Rectal Disc Excision Research Articles

Robotic Surgery for Severe Endometriosis: A Preliminary Comparative Study of Cost Estimation

To compare the postoperative outcomes and the overall expenses between conventional laparoscopy and robotic surgery, in a series of consecutive patients managed for only severe endometriosis in our institute. A cohort comparative study. Center of Excellence in Multidisciplinary Endometriosis Care. A total of 175 symptomatic patients undergoing surgery for only severe endometriosis from March 2021 to August 2022. We treated patients with endometriosis involving the digestive tract such as rectum, sigmoid colon, and ileocecal junction by rectal shaving, discoid resection, or segmental resection (141 surgeries) with or without bladder (23 surgeries), sacral plexus (19 surgeries), and diaphragm involvements (14 surgeries). Postoperative outcomes were evaluated in terms of total surgical time (total surgical room occupancy time and total operating time), hospitalization period, postoperative complications, rehospitalization, and second surgical procedures. A statistically higher total surgical room occupancy (203 minutes vs 151 minutes) and operating time (150 minutes vs 105 minutes) were observed in the robotic group (p=.001). No differences in terms of mean hospital stay (p=.06), postoperative complications (p=.91), rehospitalization (p=.48), and secondary surgical treatment (p=.78) were identified. Concerning the cost analysis only for disposable supply, the cost of colorectal resection was totaled at 2604 euros for the laparoscopic conventional approach vs 2957 euros for the robotic approach (+352.6 euros, +14%). The cost of rectal disc excision was 1527 euros for the laparoscopic conventional approach vs 1905.85 euros (+378 euros, +25%). Our study confirms the feasibility of the robotic approach for the treatment of severe endometriosis, with however a higher cost of robotic approach. Next studies should identify specific indications for robotic surgery, where technical advantages provided by the technology are followed by objective improvement of patients' outcomes.

Management of a Large Endometriotic Nodule of the Right Parametrium Involving the Sacral Roots, Vagina, Rectum, and Sigmoid Colon, with Intraoperative Bleeding

Deep endometriotic lesions may involve the deep parametrium which is highly vascular and includes numerous somatic and autonomous nerves (1,2). Surgeons who dissect in this area, must always be prepared to deal with major bleeding, and to master the different techniques of hemostasis. The goal of this video is to show the steps of laparoscopic excision of deep endometriotic lesion of the parametrium and the steps taken to control the bleeding encountered from one of the venous branches. Surgical educational video. Endometriosis referral center. Excision of the endometriotic parametrial nodule and the release of the sacral plexus, with excision of the vaginal involvement, rectal disc excision, and segmental resection of the sigmoid colon. The video shows the excision of a deep endometriosis involving the right parametrium, the mid rectum, the sigmoid colon, and the vagina. The excision of deep endometriosis of the parametrium followed the 10 steps previously described (1). During this procedure, careful dissection of arteries and veins branching from the internal iliac vessels is a crucial step. However, injury of one or more of the vessels can still occur. The movie presents the different techniques used to control the bleeding from a venous injury faced during the dissection around the nodule in the parametrium, including energy use, clips, hem-o-loks, and direct continuous pressure. Of note, hemostatic agents are available, however we have not yet successfully employed them in these circumstances in which large veins were injured. The ultimate solution in our case was the clamping of the injured vessels, allowing meticulous dissection and sectioning of all the feeding vessels, while taking care not to injure the sacral roots which were just beneath these veins. Total operative time was 4 hours. Surgery of deep endometriosis involving the sacral plexus may be successfully done laparoscopically. Thorough knowledge of the deep pelvis anatomy is mandatory, and the surgeon should master various techniques of hemostasis, particularly on deep veins.

