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Published on: February 12, 2022
Combined Robotic Transanal Transection Single-Stapled Technique in Ultralow Rectal Endometriosis Involvement
Gianmarco D'Ancona1, Benjamin Merlot2, Quentin Denost3
1Franco-European Multidisciplinary Endometriosis Institut (IFEMEndo) (Drs. D'Ancona, Merlot, Dennis, and Roman), Clinique Tivoli-Ducos, Bordeaux, France; Division of Obstetrics and Gynecology, Department of surgical sciences, University of Cagliari, Cagliari, Italy (Drs. D'Ancona and Angioni).
Objective:
To describe a combined robotic and transanal technique used to treat ultralow rectal endometriosis in a 36-year-old patient with multiple pelvic compartments, which was responsible for infertility, dyspareunia, left sciatic pain, and severe dyschezia.
Design:
Surgical video article.
Setting:
The achievement of a perfect bowel anastomosis in patients with low rectal endometriosis could be challenging owing to technical and anatomic limitations [1]. By allowing a right angle rectotomy with a single-stapled anastomosis, the transanal transection single-stapled technique overcomes these technical difficulties ensuring a good-quality anastomosis with an easier correction of postoperative anastomotic leakage when it occurs [2,3].
Interventions:
The surgery starts by splitting the nodule in 3 components according to different anatomic structures involved (parametrium, vagina, and rectum). Parametrial and vaginal fragments are excised as previously described (Supplemental Videos 1) [4]. The rectal involvement is approached following several steps: isolation and cut of inferior mesenteric vessels (inferior mesenteric artery and inferior mesenteric vein) and left colic artery to obtain a proper colon mobilization; transanal rectotomy immediately below the lower limit of the nodule; extraction of the specimen through the anus (Supplemental Videos 2); proximal bowel segment transection 1 cm above the upper limit of the nodule; introduction of circular stapler anvil into the sigmoid colon; placement of 2 purse string to secure the anvil and at distal rectal cuff, respectively; connection of the anvil to the shoulder of circular stapler; stapler closing and firing with coloanal anastomosis formation; stapled line reinforcement by stitching; and integrity anastomosis test (Supplemental Videos 3). No preventive diverting stoma was performed in accordance with our policy [5].
Conclusions:
Although no data are yet available in patients with endometriosis, the use of transanal transection single-stapled technique may be an interesting approach in patients with very low rectal endometriosis involvement.
