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Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement
ORIGINAL SCIENTIFIC ARTICLES
Laparoscopic Resection of Deep Pelvic Endometriosis with Rectosigmoid Involvement Hans J Duepree, MD, Anthony J Senagore, MBA, MD, FACS, Conor P Delaney, MCh, PhD, FRCSI (GEN), Peter W Marcello, MD, Karen M Brady, RN, C, Tommaso Falcone, MD Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement. STUDY DESIGN: All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned. RESULTS: The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n ⫽ 26), bowel resection (n ⫽ 18), and disc excision (n ⫽ 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, 1 to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy, and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms. CONCLUSIONS: Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location. ( J Am Coll Surg 2002;195:754–758. © 2002 by the American College of Surgeons) BACKGROUND:
Advanced pelvic endometriosis is typically limited to the depths of the pelvis, with involvement of the pouch of
Douglas, the uterosacral ligaments, and the uterovaginal fold.1 Although disease in this area rarely involves the full thickness of the bowel wall, it may invade deep into the muscularis of the rectosigmoid colon.2,3 Effective management of these advanced stages of endometriosis, even in mild or moderate disease, requires complete excision of all of the endometriotic tissue without necessitating oophorectomy or hysterectomy.4-6 Laparoscopic excision of deep pelvic endometriosis appears to be highly effective in reducing pelvic pain and restoring fertility in
No competing interests declared.
Received March 20, 2002; Revised May 23, 2002; Accepted July 9, 2002. From the Departments of Colorectal Surgery (Duepree, Senagore, Delaney, Marcello, Brady) and Gynecology (Falcone) and The Minimally Invasive Surgery Center (Duepree, Senagore, Delaney, Marcello, Brady, Falcone), Cleveland Clinic Foundation, Cleveland, OH. Correspondence address: Anthony J Senagore, MBA, MD, FACS, Department of Colorectal Surgery, The Cleveland Clinic Foundation, Desk A-30, 9500 Euclid Ave, Cleveland, OH 44195.
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
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women desiring a pregnancy.7,8 Options for the management of bowel wall involvement include cautery excision, laser vaporization, disc excision of bowel wall, and formal bowel resection.9-11 Laparoscopic management of intestinal endometriosis appears to be an increasingly available addition to the operative armamentarium.12-15 Despite this growing interest, there remains relatively little data describing the role of radical laparoscopic management of deep pelvic endometriosis with bowel involvement. The purpose of this article is to evaluate the outcomes after planned complete laparoscopic excision of deep pelvic endometriosis with rectosigmoid involvement or involvement of other portions of the gastrointestinal tract. METHODS All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis (according to the Revised American Fertility Society Classification of Endometriosis) and bowel involvement from February 1998 through December 2001 were eligible for data analysis. A retrospective review of a prospective database defined the clinical presentation, surgical procedures, and outcomes of the patient population. Only patients undergoing superficial excision of rectosigmoid endometriosis, full-thickness disc excision, segmental rectosigmoid resection, or some other type of bowel resection were included. Data analysis included age, previous history of endometriosis, previous pregnancies, body mass index (BMI), operative procedure, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Data are shown as median and interquartile ranges (interquartile range, 25 to 75).
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Table 1. Demographics of the Patient Cohort Age, y (range) Body mass index (range) ASA score, n (%) ASA I ASA II ASA III Prior abdominal surgery Prior surgery for endometriosis, n (%) Hysterectomy, n (%)
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34 (32–39) 24 (22–28) 24 (47.1) 26 (50.1) 1 (2.0) 39 (76.5) 4 (7.8)
Data are shown as median and interquartile ranges (25–75). ASA, American Society of Anesthesiology.
Preoperative mechanical bowel preparation and perioperative IV antibiotics were used in all cases. A laparoscopic approach was undertaken in all patients and included resection of all visible disease from the pelvic sidewall, rectovaginal septum, and intestinal serosal surfaces. Operation was performed with a combined team of a gynecologist (TF) and a colorectal surgeon (AJS, PWM). Bowel resection was reserved for cases with deep invasion involving more than 50% of the bowel circumference. Disc excision of the bowel wall was used for deep but smaller-diameter lesions. RESULTS The series included 51 patients; their demographic data are shown in Table 1. Interestingly, patients undergoing resection had a significantly higher median BMI (median 31; interquartile range, 26 to 37) compared with the overall BMI (24; range, 22 to 29) (Student’s t-test, p ⬍ 0.05). Preoperative symptoms included dysmenorrhea (85.3%), dyspareunia (55.9%), urinary symptoms (23.5%), rectal pain (41.2%), rectal bleeding (14.7%), constipation (44.1%), bloating (29.4%), and tenesmus (8.8%).
