Rectal Shaving Research Articles

Laparoscopic Modified Radical Hysterectomy for Severe Endometriosis: A Single-Center Case Series

Study objectiveThe main objective is to describe the feasibility and report a single centre experience of a standardized laparoscopic modified radical hysterectomy technique among patients with severe endometriosis and pouch of Douglas obliteration. DesignA single-center case series of laparoscopic modified radical hysterectomy performed at the Poissy Hospital between December 2012 and May 2021. SettingsSingle-center, gynecology unit (level III) with a focus on endometriosis. PatientsPatients with severe endometriosis (stage 4 AFS) and pouch of Douglas Obliteration. Measurements and Main ResultsFifty-two patients with severe endometriosis underwent the surgical procedure.Out of these patients: 23.1% underwent a rectal shaving (n= 12), 1.9 % a discoid resection (n= 1) and 17.3% a rectal resection (n= 9), including a protective ileostomy in one case. Ureterolysis was performed on 82.7% of patients (n= 43). The average hospital stay was 3.3 days (1-12). Seven patients required intermittent self-catheterization (13.5%). Minor complications (Clavien-Dindo grade 1 and 2) occurred to 25.9% of the patients and severe complications to 3.8% of them (Clavien-Dindo grade 3, no grade 4). Two patients (3.8%) were reoperated: one for a postoperative occipital alopecia (balding) and the other for vaginal dehiscence with evisceration. About 50 patients (96.2%) had a complete resection of endometriosis. The median follow-up was 14 months (interquartile range 6-23 months) with 94.3% of them improved (much and very much) and 3.8% minimally improved. ConclusionIn our experience, laparoscopic modified radical hysterectomy is a reliable procedure with a low rate of severe complications. This technique needs to be assessed by other surgeons and others centers across the country and abroad, in order to determine the likehood of it succeeding.

INTESTINAL ENDOMETRIOSIS: OUTCOMES FROM A MULTIDISCIPLINARY SPECIALIZED REFERRAL CENTER.

Deep penetrating endometriosis (DE) can affect abdominal and pelvic organs like the bowel and bladder, requiring treatment to alleviate symptoms. To study and investigate clinical and surgical outcomes in patients diagnosed with DE involving the intestines, aiming to analyze the effectiveness of surgical treatments. All cases treated from January 2021 to July 2023 were included, focusing on patients aged 18 years or older with the disease affecting the intestines. Patients without intestinal involvement and those with less than six months of post-surgery follow-up were excluded. Intestinal involvement was defined as direct invasion of the intestinal wall or requiring adhesion lysis for complete resection. Primary outcomes were adhesion lysis, rectal shaving, disc excision (no-colectomy group), and segmental resection (colectomy group) along with surgical complications like anastomotic leak and fistulas, monitored for up to 30 days. Out of 169 patients with DE surgically treated, 76 met the inclusion criteria. No colectomy treatment was selected for 50 (65.7%) patients, while 26 (34.2%) underwent rectosigmoidectomy (RTS). Diarrhea during menstruation was the most prevalent symptom in the RTS group (19.2 vs. 6%, p<0.001). Surgical outcomes indicated longer operative times and hospital stays for the segmental resection group, respectively 186.5 vs. 104 min (p<0.001) and 4 vs. 2 days, (p<0.001). Severe complications (Clavien-Dindo ≥3) had an overall prevalence of 6 (7.9%) cases, without any difference between the groups. There was no mortality reported. Larger lesions and specific symptoms like dyschezia and rectal bleeding were associated with a higher likelihood of RTS. Bayesian regression highlighted diarrhea close to menstruation as a strong predictor of segmental resection. In patients with DE involving the intestines, symptoms such as dyschezia, rectal bleeding, and menstrual period-related diarrhea predict RTS. However, severe complication rates did not differ significantly between the segmental resection group and no-colectomy group.

Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection

To describe the management of recurrent bowel endometriosis after previous colorectal resection. Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

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.

Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): TheSydney partial thickness discoid excision technique.

Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.

Robotic-assisted versus conventional laparoscopic approach in patients with large rectal endometriotic nodule: the evaluation of safety and complications.

