Rectosigmoidectomy with Complete Neurovascular Preservation for Deep Endometriosis

Abstract

Study Objective To demonstrate the surgical steps involved in nerve-sparing and mesorectal-sparing segmental rectosigmoid resection. Design Step-by-step video demonstration of the technique. Setting Tertiary University Hospital. Patients or Participants The surgery was performed on a 34-year-old woman with complaints of progressive dysmenorrhea, dyspareunia, chronic pelvic pain, and menstrual dyschezia associated with infertility. Imaging exams showed extensive retrocervical lesions and two confluent intestinal lesions measuring 70mm and 25mm starting at approximately 13cm from the anal verge, with involvement of 40% of its circumference. Interventions Believe that the preservation of vascularization promotes adequate healing, and the preservation of the motor innervation that runs through the mesentery promotes good peristalsis. Initially correctly identifying the extent of the lesion and planning the resection. When the lesion is adhered to the rectovaginal septum or to the cervix, it must initially be isolated through the lateralization of the noble structures and centralization of the disease, keeping the hypogastric nerves, the splanchnic nerves, the inferior hypogastric plexus, and the middle rectal artery preserved. Start separating the rectum or sigmoid from its mesentery by sectioning it near to the dorsal wall, using energy forceps, dissecting up to above and below the lesion. Traction and counter-traction will show the correct space for dissection. Closer to the wall, the lower the probability of bleeding and the greater the preservation of the vascular-nervous elements. Rectosigmoidectomy performed with the section of the distal rectum, mini-laparotomy for exteriorization of the surgical piece, and placement of the circular stapler's anvil followed by stapled end-to-end colorectal anastomosis under laparoscopic view. Measurements and Main Results Surgical time of 120min, with minimal blood loss, favorable postoperative evolution, being discharged on the third day of hospitalization. Conclusion Although many centers already perform rectosigmoidectomy with complete neurovascular preservation, this technique has not yet been widely described. However, it is an effective, safe technique with greater damage control. To demonstrate the surgical steps involved in nerve-sparing and mesorectal-sparing segmental rectosigmoid resection. Step-by-step video demonstration of the technique. Tertiary University Hospital. The surgery was performed on a 34-year-old woman with complaints of progressive dysmenorrhea, dyspareunia, chronic pelvic pain, and menstrual dyschezia associated with infertility. Imaging exams showed extensive retrocervical lesions and two confluent intestinal lesions measuring 70mm and 25mm starting at approximately 13cm from the anal verge, with involvement of 40% of its circumference. Believe that the preservation of vascularization promotes adequate healing, and the preservation of the motor innervation that runs through the mesentery promotes good peristalsis. Initially correctly identifying the extent of the lesion and planning the resection. When the lesion is adhered to the rectovaginal septum or to the cervix, it must initially be isolated through the lateralization of the noble structures and centralization of the disease, keeping the hypogastric nerves, the splanchnic nerves, the inferior hypogastric plexus, and the middle rectal artery preserved. Start separating the rectum or sigmoid from its mesentery by sectioning it near to the dorsal wall, using energy forceps, dissecting up to above and below the lesion. Traction and counter-traction will show the correct space for dissection. Closer to the wall, the lower the probability of bleeding and the greater the preservation of the vascular-nervous elements. Rectosigmoidectomy performed with the section of the distal rectum, mini-laparotomy for exteriorization of the surgical piece, and placement of the circular stapler's anvil followed by stapled end-to-end colorectal anastomosis under laparoscopic view. Surgical time of 120min, with minimal blood loss, favorable postoperative evolution, being discharged on the third day of hospitalization. Although many centers already perform rectosigmoidectomy with complete neurovascular preservation, this technique has not yet been widely described. However, it is an effective, safe technique with greater damage control.