En Bloc Resection of Deep Infiltrating Endometriosis with a Novel Tissue Extraction and Anastomotic

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Video Description

This video demonstrates the use of natural orifice vaginal extraction for the completion of a laparoscopic bowel resection in the setting of deep infiltrating endometriosis.

Presented By

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Dr. Brigid Nee
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Dr. Sarah Mah


University of Calgary

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What is En Bloc Resection of Deep Infiltrating Endometriosis with a Novel Tissue Extraction and Anastomotic?

En Bloc Resection of Deep Infiltrating Endometriosis with a Novel Tissue Extraction and Anastomotic refers to a surgical technique for treating deep infiltrating endometriosis (DIE), a particularly severe form of endometriosis. This procedure seems to involve a new method for removing affected tissue and restoring anatomy, primarily when DIE involves the bowel. Here’s a brief explanation, broken down into bullet points for clarity:

  • Deep Infiltrating Endometriosis (DIE):

    • Refers to a severe form of endometriosis where tissue similar to the lining of the uterus grows into the muscular wall layers of organs, commonly the bowel and bladder.
    • It’s often associated with significant pain, infertility, and gastrointestinal or urinary symptoms.
  • En Bloc Resection:

    • A surgical technique that involves the removal of diseased tissue in one single piece, along with a margin of healthy tissue, to ensure complete removal of the affected areas.
    • This is important in DIE to reduce the risk of recurrence and potentially improve pain and fertility outcomes.
  • Novel Tissue Extraction Method:

    • Likely refers to a new or improved surgical technique or tool designed to facilitate the safe and effective removal of endometriotic lesions from deep within affected tissues.
    • This could involve specialized instruments or approaches that minimize damage to surrounding tissues during extraction.

What are the Risks of En Bloc Resection of Deep Infiltrating Endometriosis with a Novel Tissue Extraction and Anastomotic?

  • Bleeding:

    • As with any surgery, there is a risk of significant bleeding during or after the procedure.
  • Infection:

    • The risk of infection is present at the incision sites or internally within the pelvic cavity or abdominal wall.
  • Organ Damage:

    • During the removal of deeply infiltrated endometrial tissue, there’s a risk of unintentional injury to surrounding structures such as the bladder, ureters, bowel, or blood vessels.
  • Anastomotic Leakage:

    • If the surgery involves bowel resection and anastomosis, there’s a risk of leakage from the site where the bowel segments are rejoined, potentially leading to infection or sepsis.
  • Adhesions:

    • Surgery can lead to the formation of scar tissue, causing organs and tissue to stick together and potentially leading to pain, bowel obstruction, or fertility issues.
  • Altered Bowel Function:

    • Depending on the extent of the bowel surgery, patients may experience temporary or long-term changes in bowel habits, including constipation, diarrhea, or incontinence.
  • Recurrence of Endometriosis:

    • While en bloc resection aims to reduce the risk of disease recurrence by removing all affected tissues, endometriosis can still recur.
  • Thrombosis:

    • The risk of blood clots, such as deep vein thrombosis or pulmonary embolism, increases with surgical procedures, especially complex ones.
  • Nerve Damage:

    • There’s a possibility of nerve damage during surgery, which could result in pain, numbness, or weakness.
  • Fertility Issues:

    • While the procedure aims to preserve fertility, surgery involving reproductive organs can sometimes affect a woman’s fertility.
  • Psychological Impact:

    • Dealing with a severe health condition and undergoing major surgery can have significant psychological and emotional effects.
  • Anesthetic Risks:

    • There are always risks associated with anesthesia, including allergic reactions or respiratory issues.
  • Novel Technique Unpredictability:

    • As the tissue extraction and anastomotic techniques are described as “novel,” there may be unforeseen risks or complications that are not yet well-documented or understood due to limited historical data.

Patients considering this surgery should have detailed discussions with their healthcare providers to understand these risks and weigh them against the potential benefits.

Video Transcript: En Bloc Resection of Deep Infiltrating Endometriosis with a Novel Tissue Extraction and Anastomotic

This video presents an innovative surgical approach to deep infiltrating endometriosis of the vagina and rectosigmoid. En bloc resection of DIE with a novel tissue extraction and anastomotic technique will be described.

Deep infiltrating endometriosis is involvement of the peritoneum to a depth greater than 5 mm and affects 3% of the endometriosis population. Diagnostic imaging techniques include MRI or transvaginal ultrasound with a sliding sign.

Several studies have reviewed novel approaches to laparoscopic bowel resection and specimen extraction which traditionally was performed via mini-laparotomy or extension of port incisions. Transvaginal natural orifice specimen extraction is an alternative to reduce abdominal incision complications and improve recovery.

Abrao in 2005 described the laparoscopically assisted vaginal rectosigmoidectomy without hysterectomy using new stapler technology applied through a rectovaginal pouch incision.

