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Laparoscopic Management of Intestinal Endometriosis
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
Laparoscopic Management of Intestinal Endometriosis Nesrin Varol, M.D., Peter Maher, M.D., and Rod Woods, M.D.
Abstract Intestinal involvement by endometriosis traditionally required open laparotomy for bowel resection and anastomosis. Operative laparoscopy may offer the most effective form of treatment for these women. Two women with endometriosis of the rectum and right hemicolon, respectively, underwent transvaginal resection of the rectum and laparotomy for hemicolectomy, assisted by laparoscopy. The only morbidity was postoperative ileus in the former patient. Both women were asymptomatic at the 6-week postoperative visit. (J Am Assoc Gynecol Laparosc 7(3):405–409, 2000)
for bowel resection was severe constipation after mesh rectopexy. This complication is often attributed to kinking or narrowing of the rectum due to the mesh, which in this patient could have been exacerbated by perirectal fibrosis and endometriotic nodule. The woman had also undergone total abdominal hysterectomy. Preoperative examination revealed tenderness and nodularity in the cul-de-sac. Operative laparoscopy was performed after bowel preparation. A 5-cm nodule of endometriosis was present at the level of the rectal mesh, involving the anterior rectal wall and posterior vagina. Moreover most of the sigmoid colon appeared redundant. Once bilateral ureterolysis and lysis of adhesions were accomplished, the obliterated cul-de-sac was mobilized by en bloc resection of invasive endometriosis of the pelvic floor (Figure 1). Bilateral peritoneal incisions were made in the paracolic gutters with monopolar electrosurgery. The plane of dissection was continued until the rectovaginal septum was reached to expose normal rectal wall distal to the rectal nodule and mesh. An assistant delineated the rectovaginal septum with simultaneous vaginal and rectal probes. The rectum was freed from the posterior vaginal wall and a
Endometriosis can be severely debilitating. It affects between 4% and 17% of women of reproductive age. Severe endometriosis requires aggressive management, which involves radical surgery.1 The bowel is involved in 50% of patients with severe disease; overall 5% to 10% of women have disease affecting the large bowel: rectum or sigmoid in 76%, appendix in 8%, and cecum in 5%. Endometriotic nodularity of the bowel and rectovaginal septum is the most difficult aspect of this disease to approach surgically. Low morbidity and good long-term symptomatic relief can be expected after full-thickness bowel resection and immediate reanastomosis by a surgical team familiar with severe endometriosis.2 We performed laparoscopic-assisted extracorporeal right hemicolectomy and transvaginal low anterior resection of the rectum in two patients with bowel endometriosis. Case Reports Patient No. 1 A 41-year-old para 2 woman had a history of dyschezia, constipation, and intractable pelvic pain that intensified with menses. The primary indication
From the Departments of Endosurgery (Drs. Varol and Maher) and Colorectal Surgery (Dr. Woods), Mercy Hospital for Women, Cliveden Hill Hospital, Melbourne, Australia. Address reprint requests to Dr. Nesrin Varol, Royal Prince Alfred Hospital Medical Centre, Suite 404, Level 4, 100 Carillon Avenue, Newtown, N.S.W. 2042, Australia; fax 61 2 9550 6257. Accepted for publication February 22, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
405
Laparoscopic Management of Intestinal Endometriosis Varol et al
FIGURE 1. En bloc resection of endometriosis of the pelvic floor and transvaginal excision. (A) Diseased cul-de-sac. (B) Mobilization of diseased tissue. (C) Exteriorization of involved bowel.