The aim was to compare postoperative complications in patients undergoing the excision of a rectal endometriotic nodule over 3 cm by a robotic-assisted versus a conventional laparoscopic approach. We conducted a retrospective cohort study evaluating prospectively collected data. The main interventions included rectal shaving, disc excision or colorectal resection. All the surgeries were performed in one endometriosis reference institute. To evaluate factors significantly associated with the risk of anastomosis leakage or fistula and bladder atony, we conducted a multivariate logistic regression model. A total of 548 patients with rectal endometriotic nodule over 3 cm in diameter (#ENZIAN C3) were included in the final analysis. The demography and clinical characteristics of women managed by the robotic-assisted (n = 97) approach were similar to those of patients who underwent conventional laparoscopy (n = 451). The multivariate logistic regression demonstrated that the surgical approach (robotic-assisted vs. laparoscopic) was not associated with the rate of anastomosis leakage or fistula (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 0.3-4.0) and bladder dysfunction (aOR 0.5, 95% CI 0.1-1.8). A rectal nodule located lower than 6 cm from the anal verge was significantly associated with anastomosis leakage (aOR 4.1, 95% CI 1.4-10.8) and bladder atony (aOR 4.3, 95% CI 1.5-12.3). Anastomosis leakage was also associated with smoking (aOR 3.2, 95% CI 1.4-7.4), significant vaginal infiltration (aOR 2.7, 95% CI 1.2-6.7) and excision of nodules involving sacral roots (aOR 5.6, 95% CI 1.7-15.5). The robotic-assisted approach was not associated with increased risk of main postoperative complications compared to conventional laparoscopy for the treatment of large rectal endometriotic nodules.

The implications of the anatomy of the nerves and vessels in the treatment of rectosigmoid endometriosis.

Endometriosis is a common benign gynecological disease characterized by the presence of endometrial glands and stroma outside the uterus. It can be defined as endometrioma, superficial peritoneal endometriosis or deep infiltrating endometriosis (DIE) depending on the location and the depth of infiltration of the organs. In 5%-12% of cases, DIE affects the digestive tract, frequently involving the distal part of the sigmoid colon and rectum. Surgery is generally recommended in cases of obstructive symptoms and in cases with pain that is non-responsive to medical treatment. Selection of the most optimal surgical technique for the treatment of bowel endometriosis must consider different variables, including the number of lesions, eventual multifocal lesions, as well as length, width and grade of infiltration into the bowel wall. Except for some major and widely accepted indications regarding bowel resection, established international guidelines are not clear on when to employ a more conservative approach like rectal shaving or discoid resection, and when, instead, to opt for bowel resection. Damage to the pelvic autonomic nervous system may be avoided by detection of the middle rectal artery, where its relationship with female pelvic nerve fibers allows its use as an anatomical landmark. To reduce the risk of potential vascular and nervous complications related to bowel resection, a less invasive approach such as shaving or discoid resection can be considered as potential treatment options. Additionally, the middle rectal artery can be used as a reference point in cases of upper bowel resection, where a trans mesorectal technique should be preferred to prevent devascularization and denervation of the bowel segments not affected by the disease.

Laparoscopic modified radical hysterectomy for women with stage IV AFS endometriosis and obliterated Douglas space: a technical note (with video).

Excision of deep infiltrating endometriosis has to be complete to prevent symptomatic recurrences but with more complications. The patients with obliterated Douglas space who wish a definitive treatment for their pain require a more complex hysterectomy to remove all the lesions. Laparoscopic modified radical hysterectomy may allow to perform safely this surgery following 9 steps. The dissection is standardized according to anatomical landmarks. The key steps are: extrafascial dissection of uterine pedicle by opening the pararectal spaces and paravesical space, nerve sparing, ureterolysis if needed, the retrograde dissection of rectovaginal space and the rectal step if needed. The rectal step depends on depth of rectal infiltration and on the number of nodules (rectal shaving, disc excision or rectal resection). This standardized procedure could help surgeons to achieve a complex radical surgery for patients with endometriosis and obliterated Douglas space.

Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned

To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm. Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data. A tertiary referral center. Patients undergoing excision of rectal endometriosis. Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach. Feasibility of the technique. The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler's jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required. The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.

ICG Enema to Make Rectal Shaving Easier and Safer

Study Objective To use ICG enema to improve the surgical quality during rectal shaving. Design Surgical video. Setting Local GYN MIS hospital, single surgeon. Patients or Participants Patients with solitary rectal DIE nodule. Interventions After complete adhesiolysis and excision of all other pelvic endometriosis lesions except the rectal nodule, 12.5 mg ICG was diluted in 60 cc normal saline. The diluted ICG solution was injected into rectal lumen through anus and was retained in rectum (ICG enema) during the whole rectal shaving procedure. Measurements and Main Results After ICG enema, we started the rectal shaving procedure, carefully mapped the lesion margin, cut into rectal muscular layer with monopolar scissors under pure cutting mode. The submucosa layer can be easily recognized by the ICG green color. As long as we identified the green submucosa layer, we can easily stay precisely between the muscle layer and submucosa layer, keep the green submucosa and mucosa layer intact, with minimal risk of enterotomy. After rectal shaving, the muscular defect of the rectal wall can also be clearly identified by the exposed green submucosa layer. Rectal wall repair can then be confidently performed, transversely re-approximating the seromuscular layer, embedding all the green submucosa layer. Conclusion By ICG enema, staining the mucosa and submucosa layer with green ICG color, we can easily identify the submucosa layer during the rectal shaving procedure. The risk of enterotomy, and incomplete rectal wall repair after shaving can both be minimized. To use ICG enema to improve the surgical quality during rectal shaving. Surgical video. Local GYN MIS hospital, single surgeon. Patients with solitary rectal DIE nodule. After complete adhesiolysis and excision of all other pelvic endometriosis lesions except the rectal nodule, 12.5 mg ICG was diluted in 60 cc normal saline. The diluted ICG solution was injected into rectal lumen through anus and was retained in rectum (ICG enema) during the whole rectal shaving procedure. After ICG enema, we started the rectal shaving procedure, carefully mapped the lesion margin, cut into rectal muscular layer with monopolar scissors under pure cutting mode. The submucosa layer can be easily recognized by the ICG green color. As long as we identified the green submucosa layer, we can easily stay precisely between the muscle layer and submucosa layer, keep the green submucosa and mucosa layer intact, with minimal risk of enterotomy. After rectal shaving, the muscular defect of the rectal wall can also be clearly identified by the exposed green submucosa layer. Rectal wall repair can then be confidently performed, transversely re-approximating the seromuscular layer, embedding all the green submucosa layer. By ICG enema, staining the mucosa and submucosa layer with green ICG color, we can easily identify the submucosa layer during the rectal shaving procedure. The risk of enterotomy, and incomplete rectal wall repair after shaving can both be minimized.

Intraoperative Ultrasound Elastography Guided Rectal Shaving for Endometriosis

<h3>Study Objective</h3> Rectal surface endometriosis is more common in cases of cul-de-sac obstruction, and it is preferable in endometriosis surgery to remove as much of the deep endometriosis region as possible. The degree of rectal shaving may be confusing because the depth of the rectal superficial lesion cannot be assumed from the outside during surgery. For safe and appropriate resection, we attempted to confirm the location of the endometriosis lesion with intraoperative ultrasonography and elastography. <h3>Design</h3> Case report. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> A 23-years-old woman with dysmenorrhea diagnosed with left endometrioma and cul-de-sac obstruction by magnetic resonance imaging (MRI). <h3>Interventions</h3> Nerve-sparing endometriosis surgery including left ovarian cystectomy, cul-de-sac adhesiolysis, and deep endometriosis resection was planned. To evaluate the rectal surface endometriosis, a sterilized small ultrasound probe was inserted into the abdominal cavity through an abdominal trocar or small incision in the posterior vaginal fornix. Rectal surface fibrosis and the distance from the rectal muscularis were tried to be visualized with ultrasound elastography. <h3>Measurements and Main Results</h3> Intraoperative ultrasonography clearly indicated the safety distance from the rectal muscularis, and elastography showed hard fibrotic region on rectal surface with color visualization. There was no intra/post-operative complication. The pathological examination revealed the presence of endometriosis in the resected tissue. The visual analog scale (VAS) for dysmenorrhea was reduced from 70 to 10, and the VAS for dyspareunia was reduced from 50 to 0. <h3>Conclusion</h3> Intraoperative ultrasound elastography is considered to be a useful auxiliary means for safe rectal shaving by visualizing the fibrosis caused by endometriosis.

