A new laparoscopic-transvaginal technique for rectosigmoid resection in patients with endometriosis

A new laparoscopic-transvaginal technique for rectosigmoid resection in patients with endometriosis
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  A new laparoscopic-transvaginal technique forrectosigmoid resection in patients with endometriosis Fabio Ghezzi, M.D., a  Ant onella Cromi, M.D., Ph.D., a Giuseppe Ciravolo, M.D., b Fabio Rampinelli, M.D., b  Marco Braga, M.D., c and Luigi Boni, M.D. d a Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese;  b Department of Obstetrics andGynecology, University of Brescia, Brescia;  c Department of Surgery, Spedali Civili of Brescia, Brescia; and  d Department of Surgical Sciences, University of Insubria, Varese, Italy Objective:  Topresentourexperiencewithanewtechniqueforlaparoscopicrectosigmoidresectioninpatientswithendometriosis. Design:  Prospective collaborative cohort study. Setting:  Gynecologic departments of two university hospitals. Patient(s):  Thirty-three women with rectosigmoid endometriotic lesions requiring segmental bowel resection. Intervention(s):  Laparoscopic intracorporeal division of the distal bowel and exteriorization of the affectedsegment via a colpotomy incision to complete the resection. Main Outcome Measure(s):  Intraoperative and postoperative complications, and relief from symptoms. Result(s):  The only intraoperative complication was bleeding from the inferior mesenteric artery that requiredconversion to laparotomy to obtain hemostasis. No patient required a temporary colostomy. No anastomotic com-plications were identified. Postoperative complications included a symptomatic pelvic seroma that required oper-ative drainage in 1 patient and urinary retention that required intermittent self-catheterization in 3 women. Themedian follow-up duration was 13 months (range, 3–27 mo). Twenty-seven women were symptom free at thetime of last follow-up evaluation. No patient had recurrent cyclic rectal bleeding, rectal pain on defecation, ortenesmus. Postoperatively, 4 of 13 patients who tried to conceive were successful. Conclusion(s):  Segmental colorectal resection with a combined laparoscopic-transvaginal approach, avoiding theextension of port-site incisions, represents a viable option for the treatment of bowel endometriosis. (Fertil Steril  2008;90:1964–8.  2008 by American Society for Reproductive Medicine.) Key Words:  Bowel endometriosis, rectosigmoid resection, laparoscopic segmental bowel resection Overthe past 2 decades, the surgical management of colorec-tal endometriosis has evolved from a debulking approach,with minimal excisional surgery, to a more aggressive ap-proach that involves segmental bowel resections when le-sions are not amenable to disc excision because of theirsizeordepthofinvasion.Thischangeinoperativephilosophyparalleled the evolutionfrom a specialistapproach to a multi-disciplinary one that combines the skills of the gynecologicand colorectal teams, with the aim of achieving completeexcision of endometriosis in one operation. Surgeons arebenefiting both from the advancements made in instrumenta-tion and from accumulating experience with minimal-accesssurgery for primary colorectal diseases and are increasinglymanaging intestinal endometriosis laparoscopically, evenwhen bowel resection is indicated.In the relatively few series of laparoscopic bowel resectionfor endometriosis, the retrieval of the surgical specimen usu-ally is accomplished by enlarging the suprapubic or rightlower quadrant port site incision to 3–7 cm (1–7). Becausethe rationale of minimal-access techniques is that smaller in-strumentscauselessabdominalwalltraumaandconsequentlyreduce the stress response to surgery and postoperative inci-sional pain, in many surgical fields, operative techniqueshavebeenrefinedinanattempttofurtherminimizetheoverallwound size.A combined laparoscopic-transvaginal approach thatavoided alaparotomyincision, whileallowingan extracorpo-real resection and hand-sutured anastomosis, was describedin 1996 by Redwine et al. (8) but did not gain much popular-ity. This was because of the reluctance of colorectal surgeonsto operate out of their comfort zone and because of concernsabout the risk of rectovaginal fistula development.Over the last 3 years, we have developed a new techniquefor laparoscopic rectosigmoid resection in patients with deepinfiltrating endometriosis. It