Excision of Deep Rectovaginal Endometriosis Nodules with Large Infiltration of Both Rectum and Vagina: What Is a Reasonable Rate of Preventive Stoma? A Comparative Study

To compare postoperative complications and rectovaginal fistula rate in women undergoing excision of large rectovaginal endometriosis requiring concomitant excision of rectum and vagina during 2 time periods with differing policies for preventive stoma confection. Retrospective before-and-after comparative cohort study on data prospectively recorded in a database. Patients managed from September 2018 to March 2020 (first period) were compared with those managed from April 2020 to June 2022 (second period). Endometriosis Institute. One hundred sixty-eight patients presenting with deep endometriosis infiltrating the rectum and vagina, with lesions more than 3 cm in diameter during 2 consecutive time periods with differing policies regarding use of preventive stoma. Rectal disc excision or colorectal resection, concomitantly with large vaginal excision. A total of 87 and 81 women received surgery during the first and the second period, respectively, during which the rate of preventive stoma was, respectively, 32.2% and 8.6%. Deep rectovaginal nodule characteristics were comparable. The mean height (SD) of rectal sutures after disc excision and colorectal resection were, respectively, 6.5 cm (2.3 cm) and 7.2 cm (3.8 cm). Rectovaginal fistula was recorded in 17 patients, corresponding to an overall rate of 10.1%. The rates of rectovaginal fistula in the group of patients with and without preventive stoma, regardless of the period in which surgery was performed, were 11.4% and 9.8%, respectively (p=.76). The rates of fistula recorded during the first and the second period were, respectively, 9.2% and 11.1% (p=.80), and that of overall early main complications were 31% and 29.6% (p=.84). Regression logistic model identified an independent relationship between smoking and rectovaginal fistula (adjusted odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-14) after adjustment for the period (adjusted OR 1.4, 95% CI 0.4-4.9 related to the second period), stoma confection (adjusted OR 1.8, 95% CI 0.5-7.1 related to stoma confection), robotic surgery (adjusted OR 1.7, 95% CI 0.3-10.1 related to robotic assistance), and type of rectal surgery (adjusted OR 0.4, 95% CI 0.1-1.4 related to disc excision when compared with colorectal resection). No statistically significant differences were found concerning risk of rectovaginal fistula in women with rectovaginal endometriosis requiring large rectal and vaginal excision after a decision to no longer routinely perform preventive stoma.

Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients.

The aim of this work was to assess whether placement of a biological mesh (Permacol® ) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis. We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups. Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4±1.4cm vs. 6±2.9cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3-9.5). A distance of less than 7cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7-132). Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

Laparoscopic Technique for Discoid Resection of Rectal Endometriotic Nodules

To show the surgical steps used to perform a rectal disc excision in the context of deep infiltrating endometriosis characterized by contiguity between an intestinal lesion and the retrocervical region. Step-by-step video demonstration of the technique. Although surgical options for the management of rectosigmoid endometriosis have been investigated increasingly, there is no consensus regarding patient eligibility for shaving, discoid resection, or segmental resection. In our practice, women with nodules ≤3 cm in size and >7 mm deep were considered as candidates for rectosigmoid disc excision [1]. Therefore patients' selection, together with the adoption of a standardized surgical technique, has allowed us to maximize the chance of a successful discoid resection, minimizing the complications potentially derivable from this surgical procedure. The patient was a 30-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. A preoperative ultrasonography showed complete obliteration of the pouch of Douglas owing to a rectal endometriotic nodule (21 × 7 × 12 mm) in contiguity with a deeply infiltrating retrocervical lesion (28 × 10 × 27 mm). As a result, the rectal nodule infiltrated the tunica muscularis with a distance from the anal verge of 9 cm and an estimated stenosis of 35%. A 3-dimensional laparoscopy was performed. After rectal mobilization and rectovaginal space opening, the intestinal nodule was isolated in its entire circumference (Fig. 1). A 33-mm transanal circular stapler was inserted into the rectum through the anus and used to perform disc excision and suture the rectal wall. The overall operative time was 55 minutes. No intraoperative complication occurred. A complete excision of endometriosis was achieved. The estimated blood loss was 10 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of the surgery. The patient was discharged 3 days after surgery and did not experience postoperative complications. The diameters of the bowel endometriotic nodule, on measuring fresh specimen, were 20 × 7 × 13 mm. Advanced laparoscopic surgical skills are needed to perform an effective and safe rectal discoid resection. Subspecialization and an adequate preoperative evaluation are of utmost importance to appropriately plan the treatment strategy against bowel endometriosis.