8795 Impact of Surgical Procedures on Intestinal Function and Quality of Life in Patients with Deep Endometriosis: A Prospective Study

<h3>Study Objective</h3> To analyze the prevalence of intestinal discomforts in patients with deep endometriosis (DE) and the alteration of different surgical procedures on their intestinal function and quality of life at short-term follow-up. <h3>Design</h3> A prospective cohort study. <h3>Setting</h3> A university-based tertiary obstetrics and gynecology hospital. <h3>Patients or Participants</h3> Patients with deep endometriosis infiltrating the rectum treated in the same medical team since April 1, 2018. <h3>Interventions</h3> Patients underwent rectal shaving, disk excision or segmental bowel resection depending on the severity of DE. <h3>Measurements and Main Results</h3> The primary end point was the prevalence of intestinal discomforts, pain symptoms ranked by VAS (visual analogue score). The secondary end points were values of gastrointestinal questionnaires, including GIQLI(gastrointestinal quality of life index), Wexner constipation score, CRADI-8 (colorectal-anal distress inventory 8),and SF 36 to evaluate quality of life. As of March 15, 2019,88 patients were enrolled, including 58 patients in group rectal shaving, 25 in disk excision and 5 in segmental bowel resection.59.04% (49/88) of patients had intestinal symptoms preoperatively, manifested as menstrual diarrhea 26(53.06%), bulge 19(38.78%)and hematochezia 13 (26.53%). However, postoperatively, the discomforts were mainly caused by diarrhea 10.23% (9/17) at 1-month follow-up(V1), constipation 40% (4/10) at 6-month follow-up(V6). According to the follow-up, there are significant improvement in dysmenorrhea in all three group, but the improvement of intestinal discomfort only in group shaving were significant 0(0,2) vs 0(0,0) at V1 and 0(0,2) vs 0(0,0) at V6,<i>P</i><0.05,respectively.Patients in group shaving had mild symptoms preoperatively, who had lower CRADI-8 and Wexner constipation scores than the other two groups. After surgical treatment, patients' gastrointestinal function were mild improved, but the SF-36 and the GIQLI score did not reach statistical significance among these 3 groups compared to the baseline. <h3>Conclusion</h3> For patients with complaints of periodic diarrhea, anal bulge and hematochezia, endometriosis should be considered. Although surgical procedures can improve patients' dysmenorrhea and intestinal discomfort, but, the occurrence of constipation in short term after surgery should be alert, especially in radical procedures.

7548 “Second Parts Were Never Good:” Early Repeated Deep Infiltrating Endometriosis Surgery for Persistent Dyschezia

<h3>Study Objective</h3> To raise awareness of how complicated second and subsequent surgeries for deep infiltrating endometriosis are. To emphasize the relevance of good quality preoperative imaging when planning the first surgery for suspected DIE. <h3>Design</h3> Observational cohort study. <h3>Setting</h3> Single institution, Single-center endometriosis unit. <h3>Patients or Participants</h3> Five consecutive patients referred for persistent dyschezia after recent DIE surgery and postoperative hormonal support treatment with Dienogest. <h3>Interventions</h3> DIE imaging study protocol and second surgery by Endometriosis unit Surgical team. <h3>Measurements and Main Results</h3> Patients age ranged from 36 to 41 years. All 5 patients had previous DIE surgery within 12 months of referral/consultation in our unit. All patients presented with persistent dyschezia as their main complaint. Only one patient declared fertility desire. Previous surgical procedures included pelvic adhesiolysis (5), rectal shaving (3), subtotal hysterectomy (1), rectal segmental resection (1), unilateral adnexectomy (1) and unilateral oophorectomy. Imaging studies (Ultrasound Endometriosis systematic mapping protocol and pelvic contrasted MRI) depicted gross rectal nodules (1,5-4,5 cm), all of which had transmural rectal infiltration with variable distance to the anal verge (11-6 cm). All surgical procedures included rectal resection (2 discoid, 3 segmental), with 1 patient requiring a protective ileostomy. Operative time ranged from 150 to 210 minutes. All patients were discharged between 3-5 days. Follow up after surgery (8-20 months) show no late complications and no dyschezia recurrence. <h3>Conclusion</h3> An incomplete surgical excision of DIE rectal nodules can result in persistent dyschezia and prompt the need for further complex surgical procedures. We believe the first surgery for DIE should be preceded by an exhaustive clinical and imaging workup to plan an adequate personalized surgical procedure.