Table 2. Operative Procedures and Intraoperative Data OR time, min
Blood loss, mL
Type of procedure
n
%
n
IQ range
n
IQ range
Superficial excision Segmental resection Disc excision* Others Small bowel resection Ileocolic resection Rectal excision ⫹ appendectomy Excision transverse colon
26 18 5 5 2 1 1 1
51.0 35.3 9.8 9.8
168 200 382 315
141–205 132–260 346–418 200–315
125 175 300 200
100–200 100–237 300–300 200–200
IQ, interquartile (25–75); OR, operating room.
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Table 3. Frequency of Intra- and Postoperative Complications by Operation Type Intraoperative complications
Postoperative complications
Type of procedure
n
%
n
%
Overall Superficial excision Segmental resection Disc excision Others
6/51 2/26 3/18 0/5 1/5
11.8 7.7 16.7 0 20
4/51 1/26 2/18 0/5 1/5
7.8 3.8 11.1 0 20
The distribution of procedures is shown in Table 2. The majority of patients were managed without bowel resection, and only 7 of 47 (14.9%) who had not had an earlier hysterectomy required abdominal hysterectomy or bilateral salpingo-oophorectomy. It is important to note that five patients (9.8%) required surgical management of a portion of the gastrointestinal tract other than or in addition to management of the rectosigmoid disease. The complexity of operation for endometriosis is demonstrated by the relatively long operating times (Table 2). Despite this complexity, 11 of 51 (21.6%) operations were performed as an outpatient procedure, which represents 11 of 26 (42.3%) patients treated with superficial excision of the rectosigmoid disease. The median length of stay in the remaining 40 patients who were admitted was 4 days (range, 3 to 5 days). The longest length of stay occurred in patients undergoing a segmental colectomy (4 days; range, 3 to 5 days), compared with those undergoing either disc excision or superficial excision (1.25 days; range, 1 to 4 days) without formal resection. No patients with either segmental or disc bowel resection were treated as an outpatient. The distributions of intra- and postoperative complications by type of operation are shown in Table 3. The single bladder injury was managed by laparoscopic cystorrhaphy. The ureteral injury was treated by cystoscopic stent placement and healed uneventfully with subsequent stent removal. The three rectal injuries were managed as follows: one was repaired primarily; one was repaired by segmental colorectal resection and primary anastomosis; and a combined ileal and rectal injury required conversion to an open double segmental resection with anastomosis. Finally, there was one episode of intraoperative bleeding from uterine vessels that required conversion to obtain hemostasis. Postoperative complications were relatively low given the magnitude of the operative procedure (n ⫽ 4; 7.8%). These com-
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plications included pyosalpinx (n ⫽ 1), delayed presentation of a contained anastomotic leak/pelvic abscess requiring temporary laparoscopic ileostomy and drainage (n ⫽ 1), antibiotic-associated diarrhea (n ⫽ 1), and pneumonia (n ⫽ 1). Three of these patients (5.9%) were readmitted for their postoperative complications. The patient with pneumonia did not require rehospitalization. Four cases (7.8%) were converted to formal laparotomy: ileal/rectosigmoid injury (n ⫽ 1); bleeding/ difficult dissection (n ⫽ 1); bowel thickness, technical difficulty to place linear stapler (n ⫽ 2). Two patients who required conversion underwent a low anterior resection, and the third patient underwent ileal resection and repair of the rectal injury. All patients who required conversion were obese (BMI 36 to 38). Only 7 of the 47 patients (14.9%) who had not previously undergone hysterectomy required abdominal hysterectomy or bilateral salpingo-oophorectomy. DISCUSSION Donnez and colleagues16 described three different forms of pelvic endometriosis: peritoneal endometriosis, ovarian endometriosis, and rectovaginal septal endometriosis. Deeply infiltrating endometriosis may invade the rectovaginal septum and lead to obliteration of the culde-sac by adenomyotic nodules.16 Deeply infiltrating pelvic endometriosis can be further subdivided by pattern of local invasion.16 These patterns of disease are type I, large lesions invade conically, with deeper portions progressively smaller; type II, invasion leads to bowel retracted over the lesion, but there is rarely bowel invasion; type III, sphere-shaped lesions occur deep in the rectovaginal septum and are rarely visible but rather palpable. The type III lesions usually consist of an aggregate of smooth muscle, endometrial glands, and endometrial stroma without secretory changes.16 Pelvic endometriosis involving the cul-de-sac frequently presents with pain and dyspareunia caused by involvement of the rectovaginal septum and uterosacral ligaments.17-19 Involvement of the rectosigmoid results in retraction of the bowel wall over the lesion, as mentioned earlier, and may result in alternating diarrhea and constipation or partial obstructive symptoms.16 Pelvic examination is essential to identify the presence of extensive pelvic disease. Focal tenderness or nodularity of the cul-de-sac or uterosacral ligaments is the best means of identifying disease.20 The necessity of performing this