Posterior rectal pouch after large full-thickness disc excision of deep endometriosis infiltrating the low/mid rectum and relationship with digestive functional outcome

IntroductionThe aim of our study is to describe MRI appearance of a posterior rectal pouch (PRP) for patients managed for low rectal endometriosis by large full-thickness disc excision and to assess its relationship with postoperative functional digestive symptoms. Material and MethodsSingle center retrospective study including patients managed by low/mid rectal disc excision using a semi-circular stapler (the Rouen technique) from June 2009 to October 2016. Intraoperative findings and data provided by standardized gastrointestinal self-questionnaires (GIQLI, KESS, Wexner and Bristol), before and 1 year after the surgery, were prospectively recorded. Postoperative pelvic MRI were reviewed and PRP was assessed in three planes and its volume was estimated on a 3D T2 weighted sequence. ResultsEighteen patients were included in the study. All patients had postoperative PRP while none of them presented with rectal stenosis. The mean (± SD) volume of the PRP was estimated at 66 ± 32 mL. The mean antero-posterior diameter was 56 mm ± 22 mm, mean height at 44 mm ± 15 mm and mean width at 46 mm ± 11 mm. No positive correlation between the volume of the PRP and the GIQLI questionnaire was found at one year after surgery (r = −0.24, 95%CI -0.51−0.69, p = 0.44). ConclusionLarge disc excision of low and mid rectum leads to a posterior rectal pouch, with no significant impact on postoperative functional digestive outcomes, but it is not followed by bowel stenosis.

Diverting stoma-related complications following colorectal endometriosis surgery: a 163-patient cohort

ObjectiveDeep endometriosis may simultaneously infiltrate the vagina and the rectosigmoid, which associated resection may increase the risk of postoperative complications. Among these complications, rectovaginal fistula is one of the worst. To reduce the risk of rectovaginal fistula and related complications, surgeons may employ diverting stoma. The literature is rich in data concerning the usefulness of stoma in patients managed for low rectal cancer. However, extrapolation of these data to patients managed for rectal endometriosis is disputable. For this reason, there are no guidelines on the role of stoma in preventing rectovaginal fistula in patients managed for colorectal endometriosis. The objective of our study was to assess the risk of complications related to the use of stoma in patients managed for colorectal endometriosis. Study DesignA retrospective comparative study has been performed using data prospectively recorded in the CIRENDO database. 163 consecutive women with colorectal endometriosis who had temporary stoma have been enrolled at the University Hospital of Rouen, from June 2009 to December 2016. The main outcome was stoma-related complications rate using Clavien-Dindo classification. No women were lost to follow-up. ResultsAmong the 163 women, 158 (96.9%) had a primary diverting stoma and 5 women (3.1%) with an immediate post-surgical bowel fistula had a secondary diverting stoma. Stoma involved the ileum in 28 women (17.2%) and the colon in 135 (82.8%). Surgical management of the rectosigmoid junction was rectal shaving in 2 women (1.2%), disc excision in 62 (38%), colorectal resection in 87 (53.4%), and combined rectal disc excision and sigmoid colon segmental resection in 12 (7.4%). Clavien Dindo I stoma-related complications occurred in 38 patients (23.3%) and were related to abnormal healing of stoma scar. Most Clavien-Dindo II complications were wound or urinary infections following stoma closure. Clavien Dindo III complications occurred in 14 patients (8.6%) and were related to leakage, hemoperitoneum, hernia of the abdominal wall, subcutaneous abscess and bowel obstruction syndrome. ConclusionSpecific complications may occur directly related to the use of stoma in the surgery of deep endometriosis of the rectosigmoid. The risk of these complications should be taken into account and full preoperative information should be provided to patients and their family.

Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients

To assess the postoperative outcomes of patients with rectal endometriosis managed by disc excision using transanal staplers. Prospective study using data recorded in the CIRENDO database (NCT02294825). University tertiary referral center. A total of 111 consecutive patients managed between June 2009 and June2016. We performed rectal disc excision using two different transanal staplers: [1] the Contour Transtar stapler (the Rouen technique); and [2] the end to end anastomosis circular transanal stapler. Pre- and postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. The two staplers were used in 42 (37.8%) and 69 patients (62.2%), respectively. The largest diameter of specimens achieved was significantly higher using the Rouen technique (mean ± SD, 59 ± 11mm vs. 36 ± 7mm), which was used to remove nodules located lower in the rectum (5.5 ± 1.3cm vs. 9.7 ± 2.5cm) infiltrating more frequently the adjacent posterior vaginal wall (83.3% vs. 49.3%). Associated nodules involving sigmoid colon were managed by distinct procedures, either disc excision (2.7%) or segmental resection of sigmoid colon (9.9%). Postoperative values for the Gastrointestinal Quality of Life Index increased 1 and 3years after the surgery, but improvement in constipation was not significant. The probability of pregnancy at 1year after the arrest of medical treatment was 73.3% (95% confidence interval 54.9%-88.9%), with a majority of spontaneous conceptions. Disc excision using transanal staplers is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, allowing for good preservation of rectal function.

New disc excision procedure for low and mid rectal endometriosis nodules using combined transanal and laparoscopic approach

Colorectal resection in women with endometriosis involving the low and mid rectum may result in a poorer outcome than conservative procedures. In this technical note we present a new technique for transanal full thickness disc excision of endometriosis nodules involving the rectum. The procedure is performed by combined laparoscopic and transanal routes. The former involves paring the area of the rectum infiltrated by the nodule, which is then made amenable to endoluminal removal using the Contour Transtar stapler to carry out a large disc excision. The technique can remove a specimen as large as 80 mm in diameter and can be applied to patients with infiltrating rectal endometrial nodules up to 10 cm from the anal margin and 50-60% of the rectal circumference. The procedure is probably less likely to lead to rectal stenosis and denervation than colorectal resection. This technique of transanal rectal disc excision using the Contour stapler is suitable in patients with infiltrating deep endometriosis nodules of the lower and mid rectum. It avoids a low rectal resection with its potential complications and unfavourable function.

Combined transanal and laparoscopic approach for the treatment of deep endometriosis infiltrating the rectum

Two surgical approaches are employed in the treatment of deep infiltrating endometriosis of the rectum (DIER): colorectal resection and nodule excision. In 2009, we introduced a new technique for transanal full thickness disc excision of endometriotic nodules infiltrating the low and middle rectum, using the Contour® Transtar™ stapler (Ethicon Endo-Surgery inc., Cincinnati, OH, USA). The aim of this retrospective study was to describe the technique and to present data on the feasibility of this technique. From April 2009 to October 2010, all patients presenting with DIER and undergoing full thickness excision using the Contour® Transtar™ stapler were enrolled in the study. Pre-, intra- and post-operative data were collected and reported. Six nulliparous women were managed using this technique during the study period. The rectal wall discs removed measured from 40 × 45 to 60 × 50 mm. In two cases, microscopic foci were noted on one of the margins but in four cases the limits were clear. Operating time varied from 180 to 450 min. Four women were completely free of post-operative digestive complaints. Despite the small numbers in this series, our data suggest that the new technique of transanal rectal disc excision using the contour stapler may be applied in patients with infiltrating endometrial nodules of the rectum up to 10 cm from the anal margin and up to 5 cm in diameter. This new procedure promises to be a useful addition to the surgeon's armamentarium in a multidisciplinary approach to deep pelvic endometriosis.