8118 A Conservative Tailor-Made Approach on Treating Bowel Endometriosis

<h3>Study Objective</h3> To display how the surgical inclination to perform a sub-radicle shaving procedure in place of resection and Anastomosis in cases of non-mucosal colonic involvement of endometriosis can lead to significantly better outcomes for the patient's quality of life. <h3>Design</h3> Based on empirical understanding of the authors following 1000+ surgeries of colonic involvement of endometriosis, they have formed their opinions around radicalization of procedures in cases of DIE involving the colon. <h3>Setting</h3> The patient is positioned in the dorsal lithotomy in Trendelenburg position. Primary tracer is through the umbilicus, 3 operative ports are used, 2 at respective right and left flank and middle at supra pubic port. <h3>Patients or Participants</h3> The learnings presented in this video have been compiled over several years with observations from numerous surgeries following close observations of patient recovery curves and reports on quality of life. For the purpose of simplicity, the author presents a single case of colonic involvement to elucidate the argument. <h3>Interventions</h3> The surgery displayed in this video presentation is a laparoscopic surgery for a case of colonic involvement in deep infiltrating endometriosis <h3>Measurements and Main Results</h3> Surgical excellence and an inclination to perform sub-radical procedures can help with the same level of disease minimization while ensuring the patient a far better outcome and post-surgical quality of life <h3>Conclusion</h3> Recent trends in surgery have led to an increase in resection procedures even in candidates that could undergo rectal shaving. While it is easy to believe that resection is a more total procedure and reduces the risk of diseases recurrence, it comes at the cost of long recovery times and often longer lasting repercussions, both of which can be avoided with almost equal recurrence avoidance in some candidates that qualify for rectal shaving.

Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications.

ObjectiveThe present work aimed to investigate the feasibility, complications, recurrence rate, and infertility outcomes of the radical and conservative surgical methods for colorectal endometriosis in short- and long-term follow-ups.MethodsIn this prospective study, the patients with confirmed diagnosis of colorectal DIE were included from March 2015 to March 2021, who were referred to an Endometriosis Surgery Center affiliated with Shiraz University of Medical Sciences (SUMS). Information on demographics, surgical approaches, intra-operative, and post-operative findings as well as complications were collected and compared. Six- and 12-month interviews were conducted to evaluate the functional outcomes of all the procedures.ResultsOut of 3,111 patients who underwent endometriosis surgery, 837 (28.19%) with the average age of 34.2 ± 5.9 years and average ASRM score of 102.1 ± 36.8 had rectosigmoid endometriosis. Laparoscopic rectal shaving was performed in 263(30.0%) patients while 326 (37.2%) underwent segmental bowel resection, and 248 (28.30%) were treated with disc excision. Prophylactic ileostomy was performed in six (0.68%) patients and peritonitis was reported in four (0.45%). Five (0.58%) subjects developed rectovaginal fistula and one (0.11%) was diagnosed with bladder atonia. The recurrence rate was 3.8%, 1.2%, and 0.3% in rectal shaving, disc, and segmental bowel resection techniques, respectively. Dysmenorrhea, dyspareunia, and dyschezia were improved after surgery by 7.3, 9.4, and 12.5 times, respectively. We observed 25.2% of total pregnancy following the operation, the majority of which occurred in the first year after the surgery.ConclusionThere were very few short-term or long-term complications in the three different techniques when the choice was correct.

