Transvaginal-laparoscopic Anterior Rectum Resection in a Hysterectomized Woman with Deep-infiltrating Endometriosis: Description of a Gynecologic Natural Orifice Transendoluminal Surgery Approach

Abstract

Deep-infiltrating endometriosis may affect the vagina, the rectum, and the cervicoisthmic part of the uterus, resulting in severe pain, particularly dyschezia, dysmenorrhea, dyspareunia, and diminished quality of life. Advanced surgical techniques, such as laparoscopic-assisted anterior rectum resection, are recognized as safe and effective therapeutic approaches. In some cases, a laparotomy or minilaparotomy has to be performed for technical reasons. This can be avoided in some cases by transvaginal-laparoscopic low anterior rectum resection. The technique is a 4-step procedure, which can be described as follows: step 1 (vaginal) - rectovaginal examination, preparation of the rectovaginal septum, opening of the pouch of Douglas, mobilization of the endometriotic nodule and the rectum, temporary vaginal closure; step 2 (laparoscopic) - removal of additional endometriotic lesions, adhesiolysis, final mobilization of the rectum, mobilization of the rectosigmoid, endoscopic resection using an endoscopic stapler step 3 (vaginal) - transvaginal resection of the lesion, preparation of the oral anvil, closure of the vagina; and step 4 (laparoscopic) - endoscopic transanal stapler anastomosis and underwater rectoscopy, prophylaxis of adhesions, drainage. We used this procedure to treat a 46-year-old woman (gravida 2, para 2) who was admitted to our hospital for severe lower abdominal pain, constipation, dyspareunia, dyschezia, and cyclic rectal bleedings. The symptoms were caused by an endometriotic nodule accompanied by a palpable rectum stenosis. In addition, she reported a past abdominal hysterectomy with complications caused by symptomatic myomatous uterus. As a gynecologic natural orifice surgery approach, the transvaginal-laparoscopic anterior rectum resection may be an additional useful surgical technique that could be offered by surgical gynecologists to some women with deep-infiltrating endometriosis.