segment of the vagina (1 × 3 cm) involved by endometriois was excised. Because the vaginal incision resulted in loss of pneumoperitoneum, a Maher abdominal wall elevator (Cook Ob/Gyn, Spencer, IN) was introduced to allow the operation to continue. The inferior mesenteric artery was divided and the rectum and lower sigmoid colon completely mobilized by dissecting the rectosigmoid mesentery laterally and posteriorly with 5-mm scissors with electrocoagulation and hydrodissection. The distal rectum was transsected with a 30-mm stapler and the proximal bowel pulled through the vaginal opening. A pursestring suture was applied and the bowel reanastomosed with standard double-stapling technique.3 The vagina was closed after the repaired bowel was returned to the pelvis. Anastomotic integrity was confirmed by instilling betadine through the rectum. Although endometriosis did not involve the full thickness of the rectum, the rectovaginal nodule and previous rectopexy had resulted in severe fibrosis and narrowing of the excised portion of the rectosigmoid colon. The patient’s postoperative course was complicated by ileus, which resulted in a prolonged hospital stay of 9 days. At the 6-week postoperative visit she was very well. She had normal bowel function and no further pain. Histopathology revealed endometriosis
of the rectovaginal and pararectal nodule, vagina, and uterosacral ligaments. The rectum showed diverticulitis, and the pararectal tissue a focus of endometriosis with endometrial glands lined by low columnar or cuboidal epithelium surrounded by endometrial stroma (Figure 2). Patient No. 2 A 34-year-old gravida 2, para 0 woman had a history of dysmenorrhea, pelvic pain, and infertility. She had had a previous laparoscopy with excision of a nodule of endometriosis from the right inguinal ligament and rectovaginal septum. As endometriosis involving the cecum, appendix, and distal ileum was diagnosed at that procedure, laparoscopic-assisted right hemicolectomy was planned. Macroscopically, endometriosis involved 85 mm of terminal ileum. At the base of the appendix as well as in the surrounding cecum an area of dense fibrosis measured 25 mm in diameter (Figure 3). The cecum, terminal ileum, and ascending colon were easily mobilized laparoscopically, and together with the appendix were delivered through a 3-cm right iliac fossa transverse incision (Figure 4). After clamping and ligation of the mesentery, ileocolic resection was performed and an anastomosis was constructed
406
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 4. Excision of appendix, cecum, and ileum through McBurney’s point after laparoscopic mobilization.
with a Proximate stapler, resulting in a functional end-to-end anastomosis of proximal ileum to ascending colon (Figure 5). The patient had an unremarkable recovery and tolerated a full diet on the first postoperative day. She was discharged on day 4 and was asymptomatic at the 6-week postoperative visit. Histopathology confirmed endometriosis of the appendix, cecum, and ileum with obstructive mucocele of the appendix (Figure 6).
FIGURE 2. Histopathology of pararectal tissue shows a focus of endometriosis with endometrial glands lined by low columnar or cuboidal epithelium surrounded by endometrial stroma. Hemorrhagic areas in the rectal mucosa represent ostia of inflamed diverticula.
Discussion Aggressive surgical management with colorectal resection for women with advanced endometriosis has a high rate of symptom relief, ranging from 100% for rectal bleeding to 91% for rectal pain.4 Rectal endometriosis is often treated inadequately by gynecologists, who are uncomfortable operating on the colon, and by general surgeons, who are unfamiliar with endometriosis.2 In spite of the prevalence of the disease, few surgeons encounter it frequently enough to develop expertise in its management. These two patients indicate management of intestinal endometriosis by laparoscopy. The transvaginal approach to bowel resection in patient 1 allowed palpation of the rectum, dissection with the finger, and excision of the rectum as well as an anterior rectal wall
FIGURE 3. Endometriosis of the appendix and cecum.
407
Laparoscopic Management of Intestinal Endometriosis Varol et al
FIGURE 5. Anastomosis of proximal ileum to ascending colon after ileocolic resection.
FIGURE 6. Histopathology of the appendix shows endometriosis and a mucocele.
TABLE 1. Bowel Resection and Anastomosis for Endometriosis Reference 2
No. of patients Surgical approach Type of colon resection (88%)
6
8
9
Group 1
Group 2
Group 3
3
5
10
Laparoscopy
Laparotomy
77
5
1
Laparotomy
Laparoscopy
Laparoscopy
Laparoscopy Laparoscopy
Segment of colon
Anterior rectal wall
Transanal segment of colon
Transanal 15, trans vaginal 1, segment of colon 190
Mean operating time (min) Mean hospital stay (days; laparoscopy pts) Conversion to laparotomy Return to operating room Anastomotic leak
120–240
160
7.4
4
2
NA
2
2
0
16
7
Intracorporeal Transvaginal segment of segment of colon colon
Segment of colon
345
248
211
3.4
4.3
4.4
5.6
0
1
0
0
NA
0
0
1
0
0
0
0
0
0
0
0
0
NA = not applicable.
408
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
endometriosis is a great advance in intracorporeal technique.
