Endometriosis
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Discoid Resection of Deep Rectosigmoid Endometriosis with the Assistance of a Laparoscopic Ultrasound Probe

Discoid Resection of Deep Rectosigmoid Endometriosis with the Assistance of a Laparoscopic Ultrasound Probe
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Video Description

Laparoscopic ultrasound has been used in the assessment and management of some intra-abdominal malignancies, buts its use in gynecologic surgery has been limited. However, it holds promise in the management of deep endometriosis. We present a 47-year-old female with a previous history of shaving of deep rectosigmoid endometriosis, followed by oversewing of the bowel. Due to recurrence of rectal symptoms, the patient had a repeat procedure for more definitive management. This video illustrates the use of laparoscopic ultrasound in the identification and management of deep endometriosis, particularly when deep endometriotic implants are difficult to identify. We then highlight how the in-time feedback from this imaging modality was used to select the most conservative management option for the patient, a discoid resection.

Presented By

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Dr. Nicole Delaloye
Dr. Caroline Lee
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Dr. Brittany Macgregor
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Dr. Jack Chui

Affiliations

University of British Columbia

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What is Discoid Resection of Deep Rectosigmoid Endometriosis with the Assistance of a Laparoscopic Ultrasound Probe?

Discoid resection of deep rectosigmoid endometriosis with the assistance of a laparoscopic ultrasound probe is a specialized surgical technique used to treat severe endometriosis affecting the rectosigmoid colon (the last part of the colon and the rectum). Here’s how it works:

  1. Discoid Resection: In this procedure, a disc-shaped portion of the affected bowel wall is removed, rather than performing a full bowel resection. This approach targets endometriotic lesions deeply embedded in the rectosigmoid area, minimizing the amount of healthy tissue removed while excising the diseased tissue.

  2. Laparoscopic Assistance: The surgery is minimally invasive, using small incisions and a laparoscope (a thin tube with a camera) to guide the surgeon’s movements. This technique reduces recovery time, lowers the risk of complications, and allows for a more precise approach compared to open surgery.

  3. Ultrasound Probe Guidance: A laparoscopic ultrasound probe helps locate and assess the depth and extent of endometriotic lesions. By using real-time imaging, the probe enables the surgeon to clearly differentiate endometriotic tissue from healthy tissue, ensuring accurate resection and minimizing the risk of leaving behind diseased tissue.

  4. Benefits: This method is effective for managing deep endometriosis while preserving bowel function and minimizing complications. It typically improves symptoms like pain and discomfort associated with bowel involvement in endometriosis, offering an effective option for patients with deeply infiltrative disease.

This procedure is often considered for patients with rectosigmoid endometriosis, especially when medical therapies are insufficient to control symptoms, providing a focused and less invasive option for surgical treatment.

What are the Risks of Discoid Resection of Deep Rectosigmoid Endometriosis with the Assistance of a Laparoscopic Ultrasound Probe?

Discoid resection of deep rectosigmoid endometriosis with laparoscopic ultrasound assistance carries specific risks, including:

  1. Bowel Perforation or Injury: Working near the rectosigmoid colon poses a risk of perforating the bowel wall. If the resection goes deeper than planned, it may lead to bowel injury, which might require further surgical intervention.

  2. Anastomotic Leak: If a portion of the bowel wall is removed and needs repair, there’s a risk of leakage at the surgical site (anastomosis), which can cause infection, sepsis, and may require additional surgery.

  3. Infection and Abscess Formation: As with any surgery, there is a risk of infection at the site, and in cases involving bowel resection, this can lead to localized infections or abscesses within the abdomen, requiring antibiotics or drainage.

  4. Stricture Formation: Scar tissue from the resection can form a stricture, or narrowing, at the site of the resection, potentially causing bowel obstruction and necessitating further intervention.

  5. Bleeding: There is a risk of significant bleeding, particularly in deeply infiltrative cases where vascular tissue is affected. Bleeding may require blood transfusions or, in rare cases, conversion to open surgery to control the hemorrhage.

  6. Recurrence of Endometriosis: While discoid resection removes visible endometriotic lesions, endometriosis can recur, especially if microscopic lesions remain, potentially leading to persistent or recurrent symptoms.

  7. Impact on Bowel Function: Patients may experience temporary or, in rare cases, long-term bowel issues, including pain, constipation, or diarrhea. There may also be changes in bowel habits due to resection and subsequent healing.

The use of a laparoscopic ultrasound probe aims to reduce some of these risks by helping the surgeon accurately locate and assess the depth of lesions, minimizing unnecessary tissue removal and enhancing precision. However, thorough preoperative planning and discussion of these risks are essential for informed decision-making.

Video Transcript: Discoid Resection of Deep Rectosigmoid Endometriosis with the Assistance of a Laparoscopic Ultrasound Probe

Discoid resection of deep rectosigmoid endometriosis with the assistance of a laparoscopic ultrasound probe.