involves intracorporeal divisionofthedistalbowelandexteriorizationoftheaffectedsegmentviaacolpotomyincisiontocompletetheresection.Wehereinpresent our initial experience with this procedure. MATERIALS AND METHODS From October 2005 to June 2007, consecutive patients in tworeferringacademicinstitutionswhorequiredsegmentalbowel Received July 31, 2007; revised and accepted September 4, 2007.Reprint requests: Fabio Ghezzi, M.D., Department of Obstetrics and Gy-necology, University of Insubria, Del Ponte Hospital, Piazza Biroldi 1,21100 Varese, Italy (FAX: 39-0332-299-307; E-mail: ). Fertility and Sterility  Vol. 90, No. 5, November 2008 0015-0282/08/$34.00Copyright ª 2008 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2007.09.002 1964  resection for colorectal endometriosis underwent the proce-dure with a combined laparoscopic-transvaginal approach.Written informed consent was obtained from the patientsafter thorough counseling. Institutional review board ap-proval was obtained before the beginning of the study. Ontheday before surgery,patients weregivenbowelpreparationthat consisted of a laxative with osmotic action. Prophylacticantibiotic therapy with amoxicillin–clavulanic acid (2 g) andmetronidazole (0.5 g) was administered 1 hour before theprocedure.Only patients undergoing a fertility-sparing procedure, de-fined as the preservation of the uterus and of at least one tubeor ovary, were included. All procedures were performed byacombinedteamofagynecologist(F.G.,G.C.)andacolorec-tal surgeon (L.B., M.B.) in each institution. Segmental bowelresection was reserved for cases in which there were endo-metriotic lesions that were of  > 3 cm in size or that involvedmore than one third of the bowel circumference or in whichtherewere multiple sites of bowel involvementin the disease.All procedures were performed under general anesthesia.Trocar configuration included a 10-mm, 0  umbilical laparo-scope; two 5-mm ancillary trocars (one suprapubic and onelateral to the left epigastric artery); and a 10-mm workingport in the right lower abdominal quadrant.The patient was placed in a steep Trendelenburg positionwith the right side tilted down. The sigmoid and left colonwere fully mobilized from their lateral peritoneal attach-ments by using a combination of electrocautery and sharpdissection. The left ureter was identified and swept laterallyawayfromthebase ofthemesentery,andthevascular pediclewas divided intracorporeally with ultrasonic shears. Once thedesiredlengthofsigmoidcolonhadbeenmobilizedforresec-tion, the sigmoid or rectum was transected distal to the lesionwith a linear laparoscopic stapler.If the vaginal vault had not been entered previously toremove endometriosis involving the vaginal wall, a posterior1- to 2-cm transverse colpotomy was performed, usinga vaginal extractor for laparoscopic surgery (Karl Storz,Tuttlingen, Germany). This device, consisting of a canulafittedwithaball-shapedheadatoneend,providesalandmark for dissection by ensuring excellent delineation of the poste-rior vaginal fornix and ensures that pneumoperitoneum ismaintained during and after colpotomy. In one institution(University of Insubria), a 15-cm retrieval bag, which hadbeenmodifiedexvivobycuttingthebottomtocreateaplastictunnel with double opening, was used to prevent any directcontact between the rectosigmoid and the vagina. The devicewas rolled up and introduced into the abdominal cavitythrough a 10-mm port. One opening of the tunnel was pulledthroughthecolpotomyincision totheintroitus,withtheotheropening being in the peritoneal cavity. The proximal bowelthen was exteriorized through the vagina, and the affectedsegment was resected (Fig. 1). The anvil of a circular staplerwas secured to the proximal end of the rectum or sigmoidwith a pursestring suture, and the bowel was replaced intothe peritoneal cavity. The colpotomy was closed transvagi-nally with a continuous 2–0 polyglactin suture. The trocar of a circular stapler was inserted transanally, advanced throughthe rectum, and united with the anvil under direct laparo-scopic vision to create the anastomosis. Upon completionof the anastomosis, the abdominal cavity was thoroughlyirrigated with sterile saline, and the anastomosis was testedunder water to confirm the absence of an air leak.Follow-up evaluations were scheduled at 1, 3, and 6months, as well as annually from the date of the procedure.During follow-up, patients were asked whether