endometriotic nodule. Although bowel endometriosis usually involves the rectum and/or sigmoid colon, it can occur elsewhere in the bowel, such as ileum, cecum, and appendix, as shown by patient 2. Gasless laparoscopy maintained the surgeon’s vision of the pelvis once pneumoperitoneum was released by vaginal and abdominal incisions. In 1990 bowel resection at laparotomy without colostomy or serious surgical morbidity was performed by a team of gynecologists and colorectal surgeon.2 This was followed by laparoscopic intracorporeal segmental resection and anastomosis of the lower colon for endometriosis.5 This technique, however, has been abandoned by those who developed it due to surgical complications and long operating times.6 Extracorporeal bowel resection introduced a new dimension to laparoscopic treatment of bowel disease. As rectal lesions cannot be mobilized to the anterior abdominal wall, traditionally a separate abdominal incision was required for resection and anastomosis after laparoscopic mobilization. Transanal and transvaginal resections of the rectosigmoid colon are efficient and reproducible (Table 1).2,6–9 Moreover, they reduce the chance of intraperitoneal contamination and avoid the problems6 and fatigue associated with long surgery using the intracorporeal method.7–9 Disease involving the ileum or cecum is not amenable to a transvaginal approach and is better managed by laparotomy or laparoscopic-assisted laparotomy. If the cecum or appendix is involved without ileal disease, it may be possible to excise this with intracorporeal transection. Surgery for endometriosis of the cul-de-sac and bowel involves some of the most difficult dissections encountered, but it can be accomplished successfully with the low postoperative morbidity typical of laparoscopy. It requires comprehensive knowledge of pelvic anatomy and disease pathology. Laparoscopic extracorporeal bowel resection with anastomosis for
References 1. Magos A: Endometriosis: Radical surgery. Baillieres Clin Obstet Gynaecol 7:849–864, 1993 2. Coronado C, Franklin R, Lotze E, et al: Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 53:411–416, 1990 2. Feinberg SM, Parker F, Cohen Z, et al: The double stapling technique for low anterior resection of rectal carcinoma. Dis Colon Rectum 29:885–890, 1986 3. Bailey HR, Ott MT, Hartendorp P: Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 37:747–753, 1994 5. Redwine DB, Sharpe DR: Laparoscopic segmental resection of the sigmoid colon. J Laparoendosc Surg 1:217– 220, 1991 6. Sharpe DR, Redwine DB: Laparoscopic segmental resection of the sigmoid and rectosigmoid colon for endometriosis. Surg Laparosc Endosc 2:120—124, 1992 7. Redwine D, Koning M, Sharpe D: Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. Fertil Steril 65: 193–197, 1996 8. Nezhat C, Pennington E, Nezhat F, et al: Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis. Surg Laparosc Endosc 1:106–108, 1991 9. Nezhat F, Nezhat C, Pennington E, et al: Laparoscopic segmental resection for infiltrating endometriosis of the rectosigmoid: A preliminary report. Surg Laparosc Endosc 2:212–216, 1992
409
The Journal of the American Association of Gynecologic Laparoscopists
Laparoscopic Management of Intestinal Endometriosis Nesrin Varol, M.D., Peter Maher, M.D., and Rod Woods, M.D.
Abstract Intestinal involvement by endometriosis traditionally required open laparotomy for bowel resection and anastomosis. Operative laparoscopy may offer the most effective form of treatment for these women. Two women with endometriosis of the rectum and right hemicolon, respectively, underwent transvaginal resection of the rectum and laparotomy for hemicolectomy, assisted by laparoscopy. The only morbidity was postoperative ileus in the former patient. Both women were asymptomatic at the 6-week postoperative visit. (J Am Assoc Gynecol Laparosc 7(3):405–409, 2000)
for bowel resection was severe constipation after mesh rectopexy. This complication is often attributed to kinking or narrowing of the rectum due to the mesh, which in this patient could have been exacerbated by perirectal fibrosis and endometriotic nodule. The woman had also undergone total abdominal hysterectomy. Preoperative examination revealed tenderness and nodularity in the cul-de-sac. Operative laparoscopy was performed after bowel preparation. A 5-cm nodule of endometriosis was present at the level of the rectal mesh, involving the anterior rectal wall and posterior vagina. Moreover most of the sigmoid colon appeared redundant. Once bilateral ureterolysis and lysis of adhesions were accomplished, the obliterated cul-de-sac was mobilized by en bloc resection of invasive endometriosis of the pelvic floor (Figure 1). Bilateral peritoneal incisions were made in the paracolic gutters with monopolar electrosurgery. The plane of dissection was continued until the rectovaginal septum was reached to expose normal rectal wall distal to the rectal nodule and mesh. An assistant delineated the rectovaginal septum with simultaneous vaginal and rectal probes. The rectum was freed from the posterior vaginal wall and a
Endometriosis can be severely debilitating. It affects between 4% and 17% of women of reproductive age. Severe endometriosis requires aggressive management, which involves radical surgery.1 The bowel is involved in 50% of patients with severe disease; overall 5% to 10% of women have disease affecting the large bowel: rectum or sigmoid in 76%, appendix in 8%, and cecum in 5%. Endometriotic nodularity of the bowel and rectovaginal septum is the most difficult aspect of this disease to approach surgically. Low morbidity and good long-term symptomatic relief can be expected after full-thickness bowel resection and immediate reanastomosis by a surgical team familiar with severe endometriosis.2 We performed laparoscopic-assisted extracorporeal right hemicolectomy and transvaginal low anterior resection of the rectum in two patients with bowel endometriosis. Case Reports Patient No. 1 A 41-year-old para 2 woman had a history of dyschezia, constipation, and intractable pelvic pain that intensified with menses. The primary indication
From the Departments of Endosurgery (Drs. Varol and Maher) and Colorectal Surgery (Dr. Woods), Mercy Hospital for Women, Cliveden Hill Hospital, Melbourne, Australia. Address reprint requests to Dr. Nesrin Varol, Royal Prince Alfred Hospital Medical Centre, Suite 404, Level 4, 100 Carillon Avenue, Newtown, N.S.W. 2042, Australia; fax 61 2 9550 6257. Accepted for publication February 22, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
405
Laparoscopic Management of Intestinal Endometriosis Varol et al
FIGURE 1. En bloc resection of endometriosis of the pelvic floor and transvaginal excision. (A) Diseased cul-de-sac. (B) Mobilization of diseased tissue. (C) Exteriorization of involved bowel.