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examination is supported by the fact that the majority of patients with intestinal involvement will have findings on pelvic examination.20 Surgical management of intestinal involvement of pelvic endometriosis requires complete excision of all visible and palpable disease for maximal pain relief and return of fertility. Redwine21 has suggested a severity scoring system for intestinal endometriosis based on the form of surgical management required: grade I, superficial seromuscular; grade II, partial thickness to mucosa; grade III, full thickness; grade IV, segmental.21 The surgical approaches to intestinal disease include simple excision (with cautery or laser), mucosal skinning, fullthickness disc excision with primary closure, and formal bowel resection.22-25 Identification of disease in the culde-sac requires placement of a sponge within the vagina so that the entire cul-de-sac can be exposed.21 The retraction of the rectosigmoid colon over the adenomyotic nodules in the cul-de-sac frequently obscures the amount of disease and can result in incomplete excision. It is essential that the dissection continue until the soft yellow fat within the septum is identified to ensure that the entire rectum has been freed from the posterior vagina and that all the disease has been removed. Outcomes after excisional or resective therapy of intestinal disease have generally been excellent, with low morbidity and mortality.7,10-15,22,26,27 The distribution of techniques for managing intestinal disease in this series is similar to the body of literature describing either laparoscopic or conventional approaches. We rely on either superficial or deep excision, using disc excision for rectosigmoid lesions of less than 3 cm for the majority of bowel endometriotic implants. Formal rectosigmoid resection was required in only 35% of patients in our series, but increased experience with laparoscopic colectomy and improved instrumentation for performing these resections has made this a more attractive option for pelvic endometriosis.7,10-15,22,26,27 The results of these series demonstrate the benefits of highly effective pain control and low morbidity when complete rectovaginal separation and excision of the extensive infiltrating pelvic endometriosis are achieved. Our data further support the contention that these benefits can be obtained without removal of the uterus and ovaries, thereby maintaining the potential for a successful pregnancy. We performed abdominal hysterectomy or bilateral salpingooophorectomy in only 17.8% of this select group of
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patients and only when the patient no longer desired to preserve fertility. A notable difference between this article and earlier reports of rectosigmoid resection for endometriosis is our use of a small (⬍ 3 cm), low, muscle-splitting incision in the left lower quadrant for removal of the specimen and insertion of the anvil for a circular stapled anastomosis. We believe that this approach avoids potential trauma during mobilization of a relatively long distal rectum for transanal prolapse of the specimen and for anastomosis. Our approach also avoids juxtaposing the vaginal closure and bowel closure, which occurs when transvaginal delivery of the specimen and closure of the rectum are used.11 This close proximity may contribute to formation of a rectovaginal fistula. CONCLUSIONS The data indicate that a laparoscopic approach to severe pelvic endometriosis with bowel involvement is possible and can be highly successful. Superficial or deep excision—or even formal rectosigmoid colectomy—can be performed safely to ensure complete removal of the endometriosis. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location. Author Contributions
Study conception and design: Duepree, Senagore, Falcone Acquisition of data: Duepree, Senagore, Delaney, Marcello, Brady, Falcone Analysis and interpretation of data: Duepree, Senagore, Delaney, Brady, Falcone Drafting of manuscript: Duepree, Senagore, Delaney, Marcello, Falcone Critical revision: Duepree, Senagore, Delaney, Marcello, Falcone Statistical expertise: Duepree, Senagore, Delaney Supervision: Senagore REFERENCES 1. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenic implications of the anatomic distribution. Obstet Gynecol 1986;67:335–338.
