Deep Endometriosis of the Bowel: A Surgical Approach

Abstract

Video Objective The objectives of this video are to define bowel endometriosis and to explore various surgical parameters for the different types of surgical excision. Then, a specific surgical approach will be demonstrated. Setting Our case is of a 34 year old nulliparous woman who presented for surgical management of deep endometriosis, as she was unable to tolerate medical management. She also presented with rectal bleeding and fecal urgency. This case was performed at a tertiary care setting hospital in Canada. Interventions Surgical management of bowel endometriosis is indicated for symptom and pain relief, intolerance to medical management and to prevent complete obstruction. Importantly, operative planning and management should involve a multidisciplinary team involving gynecologists, general or colorectal surgeons and radiologists. When planning a surgical approach to deep endometriosis of the bowel, patient characteristics such as age and BMI, as well as their specific symptoms and level of pain, quality of life and fertility goals must be considered. As well, the actual lesion must be investigated with respect to size, number, location, depth of infiltration, and amount of intestinal wall circumference involved. Then, various surgical techniques can be performed depending on these specific characteristics, such as nodule shaving, nodular resection and segmental resection and re-anastomosis. For our surgical case, segmental resection and re-anastomosis was indicated after intra-operative colonoscopy showed significant luminal obstruction. The video demonstrates a blood vessel preservation and nerve sparing approach, highlighting blood supply, sympathetic and para-sympathetic innervation. Conclusion The patient was discharged post-operative day 2 and reported complete resolution of symptoms at her clinical follow-up. This surgical video demonstrates and advocates a multidisciplinary approach to bowel endometriosis to improve patient quality of life.