their symp-toms had improved, were the same, or were worse as a resultof surgery. Details also were requested about symptoms re-lated to functional bowel and urinary disturbance and abouteach patient’s postoperative fertility history. Data weretabulated prospectively in the surgical database of eachinstitution. RESULTS The study group consisted of 33 women undergoing laparo-scopic rectosigmoid resection by the combined laparoscopic-transvaginal approach for the treatment of endometriosisinvolvingtherectosigmoid.Thecharacteristicsofthepatientsand preoperative symptoms are listed in Table 1.Detailed data for the surgical procedures are described inTable 2. One patient had intraoperative bleeding from the in-ferior mesenteric artery that required conversion to laparot-omy to obtain hemostasis. There was neither unintendedinjury to bowel or urinary tract nor need for intraoperativetransfusion. No patient required a temporary diversion loopileostomy or colostomy. No anastomotic complicationswere identified in the study group. Histology showed endo-metriosis in the muscularis propria in 30 cases, whereas 3patients had pathologic evidence of endometrial tissue inthe mucosa.Postoperative complications included a symptomatic pel-vic seroma that required operative drainage in one patientand urinary retention that required intermittent self-catheter-izationinthreewomen.Bladderfunctionnormalizedwithin1month after surgery in two cases, whereas one patient expe-rienced voiding dysfunction for 5 months. Follow-up timeranged from 3 to 27 months, with a median of 13 months.Twenty-seven women were symptom free at the time of last follow-up evaluation. No patient had recurrent cyclicrectal bleeding, rectal pain on defecation, or tenesmus. Twopatients with isolated preoperative dysmenorrhea reportedunchanged symptoms after surgery. Fifteen women whohad dyspareunia before surgery reported complete symptomrelief at the time of follow-up, whereas 3 patients with non-menstrual pelvic pain and dyspareunia reported only a slightimprovement as a result of surgery. One patient complainedof de novo abdominal pain related to constipation occurringafter surgery. At the 1-month assessment, 16 (48.5%) womencomplained of functional bowel disturbance (mainly fre-quency and urgency), which was settled with dietary Fertility and Sterility  1965  manipulation in 13 of 14 women who completed the 6-monthfollow-up.Postoperatively, two women with a history of infertilitydecided to postpone achieving pregnancy because of changesof social and family circumstances. Of the 13 patients whotried to conceive, 4 were successful, and none of themrequired assisted reproductive technology. There have beenthree term pregnancies, and one of them is still ongoing atthe time of this writing. DISCUSSION The findings of this study demonstrate that a combined lapa-roscopic-transvaginal approach to performing segmental co-lorectal resection in patients with intestinal endometriosis isfeasible, with minimal morbidity, no anastomotic complica-tions, and no need for elective defunctioning stomas.Despite growing interest in the laparoscopic treatment of deep infiltrating endometriosis, there have been few pub-lished works describing the outcome of laparoscopic recto-sigmoid resection for bowel involvement by the disease. AMEDLINE search of the English language literature fromJanuary 1991 to June 2007, using as search terms ‘‘bowel FIGURE 1 Once the sigmoid or rectum is transected distal tothe endometriotic lesion, the proximal bowel isexteriorized through the vagina, and the affectedsegment is resected. A retrieval bag is modified tocreate a plastic tunnel to prevent any direct contactbetween the rectosigmoid and the vagina. Ghezzi. Rectosigmoid resection for endometriosis. Fertil Steril 2008. TABLE 1 Characteristics of the study population(N [ 33).Characteristics Data  Age (y) 33.4 (25–43)Body mass index (kg/m 2  ) 19.6 (16.3–22)Nulliparae 27 (81.6)Previous surgery for endometriosisOpen procedures 4 (12.1)Laparoscopic procedures 23 (69.7)No. of prior procedures 2.4    1.4Presenting symptomsDysmenorrhea 27 (81.8)Chronic pelvic pain 15 (45.5)Dyspareunia 18 (54.5)Cyclic rectal bleeding 9 (27.3)Rectal pain 7 (21.1)Tenesmus 8 (24.2)History of infertility 15 (45.5) Note:  Dataare reported asmedian (range), mean   SD,or n (%). Ghezzi. Rectosigmoid resection for endometriosis. Fertil Steril 2008. TABLE 2 Intraoperative and early