segment of the vagina (1 × 3 cm) involved by endometriois was excised. Because the vaginal incision resulted in loss of pneumoperitoneum, a Maher abdominal wall elevator (Cook Ob/Gyn, Spencer, IN) was introduced to allow the operation to continue. The inferior mesenteric artery was divided and the rectum and lower sigmoid colon completely mobilized by dissecting the rectosigmoid mesentery laterally and posteriorly with 5-mm scissors with electrocoagulation and hydrodissection. The distal rectum was transsected with a 30-mm stapler and the proximal bowel pulled through the vaginal opening. A pursestring suture was applied and the bowel reanastomosed with standard double-stapling technique.3 The vagina was closed after the repaired bowel was returned to the pelvis. Anastomotic integrity was confirmed by instilling betadine through the rectum. Although endometriosis did not involve the full thickness of the rectum, the rectovaginal nodule and previous rectopexy had resulted in severe fibrosis and narrowing of the excised portion of the rectosigmoid colon. The patient’s postoperative course was complicated by ileus, which resulted in a prolonged hospital stay of 9 days. At the 6-week postoperative visit she was very well. She had normal bowel function and no further pain. Histopathology revealed endometriosis
of the rectovaginal and pararectal nodule, vagina, and uterosacral ligaments. The rectum showed diverticulitis, and the pararectal tissue a focus of endometriosis with endometrial glands lined by low columnar or cuboidal epithelium surrounded by endometrial stroma (Figure 2). Patient No. 2 A 34-year-old gravida 2, para 0 woman had a history of dysmenorrhea, pelvic pain, and infertility. She had had a previous laparoscopy with excision of a nodule of endometriosis from the right inguinal ligament and rectovaginal septum. As endometriosis involving the cecum, appendix, and distal ileum was diagnosed at that procedure, laparoscopic-assisted right hemicolectomy was planned. Macroscopically, endometriosis involved 85 mm of terminal ileum. At the base of the appendix as well as in the surrounding cecum an area of dense fibrosis measured 25 mm in diameter (Figure 3). The cecum, terminal ileum, and ascending colon were easily mobilized laparoscopically, and together with the appendix were delivered through a 3-cm right iliac fossa transverse incision (Figure 4). After clamping and ligation of the mesentery, ileocolic resection was performed and an anastomosis was constructed
406
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 4. Excision of appendix, cecum, and ileum through McBurney’s point after laparoscopic mobilization.
with a Proximate stapler, resulting in a functional end-to-end anastomosis of proximal ileum to ascending colon (Figure 5). The patient had an unremarkable recovery and tolerated a full diet on the first postoperative day. She was discharged on day 4 and was asymptomatic at the 6-week postoperative visit. Histopathology confirmed endometriosis of the appendix, cecum, and ileum with obstructive mucocele of the appendix (Figure 6).
FIGURE 2. Histopathology of pararectal tissue shows a focus of endometriosis with endometrial glands lined by low columnar or cuboidal epithelium surrounded by endometrial stroma. Hemorrhagic areas in the rectal mucosa represent ostia of inflamed diverticula.