The authors have the following disclosures.

Our objectives are to, one, review the techniques used in the surgical management of deep endometriosis of the rectosigmoid. Two, demonstrate the use of laparoscopic ultrasound in the setting of endometriosis. And three, discuss the use of a sterile discoid resection for the management of a deep rectosigmoid lesion.

Deep endometriosis, previously referred to as deep infiltrating endometriosis, is characterised by the extension of endometriotic implants beyond the peritoneal surface. At times, this can involve adjacent structures, such as the bowel, and can be associated with symptoms such as dyschezia and/or hematochezia during menstruation.

Surgical management of deep endometriosis involving the bowel, specifically the rectosigmoid, often depends on the depth and size of the lesion. Management options include shaving, discoid resection and segmental resection. Shaving is considered a conservative surgical management approach and is often used for nodules that do not extend beyond the external muscularis.

Discoid resection is considered another conservative option, but can be used in the setting of lesions that extend beyond the inner muscularis and remain less than 3 cm in maximal diameter. This technique involves removing a portion of the bowel without requiring a complete end-to-end anastomosis. On the other hand, segmental bowel resections are typically reserved for cases with large endometriotic implants, multiple nodules, infiltration beyond the muscularis or luminal stenosis.

Initial surgical planning in the setting of deep endometriosis often relies on preoperative imaging. However, distortion secondary to high-stage endometriosis and adhesions can lead to inaccurate estimates of the size, depth and concurrent organ involvement of these lesions. With this, surgical teams are often forced to rely upon tactile response and interoperative decision making to determine how best to proceed in the management of deep endometriosis.

Laparoscopic ultrasound has been used in the assessment and management of some intra-abdominal malignancies, particularly in the setting of gastric, adrenal and hepatic tumours. Its use in gynaecologic surgery has been limited but shows promise in the management of deep endometriosis. This tool can provide real-time feedback on the size, depth and involvement of surrounding structures. Such information can help to ensure the best surgical approach is selected.

We present a 47-year-old female with a known history of stage IV endometriosis, with recurrent, chronic pelvic pain and pressure-like symptoms around the rectum. She had a previous shaving of deep rectal endometriosis at the time of total laparoscopic hysterectomy, bilateral salpingectomy and excision. A follow-up specialised preoperative ultrasound revealed an ongoing recurrent nodule that was located at the anterior rectosigmoid junction, measuring roughly 2.5 cm in maximal diameter.

This was confirmed with a high-resolution rectosigmoid MRI protocol. Images seen highlight the lesion extending into the muscularis. The patient declined ongoing hormonal suppression and desired definitive surgical management with excision.

On initial inspection of the pelvis, the lesion was difficult to identify. This was because of the patient’s previous surgical history, where an area of deep endometriosis of the rectosigmoid colon was shaved and subsequently oversewn. This caused the nodule to lie deeper within the muscularis, and thus was harder to identify with inspection and tactile feedback alone.

The pelvis was irrigated with fluid to minimise artefact. Simultaneously, the bowel was filled with sterile water, using a 14 French catheter, and an Allis grasper was placed more cephalad to ensure the rectal fluid remained within the area of interest. These techniques allowed for the establishment of an appropriate acoustic window. The laparoscopic ultrasound probe was then placed in the region. The bowel was then traced until the lesion was clearly identified near the rectosigmoid junction.

Interoperative images provided in-time feedback, highlighting the depth and extent of the lesion. Here, there is evidence of the lesion extending into the muscularis of the rectosigmoid colon. In a joint decision with general surgery, it was determined that the most appropriate and conservative option was a discoid resection.

Following a bilateral oophorectomy, general surgery began the discoid resection by confirming the location of the lesion with a rectal probe. The right pararectal space was opened. A suture was then used to outline the lesion and aid with invagination of the rectosigmoid lesion.

A circular transanal stapler was then inserted rectally, with the head and tail of the stapler placed superior and inferior to the lesion respectively. Attention was paid to ensure the partial anastomosis was appropriately aligned. Once the lesion was completely invaginated, the stapler was fired, resecting only the area of interest in a sterile manner. The region was then oversewed.

Following resection, a rigid sigmoidoscopy and bubble test was performed and was negative. The ultrasound probe was then placed over the region to ensure complete resection of the deep endometriotic lesion. Review of the post-resection images illustrates complete removal of the lesion.

In summary, laparoscopic ultrasound is a beneficial tool, providing real-time feedback on the extent of deep endometriosis that may not otherwise be attained through standard preoperative imaging or laparoscopy.

In particular, it can help to identify difficult lesions, as seen in this case, where previous shaving and oversewing of the bowel made it difficult to recognise the lesion with inspection and tactile feedback alone. It holds potential to ensure that when shaving is selected, the entire lesion is appropriately removed. Such information can also help to ensure that the most appropriate and conservative surgical option is selected.

Thank you for your time, and thank you to all our collaborators.