In this video, we’ll demonstrate an anterior rectal resection of endometriosis with the use of an intraluminal stapler. In this video, we’ll review the components of the intraluminal stapler. We’ll outline the technique of the anterior rectal resection using the intraluminal stapler, and we’ll discuss appropriate patient selection for this procedure. The sigmoid and anterior rectum are the most commonly affected sites of bowel deep endometriosis, and endometriosis in this region poses unique management and operative challenges.
Challenges Treating Bowel Endometriosis
Some of the diagnostic dilemmas come from overlapping symptomatology with some benign conditions such as IBS and IBD, as well as malignant conditions such as colorectal cancer. The decision to proceed with surgery for those with bowel endometriosis is a complex one. It’s further complicated by knowing which approach to use as the indications for each are not well defined. We present an anterior rectal resection with the intraluminal stapler.
This is a form of disc excision, meaning it removes the lesion full thickness into the lumen of the bowel. In contrast to shaving, but does not require circumferential end-to-end anastomosis as seen with segmental resection. A similar technique was first described in 2001, and its update has been adapted and increased in the last decade.
Advantages and Disadvantages of Anterior Rectal Resection
A few of the documented advantages of this approach are that it employs a minimally invasive technique. There are comparable functional outcomes and recurrence rates to the other forms of bowel endometriosis surgery. There are lower rates of immediate complications such as anastomosis leaks. It does employ a multidisciplinary approach, and resection is made easier by the use of the stapler. Some potential disadvantages are that there may be higher rates of immediate post-op pain when compared to rectal shaving, and some maintain that recurrence may be lower with segmental resection, given it may have a lower incidence of positive margins.
The components of this intraluminal stapler include the anvil, the staple holder, the shaft, the firing lever, the firing lock, and the adjustment dial, which controls the position of the anvil and tissue compression as measured by the compression guide. The technique is as follows. First, you must have appropriate patient selection. During the procedure, isolation of the rectal endometriotic lesion is then performed, and stay sutures are placed proximally and distally to the lesion on the surface of the bowel.
In-depth Demonstration of the Procedure
The anvil of the intraluminal stapler is then advanced proximal to the lesion. The stay sutures are then used to retract the entire lesion into the stapler. The stapler line is then thoroughly inspected. The stapler is then activated, excising the lesion, and stapling the anastomosis. We then confirm secure anastomosis.
Case Study: A 31-Year-old Woman with Refractory Endometriosis
We demonstrate this here. Steps 1 to 3 have already been performed. The purple represents a lesion of endometriosis. Stay sutures have already been placed, and they are now used to retract the lesion into the stapler. The anvil is then retracted back into the stapler, and then the suture line will be checked. Once we confirm that no extra tissue is brought into the stapler, the stapler can be fired, excising the lesion, and at this time, we would then check the staple line for secure anastomosis.
Patient Selection Criteria for Anterior Rectal Resection
This view from within the lumen shows the staple line and the preserved bowel lumen diameter. We present the case of a 31-year-old nulliparous woman referred for refractory endometriosis. Although she has moderate to severe dysmenorrhea, her most bothersome symptoms are those of lower GI and bowel endometriosis. One pertinent finding from her physical exam is that a 34mm bowel sizer was unable to pass 8cm into the rectum, indicating bowel lumen narrowing.
Implementing the Anterior Rectal Resection Procedure
We correlate her history and physical exam with ancillary testing by use of a transvaginal ultrasound, as well as an MRI. This case helps us outline some of the patient selection criteria when using this approach, generally, lesion characteristics are defined best by transvaginal ultrasound, although other ancillary tests can be used. This approach has been previously described to be successful in lesions less than 3cm in size, unifocal, involving less than 1 third the circumference of the rectum.
Procedure Check and Anastomosis Integrity Verification
And a distance from the anal verge must be able to be reached by your make and model of stapler. We now return to our case presentation. This was our patient’s pelvis at the start of the case. We note the obliterated cul-de-sac as previously predicted. We proceed now after dissection in the pelvis has already been performed, and we have isolated the endometriotic lesion on the anterior rectum. Stay sutures are now placed proximally and distally to the lesion with an absorbable suture and tied down.
These will be used to anchor our lesion into the stapler while it is fired. Next, the intraluminal stapler is guided into the rectum, and the anvil is deployed and advanced approximately to the lesion as depicted here. Both stay sutures are then grasped, and downward traction is placed to bring the lesion into the active area of the stapler. The anvil is then withdrawn into the staple holder. Anterior traction is placed on the stapler as to not include any of the posterior wall of the rectum.
The staple line is then thoroughly inspected to ensure that no unwanted tissue has been drawn inside the stapler. Once this check has been performed, the stapler can now be activated, excising the lesion, and stapling the anastomosis. Here, we re-examine the pelvis and our staple line. We can see that no unwanted structures or tissue have been brought inside the stapler line as defined by our dissection.
Confirming Anastomosis Integrity and Inspecting the Staple Line
Lastly, we confirm anastomosis integrity. This is achieved by filling the pelvis with water, then occluding the proximal end of the rectum with an instrument. A rigid sigmoidoscopy is then performed. The rectum is inflated with air, to its capacity. The lack of bubbles rising from the staple line or anastomosis site helps to confirm its integrity. The intraluminal staple line should also be inspected with the sigmoidoscopy to confirm that there is no bleeding at the anastomosis site and that the staples have fired appropriately.
The excised disc of bowel containing the lesion is removed inside the stapler and can now be inspected. In summary, we reviewed the components of the intraluminal stapler. We’ve outlined a technique of anterior rectal resection using the intraluminal stapler, and we’ve discussed appropriate patient selection for this procedure. Thanks for watching.