Resection Of Endometriosis Research Articles

Novel Technique: Colonic Sleeve Resection in Endometriosis.

Novel Technique: Colonic Sleeve Resection in Endometriosis.

12359 Application of Indocyanine Green (ICG) for Ureterolysis During Endometriosis Resection

12359 Application of Indocyanine Green (ICG) for Ureterolysis During Endometriosis Resection

Resection of Ischiorectal Endometriosis and Martius Flap Reconstruction

Resection of Ischiorectal Endometriosis and Martius Flap Reconstruction

Assessing Feasibility and Outcomes of Robotic Single Port Transvaginal NOTES(RSP-vNOTES) Hysterectomy: A Case Series

ObjectiveTo demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages. DesignRetrospective case series. SettingSingle academic tertiary care hospital in Houston, Texas, USA. Participants28 adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection. InterventionsHysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform). Main Results28 patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m2 (range 19.5-48.4 kg/m2), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0mL). One case required a mini-laparotomy as the irregularly-shaped 1668g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection. ConclusionOur findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries.

Segmental Bowel Resection for Rectal Endometriosis Using the da Vinci SP

ObjectiveThe da Vinci SP Surgical System (SP) received regulatory approval for use in gynecological surgeries in Japan in 2023. Given the advantages of the precision of a robot, less pain, and the cosmesis of single-port surgery, the da Vinci SP is expected to be further used for minimally invasive surgeries. To the best of our knowledge, this is the first report of the use of SP for the treatment of rectal endometriosis with segmental bowel resection. SettingAn urban general hospital. Stepwise demonstration of the technique with narrated video footage. ParticipantsThe patient was a 46-year-old woman presented with chronic pelvic pain, pain on defecation, and constipation. Magnetic resonance imaging showed uterine large fibroid, left ovarian endometrioma, and 38 mm of rectal endometriosis, with complete cul-de-sac obliteration. InterventionsWe made a 30-mm vertical incision at the umbilicus, then placed the access port, and inserted three articulating instruments and a camera. An assistant port was placed in the right lower quadrant for using the linear stapler. The surgical steps were completely identical to conventional multiport laparoscopic robotic surgery. This suggests that conventional laparoscopic or robotic skills are highly transferrable to SP. SP offer several advantages, including high-resolution three-dimensional visualization, articulating instruments, and improved dexterity and range of motion. In addition, the umbilical access port was particularly useful for proximal bowel resection, specimen retrieval, and anvil positioning during bowel resection. The total operative time was 216 minutes. The estimated blood loss was 100 ml without any complications. The uterine weight was 800 g. The postoperative course was uneventful, with no perioperative complications, including no postoperative bladder dysfunction or low anterior resection syndrome [1,2]. ConclusionThe use of SP with the access port for segmental bowel resection for rectal endometriosis is technically safe and feasible, with good cosmesis and less pain.

Robotics In Gynecology- A Review

This review article focuses on the development of robotics-based operations in the medical field especially in gynecology. The goal of the surgical robot is to improve surgical skills and compensate for human limitations. The robot's performance in performing duties correctly and consistently has been the key to its success. Tubal anastomosis was the first gynecologic surgery performed with Robotic assistance in 2000 followed by first Robotic Hysterectomy in 2002. In 2003 Da Vinci surgical system was developed which was FDA approved for gynecological surgery in 2005. It has gained popularity fast and is already playing a big part in many of the places where it is available. It consists of a high-resolution three-dimensional (3D) vision system adjacent to the patient on a cart with robotic branches. It provides unique technical advancement, with tremor filtration, improved ergonomics and lower muscular load as compared to both laparoscopic and open surgeries. Autonomous camera and energy instrument control, wrist articulation with 7 degree freedom, telestration and dual- console capabilities, overcoming the limitations of conventional laparoscopy, such as counterintuitive hand movements, 2 dimensional visualization, limited degree of motion and tremor amplification. Compared to laparoscopy, robotic assistance has a lower conversion rate to open procedures. Endo wrist movement of an automated machine during myomectomy surgery can perform proper and better suturing than traditional laparoscopy. The automated program is a noticeable improvement over laparoscopic surgery and, if price issues are resolved, can gain popularity among gynecological surgeons around the globe. Not unique to robotic system, the integration of indigo cyanine green fluorescence with the Da Vinci robotic system allows identification of lesions, and assessment of perfusion of bowel and ureter during deep infiltrating endometriosis resection.

Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more

PurposeTo compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH-SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection.MethodsRetrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis.Results100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively).ConclusionNo statistically significant differences were found in the rate of digestive complications in case of total hysterectomy and concomitant segmental resection when performing or not preventing stoma.