Rates of severe complications in patients undergoing colorectal surgery for deep endometriosis-a retrospective multicenter observational study.

Surgical experience and hospital procedure volumes have been associated with the risk of severe complications in expert centers for endometriosis in France. However, little is known about other certified units in Central European countries. This retrospective observational study included 937 women who underwent surgery for colorectal endometriosis between January 2018 and January 2020 in 19 participating expert centers for endometriosis. All women underwent complete excision of colorectal endometriosis by rectal shaving, discoid or segmental resection. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification system including anastomotic leakage, fistula, pelvic abscess and hematoma. Surgical outcomes of centers performing less than 40 (group 1), 40-59 (group 2) and≥60 procedures (group 3) over a period of 2 years were compared. The overall complication rate of grade III and IV complications was 5.1% (48/937), with rates of anastomotic leakage, fistula formation, abscess and hemorrhage in segmental resection, discoid resection and rectal shaving, respectively, as follows: anastomotic leakage 3.6% (14/387), 1.4% (3/222), 0.6% (2/328); fistula formation 1.6% (6/387), 0.5% (1/222), 0.9%; (3/328); abscess 0.5% (2/387), 0% (0/222) and 0.6% (2/328); hemorrhage 2.1% (8/387), 0.9% (2/222) and 1.5% (5/328). Higher overall complication rates were observed for segmental resection (30/387, 7.8%) than for discoid (6/222, 2.7%, P=0.015) or shaving procedures (12/328, 3.7%, P=0.089). No significant correlation was observed between the number of procedures performed and overall complication rates (rSpearman =-0.115; P=0.639) with a high variability of complications in low-volume centers (group 1). However, an intergroup comparison revealed a significantly lower overall severe complication rate in group 3 than in group 2 (2.9% vs 6.9%; P=0.017) without significant differences between other groups. A high variability in complication rates does exist in centers with a low volume of activity. Major complications may decrease with an increase in the volume of activity but this effect cannot be generally applied to all institutions and settings.

Perspectives on modes of labour and delivery after different modalities of surgery for bowel endometriosis

Bowel or intestinal endometriosis is estimated to affect 5–37% of women with deep infiltrative endometriosis (DIE), especially in the rectum and recto-sigmoid junction. However, there are no current guidelines or consensus regarding safest mode of delivery in pregnant women after different surgical interventions for bowel/intestinal endometriosis. From October 2019 to February 2020, we conducted an online survey of members of the British Society for Gynaecological Endoscopy (BSGE). These included questions on what gynaecologist members would recommend as modes of delivery in women who had different surgical modalities for bowel endometriosis, and the particular factors that influence such recommendations. Analysis of data was performed using SPSS for Windows (V9) software package. One hundred and two members of BSGE completed the survey (61.76% of BSGE gynaecologist members). Only 30.39% of respondents counsel women, pre-operatively, about possible effects of surgical treatment of bowel endometriosis on their subsequent mode of delivery. Our survey highlights wide variation in practice that currently exists. Around 70% of clinicians are not counselling patients regarding delivery options pre-surgery despite almost one-third recommending planned caesarean section if the vagina is opened. Further studies are required to stratify the risk factors for such patients when attempting vaginal delivery or caesarean section. IMPACT STATEMENT What is already known on this subject? Treatment of colorectal endometriosis consists of rectal shaving, discoid resection or segmental colorectal resection. However, the relationship between different surgical modalities for bowel endometriosis and the subsequent safe mode of labour and delivery remains unclear. What do the results of this study add? No study has been published that specifically looked at the particular course and outcome of labour and delivery after each of these bowel surgeries; rectal shaving, disc excision, or segmental colorectal resection. Our study highlights the wide variations in practice that currently exists. Despite around 70% of clinicians not counselling women regarding delivery options pre-surgery, almost one-third would recommend a planned caesarean section if the vagina is opened. What are the implications of these findings for clinical practice and/or further research? This study suggests that risk factors should be stratified for such patients when attempting a vaginal delivery or undergoing a caesarean section. Guidance from the ESGE and/or BSGE would be useful to aid in the counselling and informed consent of such patients.

Surgical lysis of nerve entrapment caused by retroperitoneal fibrosis/adhesions; two case reports and a literature review

Introduction: Retroperitoneal fibrosis (adhesions) in the pelvic area is rare and not well known in gynecology. However, their presence can cause compression neuropathy leading to severe pain symptoms involving the lower extremities. A neuropelveological approach can be applied in dealing with such cases in diagnosis and management. Objective: To demonstrate neurolysis of sacral nerves in patients with retroperitoneal fibrosis (adhesions). Case presentations: Case 1: A 43-year-old gravidity 1 parity 1 female patient with known endometriosis presented with dysmenorrhea, dyspareunia, and left-sided sciatica. Gynecological examination revealed a rectovaginal nodule and full obliteration of pouch of Douglas. Robot-assisted laparoscopic sacral neurolysis and dissection of pouch of Douglas with rectal nodule shaving was performed. The patient was symptom free 6 months postoperatively. Case 2: A 49 years old gravidity 2 parity 2 female patient presented with severe pain on the left groin and leg, dysuria, and constipation, which required frequent manual evacuation of the feces. The begin of her symptoms coincided with a previous laparoscopic total hysterectomy, where she experienced postsurgical hemorrhage. Laparoscopic sacral neurolysis with adhesiolysis was performed. The patient was symptom free 6 months postoperatively. Conclusion: Pelvic retroperitoneal fibrosis (adhesions) are rarely encountered in gynecology. However, they should be included in differential diagnosis in patients presenting with pelvic pain accompanied by lower extremity pain, urinary, and/or bowel symptoms. Since presurgical diagnosis of fibrosis (adhesions) is hard with visualization techniques such as transvaginal ultrasound or magnetic resonance imaging, a thorough neuropelveological examination can be helpful in such cases.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases.

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.

Rectal Shaving in Stage IV Endometriosis

Study Objective To describe rectal shaving as a surgical approach to perform resection of deep infiltrating endometriosis of the bowel and to highlight available evidence for surgical management of colorectal deep infiltrative endometriosis. Design Video presentation. Setting University tertiary care hospital. Patients or Participants 42-yo nulliparous patient with abnormal uterine bleeding, leiomyomas, pelvic pain, 3 cm rectovaginal nodule, and a 12 cm endometrioma who underwent an uncomplicated total laparoscopic hysterectomy, right salpingo-oophorectomy, left salpingectomy, rectal shaving, endometriosis resection, enterolysis, and cystoscopy for Stage IV endometriosis. Interventions Studies have shown that laparoscopic surgery can improve pain in the context of deep infiltrating endometriosis. A complete resection of deep infiltrative endometriosis with definitive hysterectomy and salpingo-oophorectomy was undertaken with rectal shaving as a technique to address the colorectal endometriosis. Measurements and Main Results At the 6-week postoperative follow up, the patient reported resolution of pain symptoms. Conclusion In conclusion given its low bowel complication rate of 1 % and acceptable recurrence rate we perform conservative bowel shaving technique whenever possible. To describe rectal shaving as a surgical approach to perform resection of deep infiltrating endometriosis of the bowel and to highlight available evidence for surgical management of colorectal deep infiltrative endometriosis. Video presentation. University tertiary care hospital. 42-yo nulliparous patient with abnormal uterine bleeding, leiomyomas, pelvic pain, 3 cm rectovaginal nodule, and a 12 cm endometrioma who underwent an uncomplicated total laparoscopic hysterectomy, right salpingo-oophorectomy, left salpingectomy, rectal shaving, endometriosis resection, enterolysis, and cystoscopy for Stage IV endometriosis. Studies have shown that laparoscopic surgery can improve pain in the context of deep infiltrating endometriosis. A complete resection of deep infiltrative endometriosis with definitive hysterectomy and salpingo-oophorectomy was undertaken with rectal shaving as a technique to address the colorectal endometriosis. At the 6-week postoperative follow up, the patient reported resolution of pain symptoms. In conclusion given its low bowel complication rate of 1 % and acceptable recurrence rate we perform conservative bowel shaving technique whenever possible.