Preface

Deep endometriosis may simultaneously infiltrate the vagina and the rectosigmoid, which associated resection may increase the risk of postoperative complications. Among these complications, rectovaginal fistula is one of the worst. To reduce the risk of rectovaginal fistula and related complications, surgeons may employ diverting stoma. The literature is rich in data concerning the usefulness of stoma in patients managed for low rectal cancer. However, extrapolation of these data to patients managed for rectal endometriosis is disputable. For this reason, there are no guidelines on the role of stoma in preventing rectovaginal fistula in patients managed for colorectal endometriosis. The objective of our study was to assess the risk of complications related to the use of stoma in patients managed for colorectal endometriosis.A retrospective comparative study has been performed using data prospectively recorded in the CIRENDO database. 163 consecutive women with colorectal endometriosis who had temporary stoma have been enrolled at the University Hospital of Rouen, from June 2009 to December 2016. The main outcome was stoma-related complications rate using Clavien-Dindo classification. No women were lost to follow-up.Among the 163 women, 158 (96.9%) had a primary diverting stoma and 5 women (3.1%) with an immediate post-surgical bowel fistula had a secondary diverting stoma. Stoma involved the ileum in 28 women (17.2%) and the colon in 135 (82.8%). Surgical management of the rectosigmoid junction was rectal shaving in 2 women (1.2%), disc excision in 62 (38%), colorectal resection in 87 (53.4%), and combined rectal disc excision and sigmoid colon segmental resection in 12 (7.4%). Clavien Dindo I stoma-related complications occurred in 38 patients (23.3%) and were related to abnormal healing of stoma scar. Most Clavien-Dindo II complications were wound or urinary infections following stoma closure. Clavien Dindo III complications occurred in 14 patients (8.6%) and were related to leakage, hemoperitoneum, hernia of the abdominal wall, subcutaneous abscess and bowel obstruction syndrome.Specific complications may occur directly related to the use of stoma in the surgery of deep endometriosis of the rectosigmoid. The risk of these complications should be taken into account and full preoperative information should be provided to patients and their family.

Laparoscopic management of colorectal endometriosis.

In the past, intestinal endometriosis diagnosed at laparoscopy has generally required conversion to conventional surgery. The purpose of this study was to describe the laparoscopic management of colorectal endometriosis at a tertiary referral center. From November 1994 to March 1998, 509 consecutive patients with endometriosis requiring laparoscopic intervention were prospectively evaluated. Those with colorectal involvement were analyzed for stage of disease, procedure, operative time, conversion rate, length of hospitalization, and complications. In 30 of the 509 patients (5.9%), colorectal involvement was identified. Twenty-eight of these 30 had stage IV disease. Intestinal involvement was suspected preoperatively in 13 of 30. Twelve required superficial excision of colon or rectal endometriomas. Protectomy/proctosigmoidectomy was done in seven cases, and rectal disc excision was performed in five patients. Four cases required conversion due to the overall severity of the pelvic disease. For those who did (n = 12) and did not (n = 18) require full-thickness excisions/resections, the median operative time was 180 min (range, 90-390) and 110 min (range, 45-355), respectively; the median length of hospitalization was 4 days (range, 3-7) and 1 day (range, 0-4), respectively. A major complication occurred in one patient (colovaginal fistula). At a median follow-up of 10 months (range 1-32), 28 patients were improved, and 24 of these had near or total resolution of preoperative symptoms. Extensive pelvic endometriosis generally requires rectal disc excision or bowel resection. In our experience, laparoscopic treatment of colorectal endometriosis, even in advanced stages, is safe, feasible, and effective in nearly all patients.