postoperative details(N [ 33).Characteristic Data Duration of surgery (min) 290 (200–390)Estimated blood loss (mL) 300 (200–1,300)Type of bowel resectionSigmoid resection 3 (9.1)High rectalresection a 2 (6.1)Low rectalresection b 17 (51.5)Ultra-low rectalresection c 11 (33.3) Associated proceduresUnilateral salpingo-oophorectomy3 (9.1)Unilateral salpingectomy 1 (3.0)Excision of endometrioma 7 (21.2)Dissection of rectovaginalnodule13 (39.4)Excision of uterosacralligaments3 (9.1)Ureterolysis 20 (60.6)Bladder resection 1 (3.0)Time to resumption of bowelfunction (d)3.0    0.6Hospital stay (d) 6.7    1.8 Note:  Values are reported as median (range), mean   SD, or n (%). a More than 10 cm from the anal verge. b Between 6 and 10 cm from the anal verge. c Less than 6 cm from the anal verge. Ghezzi. Rectosigmoid resection for endometriosis. Fertil Steril 2008. 1966  Ghezzi et al.  Rectosigmoid resection for endometriosis  Vol. 90, No. 5, November 2008  endometriosis,’’ ‘‘sigmoid endometriosis,’’ ‘‘deeply infiltrat-ingendometriosis,’’‘‘segmentalbowelresection’’,and‘‘lapa-roscopy’’, alone or in combination, identified, after exclusionof single case reports, only 10 cohort studies that addresslaparoscopicsegmentalbowelresectionasatreatmentforco-lorectal endometriosis, involving nearly 300 patients (1–10).Of these, only 20 patients, from three series, underwent theprocedure by a transvaginal approach (8–10).Thetechnique firstproposedby Redwine etal.(8) andthenembracedbyJerbyetal.(9)wasaimedmainlyatavoidingthecomplications and long operativetimes of laparoscopic intra-corporeal segmental bowel resection and anastomosis in theearly days of minimal-access colorectal surgery, before theintroduction of laparoscopic intestinal staplers that allowedthe transection of the bowel to be accomplished easily andsafely intracorporeally. The technique entailed delivery of the affected loop of bowel to the introitus via the vagina, ex-cision of the segment involved by endometriotic implants,andextracorporealcompletionoftheanastomosiswithastan-dard hand-sewn procedure. More recently, Abrao et al. (10)reported a modified version of this technique, involving sta-pledanastomosesinsteadofthoseperformedbyhandsewing.This transvaginal approach, requiring the exteriorization of the entire bowel loop involved by endometriotic lesions tothevaginalintroitus,hasbeensuccessfullyusedtotreatendo-metriosis of the sigmoid near the pelvic brim and providedadequate peritoneal-releasing incisions alongside the bowel,but it appears unsuitable for low and ultra-low rectal resec-tions when the distal healthy segment of the rectum is notof sufficient length to allow exteriorization of the diseasedbowel through the vaginal vault. It is noteworthy that in thelargest published series of surgical management of rectalendometriosis, including 137 segmental resections, low andultra-low resections accounted for 90% of the procedures (7).The use of colpotomy for the exteriorization of the recto-sigmoid offers the advantage of reducing the overall abdom-inal wound size, potentially sustaining or enhancing theknown benefits of laparoscopy over open surgery in termsof cosmetic results, risk of incisional hernias and woundinfections, and postoperative incisional pain. Although cos-metic benefits should not solely determine the surgicaltechnique of choice, they are a critical factor that shouldnotbeoverlooked,especiallyinthisyoungfemalepopulationwith nonmalignant disease.Theresultsofcontrolledcomparativetrialshaveshownlesspostoperativepainandfasterrecoverywhenportincisionsareminimized by decreasing the number of ports or downsizingthe trocars used to perform laparoscopic procedures, present-ing a strong case for creating the smallest incision possible.Interestingly, Gill et al. (11) evaluated patient satisfactionafter vaginal extraction of specimens after laparoscopic ne-phrectomy, by using a visual analogue scale questionnairewithascaleof0to10.Inacohortofsevenpatients,themedianvaginal incision discomfort was 2, and the discomfort per-sistedforamedianof2days;allwomenreportedthatabdom-inal port site incisions were more painful than the vaginalextraction site, and none of the sexually active patients re-ported any difference in sexual satisfaction. Moreover, it hasbeen demonstrated that the incidence of wound infections of theabdominalincisionsusedforspecimenretrievalinlaparo-scopic colon surgery ranges from 0 to 9%, which is