Laparoscopic ureteral repair during colorectal resection for pelvic endometriosis

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Laparoscopic ureteral repair during colorectal resection for pelvic endometriosis

Authors

J Leroy, H Inoue, J Marescaux

Media type

Surgical video

Duration

06'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1735.htm

Laparoscopic ureteral repair during colorectal resection for pelvic endometriosis

1. Clinical history 00'11''

We present the case of a 35-year-old female with severe endometriosis. She had a prior laparoscopy that aided in the diagnosis of this. She has been suffering from her disease for 15 years. Preoperative MRI demonstrated 2 endometrioma, one on the urinary bladder, and one on the rectal wall in the pouch of Douglas.

2. Trocar placement 00'37''

The patient is placed in supine position with the legs abducted. Six trocars were used as in our standard sigmoid rectal resection. The endometriosis tissue is visible throughout the pelvis, especially on the bladder. Severe adhesions between the uterus and the rectum are observed. The adhesion between the ovary and peritoneum is dissected using harmonic scalpel.

3. Rectovaginal dissection 00'57''

To improve the exposure, both ovaries are sutured to the abdominal wall.

4. Left ureter 01'04''

The dense adhesions between the rectum and the vagina are divided using an ultrasonic scalpel. During procedures in the pelvis such as in this case where severe adhesions are present, the identification of the ureter is of primary importance as the incidence of ureteral injury is much more possible.

5. Division of rectum 01'26''

Dissection in this area is made easier with the use of traction which is achieved by the retractor on the uterus and the grasper on the colon as shown here. The uterosacral ligament is shown to be fixed secondary to the endometriosis disease.

6. Dissection of ureter 01'47''

We must remember that the region of the uterosacral ligament is one of the most common areas in which to injure the ureter. The peritoneum is dissected to identify the ureter. The ureter becomes visible and its anticipated path is noted. This hard tissue is divided from the ureter utilizing once again the Harmonic scalpel. We find the Harmonic scalpel to be a useful device to dissect in cases in which dense adhesions exist. The ureter is divided from the hard peritoneum. Despite this, the ureteral injury occurs.

7. Ureteral defect 02'48''

The defect is recognized immediately. It is noted that only 30% of the ureteral injuries are recognized during the procedure.

8. Ureteral suture 03'00''

Most of the cases are diagnosed after the procedure is complete. The retrograde ureteral stent is then inserted. A guide wire insertion is performed under the laparoscopic view and the graspers from the surgeon aid in the advancement of the stent. In this case, the defect is small so the ureteral repair is performed with 2 interrupted stitches using absorbable suture. The ureteral stent is removed 5 days after the operation. The patient was discharged uneventfully 8 days after surgery and her symptomatology from her endometriosis has resolved. In this case, despite judicious monitoring of the ureteral location, ureteral injury still did occur over monitoring and a proper intervention of this injury is paramount to the patient’s morbidity.