is the pouch of Douglas with the rectal stump in the middle. There is the right ureter which is involved in the fibrosis and there is the left ureter with a small ureteric defect. You can see the ureteric stump for this defect. The dense fibrosis is dissected with scissors. It is important not to use monopolar diathermy in this area to avoid thermal spread. This is the usage example of bipolar diathermy and the aim here is to dissect all the visible fibrosis and all the visible disease. This is an organ-sparing procedure, so it is very important not to compromise the function of the organs that are present in this pelvic area. The ureter is dissected down all the way to the meeting point with the uterine arteries and care is taken not to dissect the uterine artery because in a young woman, it will compromise the blood supply to the uterus. So it is very important to stay close to the ureter and not to ligate the artery. You can see the ureter on the right being dissected off and on the left. The dissection of the ureters should be performed before removal of the nodule. Here the monopolar hook diathermy is used to remove the nodule from the pouch of Douglas and rectovaginal area. The nodule extends into the vagina and during the dissection the vaginal wall is opened. It is very important to ask the assistant to use traction as the aim is to remove only diseased tissues.

9. Closure of the vagina 14'50''

Here you can see the defect in the vagina which is closed with 3/0 Vicryl by using intracorporeal suturing technique. A glove is used to prevent air from escaping the vagina. Here you can see the panoramic view of the pouch of Douglas. The vagina is checked for the completion of the repair and here you can see the left ureter being repaired with 4/0 Vicryl. The ureteric stent will remain in place for at least 6 weeks. This is also done to promote the new vascular supply to the ureters as in the process of this dissection the blood supply to the ureters can be compromised. This is our specimen and now we must find the proximal part of the resection so we can complete anastomosis. Here the sigmoid colon is further dissected off the lateral abdominal wall to make sure that it can be brought down without any tension.

10. Specimen extraction 17'22''

Here there is a panoramic view of the Douglas pouch with pulsating right internal iliac artery. Now we prepare for the anastomosis and the first step is to remove the diseased bowel and the next step is proximal part of the sigmoid colon that is brought outside of the abdomen and the circular stapler is inserted.

11. Colorectal anastomosis 18'13''

The distal part of the rectum is identified and the other part of the circular stapler is inserted. The middle colon is removed through the port. The proximal and distal parts of the stapler are connected and it is very important to make sure that there are no twists in the sigmoid colon. The anastomosis is performed and the last part of the procedure is the leak test.