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2. Graham B, Mazier P. Diagnosis and management of endometriosis of the colon and rectum. Dis Colon Rectum 1988;31: 952–956. 3. Cameron IC, Rogers S, Collins MC, Reed MWR. Intestinal endometriosis: presentation, investigation, and surgical management. Int J Colorectal Dis 1995;10:83–86. 4. Marcoux S, Maheux R, Berube S, The Canadian Collaborative Group of Endometriosis. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Engl J Med 1997;337:217–222. 5. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993; 328:1759–1769. 6. Gambone JC, DeCherney AH. Surgical treatment of minimal endometriosis. N Engl J Med 1997;337:269–270. 7. Coronado C, Franklin RR, Lotze EC, et al. Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 1990;53: 411–416. 8. Vercellini P, De Giorgi O, Pisacreta A, et al. Surgical management of endometriosis. Baillieres Clin Obstet Gynaecol 2000; 14:501–523. 9. Bailey HR. Colorectal endometriosis. Perspect Colon Rectal Surg 1992;5:251–259. 10. Nezhat C, Nezhat F, Pennington E, et al. Laparoscopic disk excision and primary repair of the anterior wall for the treatment of full-thickness bowel endometriosis. Surg Endosc 1994;8: 682–685. 11. Redwine DB, Koning M, Sharpe DR. Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. Fertil Steril 1996;65:193–197. 12. Jerby BL, Kessler H, Falcone T, Milsom JW. Laparoscopic management of colorectal endometriosis. Surg Endosc 1999;13: 1125–1128. 13. Nezhat C, Pennington E, Nezhat F, Silfen SL. Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis. Surg Laparosc Endosc 1991; 1:106–108. 14. Redwine DB, Sharpe DR. Laparoscopic segmental resection of the sigmoid colon. J Laparoendosc Surg 1991;4:217–220.
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15. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal endometriosis by the technique of videolaparoscopy and the CO2 laser. Br J Obstet Gynaecol 1992;99:664–667. 16. Donnez J, Nisolle M, Gillerot S, et al. Rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol 1997;104:1014–1018. 17. Chapron C, Dubuisson JB. Laparoscopic treatment of deep endometriosis located on the uterosacral ligaments. Hum Reprod 1996;11:868–873. 18. Farquhar CM. Extracts from the “clinical evidence:” endometriosis. BMJ 2000;320:1449–1452. 19. Malik E, Berg C, Meyhofer-Malik A, et al. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis. Surg Endosc 2000;14:79–81. 20. Konincyk PR, Meuleman C, Oosterlynck D, et al. Diagnosis of deep endometriosis by clinical examination during menstruation and plasma CA-125 concentration. Fertil Steril 1996;65: 280–287. 21. Redwine DB. The visual appearance of endometriosis and its impact on our concepts of disease. Clin Biol Res 1990;323:393– 412. 22. Varol N, Maher P, Woods R. Laparoscopic management of intestinal endometriosis. J Am Assoc Gynecol Laparosc 2000;7: 405–409. 23. Bailey HR, Ott MT, Hartendorp P. Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 1994;37:747–753. 24. Prystowsky JB, Stryker SJ, Ujiki GT, Poticha SM. Gastrointestinal endometriosis. Arch Surg 1988;123:855–858. 25. Bromberg SH, Waisberg J, Franco MIF, et al. Surgical treatment for colorectal endometriosis. Int Surg 1999;84:234–238. 26. Chapron C, Dubuisson JB, Fernandez B, Dousset B. Traitements chirurgicaux des endometrioses [Surgical treatment of endometriosis]. Rev Prat 1999;49:276–278. 27. Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cul-de-sac in endometriosis. J Reprod Med 1992; 37:620–624.