We describe a case of rectosigmoid, and vaginal DIE laparoscopically managed with en bloc resection of the involved rectosigmoid, vagina, cervix, and uterus. With a distal rectal staple line completed laparoscopically and the proximal rectosigmoid staple line and anvil placement completed vaginally, thus liberating the en bloc specimen. This represents a novel resection and anastomotic surgical technique.

We present a case of a 42-year-old, G3P2 woman referred to a general gynaecologist with chronic pelvic pain refractory to medical management. There is a posterior tender vaginal mass on exam.

The patient was ultimately consented for a laparoscopic assisted vaginal hysterectomy and bilateral salpingectomy by the general gynaecologist.

Examination under anaesthesia revealed a large mass adjacent to the posterior vagina and uterus. General surgery was consulted and the rigid sigmoidoscope revealed an 8 cm rectal mass with no transmural disease. A diagnostic laparoscopy revealed a rectal mass at the level of the uterosacral ligaments.

The surgery was aborted, and an urgent referral was made to both colorectal surgery and minimally invasive gynaecologic surgery.

Colonoscopy did not confirm transmural involvement. Biopsies were inadequate.

A pelvic MRI revealed a rectal tumour measuring 3.6 cm within the mid rectum causing compression of the rectal lumen. The anterior rectum was involved from 10 to 3 o’clock. Extra luminal depth invasion was 9 mm.

The most distal aspect of the tumour was 6.6 cm from the anal verge and 2.2 cm from the top of the anal sphincter. There was invasion of the mass into the posterior vagina, retro-cervix, and lower uterine segment. A transvaginal ultrasound guided biopsy showed endometriosis.

The patient declined medical therapy and opted for definitive surgical management. She was consented for a combined colorectal MIGS approach to a TLH, BSO, excision of endometriosis, low anterior resection with or without temporary stoma based on surgical findings.

Global assessment of the abdomen and pelvis revealed a bulky uterus with posterior serositis, evidence of a prior tubal ligation, and normal tubes and ovaries bilaterally. There was a peritoneal window along the distal right pelvic sidewall.

Obliteration of the pouch of Douglas was seen with uterosacral ligaments visible bilaterally, and a 6 cm rectal mass densely adhered to the posterior vagina and retro-cervix. The mass was palpable transrectally with invasion into the posterior upper one third of the vagina.

The rectosigmoid was mobilised from the lateral to medial approach. The IMA was compromised, and the rectum mobilised distally to the level of the levator muscles.

The TLH was then performed to the point of skeletonization and transection of the uterine arteries bilaterally.

Ureterolysis was completed bilaterally to the level of the bladder given the planned upper vaginectomy. An anterior colpotomy was made to the level of the uterosacral ligaments.

The vagina was mobilised laterally, and the inferior aspect of the vaginal endometriosis was identified by direct visualisation. The cervix was everted intra-abdominally. The extent of the vaginal endometriosis was easily appreciated to involve the upper one third of the posterior vagina.

The lateral vagina was then incised longitudinally until soft, normal tissue was identified. Surrounding structures were identified. A digit in the rectum allowed for further assessment of the inferior aspect of the involved vagina. The inferior margin of the vaginal epithelium was incised bilaterally creating a V-shaped incision.

A plane between the interior aspect of the rectal mass and posterior vagina was delineated. The rectovaginal septum was obliterated proximally, but with distal dissection normal rectovaginal septum was identified and dissected to the level of the pelvic floor.

The distal margin of uninvolved rectum was identified, and a stapler applied to release the en bloc specimen. The proximally mobilised rectosigmoid, including the en bloc specimen, was pulled through the vagina.

 The proximal portion of the rectosigmoid was palpated, and above the area of disease the proximal line was stapled, and an anvil applied. The proximal rectosigmoid was returned to the abdomen and the pneumoperitoneum recreated.

The circular stapler was applied through the rectum and the anastomosis completed under laparoscopic visualisation. The rigid sigmoidoscope confirmed airtight closure of the anastomosis line. The vaginal vault was closed laparoscopically, and a loop ileostomy created.

Pathology confirmed endometriosis with bowel wall involvement spanning 7.5 cm with normal bowel mucosa. The postoperative course was uncomplicated other than mild urinary retention that resolved within four weeks. Combined hormone replacement therapy was initiated with excellent effect.

At routine postoperative follow up, she was pain free. On exam, vaginal length was 7 cm and stoma was functioning properly. A water-soluble contrast enema was completed seven weeks postoperatively showing no leak. Reversal of the loop ileostomy has been planned for the near future.

In conclusion, we describe an innovative surgical approach to rectosigmoid resection at the time of laparoscopic hysterectomy for DIE. Previously described techniques have touched on elements of this case. However, the combined laparoscopic en bloc resection with vaginal specimen extraction and transvaginal proximal rectosigmoid staple line with anvil placement is unique. We demonstrated this is a viable and reasonable technique for DIE involving the rectum and vagina where bowel resection is unavoidable.