Discussion Aggressive surgical management with colorectal resection for women with advanced endometriosis has a high rate of symptom relief, ranging from 100% for rectal bleeding to 91% for rectal pain.4 Rectal endometriosis is often treated inadequately by gynecologists, who are uncomfortable operating on the colon, and by general surgeons, who are unfamiliar with endometriosis.2 In spite of the prevalence of the disease, few surgeons encounter it frequently enough to develop expertise in its management. These two patients indicate management of intestinal endometriosis by laparoscopy. The transvaginal approach to bowel resection in patient 1 allowed palpation of the rectum, dissection with the finger, and excision of the rectum as well as an anterior rectal wall
FIGURE 3. Endometriosis of the appendix and cecum.
407
Laparoscopic Management of Intestinal Endometriosis Varol et al
FIGURE 5. Anastomosis of proximal ileum to ascending colon after ileocolic resection.
FIGURE 6. Histopathology of the appendix shows endometriosis and a mucocele.
TABLE 1. Bowel Resection and Anastomosis for Endometriosis Reference 2
No. of patients Surgical approach Type of colon resection (88%)
6
8
9
Group 1
Group 2
Group 3
3
5
10
Laparoscopy
Laparotomy
77
5
1
Laparotomy
Laparoscopy
Laparoscopy
Laparoscopy Laparoscopy
Segment of colon
Anterior rectal wall
Transanal segment of colon
Transanal 15, trans vaginal 1, segment of colon 190
Mean operating time (min) Mean hospital stay (days; laparoscopy pts) Conversion to laparotomy Return to operating room Anastomotic leak
120–240
160
7.4
4
2
NA
2
2
0
16
7
Intracorporeal Transvaginal segment of segment of colon colon
Segment of colon
345
248
211
3.4
4.3
4.4
5.6
0
1
0
0
NA
0
0
1
0
0
0
0
0
0
0
0
0
NA = not applicable.
408
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
endometriosis is a great advance in intracorporeal technique.
endometriotic nodule. Although bowel endometriosis usually involves the rectum and/or sigmoid colon, it can occur elsewhere in the bowel, such as ileum, cecum, and appendix, as shown by patient 2. Gasless laparoscopy maintained the surgeon’s vision of the pelvis once pneumoperitoneum was released by vaginal and abdominal incisions. In 1990 bowel resection at laparotomy without colostomy or serious surgical morbidity was performed by a team of gynecologists and colorectal surgeon.2 This was followed by laparoscopic intracorporeal segmental resection and anastomosis of the lower colon for endometriosis.5 This technique, however, has been abandoned by those who developed it due to surgical complications and long operating times.6 Extracorporeal bowel resection introduced a new dimension to laparoscopic treatment of bowel disease. As rectal lesions cannot be mobilized to the anterior abdominal wall, traditionally a separate abdominal incision was required for resection and anastomosis after laparoscopic mobilization. Transanal and transvaginal resections of the rectosigmoid colon are efficient and reproducible (Table 1).2,6–9 Moreover, they reduce the chance of intraperitoneal contamination and avoid the problems6 and fatigue associated with long surgery using the intracorporeal method.7–9 Disease involving the ileum or cecum is not amenable to a transvaginal approach and is better managed by laparotomy or laparoscopic-assisted laparotomy. If the cecum or appendix is involved without ileal disease, it may be possible to excise this with intracorporeal transection. Surgery for endometriosis of the cul-de-sac and bowel involves some of the most difficult dissections encountered, but it can be accomplished successfully with the low postoperative morbidity typical of laparoscopy. It requires comprehensive knowledge of pelvic anatomy and disease pathology. Laparoscopic extracorporeal bowel resection with anastomosis for
References 1. Magos A: Endometriosis: Radical surgery. Baillieres Clin Obstet Gynaecol 7:849–864, 1993 2. Coronado C, Franklin R, Lotze E, et al: Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 53:411–416, 1990 2. Feinberg SM, Parker F, Cohen Z, et al: The double stapling technique for low anterior resection of rectal carcinoma. Dis Colon Rectum 29:885–890, 1986 3. Bailey HR, Ott MT, Hartendorp P: Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 37:747–753, 1994 5. Redwine DB, Sharpe DR: Laparoscopic segmental resection of the sigmoid colon. J Laparoendosc Surg 1:217– 220, 1991 6. Sharpe DR, Redwine DB: Laparoscopic segmental resection of the sigmoid and rectosigmoid colon for endometriosis. Surg Laparosc Endosc 2:120—124, 1992 7. Redwine D, Koning M, Sharpe D: Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. Fertil Steril 65: 193–197, 1996 8. Nezhat C, Pennington E, Nezhat F, et al: Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis. Surg Laparosc Endosc 1:106–108, 1991 9. Nezhat F, Nezhat C, Pennington E, et al: Laparoscopic segmental resection for infiltrating endometriosis of the rectosigmoid: A preliminary report. Surg Laparosc Endosc 2:212–216, 1992
409