Laparoscopic Technique for Discoid Resection of Rectal Endometriotic Nodules

To show the surgical steps used to perform a rectal disc excision in the context of deep infiltrating endometriosis characterized by contiguity between an intestinal lesion and the retrocervical region.

Step-by-step video demonstration of the technique.

Although surgical options for the management of rectosigmoid endometriosis have been investigated increasingly, there is no consensus regarding patient eligibility for shaving, discoid resection, or segmental resection. In our practice, women with nodules ≤3 cm in size and >7 mm deep were considered as candidates for rectosigmoid disc excision [1]. Therefore patients' selection, together with the adoption of a standardized surgical technique, has allowed us to maximize the chance of a successful discoid resection, minimizing the complications potentially derivable from this surgical procedure.

The patient was a 30-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. A preoperative ultrasonography showed complete obliteration of the pouch of Douglas owing to a rectal endometriotic nodule (21 × 7 × 12 mm) in contiguity with a deeply infiltrating retrocervical lesion (28 × 10 × 27 mm). As a result, the rectal nodule infiltrated the tunica muscularis with a distance from the anal verge of 9 cm and an estimated stenosis of 35%. A 3-dimensional laparoscopy was performed. After rectal mobilization and rectovaginal space opening, the intestinal nodule was isolated in its entire circumference (Fig. 1). A 33-mm transanal circular stapler was inserted into the rectum through the anus and used to perform disc excision and suture the rectal wall. The overall operative time was 55 minutes. No intraoperative complication occurred. A complete excision of endometriosis was achieved. The estimated blood loss was 10 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of the surgery. The patient was discharged 3 days after surgery and did not experience postoperative complications. The diameters of the bowel endometriotic nodule, on measuring fresh specimen, were 20 × 7 × 13 mm.

Advanced laparoscopic surgical skills are needed to perform an effective and safe rectal discoid resection. Subspecialization and an adequate preoperative evaluation are of utmost importance to appropriately plan the treatment strategy against bowel endometriosis.