compara-ble to that of the surgery’s open counterpart (12, 13).Conversely, a review of 500 laparoscopic procedures for avariety of indications, with specimen removal accomplishedtransvaginally, found only one colpotomy-related complica-tion, with no postoperative infectious morbidity (14).Awidespread acceptance of the transvaginal approach forlaparoscopic colorectal resection for the treatment of bowelendometriosishasbeenhamperedbyconcerns overpelvic in-fectionsandtheriskofrectovaginalfistulasthatarecausedbythe juxtaposition of vaginal and rectal suture or staple lines.In the series reported by Darai et al. (6), 6 (8.4%) of 64women developed a rectovaginal fistula after laparoscopiccolorectal resection for endometriosis, and 4 of these had un-dergone concomitant colpotomy. However, Brouwer andWoods (7) did not observe any rectovaginal fistula in 41 pa-tients undergoing radical excision of rectal endometrioticimplants in whom some form of vaginal surgery was concur-rently performed. Despite lack of comparative studies be-tween abdominal and vaginal extraction of specimens, datafrom series in which specimen retrieval was accomplishedtransvaginally suggest a negligible risk of pelvic infection.We acknowledge that the small study population and thelack of a control group undergoing laparoscopic colorectalresection with the conventional technique, which wouldhave allowed comparison of pain perception, wound compli-cations, and patient satisfaction with regard to cosmetic re-sults, may be regarded as potential limitations of this study.However, our experience suggests that this technique involv-ing transvaginal exteriorization of the sigmoid, while mini-mizing morbidity and maintaining laparoscopic cosmesis,represents a viable addition to the laparoscopic armamentar-ium for patients with deep infiltrating endometriosis. REFERENCES 1. Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady KM,Falcone T. Laparoscopic resection of deep pelvic endometriosis withrectosigmoid involvement. J Am Coll Surg 2002;195:754–8.2. Campagnacci R, Perretta S, Guerrieri M, Paganini AM, De Sanctis A,Ciavattini A, et al. Laparoscopic colorectal resection for endometriosis.Surg Endosc 2005;19:662–4.3. Lyons SD, Chew SS, Thomson AJ, Lenart M, Camaris C, Vancaillie TG,et al. Clinical and quality-of-life outcomes after fertility-sparing laparo-scopic surgery with bowel resection for severe endometriosis. J MinimInvasive Gynecol 2006;13:436–41.4. Ribeiro PA, Rodrigues FC, Kehdi IP, Rossini L, Abdalla HS, Donadio N,et al. Laparoscopic resection of intestinal endometriosis: a 5-year expe-rience. J Minim Invasive Gynecol 2006;13:442–6.5. Seracchioli R, Poggioli G, Pierangeli F, Manuzzi L, Gualerzi B,Savelli L, et al. Surgical outcome and long-term follow up after laparo-scopic rectosigmoid resection in women with deep infiltrating endome-triosis. BJOG 2007;114:889–95.6. Darai E, Ackerman G, Bazot M, Rouzier R, Dubernard G. Laparoscopicsegmental colorectal resection for endometriosis: limits and complica-tions. Surg Endosc 2007;21:1572–7. Fertility and Sterility  1967  7. Brouwer R, Woods RJ. Rectal endometriosis: results of radicalexcision and review of published work. ANZ J Surg 2007;77:562–71.8. Redwine DB, Koning M, Sharpe DR. Laparoscopically assisted transva-ginal segmental resection of the rectosigmoid colon for endometriosis.Fertil Steril 1996;65:193–7.9. Jerby BL, Kessler H, Falcone T, Milsom JW. Laparoscopic managementof colorectal endometriosis. Surg Endosc 1999;13:1125–8.10. Abrao MS, Sagae UE, Gonzales M, Podgaec S, Dias JA. Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal recto-sigmoidectomy. Int J Gynaecol Obstet 2005;91:27–31.11. Gill IS, Cherullo EE, Meraney AM, Borsuk F, Murphy DP, Falcone T.Vaginal extraction of the intact specimen following laparoscopic radicalnephrectomy. J Urol 2002;167:238–41.12. Faynsod M, Stamos MJ, Arnell T, Borden C, Udani S, Vargas H. A case-control study of laparoscopic versus open sigmoid colectomy for diver-ticulitis. Am Surg 2000;66:841–3.13. Hackert T, Uhl W, Buchler MW. Specimen retrieval in laparoscopiccolon surgery. Dig Surg 2002;19:502–6.14. Ghezzi F, Raio L, Mueller MD, Gyr T, Buttarelli M, Franchi M. Vaginalextraction of pelvic masses following operative laparoscopy. SurgEndosc 2002;1:1691–6. 1968  Ghezzi et al.  Rectosigmoid resection for endometriosis  Vol. 90, No. 5, November 2008
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