Surgical Treatment of Patients with Endometriosis in the Certified Endometriosis Centers of the DACH Region - A Subanalysis of the Quality Assurance Study QS ENDO pilot.

Introduction After puberty, at least 10% of all women and girls suffer from endometriosis. Surgery is useful for both the diagnosis and therapy. To date, quality indicators for the surgical treatment of endometriosis are lacking. QS ENDO aims to record the quality of care provided in the DACH region and to introduce quality indicators for the diagnosis and treatment of endometriosis. In the first phase of the study, QS ENDO real, the reality of care was recorded using a questionnaire. The second phase, QS ENDO pilot, investigated the treatment of patients who underwent surgery in certified endometriosis centers in a defined time-period. Material and Methods The surgical data of 10 patients from each of the 44 endometriosis centers in the DACH region was recorded using an online tool. Collected data included the approach used, the endometriosis phenotype, a description of the surgical site, resection status, histological confirmation, the use of a classification, and any complications. All operations were carried out in October 2016 as the defined time-period. The surgical approaches used were compared with the recommendations in the current guidelines. Results The data of 435 patients with a median age of 34years were evaluated. 315 (72.4%) were nulliparous. 120patients had given birth to at least one child and 42.5% (51) of them had delivered their child by caesarean section. About 50% of all patients also had deep infiltrating endometriosis in addition to ovarian endometriosis, and the median NAS score was 7.5. With regards to the surgical treatment, endometriomas were completely resected in 81% (94) of patients. 87.3% of patients underwent resection of peritoneal endometriosis. Forty-one patients had a hysterectomy, with a total hysterectomy carried out in 26 (63.4%) and a supracervical hysterectomy in 15 (36.6%) patients. Of the 59 patients with bowel endometriosis, half had segmental resection and half had shaving of the anterior rectal wall. Complications requiring revision occurred in 0.9% of cases. Conclusion The surgical procedures carried out in the certified endometriosis centers of the DACH region are largely in line with the recommendations for appropriate surgical approaches in the current standard guidelines.

Exploring the feasibility of indocyanine green fluorescence for intraoperative ureteral visualisation in robotic transvaginal natural orifice transluminal endoscopy surgery during endometriosis resection.

To assess the feasibility of use of indocyanine green (ICG) in identifying and minimising urinary tract injury during surgical resection of endometriosis through robotic transvaginal natural orifice transluminal endoscopy surgery (RvNOTES). We conducted a retrospective case series in two academic tertiary care hospitals. We examined 53 patients who underwent RvNOTES hysterectomy with planned endometriosis resection. The study involved 53 patients undergoing RvNOTES with ICG fluorescence for endometriosis resection. Mean patient age was 37.98±6.65years. Operative time averaged 181.32±53.94min, with estimated blood loss at 45.57±33.62mL. Postoperative stay averaged 0.23±0.47days. No ICG-related complications occurred. No complications occurred with ICG fluorescence in RvNOTES. It appears to be a safe option for ureteral localisation and preservation. ICG fluorescence is widely used in diverse medical specialities for identifying ureters during complex surgeries. Larger studies are needed to firmly establish its advantages in intraoperative ureteral visualisation during RvNOTES for deep infiltrative endometriosis.

Low rectal resection for low rectal endometriosis and rectal adenocarcinoma: Are we discussing the same risks?

To evaluate the rate and risk factors for anastomosis leakage in patients undergoing colorectal resection with low anastomosis for rectal endometriosis and rectal adenocarcinoma. A retrospective cohort study evaluating prospectively collected data was conducted. Patients undergoing colorectal resection for rectal endometriosis and rectal adenocarcinoma with low anastomosis (<7 cm from the anal verge [AV]) from September 2018 to January 2023 were included in the analysis. The main outcome was the rate of anastomosis leakage. A multivariate logistic regression was conducted to evaluate risk factors for anastomosis leakage in both groups. A total of 159 patients underwent colorectal resection with low anastomosis due to rectal endometriosis (n = 99) and rectal adenocarcinoma (n = 60). Patients with endometriosis were significantly younger than those with adenocarcinoma (35.7 ± 5.1 vs 63.7 ± 12.6; P = 0.001). The leakage rate was similar between the endometriosis (n = 12, 12.1%) and adenocarcinoma (n = 9, 15.0%) patients (P = 0.621). The anastomosis height less than 5 cm from the AV (adjusted odds ratio [aOR] 12.12, 95% confidence interval [CI] 2.24-23.54) was significantly associated with the anastomosis leakage. Protective stoma was associated with the decrease of the leakage risk (aOR 0.12, 95% CI 0.01-0.72). The type of disease (rectal endometriosis or adenocarcinoma) was not associated with the anastomosis leakage (aOR 2.87, 95% CI 0.34-21.23). Despite the different pathogenesis, the risk of anastomotic leakage was found to be similar between patients with low rectal endometriosis and those with rectal adenocarcinoma. These results must be considered by the gynecologist and colorectal surgeon to deliver proper information before rectal surgery for endometriosis.

Feasibility of Intraoperative Proctosigmoidoscopy After Discoid Bowel Resection for Deep Infiltrating Endometriosis: A Pilot Multicenter Study

Although surgery is the gold standard treatment for pain refractory to medical management or partial occlusion owing to rectosigmoid endometriosis, surgical resection can be associated with major perioperative complications. From general surgery experience, intraoperative proctosigmoidoscopy has shown encouraging results as a feasible, safe, and effective technique in reducing the risk of complications related to intestinal anastomosis after segmental resection. Unfortunately, there are no studies evaluating its role after discoid resection for rectosigmoid endometriosis. A pilot, multicentric, observational, prospective, cohort study. Two academic hospitals, from March 1 to December 31, 2022. We enrolled all consecutive fertile-age patients affected by symptomatic endometriosis scheduled for laparoscopic discoid bowel resection. Inclusion criteria were (1) age between 18 and 50 years, (2) diagnosis of rectosigmoid endometriosis performed by transvaginal ultrasound and/or magnetic resonance imaging, and (3) women scheduled for laparoscopic discoid bowel resection of endometriosis at low risk of segmental resection. During data analysis, enrolled patients were divided into 2 study groups for comparisons based on whether or not the intraoperative proctosigmoidoscopy was performed upon surgeons' discretion after discoid resection for treating endometriosis, in addition to standard integrity tests. Primary outcome was the rate of intraoperative proctosigmoidoscopy success. Secondary study outcomes were the differences between the intraoperative proctosigmoidoscopy group and the nonintraoperative proctosigmoidoscopy group in (1) mean of total operative time and (2) rate of perioperative complications. A total of 28 patients were enrolled and equally distributed in the 2 groups. The rate of intraoperative proctosigmoidoscopy success was 86%. No significant difference was reported between the 2 groups in terms of total operative time (p = .1) and intraoperative and postoperative complications (p = .5 and p = 1, respectively), with no surgical complication related to intraoperative proctosigmoidoscopy. Intraoperative proctosigmoidoscopy seems as a feasible and non-time-consuming intraoperative procedure in women undergone discoid resection for rectosigmoid endometriosis. Larger studies with longer follow-up period are necessary to confirm our findings and assess clinical benefits over standard procedure.

Treatment techniques for rectovaginal fistulas after low rectal resection for deep endometriosis.

Endometriosis is a benign gynecologic affection that may lead to major surgeries, such as colorectal resections. Rectovaginal fistulas (RVF) are among the possible complications. When they occur, it is necessary to adapt the repair surgery as best as possible to limit their functional consequences. This video shows three different techniques for correcting RVF after rectal resection for endometriosis, with a combination of perineal surgery and laparoscopy: a mucosal flap, a transanal transection and single stapled anastomosis (TTSS) and a pull through. Supplementary file1 (MP4 469658 KB).

To drain or not to drain: A propensity score analysis of abdominal drainage after colorectal surgery for endometriosis

AimTo assess the benefit of prophylactic abdominal drainage (AD) after colorectal surgery for endometriosis. MethodsWe conducted a retrospective study of 215 patients who underwent colorectal surgery for endometriosis using a mini-invasive approach in our center from February 2019 to July 2023. A propensity score matched (PSM) analysis (1:1 ratio) identified two groups of patients with similar characteristics. Postoperative outcomes were then compared. ResultsIn the unmatched cohort, 151 patients (70 %) had AD at the end of surgery and 64 (30 %) did not. Clinical characteristics and surgical procedures were comparable between the groups after PSM. After PSM, AD was associated with a longer hospital stay (p < 0.001) and a greater number of postoperative complications (p = 0.03). There were no differences for readmission, repeat surgery, or severe postoperative complications. ConclusionIn this retrospective cohort of patients undergoing colorectal resection for endometriosis using a mini-invasive approach, prophylactic AD was not found to be beneficial.

An analysis of body mass index and the risk of postoperative complications following colorectal resection for endometriosis

An analysis of body mass index and the risk of postoperative complications following colorectal resection for endometriosis

Totally intracorporeal colorectal anastomosis (TICA) versus classical mini-laparotomy for specimen extraction, after segmental bowel resection for deep endometriosis: a single-center experience

PurposeThe surgical approach to bowel endometriosis is still unclear. The aim of the study is to compare TICA to conventional specimen extractions and extra-abdominal insertion of the anvil in terms of both complications and functional outcomes.MethodsThis is a single-center, observational, retrospective study conducted enrolling symptomatic women underwent laparoscopic excision of deep endometriosis with segmental bowel resection between September 2019 and June 2022. Women who underwent TICA were compared to classical technique (CT) in terms of intra- and postoperative complications, moreover, functional outcomes relating to the pelvic organs were assessed using validated questionnaires [Knowles-Eccersley-Scott-Symptom (KESS) questionnaire and Gastro-Intestinal Quality of Life Index (GIQLI)] for bowel function. Pain symptoms were assessed using Visual Analogue Scale (VAS) scores.ResultsThe sample included 64 women. TICA was performed on 31.2% (n = 20) of the women, whereas CT was used on 68.8% (n = 44). None of the patients experienced rectovaginal, vesicovaginal, ureteral or vesical fistula, or ureteral stenosis and uroperitoneum, and in no cases was it necessary to reoperate. Regarding the two surgical approaches, no significant difference was observed in terms of complications. As concerns pain symptoms at 6-month follow-up evaluations on stratified data, except for dysuria, all VAS scales reported showed significant reductions between median values, for both surgery interventions. As well, significant improvements were further observed in KESS scores and overall GIQLI. Only the GIQLI evaluation was significantly smaller in the TICA group compared to CT after the 6-month follow-up.ConclusionsWe did not find any significant differences in terms of intra- or post-operative complications compared TICA and CT, but only a slight improvement in the Gastro-Intestinal Quality of Life Index in patients who underwent the CT compared to the TICA technique.

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery for Frozen Pelvis

To show feasibility and techniques used to perform a total hysterectomy, bilateral salpingectomy, endometriosis resection, and ovarian reconstruction in a patient with a frozen pelvis secondary to a history of ruptured tubo-ovarian abscess. Narrated step-by-step video demonstration. Single academic institution. In patients with a history of multiple abdominal surgeries, abdominal mesh, or in the case of this patient, a history of a ruptured tubo-ovarian abscess, a vaginal approach may be safer. Immediate access to the uterine pedicles through the vagina bypasses the need for extensive enterolysis and adhesiolysis when compared to an abdominal approach. With the use of indocyanine green injected into bilateral ureters, we highlight the benefits of immediate identification of the ureters allowing for safer and more efficient dissection. We show rotational uterine maneuvers to aid in rectosigmoid-to- posterior-uterus dissection in a limited space due to dense pelvic adhesions. Lastly, we demonstrate ovarian reconstruction and oophoropexy for the purpose of easier ovarian identification in future surgeries to possibly reduce the risks of ovarian remnant syndrome. This video highlights the feasibility and strategies used to perform robot-assisted vaginal natural orifice transluminal endoscopic surgery on a patient with a frozen pelvis.

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy.

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81min vs 240 ± 79min, p = 0.010, and 216 ± 78min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.

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.

The Complexity of Colorectal Resection for Endometriosis

The Complexity of Colorectal Resection for Endometriosis

Risk factors for major complications following colorectal resections for endometriosis in the USA

PurposeWe aimed to describe the incidence and identify risk factors for the occurrence of short-term major posto-perative complications following colorectal resection for endometriosis.MethodsA cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012–2020. We included patients with a primary diagnosis of endometriosis who underwent colon or rectal resections for endometriosis.ResultsOf 755 women who underwent colorectal resection, 495 (65.6%) had laparoscopic surgery and 260 (34.4%) had open surgery. The major complication rate was 13.5% (n = 102). Women who underwent open surgery had a higher proportion of major complications (n = 53, 20.4% vs. n = 49, 9.9%, p < 0.001). In a multivariable regression analysis, Black race (aOR 95%CI 2.81 (1.60–4.92), p < 0.001), Hispanic ethnicity (aOR 95%CI 3.02 (1.42–6.43), p = 0.004), hypertension (aOR 95%CI 1.89 (1.08–3.30), p = 0.025), laparotomy (aOR 95%CI 1.64 (1.03–3.30), p = 0.025), concomitant enterotomy (aOR 95%CI 3.02 (1.26–7.21), p = 0.013), and hysterectomy (aOR 95%CI 2.59 (1.62–4.15), p < 0.001) were independently associated with major post-operative complications. In a subanalysis of laparoscopies only, Hispanic ethnicity, chronic hypertension, lysis of bowel adhesions, and hysterectomy were independently associated with major complications. In a subanalysis of laparotomies only, Black race and hysterectomy were independently positively associated with the occurrence of major complications.ConclusionThis study provides a current population-based estimate of short-term complications after surgery for colorectal endometriosis in the USA. The identified risk factors for complications can assist during preoperative shared decision-making and informed consent process.