Laparoscopic Resection of Deep Pelvic Endometriosis with Rectosigmoid Involvement Hans J Duepree, MD, Anthony J Senagore, MBA, MD, FACS, Conor P Delaney, MCh, PhD, FRCSI (GEN), Peter W Marcello, MD, Karen M Brady, RN, C, Tommaso Falcone, MD Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement. STUDY DESIGN: All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned. RESULTS: The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n ⫽ 26), bowel resection (n ⫽ 18), and disc excision (n ⫽ 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, 1 to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy, and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms. CONCLUSIONS: Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location. ( J Am Coll Surg 2002;195:754–758. © 2002 by the American College of Surgeons) BACKGROUND:
Advanced pelvic endometriosis is typically limited to the depths of the pelvis, with involvement of the pouch of
Douglas, the uterosacral ligaments, and the uterovaginal fold.1 Although disease in this area rarely involves the full thickness of the bowel wall, it may invade deep into the muscularis of the rectosigmoid colon.2,3 Effective management of these advanced stages of endometriosis, even in mild or moderate disease, requires complete excision of all of the endometriotic tissue without necessitating oophorectomy or hysterectomy.4-6 Laparoscopic excision of deep pelvic endometriosis appears to be highly effective in reducing pelvic pain and restoring fertility in
No competing interests declared.
Received March 20, 2002; Revised May 23, 2002; Accepted July 9, 2002. From the Departments of Colorectal Surgery (Duepree, Senagore, Delaney, Marcello, Brady) and Gynecology (Falcone) and The Minimally Invasive Surgery Center (Duepree, Senagore, Delaney, Marcello, Brady, Falcone), Cleveland Clinic Foundation, Cleveland, OH. Correspondence address: Anthony J Senagore, MBA, MD, FACS, Department of Colorectal Surgery, The Cleveland Clinic Foundation, Desk A-30, 9500 Euclid Ave, Cleveland, OH 44195.
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
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women desiring a pregnancy.7,8 Options for the management of bowel wall involvement include cautery excision, laser vaporization, disc excision of bowel wall, and formal bowel resection.9-11 Laparoscopic management of intestinal endometriosis appears to be an increasingly available addition to the operative armamentarium.12-15 Despite this growing interest, there remains relatively little data describing the role of radical laparoscopic management of deep pelvic endometriosis with bowel involvement. The purpose of this article is to evaluate the outcomes after planned complete laparoscopic excision of deep pelvic endometriosis with rectosigmoid involvement or involvement of other portions of the gastrointestinal tract. METHODS All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis (according to the Revised American Fertility Society Classification of Endometriosis) and bowel involvement from February 1998 through December 2001 were eligible for data analysis. A retrospective review of a prospective database defined the clinical presentation, surgical procedures, and outcomes of the patient population. Only patients undergoing superficial excision of rectosigmoid endometriosis, full-thickness disc excision, segmental rectosigmoid resection, or some other type of bowel resection were included. Data analysis included age, previous history of endometriosis, previous pregnancies, body mass index (BMI), operative procedure, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Data are shown as median and interquartile ranges (interquartile range, 25 to 75).
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Table 1. Demographics of the Patient Cohort Age, y (range) Body mass index (range) ASA score, n (%) ASA I ASA II ASA III Prior abdominal surgery Prior surgery for endometriosis, n (%) Hysterectomy, n (%)
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34 (32–39) 24 (22–28) 24 (47.1) 26 (50.1) 1 (2.0) 39 (76.5) 4 (7.8)
Data are shown as median and interquartile ranges (25–75). ASA, American Society of Anesthesiology.
Preoperative mechanical bowel preparation and perioperative IV antibiotics were used in all cases. A laparoscopic approach was undertaken in all patients and included resection of all visible disease from the pelvic sidewall, rectovaginal septum, and intestinal serosal surfaces. Operation was performed with a combined team of a gynecologist (TF) and a colorectal surgeon (AJS, PWM). Bowel resection was reserved for cases with deep invasion involving more than 50% of the bowel circumference. Disc excision of the bowel wall was used for deep but smaller-diameter lesions. RESULTS The series included 51 patients; their demographic data are shown in Table 1. Interestingly, patients undergoing resection had a significantly higher median BMI (median 31; interquartile range, 26 to 37) compared with the overall BMI (24; range, 22 to 29) (Student’s t-test, p ⬍ 0.05). Preoperative symptoms included dysmenorrhea (85.3%), dyspareunia (55.9%), urinary symptoms (23.5%), rectal pain (41.2%), rectal bleeding (14.7%), constipation (44.1%), bloating (29.4%), and tenesmus (8.8%).
