Endometriosis Affecting the Base of Appendix and the Middle Rectal Artery: A Case Report

Abstract

Study Objective To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Design Case report for anatomical study and description of the procedure using video. Setting Tertiary Hospital. Patients or Participants A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. Interventions We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Measurements and Main Results Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. Conclusion We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix. To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Case report for anatomical study and description of the procedure using video. Tertiary Hospital. A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix.