Surgical Management Of Deep Endometriosis Research Articles

Multidisciplinary surgical management of deep endometriosis with single robot port set-up

Multidisciplinary surgical management of deep endometriosis with single robot port set-up

En-block butterfly excision of posterior compartment deep endometriosis: The first experience with the new surgical robot Hugo™ RAS.

Minimally invasive surgery is the gold standard treatment for deep endometriosis when medical management fails. In selected cases, such as when bowel or urinary tract are involved, robotic assisted surgery can be useful due to its characteristics of high dexterity and manoeuvrability. This is the first case of robotic en-bloc excision of posterior compartment deep endometriosis performed with the new HugoTM RAS system. The purpose of this video article is to show for the first time the feasibility of bowel surgery for deep endometriosis with this new robotic device. A 24-years-old woman affected by severe dysmenorrhea, chronic pelvic pain, dyschezia and dyspareunia underwent to deep endometriosis excision using the new robotic platform HugoTM RAS system at the Unit of Gynaecological Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Intraoperative data, docking set up, post-operative outcomes up to three months follow up were evaluated. The surgical procedure was carried out without intra-operative or post-operative complications, operative time (OT) was 200 minutes, while docking time was 8 minutes. No system errors or faults in the robotic arms were registered. Post-operative complete disease-related symptoms relief was reported. According to our results, the introduction of this new robotic platform in the surgical management of deep endometriosis seems to be feasible, especially in advanced cases. However, further studies are needed to demonstrate the benefits of this surgical system and the advantages of robotic surgery compared to laparoscopy in this subset of patients.

7693 Deep Infiltrating Endometriosis: Laparoscopic Treatment with Discal Resection

<h3>Study Objective</h3> To show how deep intestinal endometriosis can be managed safely and effectively with laparoscopic discoid resection. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> The surgical management of deep endometriosis infiltrating the rectum employs either colorectal segmental resection or conservative techniques, i.e., shaving and discoid resection. When the nodule measures less than 3 cm in diameter, the discoid resection is applicable as an alternative to segmental colorectal resection. For surgery, the patient was placed in a dorsal modified lithotomy position. The surgeon was on the patient's left side, the first assistant on the right, and the second assistant between the patient's legs. <h3>Patients or Participants</h3> A 32-year-old patient presented to our center with dysmenorrhea, dyspareunia, dyschezia and chronic pelvic pain. On physical examination, in the pouch of Douglas, a painful nodule of approximately 2 cm was palpable, involving the left uterosacral ligament. In the MRI, it can be observed in the sagittal section T2 a hypointense nodule that obliterates the pouch of Douglas and involves the anterior wall of the rectum. The nodule contacts with the anterior wall of the rectum with a 27 mm expansion and a 9 mm maximal invasion. The distance between the nodule and the anal margin is 8 cm. <h3>Interventions</h3> Laparoscopic approach with discal resection to treat deep infiltrating endometriosis. Step-by-step demonstration of the surgery with the key points through a narrated video. <h3>Measurements and Main Results</h3> Patient evolves favorably in post operative care. Hospital discharge is given 48hs after the intervention. At 6-month follow-up, the patient reported resolution of all initial symptoms. <h3>Conclusion</h3> Discoid resection is an effective and safe alternative for trained surgeons with the aim of better preserving rectal function and reducing the risk of low anterior rectal resection syndrome that can be generated with bowel resection.

O-308 The impact of NOSE colectomy and laparoscopic conventional segmental resection on bowel function and quality of life among patients with rectal endometriosis: prospective randomized trial

Abstract Study question What is the impact of laparoscopic conventional or NOSE colorectal resection on bowel function in patients with deep endometriosis infiltrating the rectum one year postoperatively? Summary answer Both conventional and NOSE colectomy improved the functional outcomes and quality of life among patients with deeply invasive rectal endometriosis one year after bowel surgery. What is known already Conventional laparoscopic approach to the surgical management of deep endometriosis infiltrating the rectum appears to assure improved digestive functional outcomes. NOSE technique for colorectal disease can significantly reduce the duration of hospital stay, accelerate postoperative recovery with better cosmetic results, and in particular, result in less postoperative pain and fewer complications. However, long-term solid data about gastrointestinal well-being after segmental bowel or NOSE resection for deep endometriosis are still missing. Study design, size, duration Between the 1st September 2019 - 31th of December 2020 we performed a 2-arm unblinded prospective randomized trial, enroling 91 patients with deep infiltrating rectal endometriosis up to 15 cm from the anal verge. Patients aged between 18 and 45 years, with deep endometriosis infiltrating at least the muscular layer in depth, and up to 50% of rectal circumference, complaining pain, bowel symptoms and/or infertility were included. The average follow up time was 14±2.6 months. Participants/materials, setting, methods Patients were enroled at Semmelweis University, Department of Obstetrics and Gynecology, Budapest, Hungary and had either conventional laparoscopic bowel resection or NOSE resection. Randomization was performed preoperatively using the simple randomization method. The primary endpoint was to assess the bowel function and quality of life by using the Endometriosis Health Profile 30, the Gastrointestinal Quality of Life Index and the Low Anterior Resection Syndrome score preoperatively, 1 month, 6 months, 1 year after the surgery. Main results and the role of chance A total of 91 patients were enroled. 39 patients were in the NOSE surgery arm, 49 were in the Conventional laparoscopic surgery arm. One patient was lost to follow-up and we had two cases of drop out from the trial after randomization due to performing non intended disc resection. This cases were excluded from the study. There was no conversion to laparotomy.The overall scores on Gastrointestinal Quality of Life Index (GIQLI), Low Anterior Resection Syndrome scores (LARS) and Endometriosis Health Profile 30 (EHP30) scores did not reveal significant differences between the two groups. LARS scores were improved, but did not reveal significant differences 12 months (T3) after the operation compared with the preoperative (T0) values in both groups (Conventional surgery group: T0=21.41 T3= 17.90; p = 0.934, NOSE surgery goup T0= 26.53 T3= 18.23; p = 0.229). GIQLI scores were significantly improved 12 months after the operation compared with the baseline values in Conventional surgery group T0= 95.44 T3= 111.39 p = 0.002. EHP30 scores were significantly improved concerning pain, emotion well-being, control and powerlessness, self-image, social support and sexuality scale 12 months after the operation compared with the preoperative values in both groups. Limitations, reasons for caution An obvious bias of performance is the lack of blinding, however blinding was not feasible due to the clinical nature of our study. We report no imprecision in patient selection, but a potential source of attrition bias in our data occured in a total number of three cases in NOSE-group. Wider implications of the findings Our study does not show a statistically significant difference between conventional or NOSE surgery for short and mid-term functional digestive outcomes. Occurrence of longterm bowel dysfunction does not appear to be related to a specific surgical technique. Trial registration number ClinicalTrials.gov number: NCT04109378

Crude complication rate is not an accurate marker of a surgeon's skill: A single surgeon retrospective series of 1060 procedures for colorectal endometriosis.

To assess the relationship between the rate of postoperative bowel fistula and surgeon experience. Retrospective study. Two referral centers. 1060 women managed for colorectal deep endometriosis by one gynecologist surgeon from January 2005 to March 2020. Shaving, disc excision and segmental colorectal resection. Rate of bowel fistula stratified according to 4 time periods: P1 from 2005 to 2009, P2 from 2010 to 2014, P3 from 2015 to June 2018 and P4 from September 2018 to March 2020. 68 patients (6.4%) were managed during P1, 299 patients (28.2%) during P2, 422 patients (39.8%) during P3 and 271 patients (25.6%) during P4. Both diameter of rectal infiltration and rate of complex surgical procedures progressively increased from P1 to P4. Bowel fistula rate was comparable between all 4 time periods, respectively 2.9, 3.3, 4 and 4.4%. Logistic regression model revealed that risk of fistula decreased when shaving was performed when compared to segmental resection (adj OR 0.1, 95% CI 0-0.5) and increased when deep endometriosis nodules also involved sacral roots (adjOR 4.9, 95%CI 1.8-13.3) and infiltration of the vagina (adj OR 3, 95%CI 1.3-7). No statistically significant relationship was found between surgery time period and risk of fistula. Crude rates of bowel fistula following surgical management of deep endometriosis infiltrating the colon and the rectum are not an accurate marker of surgeon expertise and should be considered in conjunction with expected higher risks related to challenging procedures performed by experienced surgeons.

Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases.

STUDY QUESTIONWhat are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed?SUMMARY ANSWERIn patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage.WHAT IS KNOWN ALREADYBowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management.STUDY DESIGN, SIZE, DURATIONA retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres.PARTICIPANTS/MATERIALS, SETTING, METHODSOne thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management.MAIN RESULTS AND THE ROLE OF CHANCEOf 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom 23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision + segmental resection was 6.8 (1.9–23.8), 4.8 (1.4–16.9) and 11 (2.1–58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008)LIMITATIONS, REASONS FOR CAUTIONThe main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon.WIDER IMPLICATIONS OF THE FINDINGSDeep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures.STUDY FUNDING/COMPETING INTEREST(S)CIRENDO is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE Association. No financial support was received for this study. H.R. reports personal fees from ETHICON, Plasma Surgical, Olympus and Nordic Pharma outside the submitted work. The other authors declare no conflict of interests related to this topic.

Deep Endometriosis of the Bowel: A Surgical Approach

Video Objective The objectives of this video are to define bowel endometriosis and to explore various surgical parameters for the different types of surgical excision. Then, a specific surgical approach will be demonstrated. Setting Our case is of a 34 year old nulliparous woman who presented for surgical management of deep endometriosis, as she was unable to tolerate medical management. She also presented with rectal bleeding and fecal urgency. This case was performed at a tertiary care setting hospital in Canada. Interventions Surgical management of bowel endometriosis is indicated for symptom and pain relief, intolerance to medical management and to prevent complete obstruction. Importantly, operative planning and management should involve a multidisciplinary team involving gynecologists, general or colorectal surgeons and radiologists. When planning a surgical approach to deep endometriosis of the bowel, patient characteristics such as age and BMI, as well as their specific symptoms and level of pain, quality of life and fertility goals must be considered. As well, the actual lesion must be investigated with respect to size, number, location, depth of infiltration, and amount of intestinal wall circumference involved. Then, various surgical techniques can be performed depending on these specific characteristics, such as nodule shaving, nodular resection and segmental resection and re-anastomosis. For our surgical case, segmental resection and re-anastomosis was indicated after intra-operative colonoscopy showed significant luminal obstruction. The video demonstrates a blood vessel preservation and nerve sparing approach, highlighting blood supply, sympathetic and para-sympathetic innervation. Conclusion The patient was discharged post-operative day 2 and reported complete resolution of symptoms at her clinical follow-up. This surgical video demonstrates and advocates a multidisciplinary approach to bowel endometriosis to improve patient quality of life.

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial.

STUDY QUESTIONIs there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively?SUMMARY ANSWERNo evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel.WHAT IS KNOWN ALREADYAdopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection.STUDY DESIGN SIZE, DURATIONFrom March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up.PARTICIPANTS/MATERIALS, SETTING, METHODSPatients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles–Eccersley–Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36).MAIN RESULTS AND THE ROLE OF CHANCEA total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22–2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis.LIMITATIONS REASONS FOR CAUTIONThe inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint.WIDER IMPLICATIONS OF THE FINDINGSConservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study.TRIAL REGISTRATION NUMBERThis study is registered with ClinicalTrials.gov, number NCT 01291576.TRIAL REGISTRATION DATE31 January 2011.DATE OF FIRST PATIENT’S ENROLMENT7 March 2011.

The Impact of Laparoscopic Surgical Management of Deep Endometriosis on Fertility Outcome.

The Impact of Laparoscopic Surgical Management of Deep Endometriosis on Fertility Outcome.

Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate

Study ObjectiveTo evaluate the impact of laparoscopic excision of lesions on deep endometriosis-related infertility. DesignRetrospective study. SettingEndometriosis tertiary referral center (Canadian Task Force II-2). PatientsA group of 115 patients who had undergone laparoscopic surgery for infertility with histologic confirmation of deep endometriosis. InterventionsPatient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term follow-up of fertility outcomes. Measurements and Main ResultsEvaluation of fertility outcome after laparoscopic treatment of deep endometriosis by spontaneous conception and by assisted reproductive technology (ART) correlated with lesion number, size, and location (anterior, posterolateral, pouch of Douglas, and multiple locations). After a mean follow-up of 22 months the overall pregnancy rate was 54.78% (n = 63) with a live-birth rate of 42.6% (n = 49). Among those patients given the chance to conceive spontaneously (n = 70), the overall pregnancy rate was 60% (n = 42): 38.5% (n = 27) spontaneously and 21.4% (n = 15) by ART. The removal of multiple lesions was associated with a higher pregnancy rate after surgery. When comparing isolated lesion size and disease location, there was no difference in pregnancy rate. Furthermore, those patients who underwent surgical eradication of the disease for the first time had a higher pregnancy rate (odds ratio, 4.18). ConclusionThis study demonstrates that laparoscopic excision of deep endometriosis enhances pregnancy rate, by both spontaneous conception and ART. First surgical treatment of multiple lesions was associated with higher pregnancy rates, whereas isolated lesions influenced the pregnancy rate irrespective of their location and size.

Digestive Functional Outcomes of the Surgical Management of Deep Endometriosis Infiltrating the Rectum: Radical Versus Symptom Guided Approach? Results of a Comparative Study

Deep infiltrating endometriosis of the rectum (DIER) may be managed according to 2 surgical approaches: radical or carcinologic (based on colorectal resection) and conservative or symptomatic (rectal shaving and nodules full thickness excision).

Fertility Outcome after Surgical Management of Deep Endometriosis

Fertility Outcome after Surgical Management of Deep Endometriosis

Traitement de l'endométriose sévère par la grossesse: un pari risqué

We report the case of a young woman presenting with painful deep and rectal endometriosis. This condition had started long ago while the diagnosis had been delayed. Brutal colon occlusion followed the discontinuation of oral contraception. Left colectomy with terminal colostomy was carried out in emergency. The conservative surgical management of deep endometriosis was performed three months later. In women presenting deep endometriosis, the discontinuation of hormonal treatment in order to attempt a spontaneous pregnancy should not be recommended before undertaking a thorough endometriosis and fertility status investigation.

Adhesion Formation after Laparoscopic Resection of Uterosacral Ligaments in Women with Endometriosis

Study Objective To analyze the risk of postoperative adhesions in women who undergo laparoscopic surgical management of deep endometriosis infiltrating the uterosacral ligaments (USL) Design Retrospective analysis (Canadian Task Force classification II-2). Setting University-affiliated hospital. Patients Forty-six women with deep endometriosis infiltrating the USL. Intervention Laparoscopic resection of all USL with deep endometriotic lesions and excision of all other endometriotic lesions, followed by second-look laparoscopy. Measurements and Main Results At second-look laparoscopy, 15 patients (32.6%) had no adhesions at the site where the USL had been resected, 24 (52.2%) had filmy avascular adhesions, and 7 (15.2%) had dense or vascular adhesions. No patient had adhesions of the binding type. Only two factors, the revised American Fertility Association (rAFS) score at initial laparoscopy and surgical modality (unilateral resection of the right USL, unilateral resection of the left USL, bilateral resection of USL) had a statistically significant influence on the risk of postoperative adhesions occurring. After adjustment, the relation with initial rAFS stage and surgical modality remained significant in the stepwise logistic regression model. Conclusion These encouraging results are particularly interesting for patients with infertility due to pelvic pain syndrome. Second-look laparoscopy should not be performed routinely after laparoscopic management of deep endometriosis infiltrating the USL. We propose that it be reserved for women with rAFS stages III and IV endometriosis, especially when lesions are located on the left side.