Table 2. Operative Procedures and Intraoperative Data OR time, min
Blood loss, mL
Type of procedure
n
%
n
IQ range
n
IQ range
Superficial excision Segmental resection Disc excision* Others Small bowel resection Ileocolic resection Rectal excision ⫹ appendectomy Excision transverse colon
26 18 5 5 2 1 1 1
51.0 35.3 9.8 9.8
168 200 382 315
141–205 132–260 346–418 200–315
125 175 300 200
100–200 100–237 300–300 200–200
IQ, interquartile (25–75); OR, operating room.
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Table 3. Frequency of Intra- and Postoperative Complications by Operation Type Intraoperative complications
Postoperative complications
Type of procedure
n
%
n
%
Overall Superficial excision Segmental resection Disc excision Others
6/51 2/26 3/18 0/5 1/5
11.8 7.7 16.7 0 20
4/51 1/26 2/18 0/5 1/5
7.8 3.8 11.1 0 20
The distribution of procedures is shown in Table 2. The majority of patients were managed without bowel resection, and only 7 of 47 (14.9%) who had not had an earlier hysterectomy required abdominal hysterectomy or bilateral salpingo-oophorectomy. It is important to note that five patients (9.8%) required surgical management of a portion of the gastrointestinal tract other than or in addition to management of the rectosigmoid disease. The complexity of operation for endometriosis is demonstrated by the relatively long operating times (Table 2). Despite this complexity, 11 of 51 (21.6%) operations were performed as an outpatient procedure, which represents 11 of 26 (42.3%) patients treated with superficial excision of the rectosigmoid disease. The median length of stay in the remaining 40 patients who were admitted was 4 days (range, 3 to 5 days). The longest length of stay occurred in patients undergoing a segmental colectomy (4 days; range, 3 to 5 days), compared with those undergoing either disc excision or superficial excision (1.25 days; range, 1 to 4 days) without formal resection. No patients with either segmental or disc bowel resection were treated as an outpatient. The distributions of intra- and postoperative complications by type of operation are shown in Table 3. The single bladder injury was managed by laparoscopic cystorrhaphy. The ureteral injury was treated by cystoscopic stent placement and healed uneventfully with subsequent stent removal. The three rectal injuries were managed as follows: one was repaired primarily; one was repaired by segmental colorectal resection and primary anastomosis; and a combined ileal and rectal injury required conversion to an open double segmental resection with anastomosis. Finally, there was one episode of intraoperative bleeding from uterine vessels that required conversion to obtain hemostasis. Postoperative complications were relatively low given the magnitude of the operative procedure (n ⫽ 4; 7.8%). These com-
J Am Coll Surg
plications included pyosalpinx (n ⫽ 1), delayed presentation of a contained anastomotic leak/pelvic abscess requiring temporary laparoscopic ileostomy and drainage (n ⫽ 1), antibiotic-associated diarrhea (n ⫽ 1), and pneumonia (n ⫽ 1). Three of these patients (5.9%) were readmitted for their postoperative complications. The patient with pneumonia did not require rehospitalization. Four cases (7.8%) were converted to formal laparotomy: ileal/rectosigmoid injury (n ⫽ 1); bleeding/ difficult dissection (n ⫽ 1); bowel thickness, technical difficulty to place linear stapler (n ⫽ 2). Two patients who required conversion underwent a low anterior resection, and the third patient underwent ileal resection and repair of the rectal injury. All patients who required conversion were obese (BMI 36 to 38). Only 7 of the 47 patients (14.9%) who had not previously undergone hysterectomy required abdominal hysterectomy or bilateral salpingo-oophorectomy. DISCUSSION Donnez and colleagues16 described three different forms of pelvic endometriosis: peritoneal endometriosis, ovarian endometriosis, and rectovaginal septal endometriosis. Deeply infiltrating endometriosis may invade the rectovaginal septum and lead to obliteration of the culde-sac by adenomyotic nodules.16 Deeply infiltrating pelvic endometriosis can be further subdivided by pattern of local invasion.16 These patterns of disease are type I, large lesions invade conically, with deeper portions progressively smaller; type II, invasion leads to bowel retracted over the lesion, but there is rarely bowel invasion; type III, sphere-shaped lesions occur deep in the rectovaginal septum and are rarely visible but rather palpable. The type III lesions usually consist of an aggregate of smooth muscle, endometrial glands, and endometrial stroma without secretory changes.16 Pelvic endometriosis involving the cul-de-sac frequently presents with pain and dyspareunia caused by involvement of the rectovaginal septum and uterosacral ligaments.17-19 Involvement of the rectosigmoid results in retraction of the bowel wall over the lesion, as mentioned earlier, and may result in alternating diarrhea and constipation or partial obstructive symptoms.16 Pelvic examination is essential to identify the presence of extensive pelvic disease. Focal tenderness or nodularity of the cul-de-sac or uterosacral ligaments is the best means of identifying disease.20 The necessity of performing this
