Laparoscopic-Assisted Transanal Total Mesorectal Excision for a Patient with Bowel Endometriosis

Abstract

<h3>Study Objective</h3> To explore a less-invasive surgical route for patient with bowel endometriosis to undergo segmental colorectal resection. <h3>Design</h3> A case report. <h3>Setting</h3> A university-based tertiary hospital. <h3>Patients or Participants</h3> A 34-year-old female was readmitted two years post-conservative surgery for endometriosis due to consistent digestive dysfunction symptoms. A 3-cm nodule within the muscle layer of lower rectal wall was identified by pelvic MRI. <h3>Interventions</h3> A laparoscopic-assisted transanal total mesorectal excion (TaTME) was performed (a 4-minute video clip included). <h3>Measurements and Main Results</h3> The patient was placed in a Trendelenburg position. For the laparoscopic step, the rectovaginal space was dissected. Lateral, posterior and anterior experitoneal rectal and left sigmoid dissection was performed adequately. Pay attention to protect the ureter and hypogastric nerve. An articulated endoscopic cutter was used to transect the distal rectal segment. For the trans-anal step, the rectal lumen was irrigated, the distal end of rectum was grasped out through anus. A safe margin down to the endometriotic lesion was chosen, 3-0 suture was placed followed by reloaded staplers to close the distal rectal lumen. TME was performed utilizing a "bottom up" approach. An avil was placed inside of proximal sigmoid. Rectosigmoid anastomosis completed successfully by using a circular stapler. No protective ileostomy was adopted. The surgery was uncomplicated with minimal blood loss. Significant improvement of bowel symptoms was reported within the first month postoperatively. During 3-year follow-up period no recurrence of endometriosis or digestive dysfunction symptoms was observed. <h3>Conclusion</h3> As a novel technique, laparoscopic-assisted TaTME shows advantage over laparoscopic surgery, such as better visualization of the distal resection margin while avoiding a bigger abdominal scar. Young women with colorectal endometriosis can benefit for more radical but less invasive surgical outcome. An experienced multidisciplinary team making comprehensive evaluation and discussion before surgery will ensure this technically highly demanding operation feasible and safe.