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examination is supported by the fact that the majority of patients with intestinal involvement will have findings on pelvic examination.20 Surgical management of intestinal involvement of pelvic endometriosis requires complete excision of all visible and palpable disease for maximal pain relief and return of fertility. Redwine21 has suggested a severity scoring system for intestinal endometriosis based on the form of surgical management required: grade I, superficial seromuscular; grade II, partial thickness to mucosa; grade III, full thickness; grade IV, segmental.21 The surgical approaches to intestinal disease include simple excision (with cautery or laser), mucosal skinning, fullthickness disc excision with primary closure, and formal bowel resection.22-25 Identification of disease in the culde-sac requires placement of a sponge within the vagina so that the entire cul-de-sac can be exposed.21 The retraction of the rectosigmoid colon over the adenomyotic nodules in the cul-de-sac frequently obscures the amount of disease and can result in incomplete excision. It is essential that the dissection continue until the soft yellow fat within the septum is identified to ensure that the entire rectum has been freed from the posterior vagina and that all the disease has been removed. Outcomes after excisional or resective therapy of intestinal disease have generally been excellent, with low morbidity and mortality.7,10-15,22,26,27 The distribution of techniques for managing intestinal disease in this series is similar to the body of literature describing either laparoscopic or conventional approaches. We rely on either superficial or deep excision, using disc excision for rectosigmoid lesions of less than 3 cm for the majority of bowel endometriotic implants. Formal rectosigmoid resection was required in only 35% of patients in our series, but increased experience with laparoscopic colectomy and improved instrumentation for performing these resections has made this a more attractive option for pelvic endometriosis.7,10-15,22,26,27 The results of these series demonstrate the benefits of highly effective pain control and low morbidity when complete rectovaginal separation and excision of the extensive infiltrating pelvic endometriosis are achieved. Our data further support the contention that these benefits can be obtained without removal of the uterus and ovaries, thereby maintaining the potential for a successful pregnancy. We performed abdominal hysterectomy or bilateral salpingooophorectomy in only 17.8% of this select group of
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patients and only when the patient no longer desired to preserve fertility. A notable difference between this article and earlier reports of rectosigmoid resection for endometriosis is our use of a small (⬍ 3 cm), low, muscle-splitting incision in the left lower quadrant for removal of the specimen and insertion of the anvil for a circular stapled anastomosis. We believe that this approach avoids potential trauma during mobilization of a relatively long distal rectum for transanal prolapse of the specimen and for anastomosis. Our approach also avoids juxtaposing the vaginal closure and bowel closure, which occurs when transvaginal delivery of the specimen and closure of the rectum are used.11 This close proximity may contribute to formation of a rectovaginal fistula. CONCLUSIONS The data indicate that a laparoscopic approach to severe pelvic endometriosis with bowel involvement is possible and can be highly successful. Superficial or deep excision—or even formal rectosigmoid colectomy—can be performed safely to ensure complete removal of the endometriosis. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location. Author Contributions
Study conception and design: Duepree, Senagore, Falcone Acquisition of data: Duepree, Senagore, Delaney, Marcello, Brady, Falcone Analysis and interpretation of data: Duepree, Senagore, Delaney, Brady, Falcone Drafting of manuscript: Duepree, Senagore, Delaney, Marcello, Falcone Critical revision: Duepree, Senagore, Delaney, Marcello, Falcone Statistical expertise: Duepree, Senagore, Delaney Supervision: Senagore REFERENCES 1. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenic implications of the anatomic distribution. Obstet Gynecol 1986;67:335–338.
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